Everyone is looking to answer the same set of questions—not just how to be successful with one project or initiative, but how ultimately to build the culture, leadership and skills needed for the sustained efforts and larger organizational transformation to accomplish the bigger picture that ties to the organization’s purpose for existence.

Our team at Shift is proud to announce the arrival of this new paper Building a Culture of Learning and Improvement for Equity. This framework is deeply personal. It not only reflects the Shift team’s philosophy about organizational transformation, but also more than twenty years of my improvement journey, starting with my first role in improvement at University Research Co–Center for Human Services (URC-CHS) in the late 90s.

Twenty years ago, my coauthors and I published the monograph Sustaining Quality of Healthcare: Institutionalization of Quality Assurance, on which this new framework is based. We started with some guiding questions: What makes quality stick? How do you establish a culture of quality to make it an integral part of the system and a way of doing work? Our questions were bigger than the technical design and implementation of any singular project. We wanted to learn what factors led to the culture change needed to create fertile ground for ongoing transformation efforts.

We set out on our work to find answers to these big overarching questions, studying quality programs under the vast scope of the Quality Assurance Project’s support to Ministries of Health in over 25 countries throughout ten years. At the same time, we also learned from rising efforts in the United States to improve the quality and safety of health systems leading to the publication of the landmark report, Crossing the Quality Chasm: A New Health System for the 21st Century (Institute of Medicine, 2001).

New to the field of quality, this was a tremendous opportunity for me to learn from these coauthors and collaborators in their work in systems change all over the world. Their mentorship and enthusiasm hooked me into the world of improvement. I was inspired by their efforts to work with local governments and leaders to make big systems changes to reduce inequities in nutrition, maternal and neonatal mortality, infectious disease, and many other areas across the world. I learned about the breadth and power of improvement—not just as a methodology or set of tools—but as a way of working and collaborating. This lasting culture of improvement reconnects organizations with their purpose and ignites those within organizations and their communities to continuously reinvent themselves to achieve better outcomes.

Since its publication in 2002, the original framework has been used in multiple ways, as a planning tool to sustain improvement, an assessment tool to identify strengths and areas of growth, and as a communications tool to capture lessons about improvement efforts. We found that the framework could be applied across multiple levels of a system—from national ministries of health to district management to local health facilities—providing cascading depth and continuity to its application.

Through my continued work in improvement, I came to realize that the process of change and the challenge of sustaining improvement transcends contexts and sectors. I have since applied this framework in education, social work, and other areas of health both in the United States and internationally.  Everyone is looking to answer the same set of questions—not just how to be successful with one project or initiative, but how ultimately to build the culture, leadership and skills needed for the sustained efforts and larger organizational transformation to accomplish the bigger picture that ties to the organization’s purpose for existence.

Our intention at Shift in adapting this original piece was to celebrate the 20^th anniversary of the original framework as well as to update it with important learning (see our recent blog Introducing a New White Paper —Building a Culture of Learning & Improvement for Equity). While the essence of this framework has stood the test of time, a recent reflection on the work highlighted areas of new learning based on our experiences at Shift:

1. The commitment to equity and coproduction are critical to why we do improvement and why Shift was founded. We learned that truly seeing the system can only be achieved with intentional examination of structural elements that result in inequities and how they may impact people differently. We also came to realize the power of coproduction, building a culture of doing work with (not just for) the people most impacted by the system to truly value their lived expertise.
   
   
2. The differentiation between systems to assure and improve quality has evolved significantly over the past twenty years. We now have better language and more understanding of the different philosophies and leverage points of what at the core are very different approaches to systems change. While quality assurance was the focus of the original document, the new framework focuses on the wider set of improvement practices that are needed to improve with increasing depth and complexity.
   
   
3. At Shift, we have used the ideas in this framework in our work across healthcare, education, and social services and have learned that these concepts are relevant to building a culture of learning and improvement to any social sector. We thought it was critical to make the framework more widely applicable and relevant to other sectors.

Twenty years doing this work has afforded me the incredible opportunity to observe and influence systems change across multiple sectors and contexts. In doing so, I’ve been able to see the elements and strategies that lead to the short- and long-term change needed to grow a culture where learning and improvement flourish. One thing I’ve learned is that while improvement skills and methods are critical, the wider culture change to sustain them is not entirely a technical solution. It requires intentional dedication, planning, and growth.

Check out our new online course, SAIL (Sustaining and Advancing Improvement & Learning), which will help your organization take these critical and proactive steps.