Comprehensive quality improvement: not ‘why should we do it?’ but ‘when will we start?’

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As a chief executive in the NHS over the past 10 years, I have seen the benefits of quality improvement at first hand. Now, The King’s Fund and The Health Foundation are making a powerful case for quality improvement techniques to be applied consistently and systematically across the NHS. Leaders and their boards know the value it can bring – helping to drive quality, finance and access improvements as well as enhancing staff experience – so why hasn’t the NHS been able to embed quality improvement comprehensively across the service? Why aren’t all our patients and staff benefitting from what works so well in patches?

It is not for want of trying or a lack of desire for change, and as the report clearly demonstrates, there are examples of such initiatives driving improvements right across the service. In my experience the most transformational changes and the ones that are truly embedded are those that are developed, owned and implemented by the staff themselves. The five examples in the report make this point and I have seen it for myself – most recently with the inspiring work at East Kent Hospitals, by staff at all levels, that helped the trust get out of quality special measures. Staff worked in site-based groups – called innovation and improvement hubs­ – and identified issues they wanted to change and then worked together to address them.  One example was a week-long campaign to promote sepsis awareness as part of World Sepsis Day. The team engaged staff in conversation, promoted screening for sepsis, shared resources and key messages on sepsis management and received face-to-face feedback on how best to increase awareness amongst frontline staff in the future. This helped to improve the management of sepsis, outcomes for patients and enabled a more empowered and collaborative way of working for staff. This process is continuing as part of the Trust’s ongoing transformation journey.

Based on this and other examples across the NHS, it is clear that quality improvement can work, does work, and is happening.  After reading the report I felt all the examples were ones that could be implemented in trusts I had worked in with benefits for both patients and staff. But we hadn’t done all of them and it begs the obvious question – why?

My own reflection on this is that the pressures NHS staff feel on a daily basis crowd out time to do quality improvement work, there can be a lack of clarity about which approach to use and there is often too much time spent shifting between methodologies reflecting the latest trend or fad. On this point, the report is clear: it isn’t which methodology an organisation uses that matters, but the fact that it adopts a systematic approach to continuous quality improvement and sticks with its chosen method. There is also a risk that we over-complicate how to actually do quality improvement and we often don’t empower staff to try or give them enough time or the tools to do the job effectively.

None of this is impossible to change and as the operational, financial and workforce pressures on the service inexorably rise, now it is more important than ever that we use quality improvement to deliver benefits for patients and staff alike. Without it there is a high risk that opportunities will be missed, not only within organisations, but across whole systems. As leaders rightly look to integrate services across traditional boundaries the challenge to embed quality improvement will become harder: working between and across organisations adds complexity to the change process. However, this will also become more important as opportunities for improvement at the interface between services are as significant, if not more so, than opportunities that sit within individual bodies.

The 10 lessons set out in the report are an extremely useful starting point for boards and leaders wanting to make progress with quality improvement. Taken as a guide they will help leaders embed quality improvement as a core aspect of the drive to wider scale change. The question is not why we haven’t done this comprehensively already but when will we start?


Ian Setchfield

Acute Care Nurse Consultant,
East Kent Hospitals University Foundation NHS Trust
Comment date
12 October 2017
I wholeheartedly agree with the need to empower staff to utilise quality improvement methodology to improve not only services but to also promote a positive work based culture.
The 10 lessons provide a clear framework for implementation and sustainability of improvement across the organisation. The challenge is to demystify the different QI methodologies and translate then into a common language that is understood by all members of staff. Quality improvement needs to be seen not as an extra task but as ‘how we do business ‘ so enabling an environment of constantly improving services and patient experience.

Julian Simcox

Patient Leader and Q Member,
Comment date
12 October 2017
In 2008 commissioners were required to become World Class which included Continual Quality Improvement - the opportunity was there to model this to Providers - something that a decade later could have been paying off big time. In my experience Quality Assurance remains the only game in town as Commissioners continue to re-act rather than pro-act to NHS England de facto edicts.

I have met few professionals - either commissioners or providers - who get the difference between QA and QI. I hope the Health Foundation's Q Initiative can at last make the much needed up-skilling possible?

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