Throughout the autumn of 2018, The King’s Fund interviewed leaders and experts on quality improvement as part of an independent review of the patient safety collaboratives programme from the Academic Health Science Networks (AHSNs), a group of collaborative improvement networks set up following Don Berwick's review of patient safety after the Mid Staffordshire scandal to support NHS organisations in projects to improve safety. Over their first four years, the collaboratives have delivered some fantastic improvement programmes: an emergency laparotomy collaborative that delivered a 42 per cent reduction in risk-adjusted mortality; or a falls collaborative that delivered a 60 per cent reduction in falls. Yet the NHS’s difficult relationship with quality improvement remains apparent, for example in the varying readiness of NHS providers for improvement projects.
One reason for this wavering commitment to quality improvement must be the investments required and uncertainty about the returns on those investments. A small number of outstanding health systems – Intermountain, Virginia Mason, Jönköping – have harnessed quality improvement to deliver significant improvements in performance. But research on the impact of quality improvement projects at large numbers of sites generally points to quite small gains. Leaders from some successful systems have argued that healthcare organisations need to pass a ‘minimum investment threshold’, to train a sufficient number of staff and complete a sufficient number of projects, before they start to see the accumulation of incremental gains from using quality improvement methods. The NHS may still be some distance from this tipping point.
If we are to pass the tipping point, one priority must surely be to develop more attractive, stable NHS careers in quality improvement. Our interviewees described the challenges they faced setting up the patient safety collaboratives, tracking down staff with practical expertise in quality improvement who had been scattered to the winds in repeated organisational change. One expert in quality improvement compared the levels of training and expertise needed to take on senior quality improvement roles in the NHS with similar roles in some other European health systems. There is a dramatic contrast, with much less rigorous training in the NHS. Without the right skills and experience, there is a risk of ‘cargo-cult’ quality improvement, copying the superficial features of improvement methods that have raised performance elsewhere, without capturing the real ingredients that make them work.
These are again interesting times for quality improvement. The AHSNs have been recommissioned to run the patient safety collaboratives for a further three years. NHS Improvement has recently completed its consultation on a national patient safety strategy, signalling, we hope, a renewed national commitment to both safety and quality improvement. A number of the nascent integrated local health and care systems in England are considering the appropriate model and what backbone infrastructure they need to deliver quality improvement effectively across organisational boundaries. Our previous work called for a coherent and integrated quality improvement strategy for the NHS. From our recent research on this complex subject, we would advocate a continued commitment to localism in the delivery of improvement projects; realism about the resources required and the likely initial impact of projects, and a focus on creating stable, fulfilling improvement careers.
The focus of Quality Improvement activity will need to move from the patient to the process, i.e. what NHS employees actually do when they go to work. Until this happens current quality improvement will continue to be unsustainable and good effort will continue to be wasted.
I am sure Tom is right and this chimes closely with the principles of 'Safety II' to focus on 'work as done' not 'work as imagined', i.e. we need to genuinely try and understand the gap between the two, rather, than as we have hitherto largely assumed, that those who imagine the work are somehow in a better position to understand it and how to improve it , than those who do it.