The title of Lord Darzi's report - High Quality Care for All - proclaims the significant and welcome focus on quality improvement in the next phase of NHS reform.

Much less prominent but really important is the description in chapter five of the "core elements of any approach to leadership". These include: "the management method [leaders] will use for implementation, continuous improvement and measuring success".

Quality healthcare depends on method. All of us, whether commissioners, providers or strategic health authority leaders, need to develop skills and knowledge in methods for improvement. So it is fortuitous that the NHS Institute for Innovation and Improvement has produced a new guide, Quality Improvement: theory and practice in healthcare.

It was commissioned from experts at Manchester Business School. They have summarised the improvement approaches and methods successfully used by industry for 50 years and evaluated them all from a healthcare perspective. They assess the full spectrum, from the hits of the past, such as total quality management and re-engineering, to current favourites like lean and six sigma, to concepts such as mass customisation which are emerging in international healthcare improvement.

I have distilled five key messages:

  • When we treat clinically led improvement (audit, clinical governance, etc) as a separate entity from managerially led performance improvement, we do so at our peril. The highest performing healthcare organisations have aligned improvement objectives and operate with a definition of quality that covers both clinical and managerial domains.

  • We need to differentiate between an improvement approach and an improvement tool. An approach is a philosophy or strategy for improvement. A tool is a specific technique. Different approaches use many of the same tools. Lean and six sigma are approaches. Statistical process control is a tool.

  • From the viewpoint of research evidence, no one approach stands out as being more successful in healthcare than any of the others. It does not seem to matter which approach is used. The authors conclude that when efforts to improve quality fail, it is rarely an approach or tool problem, rather it is a human dynamics or leadership problem.

  • For healthcare leaders, committing to the method for as long as it takes to deliver the results for patients is as important as selecting the specific method of improvement.

  • There are many paths (and many method options) to improvement. The most important factor is the leadership ability to address many simultaneous challenges and to adapt solutions and strategies to the organisation concerned. Which approaches and methods will you be using to achieve your quality improvement goals?

To find out more, read Quality Improvement: theory and practice in healthcare, at

Helen Bevan is speaking at HSJ's Change Management conference on 22 October. Go to for details.