Lens of Profound Knowledge

What is it?

The Lens of Profound Knowledge (LoPK) (also known as System of Profound knowledge) is a framework introduced by Demmings to be used in quality planning. It encourages users to break down a range of variables that impact on the success of change ideas and programmes. This promotes critical self reflection, something required for successful and sustainable change.

The LoPK includes four key areas -

Appreciation of the system: this looks at what the system is doing currently. This could involve processes as well as the interaction between different processes. It is important to consider the interaction between different systems, as often change in one area may result in unintended consequences in another. This may be a place to consider potential balancing measures as well as change ideas. This area is often complemented by process maps.

Understanding variation: this looks at not only how people vary in their behaviours but also statistical variation. It is often a goal within quality improvement to reduce unnecessary variation. Do to so, one must understand the existing variation within the system before changes are made. Variation can be common cause (often from within the system), or special cause (often from outside the system). By understanding the variation improvement efforts can be focused strategically. This area is often complemented by measurement frameworks and statistical process control (SPC) charts.

Psychology of people, society and change (human behaviour): this looks at what people do within the system, what people think about the system, what motivates people and how people respond to change. Without properly considering the psychology elements, change ideas and programmes are likely to be unsuccessful. This area often ties in well with empathy maps and forcefield analyses.

Theory of knowledge: this relates to the theories around why the system looks like it does, as well as any theories as to why proposed change ideas would work.  It is important to understand why these theories are held by people, including those introducing and affected by change. Theories are just that, they are not always based on the best available evidence and in these occasions are important to understand so that they do not derail a worthy improvement effort. This area often ties in well with the model for improvement and PDSA cycles.

The four components come together to create the lens of profound knowledge.

Why use it?

Framing planning through the lens increases the likelihood that teams will consider an appropriately diverse range of concerns in their planning. This should increase the likelihood of success, as key areas have been considered.

It is appropriate to use for large scale concerns or problems. It aims to ensure that improvers do not oversimplify change.

How to use it?

The LoPK can be used to guide group discussions, particularly when discussing the system as it currently stands. The LoPK can also be a useful framework for planning.

e.g. Want to improve rates of hand washing within the practice

Appreciating the system: Items to consider could include: where are the hand wash stations placed? Are there are professional groups who may find it more difficult to get to a hand wash station? How are these stations stocked/restocked? How are these stations presented? 

It is likely that increasing hand washing compliance in a practice will increase product usage. This may impact on the ordering system, depending on how this is organised (e.g. is soap ordered every week or is it ordered when there is only one bottle remaining?). It may be that through appreciating the system it can be seen that the APP has to travel the longest distance across the practice to reach her nearest hand washing station.  

Understanding variation:

Items to consider would include: what is the variation between different team members, are some staff more compliant than others? What is the variation within individuals, is someone more compliant at different times of the week? What is the variation in quality, do most people remember to go to the hand wash station but fail to wash their hands for long enough?

It is likely that there will be variation between groups, individuals and within individuals. Collecting baseline data on this variation can help to target the most appropriate change ideas.

Psychology (human behaviour):

Items to consider would include: how do staff within the practice respond to change? What motivates team members and what could be used to motivate them to improve hand washing rates? Is there someone within the team who is a ‘super-connector’ who could positively influence the success of the improvement work?

It is possible here that the improvement team need to strike a balance between supporting change without being perceived as condescending. The psychology is dependent on the people involved, can change across time and should not be ‘copied and pasted’ from other contexts.

Theory of knowledge:

Items to consider would include: what do each professional group think about hand washing, how it works and its importance?

Understanding the theory of knowledge steps beyond the band-aid solution of ‘education’. By understanding the different theories held within the groups, change ideas can appropriately be targeted. ‘Education’ alone often fails to make long lasting change without explaining the ‘why’ of the change. By understanding the theories people hold, the change group are better able to match the right ‘why’ to promote change. (e.g. It’s unlikely to be helpful to say that hand washing needs to be for 20-40 seconds for all staff if an administration team member does not believe they carry enough pathogens to warrant regular hand washing).

By considering these four elements, the planning team have begun to understand their system and have possibly refined their aim, generated some new change ideas and ideas for measurement. The LoPK can be applied throughout the improvement effort to see how things have changed.

More information

NHS Improvement - for a guide for how to use the LoPK in practice

IHI - for videos (above) explaining LoPK

ELFT - for further perspective on LoPK