Embedding quality improvement into the fabric of the NHS organisations requires a fundamental shift in leadership, say Joni Jabbal and Siva Anandaciva

People power network

Quality improvement in healthcare is the use of systematic tools and methods to continuously improve the quality of care and outcomes for patients. When done correctly it can make care safer and more efficient, and improve staff and patient experience. But it is not for the faint hearted, and takes significant time, resources and commitment to deliver.

This autumn, The King’s Fund brought together experienced NHS trust chief executives and national leaders to talk about the opportunities of a quality improvement approach, and to understand why quality improvement is yet to fully ignite in the NHS. 

Leaders as enablers

The first thing we heard is that quality improvement can take time to embed itself in an organisation because it requires a fundamental shift in how local leaders approach their role. 

If quality improvement is to be carried out throughout the organisation and become a part of the culture, it means leaders should act as enablers and supporters for frontline staff. They need to encourage them to develop the skills required to identify quality problems, test ideas for change, measure their impact and act on the results.

This is not easy. 

Successful quality improvement is in effect a transference of power, so that everyone in an organisation is empowered to develop and own quality improvement initiatives

Not only are some leaders problem solvers who find it more comfortable to take a command and control approach to delivering improvements, but the target based culture of the last 20 years can encourage and reinforce this behaviour. 

Chief executives told us that quality improvement means having to find extra “humility, patience and energy”, as the role of leader moves from providing answers to asking questions.

Successful quality improvement is in effect a transference of power, so that everyone in an organisation is empowered to develop and own quality improvement initiatives. That does not always feel comfortable for leaders.

Tough sell

The second thing we heard is that quality improvement requires sufficient time and resources. One participant in our study noted quality improvement can be perceived as being in the “realm of scented candles”, but in fact the rigorous methodology quality improvement requires involves significant staff training and development.

In our current period of record financial deficits and growing pressure on services, investing in building quality improvement capacity and capability can be a tough sell to an NHS board.

Many of the chief executives we spoke to talked powerfully about a “hold your nerve” moment, when they realised that the reality of a quality improvement approach is that it means releasing staff from frontline duties to invest in training and development in new improvement techniques.

Easy to say, but harder to do when a hospital is on black alert and ambulances are queuing outside the door. 

In our current period of record financial deficits and growing pressure on services, investing in building quality improvement capacity and capability can be a tough sell to an NHS board

And finally, we heard that success of quality improvement also depends on relationships between an organisation and national bodies. This can feel very different to what happens at the moment.

One leader said this is about national bodies accepting uncertainty and, crucially, in delivering improvement on this scale, and they will have to hold their nerve when performance trends are not going in the right direction. “You have to demonstrate trust if you are going to really empower local leaders,” they told us.

Quality improvement relies on devolving power and focusing on incremental long term change rather than quick fixes. At a time of short term milestones and when “grip” and control by national bodies is seen as a good thing, quality improvement can feel radically against the grain.  

Guiding star

So, given that quality improvement requires changing your leadership, investing significant time and resources, and trying to forge a new relationship between local and national leaders, it begs the question: why on earth would you do it? The chief executives in our study answered this with another question in response: “How did I ever survive without it?”  

Rather than being yet another distracting initiative or fad added to the workload of clinicians and managers, these chief executives told a story of how quality improvement had become a source of coherence in their organisation. 

Rather than being yet another distracting initiative or fad added to the workload of clinicians and managers, these chief executives told a story of how quality improvement had become a source of coherence in their organisation

One chief executive described it as a kind of North Star that helped prevent his trust from being buffeted by all the forces acting on it. More than one chief executive also spoke about how quality improvement had made them feel more connected with their organisation and more aware of potential quality risks as services face increasing pressure.

The potential benefits of quality improvement in the NHS are considerable. Yes, it is far from the easy option its “scented candles” reputation implies, and doing it well requires bravery and commitment from senior leaders at local and national level. 

But neither is it a “luxury” option to be reserved for a time of burgeoning funding and stable frontline pressures. The leaders we spoke to strongly believed that introducing and sustaining a quality improvement approach can unlock more efficient and high quality services.

Read more about Embedding a Culture of Quality Improvement here