COVID-19 recovery: opportunities for building a relational approach to quality improvement

Quality improvement (QI) in the real world is never neat and tidy, and it is sometimes outright messy – especially when it involves multiple organisations, each with their own ways of working. In the midst of a pandemic, when time is precious, it can be even more demanding. My own experience of working on an intervention to improve vaccine equity across north west London, which I explore in this blog, is a case in point.

What my experience has shown me is that when it comes to quality improvement, relationships matter. Getting the right relationships in place is almost always key to the success of any improvement intervention – a point underlined in the new third edition of Quality improvement made simple (of which I’m a co-author). Other things that matter, as I explain in this blog, are understanding the root causes of the issues and using data to refine the solutions.

My experience of QI in practice

In north west London, we used a rapid improvement approach to improving vaccine equity, to reduce variation in the uptake of COVID-19 vaccines in our communities. Health care organisations (both primary and acute), community organisations, members of the public, local authority government and academic partners came together in a holistic approach. We drew on insights, quantitative data and joint decision-making processes through weekly rapid improvement huddles.

Engaging stakeholders in a meaningful way

The vaccine equity huddles we held in north west London brought together key stakeholders from across our communities to co-produce potential solutions to improve vaccine equity. The Health Foundation’s quality improvement guide highlights the relational aspects of improvement that are crucial to success, including early engagement and collaboration with a wide range of stakeholders, building effective teams and genuine co-production. This is done by involving the people closest to the improvement issue, as well as senior leadership and networks across organisational boundaries, to share expertise.

Each vaccine equity huddle started with stories and insights. These are often from those closest to the issues: for example, we heard from members of our local community about their perceptions of vaccine messaging, from young people on their attitudes to COVID-19 vaccines and from someone with a disability about difficulty accessing their local vaccination centre. These insights galvanised a sense of shared ownership, beyond organisational silos, and added local context to the solutions-focused discussions.

Understanding the root cause of a problem

The quality improvement guide also highlights the importance of gaining understanding of the improvement problem before tackling it. Identifying the root cause of the issues, using a variety of data, in collaboration with a range of staff, patients and other stakeholders, is crucial.

In our case, we focused our improvement efforts on identifying the root causes of vaccine inequity, acknowledging the longstanding impacts of inequalities from the wider determinants of health and structural racism, and realising the importance of trust between communities and organisations. Insights from the local context were crucial, exploring why these issues have not been tackled until now, and creating a sense of urgency, thus paving the way for a renewed collective desire for change.

The huddles created the space for active listening, seeking to understand and respecting, and sharing power with our communities. These insights provided a crucial foundation for the co-produced initiatives to improve vaccine uptake, which included targeted community engagement, working with local GPs and vaccine champions to provide a personalised approach to addressing vaccine concerns for individuals.

Using data to iterate your solution

QI is about identifying and testing potential solutions, and iteratively refining the solution to the problem, which may itself evolve over time. In north west London, our improvement huddles created an open forum to learn and support each other. We drew on a range of data sources, combining qualitative community insights with quantitative analysis to make sense of the variation in vaccine uptake, not as a one-off process but in iterative weekly cycles – each week would build upon insights shared the previous week.

Equally important is the constant sharing of learning and spreading of knowledge and solutions more widely. The huddles facilitated this by sharing success stories and supporting the spread of innovation – the use of community pop-up clinics expanding to other boroughs is a good example of such spread.

What next?

The pandemic means that ‘business as usual’ for our health services cannot continue. A renewed focus on the quality of patient care is paramount as we shift away from the reactive acute pandemic response and turn our efforts towards meeting the improvement challenges ahead for the NHS.

Right now, improvement approaches and a focus on quality can help us make sustainable changes to our nation’s health, to address inequalities and prevent ill health. This is also a unique window of opportunity to build back our health care services in a way that is inclusive, with quality and improvement at the heart of what we do for our patients, staff and communities.

Esther Kwong (@Dr_Esther_Kwong) is a public health specialty registrar in the improvement team at the Health Foundation.