One of the most striking features of health care management and delivery during the COVID-19 pandemic is the role of quality improvement in driving change. Not only have quality improvement mindsets, approaches and methods been used extensively at the front line to reconfigure care processes and pathways, they’ve also been deployed at executive level to shape provider organisations’ strategic response to the pandemic. Inspired and supported by a community of experienced improvers, well versed in the art of delivering improvement in complex systems, NHS trusts and boards across the UK have moved with remarkable speed to change the way they work.
But while the pace of change during the pandemic has been dramatic, the knowledge and infrastructure that’s made such change possible has often been much longer in the making. In some cases, NHS trusts and boards have been reaping the benefits of decisions taken 5 or even 10 years ago to invest in strengthening their internal capability and capacity to plan and deliver improvement. By choosing to put improvement at the front and centre of their long-term organisational strategy, and not allowing it to be crowded out by other short-term challenges, trusts and boards that have prioritised improvement and learning have put themselves in a strong position to respond effectively in a crisis.
The importance of taking a long-term, organisation-wide approach to improvement and learning is underlined by the chief executives of the NHS trusts participating in the NHS partnership with Virginia Mason Institute. In a series of recently released video interviews with the Warwick Business School team leading the evaluation of the partnership, the chief executives provide some valuable reflections on what it takes to embed a culture of continuous improvement within NHS trusts.
Michael Wilson, the chief executive of Surrey and Sussex Healthcare NHS trust, makes the point that his trust’s improvement journey began well before they started working with the Virginia Mason Institute in 2015. The Virginia Mason model gave the trust a structure and a framework for improvement, and, even more importantly, helped to foster a culture of improvement by allowing staff to come together to talk about improvement. But it built on a string of initiatives implemented before 2015 aimed at improving care quality, such as a programme to strengthen clinical leadership across the trust that helped front-line clinical teams take the lead in tackling quality challenges.
What these interviews show is that the decision to embark on a major organisation-wide improvement programme is not one to be taken lightly. Trusts need to make sure that they are strategically and culturally ready for change on this scale. One critical factor here is leadership continuity. This doesn’t just mean having the same leaders in post for some years (although that certainly helps) – it also means continuity of leadership style and values. Ideally, this includes a commitment to shared leadership and giving teams at the front line the training, support and permission to solve issues affecting care quality. An equally important factor is the level of social connection within the organisation. Strong connections within and between teams – that encourage collaboration and allow learning, knowledge and experiences to be shared easily – are found across trusts with mature improvement cultures.
Another key indicator of readiness for improvement, one highlighted by the Health Foundation’s own research, is a willingness to invest in the development of improvement knowledge and skills at every level and in each division of the trust. The presence of a supportive trust board, together with encouragement from local system partners and national policy and regulatory bodies, is vital in preparing the ground for improvement. But unless they are able to back this support up with dedicated funding to build change capability within their organisation, then no trust, no matter how focused and determined they are, will find it easy to implement and embed an organisation-wide approach to improvement.
The case for developing improvement capability at scale, at both an organisation and local system level, is now widely recognised, not least in the NHS Long Term Plan in England. More and more NHS trusts and Integrated Care Systems are now thinking about how best to do this. To support them in this work, the Health Foundation is funding a project led by NHS Providers to connect the board members of NHS trusts that are at an early stage in the implementation of an organisation-wide approach to improvement.
Through a blend of virtual visits, seminars and action learning sets, this project will provide opportunities for board members to share their experiences and support one another. They will also get the chance to hear from trusts that are further along in their improvement journey about the challenges they faced and how they overcame them. As well as thinking about what it takes to drive improvement at an organisation level, board members will also have the space to reflect on how trusts could work with their local partners to build improvement capability at system level. The ultimate aim, taking inspiration from the Q community, is to create connections between board members so that they can advise, support and (when appropriate) challenge each other in a constructive way.
The example of Surrey and Sussex, with its thriving improvement culture and networks, shows what it’s possible to achieve when a comprehensive, long-term approach to improvement and learning is taken. The challenge now, one that will require concerted and sustained support at national, regional and local level, is to replicate this success more widely so that it becomes the norm across the UK.
Bryan Jones is an improvement fellow in the improvement team at the Health Foundation.