Strategies for building capacity for improvement at scale

Our Deputy Director of Improvement, Penny Pereira (@PennyPereira1), chaired a session at the Health Foundation’s annual event to explore how the UK health and care sector can build the improvement capability it needs. David Fillingham from the Advancing Quality Alliance (AQuA), Ruth Glassborow from Healthcare Improvement Scotland, and Adam Sewell-Jones from NHS Improvement shared their expertise. We spoke to Penny to capture some of the key themes from the discussion. 

What will it take to equip the health and care sector in the UK with the improvement capability it needs?

We have to think about this challenge on multiple levels. We obviously need enough people with the right kind of improvement expertise. But if you don’t have organisations set up to enable people to do improvement then those individuals won’t get very far. And if those organisations aren’t supported by a joined up system that’s encouraging improvement, then we’ll be wasting precious talent and resources tackling the same issues in silos and will struggle to address the major challenges facing the health and care sector.

At the session you chaired, Ruth Glassborow, Director of Improvement at Healthcare Improvement Scotland talked about how Scotland has focused on creating a learning system. What can the rest of the UK learn from this approach?

Scotland has taken a country-wide approach to improvement for quite a while now and it seems to be genuinely embedded at multiple levels. Long-term improvement programmes run alongside capability building programmes that are increasingly connected into professional education. 

You see elements of that approach in other parts of the UK, but not as well developed. In Scotland they’re now moving beyond the NHS and demonstrating that improvement methods can be used to great effect across other public services, such as in education and housing.

I think we could learn from Scotland’s attempts to balance and integrate support for improvement with quality assurance and standard setting. Ruth talked about how they are trying to create a strategy for improvement that feels joined up so that people don’t get mixed signals from different organisations within the health and care sector. 

How important is training staff in improvement methods to build capacity for improvement at scale?

Having a training strategy that gives people skills in quality improvement is really important. Everybody should be equipped to understand the fundamentals of how to contribute to changes to the services they work within, and they will need to be supported by people with different levels of expertise. AQuA have a useful framework they have established to describe what’s needed.  

But as Ruth said, ‘we need more than just sheep dip training’. Improvement is a team sport, so it makes sense to think about how you bring together groups of people with different skills. And it’s not just clinicians that need to understand improvement, historically we’ve not been very good at training operational managers, but they play a vital role. Management should really be all about understanding and improving processes, bringing people together to coach teams to improve care for service users, but managers have rarely been given the development or support to play this role. The Flow Coaching Academy which originated in Sheffield is a great example of training that supports a manager and clinician to act as co-coaches working with teams to improve care across a whole care pathway.

What is needed to help frontline staff maintain their improvement efforts?  

You can’t just send people on a training course and then expect them to go away and do improvement. They’ll need time, resources and ongoing support from peers, managers, and people with more advanced expertise. 

At the event session, we talked a lot about the importance of having improvement coaches to support people to put their new found skills into practice. While organisations might need to buy this support in initially, the most promising results are seen when you build these skills in-house, investing in the long-term capability of your own staff.

There’s also something about creating an organisational culture which enables people to take risks. Improvement often involves iterative change, and sometimes that means failure. You need an environment that supports people through that process, which goes back to why it’s important to also train the managers, so that they can manage the risk safely while not blocking the improvement activity. 

Improvement is fun but challenging work, and rarely goes exactly as planned or described in a text book. That’s why support from organisations and for wider networks of peers is important. The Q community is building mechanisms for people doing this work to learn, share and collaborate more easily, because this is a key part of what’s needed to give improvement work the best chance of succeeding.  

David Fillingham from AQuA talked about the need to build sustainable systems and cultures for improvement, rather than episodic approaches or siloed teams – how can organisations do this?

It’s really about making improvement part of your core work, shifting from thinking about it as a series of projects, to being part of how the organisation delivers on its objectives. Adam Sewell-Jones from NHS Improvement put this really well in our discussions: ‘There’s a danger we’ve created a separate quality improvement community that’s working over here somewhere while everyone else tries to get A&E through the winter.’ He talked about needing to embed the approach everywhere so that the person running A&E is thinking with a quality improvement mindset. That’s about creating the right culture and support for improvement: sustainable processes for developing people’s skills and knowledge, and then supporting and rewarding them for doing improvement work, with aligned processes for measuring performance and managing resources.  

Ultimately, as David Fillingham said, this all has to be led from the top. It’s about making sure you’ve got sufficient board level understanding and backing for what you are doing. 

And nationally, what’s the role of NHS Improvement, Q, and other support bodies to ‘create the right weather’ for improvement in the health service? 

As Adam described, we need to aim towards a sufficiently coherent policy context, so that there’s alignment in the way that national bodies are supporting improvement. And while improvement is fundamentally local work, and we need to support organisations to lead it ‘from within’, national organisations also need to help create easy ways for people to learn from each other – across a local health system, across regions and ultimately across the UK.  Working collaboratively to embed Q across the UK is hopefully part of what will make a difference on this front.