This week, I met with leaders of the healthcare quality improvement movement from across the globe. The meeting was the Strategic Advisory Board for the International Forum for Quality and Safety in Healthcare, one of the biggest international healthcare improvement occasions in the world, which will be held in Nice, France, from 20 to 23 April next year.


When I talk about the “quality improvement movement”, I mean the growing mass of people across the world who are united by a mission of better health and healthcare by systematically improving the quality of care for populations and patients. The movement builds on the foundations of a 50-year evidence base of “what works”. We know we can speed up the rate of progress by transferring ideas and experiences from one system or country to another as we work on the same issues.


Colleagues at the meeting brought experiences from England, France, Italy, Sweden, the Far East, Australia and the USA. There was a consistent sense that our movement is at a crossroads. All the health systems represented face significant difficulties caused by economic downturn. The quality improvement movement must position itself as a key part of the solution to this challenge. In fact, we believe that it will be impossible to close the gap between available and required resources without major detriment to quality and safety unless we do so in a quality-driven way. However, if we cannot convince mainstream healthcare leaders to follow this path, there is a danger that the quality improvement movement will be seen as a worthy but expendable activity in a tough fiscal climate and that will create its death knell.


However, the time of greatest threat also offers the most significant opportunities that the healthcare quality movement has had in many years. But we have to adapt what we do.


Firstly, as leaders of quality improvement we need to broaden our perspective and learn some additional skills. Typically in the NHS, quality improvement people work with an approach that seeks to improve patient outcomes, safety and experiences with an assumption that “if we get these things right, productivity benefits will follow”, but with no explicit focus on cost. In fact, when working in clinical environments we are often actively discouraged from even mentioning costs because “clinicians won’t get engaged in quality projects if they think there is a cost cutting agenda”. I confess that I have spent much of my NHS quality career with this mindset


Even where we have introduced a cost saving dimension, it tends to be what our American colleagues call a “light green dollars” approach. I see this frequently in NHS “Lean” type projects. This happens in situations where we identify that cost savings are possible and we make the changes that we think will result in reduction of waste or variation. However, we do not stay with the change process for long enough to see the actual cash taken out of the system as a result of the changes (the “dark green dollars”).Relying on light green potential is not enough.NHS quality improvement leaders need to become experts in strategies for releasing dark green dollars (or the English equivalent) if we are going to be relevant and impactful in the new era. If you want to learn more about light and dark green approaches, I suggest reading



Improvement leaders also need to be far more explicit about return on investment for quality initiatives. I have worked with a number of local and national quality improvement projects that have been enthusiastically taken up by staff and patients, but have been disbanded because the people who led the initiatives were not able to demonstrate to their leaders (who made the investment decisions) the quantified difference they had made. We need to become more sophisticated in our approach to measurement for improvement and to link investment in improvement to outcomes achieved in clear cost/benefit terms.


We have to see cost reduction as an explicit dimension of quality that cannot be separated from other aspects. That is why I am a big fan of the Institute of Medicine’s (2001) six dimensions of quality (safe, effective, patient-centred, timely, efficient and equitable). From now on, every quality improvement project, at every level of the NHS, should have an explicit goal of reduction in waste, unnecessary variation and/or cost. Every cost reduction initiative should have a counterbalancing set of measures to ensure that quality is enhanced or at least maintained.


I was energised and enthused by my time with international colleagues. I gained affirmation that our current approach is on the right road. I can see the potential to build the community of leaders who will help deliver high quality, high value, cost effective care across the world.


This is the moment for our movement.