QI methods: the essentials of good clinical management?

It’s nearly 15 years since the NHS Plan set out the blueprint for a national agency tasked with applying quality improvement techniques across the NHS. In its heyday, the Modernisation Agency was running dozens of collaboratives and engaging thousands of NHS staff, contributing much to many of the standards we now take for granted. People joining the service today will probably be incredulous that the first waiting time targets were to reduce 18 month inpatient waits to 12 months, and that prior to the 4 hour A&E target, waits of up to 12 hours just to be seen were not unusual.

By 2005 though, the Agency was arguably a victim of its own success. It had grown to a size that led people to question whether its resources would not be better deployed at the front line. Those organisations that were embracing quality improvement (QI) methods made a strong case for devolving funding. However, it seems that each subsequent incarnation of the national improvement body hasn’t quite delivered what the system requires. This is not to say that there wasn’t great work done by the Agency’s successor bodies, but the whole never seemed to add up to be greater than the parts.

With the benefit of hindsight I think there are at least four reasons for this.

First, the zeal with which supporters of QI advocated the approaches often resulted in others seeing them as faddish or exclusive, rather than being embraced universally for what they are: good process and system management.

Second, the approaches initially introduced within the collaboratives – those largely based on the theories of Deming – became conflated over time with other strategies for improving quality, such as large scale change, data transparency and so on. We lost the clarity of what it meant to apply QI methods and created expectations that these methods could address the whole quality agenda.

Thirdly, we failed to get a critical mass of clinicians and managers skilled up in QI techniques at service level, and those that did often found themselves in tepid waters after the warm glow of the organised collaboratives faded.

Finally, QI was seen solely as a delivery issue which overlooked the positive – or negative – impact of wider policy.

But this isn’t to sound defeated. We now have both the opportunity and the necessity to design and implement an improvement infrastructure in the NHS capable of delivering the benefits in safety, efficiency and outcomes that we know can be achieved through routine application of QI methods.

At the Health Foundation we’ve been engaging with people across and at every level of the system to build an understanding of what is required. We would advocate the following:

• We need to restate the place of QI methods in the wider transformation agenda – more core clinical management than an optional extra. There is widespread variation – and with it waste – in the quality of day-to-day care in the NHS. Whatever the macro footprint of provider bodies, no organisational model can afford to ignore the need for standardised and reliable pathways of care. Equally it would be wrong to think that these approaches alone will deliver the change needed – we need to ensure that they sit within a broader strategic agenda for improving quality.
• For standardisation and high reliability to become ‘business as usual’, we need a critical mass of people with QI skills across every service. We are a long way from saturation point and organisations need to be supported to build capability at the front line.
• While QI methods need to become the norm in pathway management, there’ll always be wider quality challenges that will need other change approaches and shared learning to find the best solutions. There needs to be a fully developed regional improvement infrastructure that can support organisations along the improvement spectrum: supporting internal capability building; convening regional learning networks to work on more entrenched problems; and scouring for new methods to support change.
• While areas with populations of 4-6 million seem to provide the right scale for collaborative learning and are a natural footprint for regional improvement bodies, they shouldn’t develop in isolation. There needs to be a mechanism for rapid sharing of what works; peer support and development in order to provide assurance that the best methods are being used faithfully; and pooling of specialist expertise. To this end we're working with a number of regional improvement bodies to form the UK Improvement Alliance.

This leaves the question: what should be the function of a central improvement entity? There seems to be consensus that the role of the centre isn't to deliver programmes, but there is yet to be recognition of the critical role a central function needs to play. This is twofold. One, to take a strategic ‘helicopter’ view of the QI capacity and capability across the system and to work with the regional improvement bodies to fill gaps. And second, to work hand in glove with the system stewards and policy makers to ensure that system management and regulation is consistent with promoting the application of QI methods.

Finally, as well as the above, QI training has to be seen as a core skill in providing the best possible care. The recent Health Education England mandate provides welcome recognition of this and needs to be implemented at pace. With this in place we will be able to build a new generation of clinical staff knowledgeable in the delivery of safe and reliable care, which surely is the key for the future.

Jo is Director of Strategy at the Health Foundation, www.twitter.com/JoBibbyTHF