Making the case for quality improvement: lessons for NHS boards and leaders

The NHS faces the challenge of improving quality of care while coping with the biggest funding squeeze in its history. This challenge is significant and, in some parts of the NHS, quality is deteriorating rather than improving: waiting times are increasing (Murray et al 2017), the numbers of people waiting to leave hospital are at record levels (NHS England 2017a) and services in the community are struggling to meet demand for care in the face of budget cuts and staff shortages (Robertson et al 2017; Maybin et al 2016). 

Improving quality and reducing costs are sometimes seen as conflicting aims. However, as we will demonstrate in this briefing, there are numerous examples showing that this does not necessarily need to be the case. The current pressures on the NHS mean that, now more than ever, there needs to be a strong focus on delivering better-value care and putting quality and safety at the heart of the health policy agenda (Ham et al 2016).

Plans for what should change

The NHS five year forward view (Forward View) is the national plan for improving services in the NHS in England (NHS England et al 2014). It set out a vision for how NHS services need to change to meet the needs of the population, and argued that the NHS needs to make improvements in three main areas:

• improving quality of care
• improving the broader health and wellbeing of the population
• improving financial efficiency.

Since then, sustainability and transformation plans have been developed across England to provide more detail on the local changes needed to make this vision a reality (Ham et al 2017; Alderwick et al 2016). These plans are intended to be the ‘delivery plans’ for the Forward View. The plans are broad in scope, proposing changes in all parts of the NHS by 2021 (Alderwick and Ham 2017). They also call for major improvements in NHS efficiency – typically at well above the rate of improvement achieved in the recent past. A national framework to guide action on improvement capability building and leadership development in NHS services in England has also been launched (NHS Improvement 2016).

Plans for how change will happen

The challenge now lies in delivering the plans and making tangible improvements in NHS care as a result. This is easier said than done. The plans themselves lack detail on how their ambitious goals for improving care will be implemented (Ham et al 2017). And NHS leaders involved in developing the plans are concerned about their ability to make change happen in practice (Alderwick et al 2016).

This challenge is made harder still by the lack of a single, coherent national strategy for how to improve quality of NHS services (Ham et al 2016). A recent review of approaches to improving quality in the NHS found that, while improving quality remains a stated priority, implementation is weak (Molloy et al 2016). Gaps in leadership, complex organisational arrangements, inconsistent approaches to measurement and accountability, and insufficient attention to the skills needed to make change happen have held back progress. So too have changes in government policy on the approach to NHS improvement and reform (Ham 2015).

Purpose of the briefing

This briefing makes the case for quality improvement to be at the heart of local plans for redesigning NHS services. By quality improvement, we mean the use of methods and tools to try to continuously improve quality of care and outcomes for patients. The idea of making the case for quality improvement is not new, but there is an urgent need for more systematic approaches to improving quality to be adopted across the NHS in England if the ambitious goals described in the Forward View and sustainability and transformation plans are to be delivered.

The briefing does this by drawing on existing literature and examples from within the NHS of where quality has been improved and describing how this was done. It describes the potential benefits from investing in quality improvement – including for patients, staff and the financial sustainability of the system. The primary audience for this briefing is senior leaders in the NHS, given the need for new approaches within organisations and across local systems to improve quality of care. Leadership and management practices are strongly related to performance on quality, and there is a well-established relationship between board commitment to quality improvement and quality of care within their organisations (Jones et al 2017; Jones and Woodhead 2015; Tsai et al 2015). 

Many NHS organisations have started to use quality improvement techniques in discrete projects. A smaller but growing number have developed more systematic, organisation-wide programmes to ensure that continuous improvement happens at scale (Ross and Naylor 2017). 

Opportunities to improve value

Quality and finance are closely related through the many opportunities that exist to deliver better outcomes at lower cost (improving value). The NHS, like all other health care systems across the world, sometimes fails to deliver high-quality care. This can lead to poor outcomes for patients and wasted resources for the NHS. Evidence tells us that there are a range of opportunities to improve value in the NHS (Alderwick et al 2015). 

There are wide variations in how care is delivered across the NHS.

Including in primary care practices, diagnostic tests, rates of hospital referrals and procedures, and access to services (NHS Right Care 2017, 2015, 2011, 2010). These variations are too wide to be explained by differences in people’s health needs and patients’ preferences. In other words, they are both unwarranted and avoidable, and represent inappropriate care being delivered to patients.

The Getting It Right First Time (GIRFT) programme aims to bring about higher-quality care in hospitals, at lower cost, by reducing unwanted variations in services and practices. It uses national data to identify variation, shares that data with the local staff involved in running and delivering the services (including clinicians, clinical and medical directors, managers and chief executives) and monitors the changes that are implemented. The programme began with orthopaedics and is now being rolled out to 32 different surgical and medical specialisms across the NHS in England.

Early evidence suggests that the programme is identifying significant opportunities to improve value, through changes to procurement practices, productivity and quality. In January 2016, 71 of the 142 orthopaedic units in England identified combined savings of between £20 million and £30 million after an initial GIRFT visit, with an additional £15 million to £20 million forecast for the next 12 months (Timmins 2017).

There are examples of overuse, where care is delivered even though the potential for harm outweighs the benefits.

Overuse is bad for people receiving care because they get services that might cause them harm, or at least waste their time or cause unnecessary stress and anxiety. It also creates an opportunity cost for the NHS, as resources are diverted from more effective care.

Examples of overuse can be found across the NHS – including the overuse of some acute hospital services, overdiagnosis and overuse of diagnostic tests, and overprescribing of drugs. One example is the overprescribing of antibiotics for people with coughs, colds and sore throats. Estimates suggest that around £3.7 million could be saved each year through more appropriate antibiotic prescribing (Alderwick et al 2015).

There are examples of underuse, where effective care is not delivered when it is needed.

Underuse can lead to people needing more complex care as their condition gets worse – for example if they end up in hospital because their condition isn’t managed properly.

One example of underuse is care for people with diabetes. Around 22,000 people in England die from potentially avoidable diabetes-related causes every year (National Audit Office 2015). Data for 2015/16 shows that around 63.5 per cent of people with type 1 diabetes and 46.3 per cent of people with type 2 diabetes did not receive all nine care processes that could reduce complications related to their condition (NHS Digital 2017). 

There are examples of misuse, where care is poorly delivered, resulting in preventable harm to patients.

The overall scale of harm in the NHS is not clear, but evidence suggests that preventable harm happens both inside and outside of hospitals in the NHS (Alderwick et al 2015). It is important to recognise, however, that most errors happen as a result of the systems people work in, not the people who work in them. In other words, it is not a ‘bad apple problem’ (Institute of Medicine 1999).

One example is medication errors. Estimates suggest that there are around 50 million prescribing errors in the community, 45,000 prescribing errors in an average acute hospital (NHS England 2015) and 2,500 potentially preventable deaths in hospitals in England related to medication each year (NHS England 2015; Hogan et al 2012). 

There are examples of waste, delay and duplication in organisational and clinical processes.

Identifying and removing steps that do not add value for the patient, or delay their access to care on return home, can help to improve patient outcomes and experience while freeing up clinical time (Fillingham et al 2016; The Health Foundation 2013).

Examples include delays in admitting or discharging patients needing acute care due to a failure to enable timely access to clinical decision-makers, diagnostic tests or medicines. It has been estimated that productivity gains of between £1.1 billion and £2.3 billion could be achieved across England by improving or redesigning acute processes (Monitor 2013).

Will improving quality save money?

These and other examples highlight the types of opportunities available in the NHS to improve quality of care and make better use of resources. This briefing focuses on the range of benefits that can be achieved from investing in quality improvement – including better care for patients, benefits for staff and improvements in productivity and efficiency. Conventional management wisdom also often says that improving quality can save money. While this is sometimes the case, as demonstrated by the significant savings being identified through the GIRFT programme, the relationship between quality and cost in health care is complex and poorly understood (Hussey et al 2013; Smith et al 2013; James and Savitz 2011). 

Both quality and cost can be measured in different ways, and the impact of the relationship between the two is often spread widely across a health system and over time. One improvement in quality may take years to save money, while others may never save money at all. Another improvement may save money for one NHS organisation but shift costs elsewhere, while others may expose a new cost that was previously being met outside the health system. This ‘displacement of rewards’ means that providers investing in service improvements may see their return on investment fall to another part of the system, or their income fall if they have reduced activity that they were previously paid for (Leatherman et al 2003). This underlines the benefit of taking a ‘whole-system’ approach to improving quality and delivering better value. 

The evidence on whether quality improvements save money for health care providers was reviewed for The Health Foundation (Øvretveit 2009). The review confirmed that there are significant opportunities to improve quality and reduce costs in health care – mainly because of the high cost of poor-quality care to patients and the health system. But evidence showing that providers have been able to act on these opportunities is much harder to come by. While some interventions (often on a small scale) resulted in quality improvements and reduced costs for providers, others (particularly on a large scale) failed to do so. The literature is also hampered by a lack of high-quality evaluations. 

It is also worth recognising that many quality improvements will generate productivity gains – for example by removing waste and speeding up processes – rather than cashable financial savings. These improvements will nonetheless have a major impact on NHS finances – for example by allowing more patients to be treated without spending more money. Reductions in length of stay in NHS hospitals between 1998/9 and 2013/14, for example, avoided the need to provide an extra 10,000 hospital beds (Alderwick et al 2015). Increases in day surgery rates over the same period avoided the need to spend £2 billion and enabled 1.3 million more elective patients to be treated. 

The Institute for Healthcare Improvement has suggested that organisations aiming to improve value should distinguish between the ‘light green dollars’ (potential savings) and ‘dark green dollars’ (actual savings) that result from a quality improvement project, and understand how the former can be converted to the latter (Institute for Healthcare Improvement undated). 

Finally, it is important to remember that the primary goal of quality improvement is – to state the obvious – to improve quality of care, not to save money. While driving better value is important, quality improvement has a fundamental role in improving all aspects of quality – including the safety, effectiveness and experience of care. All health and care systems should be seeking to improve these aspects of care for people using their services, on a continuous basis. 

This section uses five examples to illustrate how quality improvement approaches are being used by teams and organisations in different parts of the NHS in England to improve care and value for money. For each example, we summarise the problem being addressed, the methods used to improve quality and some of the benefits that are being delivered (using data reported from the sites). We also provide links to further resources and information about the work. All of the examples have received some funding or support from The Health Foundation.

The five examples given above represent pockets of innovation in particular areas. They demonstrate that even relatively small-scale quality improvement initiatives can lead to significant benefits for patients, staff and health system costs. The potential benefit is even greater if quality improvement techniques are applied consistently and systematically across organisations and systems. As we have argued previously, ‘only by moving from pockets of innovation to system-wide improvement will the NHS deliver the changes that are needed to sustain and improve care at a time of unprecedented financial and service pressures’ (Ham et al 2016, p 11). 

However, making this happen is not simple, and many quality improvement initiatives fail to deliver positive results. In this section, we draw on relevant evidence and experience from the literature, and the examples given, to highlight 10 key lessons for NHS leaders seeking to embed quality improvement within their local systems.

1. Make quality improvement a leadership priority for boards

Senior leaders, and boards in particular, play a vital role in setting the strategic direction of NHS organisations and creating a supportive culture and environment for quality improvement. Numerous studies have found an association between board commitment to quality improvement and quality of care within their organisations (Jones et al 2017; Tsai et al 2015; Jha and Epstein 2010; Jiang et al 2009, 2008). 

Features of boards that are successful in driving quality improvement include:

• having clear goals for improving quality (and making them a top priority)
• regularly reviewing quality performance in meetings
• having a dedicated quality committee
• having board members with experience and training in quality improvement. 

Boards with higher levels of maturity in governing for quality improvement are also skilled in balancing short-term external priorities with the needs of their own long-term improvement initiatives. 

Drawing on these studies and other evidence, researchers have created a framework that can be used to assess organisational maturity in governing for quality improvement (Jones et al 2017). 

2. Share responsibility for quality improvement with leaders at all levels 

While the role of boards is key, responsibility for leading quality improvement also extends well beyond the most senior leaders in the NHS. Leadership for improvement must be distributed within organisations. A clear, unifying vision for improving quality should be enacted at multiple levels, with co-ordination and alignment between teams, departments and individuals (Bohmer 2016; Dixon-Woods et al 2014). The examples given above illustrate how leadership for improvement comes from all parts of an organisation (or multiple organisations), as well as from patients and service users. But the support of senior leaders in the organisations involved is important in getting a project off the ground and creating time for staff to design and test new ways of working, as shown in example 5 on dementia care in Sussex. 

3. Don’t look for magic bullets or quick fixes

Improving quality of care is complex and takes time to achieve. Analysis of major improvements in NHS productivity over the past 30 years shows that progress is typically made through a series of small steps rather than giant leaps forward (Alderwick et al 2015). 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. 

The drivers of health service improvement are also multiple and overlapping; there is rarely (if ever) a single, magic bullet for improving quality. Local context is crucial in understanding the success of different quality improvement programmes (Fulop and Robert 2015; Bate et al 2014; Kaplan et al 2010). Interventions that ‘worked’ in one place are rarely easy to replicate in others. The Practical Obstetric Multi-Professional Training (PROMPT) programme (example 4) is a good example of this. The programme’s success in helping Southmead Hospital in Bristol to improve its perinatal outcomes and to reduce its litigation costs has encouraged other maternity units across the UK and around the world to implement it. Yet many have found it challenging to match Southmead’s impact. Embedding the type of attitudes and behaviours that have underpinned PROMPT’s success takes time and is not straightforward.

This means that NHS leaders must make a long-term, overarching commitment to improving quality within their own organisation, and set realistic goals for improvement. Rather than searching for magic-bullet solutions, leaders should focus on developing the processes, systems and cultures to support the delivery of high-quality care on a continuous basis (Dixon-Woods and Martin 2016).

4. Develop the skills and capabilities for improvement

Frontline staff engaged in quality improvement need to be given the skills required to identify quality problems, carry out tests of change, measure their impact and act on the results. Boards and executive teams also need to have a good understanding of how change happens in complex systems (see the subsection ‘Make quality improvement a leadership priority for boards’ above). These things do not happen by accident. NHS leaders need to invest time and resources in building the capabilities required for quality improvement within their organisation. A case in point is the PROMPT training programme (example 4). A recent review (Furnival et al 2017) identified eight broad dimensions of quality improvement capability – including the effective use of data and analysis (see the subsection ‘Use data effectively’ below), systematic use of improvement methods and processes, and a core focus on meeting the needs of service users. 

Some NHS organisations that have adopted a systematic approach to quality improvement and invested in developing the skills and capabilities of frontline staff have demonstrated increases in staff satisfaction and retention rates and lower sickness and absence rates (Ross and Naylor 2017; Jones and Woodhead 2015).

5. Have a consistent and coherent approach to quality improvement

There are various methods that NHS organisations can adopt to improve quality of care – such as Lean, Six Sigma and Plan-Do-Study-Act (PDSA) cycles. Despite differences in terminology, all of these methods draw on a similar set of tools and principles (such as rapid cycles of testing). The evidence suggests that no single quality improvement method works better than others; what matters more is having a consistent approach – in other words, choosing a model and applying it rigorously in practice (Leis and Shojania 2017; Kaplan et al 2012; Powell et al 2009; Boaden et al 2008). 

To avoid quality improvement efforts becoming a disjointed (or worse, conflicting) set of initiatives, organisations also need to put in place systems to co-ordinate different improvement projects and ensure that learning is shared between them (Bohmer 2016; Dixon-Woods and Pronovost 2016).

6. Use data effectively

Intelligent use of data is central to any efforts to improve quality. Data should be used to identify quality problems, define indicators for improvement and track the impact of different interventions on quality of care. But doing this is not simple; the approach to measurement must be designed carefully if it is to be useful to clinicians and avoid unintended consequences. Clinical teams wanting to improve quality will require disaggregated data on processes and outcomes of care, as well as time trends to allow analysis such as statistical process control (time series analysis used to identify variation beyond predictable limits). This is likely to be different from data collected for overall performance assessment and management (Raleigh and Foot 2010). Measures that are too burdensome or lack credibility are likely to alienate clinicians and lead to confusion about the impact of interventions (Dixon-Woods et al 2012). And if measurement systems are poorly designed, they can create perverse incentives such as ‘gaming’, where targets are achieved but the intended changes in practice are not (Bevan and Hood 2006). 

The importance of having access to robust, real-time data is highlighted in example 1, which focuses on the surveillance system developed by the Heart of England NHS Foundation Trust to help renal teams identify people at risk of end-stage kidney disease. 

7. Focus on relationships and culture

Effective quality improvement requires much more than just the technical use of tools and models such as those listed in the subsection ‘Have a consistent and coherent approach to quality improvement’. Relationships and behaviours are just as important, if not more so. Sustained change is more likely to happen in an environment where staff across an organisation can reflect on how things are done now and think about how they could be done better in the future. Equally important, particularly from a senior leadership perspective, is a willingness to give teams working at the front line the time, resources and, crucially, the ‘permission’ to engage in quality improvement activities. Given the pressures facing NHS staff today, this licence to improve is vital. This, again, highlights the key role of senior leaders and boards, described in the subsections ‘Make quality improvement a leadership priority for boards’ and ‘Share responsibility for quality improvement with leaders at all levels’. 

Health care organisations must create a culture and environment that supports the delivery of high-quality, continually improving care. In practice, this means having:

• a compelling vision for the future, shared at all levels within the organisation
• clear, aligned objectives for all teams, departments and individual staff
• supportive and enabling people management and high levels of staff engagement
• learning, innovation and quality improvement embedded in the practice of all staff
• effective teamworking (West et al 2014).

Leadership is a major determinant of organisational culture (West et al 2015). NHS leaders must therefore work to model and build these cultural elements. For those leading specific improvement projects, it will be necessary to spend time building relationships and engaging with relevant stakeholders involved in the change – for example to gain buy-in and surface any challenges or unintended consequences. 

8. Enable and support frontline staff to engage in quality improvement 

Many of the most successful quality improvement initiatives in the NHS have been identified, designed and implemented by teams working at the front line. In some cases, they have done so without the explicit support or encouragement of senior leaders within their organisation, or without any meaningful resources (Bohmer 2016). A shared determination to make a difference, together with an ability to carve out time to focus on improvement work, have been critical to their success.

However, it can be difficult for clinicians to engage in quality improvement (Wilkinson et al 2011). They face several barriers – including a lack of time and resources and a lack of knowledge and skills for quality improvement. There is no simple solution to overcoming these barriers. Providing dedicated resources and project management capacity, having committed leaders capable of sparking enthusiasm, with skills in monitoring and evaluation to clearly demonstrate results, and ensuring alignment with other clinical priorities and health system changes, are all likely to help (Ling et al 2010). Finding ways to free up staff time to take part in improvement work or training is another necessary step. It is also important to understand what is likely to motivate clinicians to change their practices – critically, their intrinsic motivation to improve quality of care for their patients (rather than improving efficiency or cutting costs). Rather than being seen as the business of managers, it is important for there to be an understanding that quality improvement approaches can help frontline teams to deliver better and more effective services for their patients. 

It is also possible to encourage participation by using more formal measures – for example by including involvement in quality improvement as part of required professional development activities, or by visibly reporting data on performance between peers (Dixon-Woods et al 2012, 2011). However, it is important to prepare the ground carefully. Mandating participation in quality improvement training, without first making the case for it, runs the risk that it will be perceived as simply ‘another thing to do’ or a further ‘box to tick’ (Academy of Medical Royal Colleges 2016). Equally, any effort to highlight variation needs to go hand in hand with practical support to help teams and organisations to close the gap with their peers. 

One important lesson from organisations that have successfully built improvement capability at scale is to avoid doing too much, too quickly. Delivering and sustaining change in a few key areas, and working first with a small cohort of volunteers, can help to generate momentum and provide a platform for the roll-out of an organisation-wide programme (Jones and Woodhead 2015).

9. Involve patients, service users and their carers

There is generally widespread support and enthusiasm for involving patients, service users and their carers in quality improvement efforts and ensuring that change is ‘co-produced’. This is no surprise: patients have a unique role to play in identifying quality problems (such as duplication and waste), coming up with solutions to address them and ensuring that any change genuinely delivers the outcomes that matter to them (Batalden et al 2015; Fulop and Robert 2015). But it can be difficult to know how this should be done in practice. Armstrong et al (2013) identify a number of tips for successful patient involvement in improvement projects, including (but not limited to):

• taking time to think through the rationale for involving patients 
• identifying clear roles and responsibilities for patients, and doing this in collaboration with patients where possible
• thinking about the full range of roles that patients can undertake, being flexible about roles and tailoring these to the project’s context, the characteristics of the patients served and the clinical area being worked on
• defining how patients will work with other team members to achieve the project’s aims
• ensuring that patients have the skills to fit the activities chosen
• ensuring early involvement (ideally from the outset)
• establishing effective (formal and informal) communication channels between patients and other team members
• creating a non-hierarchical structure and valuing each team member’s views.

A range of tools and approaches can also be used to help achieve these aims, such as the Patient and family-centred care toolkit. Examples of how patients and professionals have worked together to embed change can also be found in the examples above. The Ambulatory Heart Failure Clinic at the University Hospitals of North Midlands NHS Trust was a response, in part, to local heart failure patients’ wishes for a service that allowed them to remain in their own home (example 2). Northumbria Healthcare NHS Foundation Trust’s care home-based medicines optimisation project, which led to reductions in the level of overprescribing and inappropriate medications, was driven by a desire to ensure that care home residents and their families were fully involved in medication decisions (example 3). Meanwhile, people with dementia and their carers helped to co-design the core elements of the Dementia Golden Ticket model of care (example 5). 

10. Work as a system

Improving quality will often require organisations to work together and pool resources across local systems of care (Ham and Alderwick 2016). Developing new care models for people with multiple long-term conditions, for example, may depend on collaboration between primary and community services, acute hospitals, mental health and social services, as well as services outside the health and care system (such as housing and employment services). The approach taken in Sussex to improve dementia services (example 5) is a good illustration of this, involving collaboration between primary care, acute and community services, and patients and their carers, to improve the quality and experience of care.

Current sustainability and transformation partnerships (STPs) in the NHS in England are one way to encourage this kind of joint working. STPs have an important role to play in co-ordinating local improvement efforts and developing new approaches across organisational boundaries. To do this, NHS leaders must develop new forms of ‘system leadership’ based on distributed power, alliances and collaborations (Timmins 2015; Senge et al 2014). 

STPs and other local partnerships could also help NHS organisations to ‘act like a sector’, bringing together professionals from different services to agree standard procedures and processes to improve care (Dixon-Woods and Martin 2016). Working as a system can also be key to spreading improvements in quality. Networks to facilitate information exchange and sharing of practical insights can create a ‘learning system’, enabling improvements to be adapted and spread (The Health Foundation 2014; McCannon and Perla 2009). 

There are a range of opportunities for NHS organisations to improve quality of care and value for money. Examples can be found across the NHS where teams and organisations are already acting on these opportunities and demonstrating positive results for their patients, as the examples given in this briefing show. But the systematic use of quality improvement approaches within the NHS is still patchy, and many improvement efforts fail to deliver the results expected. 

NHS leaders – and boards in particular – have a vital role to play in creating a supportive environment for quality improvement within their organisation – for example by providing a clear vision and objectives for improving quality and putting in place the capabilities and support needed for staff to improve services. Leaders must also work between organisations to develop new care models and co-ordinate improvements. The 10 key lessons outlined provide a starting point for NHS leaders seeking to more firmly embed quality improvement within their local plans for improving services.