Build improvement capability at scale in front-line staff: all staff need improvement skills, including professionals in training

Clinicians, including those in training, require education in improvement and patient safety methodology. Clinicians in training readily identify the problems and inefficiencies that create unreliable and wasteful care in their daily work, and can successfully address them in small teams.7 The Royal College of Physicians’ pilot, ‘Learning to Make a Difference’8 has encouraged improvement to become part of the core skill set of medical trainees9 through which providers can promote quality improvement alongside a Royal College programme and build real-life experience of improvement into specialist training.10 Providers that deploy this training widely across staff show that care can be improved in multiple areas.11

Similarly, the Royal College of Nursing has developed a comprehensive resource for governance and quality improvement, available online,12 and the Royal College of Anaesthetists have included the science of improvement in their training curriculum and have added an improvement section to their popular audit book.13 We see these examples as positive steps to enable professional staff to understand how to improve their daily work.

Recently, many more training opportunities have opened in improvement, often at the senior level, including masters-level courses in quality, safety improvement and human factors. These courses are helping to build expert faculty to support improvement, and those who have been through them provide local capacity. For example, in Ireland, the Royal College of Physicians and the Health and Safety Executive have developed a diploma in Quality Improvement and Leadership.14 Integral to the programme is an improvement initiative grounded in the realities of participants’ daily work. Many of these initiatives have already delivered results in outcome, reliability or experience. These are publicly available in the spirit of ‘all teach, all learn’.

Involve patients, families and community in the process of their care and in improvement activities: put patients at the centre of care and address needs from the patient's viewpoint

Truly serving patients and the population requires going further than talking about ‘patient-centred care’ and entails truly orienting care design and processes around the needs of those we serve. The Health Foundation's Safer Clinical Systems programme focuses on key areas of risk in hospitals, such as handovers and medication safety. This programme brings techniques to healthcare that have been used for many years in industry (such as safety cases) to proactively identify potential safety breaches and hazards that lead to unreliable care.15 Increased reliability of all steps in a process contributes to more reliable outcomes.16 This type of ‘system’ approach has resulted in greater awareness of the need to standardise work processes. Involvement of patients in quality improvement requires careful management to realise its full potential.17

Sheffield Teaching NHS Hospitals Foundation Trust has demonstrated the value of engaging patients in devising processes that are reliable and focused on their needs. Sheffield has built competencies across the care system that focus on understanding needs from the patient and family perspective, supporting redesign in a structured way to meet those needs. The ‘stories’ section on the Sheffield Microsystems Academy website demonstrates the breadth and scale of impact across various services, which has led to improvements in patient outcome and experience.18–20

The proactive involvement of patients and their carers to assess the potential for harm adds an extra dimension to the resilience and perspective of clinical teams in complex systems.21 A literature review shows a positive association between a healthcare provider's focus on clinical safety and effectiveness and patients’ experience of care.22 ‘Respectful partnerships’ are one of the key drivers of exceptional patient and family experience of care.23 ,24

Develop changes to sustain improvements in process, outcomes and experience at the Clinical Microsystems level of the front-line team and patients

Provider organisations that support improvement projects—for example, those involved in the South West of England and Scottish Patient Safety Programmes—allow front-line clinicians and managers working in tandem with patients and families to implement better practices across a wide spectrum of care. There is evidence that training and coaching front-line staff to become more reliable in the delivery of components of care reduces variation and is likely to improve outcomes in diverse care settings.25 ,26 This is the Clinical Microsystems approach27 in which the combination of clinician- and patient-led design can transform services (while often simultaneously reducing costs). An example is the Frail Older Persons service in Sheffield where a significant reduction in length of stay has been achieved without mortality or readmissions increasing.28

Use system- or region-wide programmes at a Macrosystem level to facilitate collaboration across the spectrum of providers

Sustained change in healthcare is more likely to be achieved if addressed at all system levels, from individual to policy.29 Collaboration is defined as working with another or others on a joint project with common goals or aims. Rather than one specific approach, we consider various types of collaboration that encourage the mutual sharing, learning and partnership to be of value. There is evidence that lack of a collaborative community (characterised in part by low commitment from front-line clinicians) may hinder sustained improvement,30 and the Keogh Report2 highlights isolation as a key risk to high quality and safety performance. However, it can be difficult to identify which specific components of a collaborative lead to improved care.30 ,31 A recent successful collaborative study performed in Ambulance Trusts in England32 identified critical elements of collaboration as: (i) the use of care bundles as measures; (ii) ownership by front-line staff; (iii) application of quality improvement methods (such as process mapping, plan–do–study–act cycles and annotated control charts); (iv) provider prompts and individualised feedback highlighting opportunities for learning and interaction within and across organisations. Furthermore, collaboration today is often supported by information technology, which makes it easier to share data and build communities distributed across locations.33

Regional collaborations, such as the Patient Safety Programme in Scotland, have driven substantial improvements, underpinned by the application and learning of improvement methodology at scale. NHS Scotland's Acute Patient Safety Programme has contributed to a 12.5% reduction in hospital standardised mortality ratio across all acute hospitals since 2008 by focusing on increasing the delivery of evidence-based care bundles in management of critical care, surgery, general wards and medication.34

Collaborative approaches to improvement can have an impact beyond hospitals across a wider health economy.35 The Scottish programme was widened to include community and mental health providers, enabling development and sharing of improved practices, such as early warning scores, pressure area care, and falls prevention, across the whole care system through which patients travel.

Drive improved results by measuring for improvement, linked to consistent application of an improvement methodology

Since the UK began systematically collecting and reporting national cardiac surgery outcomes, all dimensions of quality for patients undergoing cardiac surgery have improved.36 Measurement for improvement does not need to be complicated or large scale—for example, sample audits of five case notes a week can quickly highlight problems in reliable delivery of key components of care, such as giving antibiotics on time.37 Local audits, linked by enthusiasts, can grow to create a national programme for change, as has occurred with the emergency laparotomy audit.38 This audit has a quality improvement programme linked to it and seeks to replicate pilot results, which has significantly reduced perioperative and operative mortality.39

The Keogh Report2 describes how reliability of key processes drives improved outcomes. Put differently, to improve on metrics that matter to patients, providers must focus on becoming reliable in those processes that drive the outcomes they seek. Understanding which processes drive desired outcomes, and implementing systems capable of achieving the necessary reliability, tied to continuous improvement in daily practice, can deliver step changes in performance. This is demonstrated, for example, by London's acute stroke services since 2009, where reconfiguration to a small number of specialist receiving centres for stroke, combined with attention to reliable delivery of care at each site, has driven substantial improvements in mortality while also saving money across the system as a whole—a 12% reduction in death at 90 days and a saving of £5.2 million per year.40

Lead for improvement

In order to achieve sustained improvement, consistent commitment from leaders at all levels is essential. Without broad-based consensus, local coalition building, a sound measurement strategy and the constant attention of leadership to the principles of safe systems of care, staff can easily be diverted from the challenges of long-lasting and continuous improvement.

Alignment of the actions that leaders take and the consistency of the messages that they give is crucial in order to build sustained improvement capacity in an organisation. Leaders must take multiple actions to enable sustained improvement—from aligning their organisation's or unit's strategy and incentives with improvement activities to relentlessly role modelling and otherwise signalling the attitudes and behaviours required of staff at all levels of the organisation.30 Successful efforts are characterised by the simultaneous presence of all these leadership elements.

Reinforce changes through policy that promotes improvement, including for commissioning

Governments, health departments, professional societies and other entities can make improvement more or less likely to happen through a framework of priorities, mechanisms and incentives set by the policy context. Payment for activity alone does not necessarily incentivise improvement in quality of care.41 The developments of ‘best practice tariffs’ that incorporate explicit quality elements, such as that for treatment of fractured neck of femur, have encouraged providers to respond by realigning resources to deliver all components suggested by the available evidence. Such an approach can take several years to gain traction across the system, and may lead to some unintended consequences.42 Where clinical consensus and leadership have driven service reorganisation, the clinical benefits can be significant, and resource savings at system level often follow—for example, stroke services in London described above.40

Concluding remarks

Taken together, these seven ‘ingredients’ can establish a clinical and managerial environment which nurtures and feeds off staff's intrinsic sense of purpose and desire to strive for excellence in the face of changing and increasing demands—in short, a culture of learning and improvement (the antithesis of a culture of bullying). A culture of ‘fast thinking’ and decision making, reinforced by a ‘perceptual primacy’ whereby attention focuses on the latest results rather than reviewing and managing longer-lasting trends, is counterproductive when trying to achieve sustained improvement in complex systems.43 In recent years, the NHS has interpreted ‘performance’ too simplistically, too narrowly, and often without reference to quality in terms meaningful to patients or staff—evidenced by the incongruous separate conversations often had on ‘performance’ and on ‘quality’ at all levels of the system. The ‘toxic culture’ vividly described by Francis1 is encouraged when leaders, whether clinicians or managers (or clinician managers), subjugate their professional values to oversimplistic ends.

Health systems globally should strive systematically and continually to improve the results achieved for patients and populations. For the NHS in England, the 2013 reports1–3 delineate the challenge and begin to identify what changes are required. The seven ‘ingredients’ outlined in this paper, combined with the evidence illustrating each ingredient, can help the NHS in all four UK home countries (and health systems elsewhere) to accelerate thoughtful, sustained and purposeful action which will facilitate the reliable delivery of better care. Our patients, and the populations we serve, demand that we act urgently and at scale.