Posted October 20, 2014 by Marianne McPherson, PhD, MS
In previous blog posts, I’ve often featured a children’s story as the jumping off point for my message. This time, “story” is the message. I’d like to share how we at NICHQ are uncovering and learning from stories to improve children’s health around the country.
I recently returned from the BIF10 Innovation Summit. After two days listening to stories from fascinating people such as a 14 year-old robotics whiz, a New Yorker cartoonist, the pilot who helped rebuild the Afghan Air Force, and a woman who will transform the Future of Fish, I was inspired – which may be my understatement of the year.
Stories matter. They tell us the “why” and “how did that happen?” below the headline. At NICHQ, the team I lead asks three critical questions when evaluating our projects: “What happened?” “Why?” and “What's next?”
To illustrate, I'm sharing a specific example from one of NICHQ’s breastfeeding projects, which aims to improve breastfeeding practices in hospitals. I share this example with two important caveats: (1) In this brief post, I can provide just one small chapter in the overall story. There is much more to tell. Some of the other chapters can be found elsewhere on NICHQ's website, and still other chapters are being shared by the project teams themselves (see this example). (2) This story is still being written.
What happened is the core of results: it’s what the outcome measures of our improvement data tell us. By how much did hospitals' breastfeeding rates increase? How many practices provided more coordinated care? What happened is critical information. But it's just the first part of the story – and it can be hard to know what to do with it.
In NICHQ's Best Fed Beginnings initiative, 89 hospitals nationwide have been working on improving breastfeeding-related maternity care in pursuit of Baby-Friendly designation. Here's a very high-level snapshot of how rapidly the teams are progressing along the eight process measures they have been tracking over the course of their improvement journey; each measure is a separate line that includes aggregate data across all teams.
So what's happening? Overall, teams are improving in some areas more than in others. More specifically, they have been slowest to improve in the process of providing assistance and support for breastfeeding (the bottom red line). But why?
The why behind the what happened is where the story comes in. To uncover that story, our evaluation team will draw on qualitative data from interviews or focus groups or teams’ own reports of the changes they made. Our improvement advisors and project faculty and staff uncover the story, too, as they provide on-the-ground coaching and support to teams. The story paints the rich picture of what happened for whom, in what contexts and under what conditions.
In a recent evaluation survey, we asked Best Fed Beginnings teams to share any barriers they are facing in the final months of the project as they work toward designation. Their answers illuminated some of the why behind that bottom line in the above graph related to providing assistance and support with breastfeeding. The why story included challenges related to gaining support and buy-in from providers, barriers in the system of care and staff turnover:
"Some nurses and peds [pediatricians] still want to grab the old formula bottle-- too easy! Even with education [they] want to follow old paths."
"Gaining buy-in from the physicians has been difficult at best."
"Lack of nurse time with patients in our OB clinic."
"Numerous staffing and administrative changes in that unit have made implementation of standard teaching [on breastfeeding] an ongoing challenge."
Through that why story, we also learn about the story behind the variations in outcomes – why did some teams improve quickly and others not get traction? What were some teams' solutions to the barriers voiced above so that other teams can test those solutions? Understanding the why story helps bring us to the next question...
What's next? Improvement is a journey of learning. Knowing what happened and even understanding why it happened isn’t fully meaningful unless we have a what’s next. How can we apply what we learned to new communities? If a change worked in an urban setting, will it work in a rural one? Can we spread or scale up what we learned? How can we address what didn’t work? Based on what we’ve learned in Best Fed Beginnings, project faculty and staff are able to better focus their technical assistance to teams, helping work toward full provider buy-in, for example. We also can apply what we are learning from this story to our other breastfeeding projects.
One more thing about stories: the best stories always leave you wanting more. I invite you to consider the improvement journey as a “choose your own adventure” series. The changes we test and the data we collect (both quantitative and qualitative) help us choose which chapter to create next. We have a long way to go to fulfill NICHQ's vision of all children achieving their optimal health. We definitely can't do it alone. Will you join our story?