A three-year study is exploring the relationships between the organisational and cultural characteristics of hospitals, and how these impact clinical effectiveness, patient safety and patient experience in EU countries. Susan Burnett, Naomi Fulop and colleagues report

Delivering better healthcare in the current financial climate is a challenge being faced by hospital leaders and commissioners of services across Europe.

Working with research teams from leading universities in Portugal, the Netherlands, Norway, Sweden and England, we spent three years studying the organisational and cultural aspects of quality improvement (relating to clinical effectiveness, patient safety and patient experience) in 10 hospitals in five countries.

We also looked at the effect of the different national policy contexts for quality in hospitals and the impact this had in them. One of the aims of the research was to take the lessons from these hospitals, including what works and what hinders quality work, and to put this into a format that can be used by hospital leaders and commissioners in all European countries to help them to reflect on and develop their quality improvement strategies.

Funded by the EU, the purpose of the research is to help patients across Europe be confident about the quality and safety standards of the treatment they receive in any EU member state.

‘The research is to help patients across Europe be confident about the quality and safety standards of the treatment they receive’

The output of our work will take the form of two research-based tools: one for use by senior hospital leaders; and one for use by funders to help in their work to improve healthcare quality. While we are calling these tools “guides”, their purpose is to help structure and change conversations about the organisational and cultural factors that are so vital to developing and embedding quality improvement work at all levels.

Eight challenges for quality improvement

Political Addressing the politics and negotiating the buy-in, conflict and relationships of change

Cultural Giving quality a shared, collective meaning, value and siginificance

Educational Creating and nurturing a learning process that supports continuous improvement

Managing the external environment Responding to broader social, political and contextual factors

Leadership Providing clear, strategic direction

Emotional Inspiring, energising and mobilising people for quality improvement work

Physical and technological Designing physical infrastructure and technological systems supportive of quality efforts

Structural Structuring, planning and coordinating quality efforts

The central challenges for senior leaders are cultural, educational, emotional, structural, political, physical/technological, leadership, and managing the external environment. All these require attention, but each can require a different amount of time, energy and attention, depending on local circumstances and strategies available to address these challenges. In this article we report on a selection of strategies relating to five of the challenges, pointing to some of the examples that will appear in the Quality and Safety in European Union Hospitals guides.


We found different meanings given to quality by doctors, nurses and managers. The hospitals that had acknowledged these differences and had spent time debating and developing a shared collective meaning, rather than imposing one from the top, were also those where quality was described by frontline staff as being a routine part of their everyday work. We found a range of strategies being used to help achieve this. For example, taking time to reflect on hard data about quality as well as softer information from patients about their experiences of care.


Central to the hospitals where quality was more embedded in routine work was a focus on learning and, in particular, space and time set aside for staff to meet in multi-disciplinary forums to reflect together on their work.

Where staff had time to reflect they also had time to make plans to improve the quality of care. The hospitals where quality was not embedded were those where staff had no time to reflect on the quality of the care they were giving or to talk to colleagues about how to make changes to improve quality. We did, however, find examples of where different learning strategies had been successful, and where funding for learning had been found from external sources.


The hospitals that took part in the study are using many different ways to inspire and energise staff for quality improvement work. These include bringing patient experiences of care into conversations about quality; celebrating success in quality improvement work with awards and presentations; as well as using resources to fund educational activities for groups of staff focusing on quality improvement.

Often vital to this work were respected nurses and doctors who were able to inspire and mobilise staff across hospitals and between the different managerial levels from the board to the ward. In the English hospitals this was often co-ordinated by the chief nurse.


Too often we found managers focusing solely on establishing structures and systems for quality assurance and spending less time on enabling the processes of quality improvement work. Indeed in some hospitals, the structures were seen as too bureaucratic and time consuming; this had the effect of steam rolling any collective enthusiasm and energy, since it could take months for a decision.

One key leadership challenge is to align structures with the ambitions of the organisation to enable staff to improve the quality of care while simultaneously working within mandated requirements for clinical governance and financial management.

Managing the external environment

Hospital leaders in all the countries studied were grappling with pressures from government, commissioners, regulators and professional bodies. These pressures varied between countries. For example, the Netherlands has a market-based system and managers have to juggle the different requirements from multiple funders, whereas managers in Portugal are struggling with the requirement to improve quality while their budgets have been reduced by more than 10 per cent.

‘There are no easy solutions for hospital leaders, nor is there an obvious path that can be set out that will address all the challenges in all hospitals’

Here are just a small selection of the strategies we found leaders using to meet the eight common challenges for quality improvement. There are no easy solutions, nor is there an obvious path that will address all the challenges in all hospitals. Time must be taken to think things through locally and to discuss and debate the way forward with colleagues and important stakeholders, including staff and patients and involving external stakeholders, such as commissioners.

For this reason, the outputs we have developed from this research are tools for senior leaders and funders to facilitate conversations to address these challenges and the interactions between them, with the aim of helping develop their strategies.

This is different from other ”how to” quality improvement guides in recognition of the fact that conversations are needed about the organisational and cultural aspects of quality improvement, firmly rooted in the local hospital context and tailored for this environment.

Find out more: about the Quaser project at www.quaserproject.eu

Susan Burnett, Imperial College London; Naomi Fulop, University College London; Karina Aase, University of Stavanger, Norway; Janet Anderson, King’s College London; Boel Andersson Gäre, Jönköping University, Sweden; Roland Bal, Erasmus University, the Netherlands; Johan Calltorp, Jönköping University, Sweden; Francisco Nunes, ISCTE-IUL, Portugal; Glenn Robert, King’s College London and the QUASER team