Picture of Helen BevanEvery so often, I come across research or evidence that gives me profound insight into why things happen the way they do. I experienced just such an epiphany in December, when I led a workshop on transformational learning at the Institute for Healthcare Improvement Forum, the largest healthcare improvement gathering in the world.

Picture of Helen Bevan

Every so often, I come across research or evidence that gives me profound insight into why things happen the way they do. I experienced just such an epiphany in December, when I led a workshop on transformational learning at the Institute for Healthcare Improvement Forum, the largest healthcare improvement gathering in the world.

My co-presenter was researcher Anthony Staines. His latest findings, unveiled for the first time at the forum, come from an in-depth study of the healthcare organisations globally that have made the greatest improvements in clinical outcomes and quality.

The good news is that it is possible to make transformational improvements in clinical performance.

The bad news is that, even with significant resources and leadership effort, it takes a long time. Among the 'world class' organisations that Mr Staines had studied, it had taken a minimum of 10 years of sustained effort to achieve measurable results.

Better before it gets worse

Any healthcare body that pursues such a strategy has to reach a 'threshold' before it sees results. The tipping point will only be reached when a number of 'infrastructure' elements (those that create the conditions that lead to better outcomes) have been in place for a significant time. These include building leadership will and commitment, freeing resources for clinical quality improvement, training staff, and establishing indicators and data collection systems.

In fact, performance may appear to deteriorate before it gets better. This typically happens because more efficient data collection systems are introduced that capture more data - and illuminate more problems - before improvements kick in. As Mr Staines puts it: 'Initial investment in change goes into the balance sheet, not the operating results.'

In the NHS, I see evidence of Mr Staines' 'investment threshold', not only in efforts to improve clinical quality but also in strategies to raise NHS performance across multiple dimensions such as patient access and sustainable cost improvement.

I would highlight big gaps in leadership development, clinical engagement and clinical systems improvement skills - our version of the kind of skills that industry has been using for 50 years to bring about ongoing performance improvement. I would also highlight making enough dedicated, skilled support available.

As leaders, we have to hold our nerve in sustaining this investment, even if results are not quick to emerge. It reminds me of a principle of statistical process control, which is to 'avoid tampering'. This means refraining from continually adjusting the change process before it has time to work. Leadership tampering is a major barrier to reaching the investment threshold and achieving results.

Examples of tampering in the NHS include organisational restructuring, continuously introducing new policies and initiatives and changing direction before the existing systems have had time to deliver.

We can learn greatly from healthcare organisations that have made the leaps in service quality we aspire to. I am going to consider the 'investment threshold' in all my future improvement activities.

Helen Bevan is director of service transformation at the NHS Institute for Innovation and Improvement.