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Embedding a culture of quality improvement



  • Quality improvement refers to the use of systematic tools and methods to continuously improve the quality of care and outcomes for patients. This report explores the factors that have helped organisations to launch a quality improvement strategy and sustain a focus on quality improvement.

  • The report draws on a roundtable event attended by senior local and national NHS leaders, semi-structured interviews with NHS leaders and senior stakeholders involved in quality improvement initiatives, and a literature review.

  • We identified three common themes for successfully launching a quality improvement strategy: having a clear rationale; ensuring staff are ready for change; understanding the implications for the organisation’s leadership team in terms of style and role.

  • Key enablers for embedding a culture of quality improvement included: developing and maintaining a new approach to leadership; allocating adequate time and resources; ensuring there is effective patient engagement and co-production; maintaining staff engagement. Fidelity to a chosen approach is critical to sustaining and embedding quality improvement in an organisation’s culture.

  • The report finds that NHS leaders play a key role in creating the right conditions for quality improvement. Leaders need to engage with staff, empower frontline teams to develop solutions, and ensure that there is an appropriate infrastructure in place to support staff and spread learning.

What is quality improvement and why is it important?

Quality improvement is a systematic approach to improving health services and the quality of care and outcomes for patients based on iterative change, continuous testing and measurement, and empowerment of frontline teams.

Quality improvement tools can play a key role in improving health care, including improvements in time-savings, timeliness of service provision, cost reductions and a decrease in the number of errors or mistakes. At a time of severe financial restraint, rising demand for services and significant workforce pressure, quality improvement approaches offer opportunities to improve the quality of care and increase productivity.

Our research

This report is based on a roundtable event and interviews with key stakeholders and NHS provider chief executives who have already engaged with quality improvement as a routine way of working. It identifies practical lessons and focuses on how to create the right conditions for quality improvement to emerge and flourish. The chief executives interviewed included those whose trusts were involved with NHS Improvement and the Virginia Mason Institute Partnership.

Key lessons for leaders

Issues to consider before starting work on quality improvement

Adopting a quality improvement approach involves significant and sustained cultural change within organisations, which will require time and resource. Before starting on a quality improvement journey, organisations – and particularly leadership teams – should establish a clear rationale for pursuing a quality improvement approach and accept that quality improvement is neither a ‘quick fix’ in the face of huge operational pressures nor a form of ‘turnaround’ strategy.

Quality improvement methods require a fundamental change to how organisations work, and leaders need to ensure that staff are engaged with and actively involved in developing a shared vision of the quality improvement strategy. Quality improvement approaches require a very different leadership style from the one many organisations have: leaders need to commit to a shift from ‘problem-solving’ to being enablers of change.

It is vital to build board-level commitment to the principles of quality improvement and support for the shift in emphasis from assurance to improvement.

Key enablers for embedding a culture of quality improvement

In order to successfully embed quality improvement approaches, organisations need to develop a new approach to leadership that moves away from imposing top-down solutions to recognising that frontline teams, service users and carers are often best placed to develop solutions. Several interviewees noted that patient involvement and co-production were key enablers for a successful quality improvement strategy. Staff engagement – through developing a shared vision, sharing progress and allowing staff the time and space to make changes and innovate – is also vital for success.

In addition, leaders should recognise the need to allocate sufficient time and resources to quality improvement – including time for staff away from their ‘day jobs’ to undertake training or participate in quality improvement activities. Resources are also required to invest in an educational infrastructure that means staff can be trained in the tools and techniques of the chosen approach.

At its core, quality improvement is about change and commitment to continuous improvement. While there are various approaches to quality that organisations can adopt, improvement – including Lean, Six Sigma and Plan-Do-Study-Act cycles, participants noted the importance of fidelity to one improvement method.

Wider challenges

Evaluating and communicating the impact of quality improvement is not straightforward. Individual quality improvement initiatives often take considerable time to demonstrate impact, and even the most successful efforts will face obstacles and setbacks along the way. Although more work is needed to understand how quality improvement initiatives can be robustly and meaningfully evaluated, those engaged in quality improvement have already begun to use a series of informal indicators as a guide. These included qualitative comments from staff on the quality improvement approach in staff surveys, and the demand for places on quality improvement training courses and subsequent attendance.

Although most of those involved in the study had only started on a quality improvement journey within the previous two years, they noted that in the future it would be increasingly important to have a coherent strategy for spreading improvement approaches throughout the NHS. They also highlighted the need for a clear shared understanding, at local and national levels, of what quality improvement can achieve and how it should be integrated into the wider measures of operational performance and success.

Given the huge operational pressures currently facing the NHS, providers need to be adequately supported by the national bodies – giving organisations the space and ‘permission’ to focus on their improvement journey. This may require a new ‘compact’ between NHS providers and the national bodies, which moves away from performance management to a more supportive relationship.