Next steps for the quality improvement community in Scotland
It feels like quality improvement programmes are everywhere in healthcare just now. Everybody wants to embed it in daily practice, so that quality improvement is ‘just how we do things here’. But is it truly embedded where you work? Probably not.
In NHS Scotland, we have been implementing patient safety and QI approaches since 2003 with the Scottish Primary Care Collaborative, the Safer Patients Initiative, the Scottish Patient Safety Programme (a national programme in collaboration with the Institute for Healthcare Improvement, involving every hospital in the country), and a national Lean programme. All sorted? Not quite.
NHS Scotland is a small, integrated health service, so it should be easier to roll out quality improvement across our service than it would be across the whole of the USA, for example. We do see evidence of quality improvement tools and techniques across all of our hospitals: statistical process control charts on the walls of most wards; PDSA as a commonly used approach to change; and pathways examined by value stream maps. Many staff have experienced some elements of quality improvement, and the language is increasingly familiar. But is quality improvement embedded, or is it just project work? Somewhere inbetween, we think.
The IHI approach got us where we are today. But how does NHS Scotland take the next steps, so that we become a service that uses quality improvement as second nature? This was the question we asked at a gathering last year of quality improvement practitioners in Scotland. We invited a broad range of NHS Scotland staff with quality improvement experience through national or international fellowship programmes. Using techniques we’ve learned through the Health Foundation’s GenerationQ programme, we took an emergent approach to the meeting, aiming to generate knowledge through a Bohm dialogue.
We expected to hear of clashes and confusion between the two dominant schools of improvement science in Scotland, and a need to synthesise a unified approach, but there was no discussion of quality improvement tools and techniques.
Instead two main themes came out: our quality improvement practitioners felt isolated in their own hospitals. As a consequence, they doubted their effectiveness at implementing change, and even their own knowledge and abilities.
The second theme was about how change could be driven. In the English NHS, competition and financial incentives have been used, but these were neither available nor desirable in the collaborative model of NHS Scotland.
The unanimous view was that the driver for improvement in NHS Scotland should be patient-centredness. All healthcare workers share the desire to improve patient care, and listening to the patient voices helps resolve disagreements between professional groups about how to do that.
The group identified five factors associated with successful change:
- unlocking passion using patient stories
- building will with genuine staff engagement
- defining broad aims from the top, allowing flexible implementation at ground level
- investigating problems by enquiry rather than for judgement
- committing to consistent leadership for quality improvement.
On a practical level, what do we need to do next? While developing new quality improvement practitioners, we need to do a better job of supporting the ones we have. Central resources such as NHS Scotland’s Quality Improvement Hub are helpful, but local networks are also crucial in providing accessible day to day help.
We need to address the human element of change in more depth not just for quality improvement practitioners, but for all of our leaders. In the longer term, quality improvement and patient safety need to be core parts of our undergraduate and postgraduate programmes.
You can read the full report from our meeting. What next steps would you take to embed quality improvement in your healthcare organisation?
Mark is Clinical Director (Medical Specialities) at NHS Ayrshire & Arran and Eileen is Director of Nursing at Healthcare Improvement Scotland. They are both Health Foundation GenerationQ fellows.
