A guide to making the case for improvement

It has been shown that improvement approaches can have a positive impact on workplace culture. An evaluation of the NHS partnership with Virginia Mason Institute, for instance, revealed high levels of social connectedness at the highest-performing participating trusts. Relationships at these trusts were characterised by closeness, mutual collaboration and feedback. Similarly, staff at the North Bristol NHS Trust maternity unit that developed PROMPT – a multi-professional safety training intervention – were found to have strong social ties, collegial behaviours and mutual respect across disciplines. Equally significantly, disagreements in the unit are often settled through open discussion rather than personal or positional authority. The Big Room improvement approach that underpins the Flow Coaching Academy is similarly designed to foster a culture in which all staff can participate on equal footing, regardless of seniority. Improvement approaches drive a workplace culture of respect, trust and shared values typical of the most progressive and respected employers in the UK today.

Improvement done well gives staff the time, space, tools and permission to identify and implement solutions to issues affecting the quality of care. By giving staff members discretion over how they use their skills, time and energy, improvement has the potential to enhance their sense of job control, which is closely associated with employee health and wellbeing. Organisation-wide approaches to improvement that seek to embed civility and an open, respectful and collaborative way of working ensure that the sense of job control members of staff experience when working on an improvement intervention carries through to the rest of their working lives. The NHS trusts in England that are strongly committed to fostering such cultures consistently perform among the best in the NHS staff survey. For example, Northumbria Healthcare NHS Foundation Trust is one of the highest-scoring trusts in questions relating to staff engagement, morale, and autonomy and control.

Improvement participation can help people develop an array of leadership, management, learning and technical skills that are well suited to today’s increasingly networked and data-driven health care landscape. For example, those experienced in improvement are proficient in using their relational leadership skills to collaborate and build coalitions across teams and organisations and understand how to enact change in complex systems. They will also have developed a range of improvement habits such as a questioning and reflective mindset, a tolerance of uncertainty and an ability to take calculated risks. These are critical to the ability of health care services to identify and embed innovation and new care models.

Those experienced in improvement also often excel in using disparate sources of data, both quantitative and qualitative, to understand the root cause of quality challenges and measure the impact of their intervention. In an NHS rich with data but often struggling to identify and analyse the right kind, these are vital transferable skills. The value of these improvement skills was perhaps best illustrated by the central role many improvement leads played in adapting and redesigning their organisations’ services in light of COVID-19. Their creativity, agility and leadership were one reason health care services were able to respond so rapidly to the service delivery challenges posed by the pandemic. These skills will be in increasingly high demand in the years ahead as the NHS and other care sectors reshape their services.

Patients’ access to appointments and services at a time, place and format of their choosing is one of their highest priorities. Delivering on patient expectations around the ease of appointment making and accessing services has been a particular challenge for general practice in recent years, not least due to the workforce shortages and demand pressures facing the sector. Improvement approaches have helped improve access to general practice without displacing care elsewhere, reducing care continuity or increasing practice workloads. The capacity challenges facing general practice are more pronounced today, but practices have had some success using improvement methods, among other things, to implement the ‘total triage’ system (where every patient is triaged before an appointment) and matching clinical workforce with day-to-day demand. Improvement methods are not a panacea in themselves. For improvement to have the most impact, it needs to be accompanied by, among other things, an increase in general practice workforce numbers. Nonetheless, it offers real potential to tackle barriers to accessing general practice (and indeed all care sectors) and, in doing so, improve patients’ care experiences.

Many care pathways have been designed to fit the needs of organisations rather than patients. In hospitals, for instance, it is common for patient blood tests to be processed in batches, not as soon as they arrive in the lab. Consultant ward rounds operate similarly. This can delay patients’ diagnoses and treatment and increase the amount of ‘medically non-value adding time’ they spend in hospital. Changing hospital operations so that patients can access diagnostic and care services as soon as they need them could significantly improve patient outcomes and experiences. The Flow Cost Quality programme, for instance, used an improvement approach based on lean and other methods to deliver sustained reductions in emergency care length of stay, bed occupancy and readmissions at two NHS trusts in England. Crucially, by more effectively matching capacity with demand and removing bottlenecks in the system, the programme improved patients’ overall care experiences. 

For patients with chronic conditions, a priority is to avoid exacerbations that require acute treatment. Improvement approaches, with their emphasis on refining new ways of working through small tests of change and collaborative working, are well suited to finding solutions to this challenge. One example is ASSIST-CKD, an intervention that identifies deteriorating kidney function in patients with chronic kidney disease and alerts their GPs. Originally set up in Birmingham, the surveillance system led to a fall in the number of patients starting renal replacement therapy at one trust. The intervention has since been implemented in over 20 renal units across the UK.

In recent decades, significant progress has been made in understanding specific causes of harm to patients. These can be addressed by front-line teams using improvement methods. Prescription errors, which can result in harm, hospitalisation or even death, provide one such example. To tackle hazardous prescribing in general practice, a pharmacist-led intervention (PINCER) has been set up. A 2-year collaborative in the East Midlands featuring 12 clinical commissioning groups and 370 GP practices led to an approximately 24% reduction in the proportion of patients exposed to at least one type of hazardous prescribing. PINCER has now been widely rolled out among GP practices in England using a collaborative quality improvement approach. Another project, iSIMPATHY, has delivered a new approach to medicines optimisation in Northern Ireland, Scotland and parts of the Republic of Ireland in a bid to improve outcomes for patients.

At its best, health care is built on an equal partnership between staff, patients, carers and the wider public. Underpinning this partnership is a shared purpose. This is informed by discussions with patients about what matters most in terms of their own care and the ways in which services are designed and delivered. Effective partnership working can improve patients’ experiences and control over their care. For example, patients who have the opportunity and support to make decisions about their care and treatment in partnership with health professionals are more likely to be satisfied with their care. Meanwhile, the co-production of health care services between patients and health professionals is an important means of helping people restore or maintain their health. Improvement approaches, such as experience-based co-design and person-and-family-centred care, have been widely used to help achieve these goals. In using such approaches, though, it is important to confront any knowledge and power imbalances that may make it difficult for some patients to contribute equally or make the transition from being simply ‘users and choosers’ to ‘makers and shapers’ of services.

Tackling variations in the way care is delivered has long been a priority for health care services. In addition to creating opportunities for efficiencies and cost savings, efforts to combat such variations are recognised as key to an equitable service in which everyone has access to high-quality care and outcomes. Improvement approaches are well suited to both identifying and addressing unwarranted variations in a wide range of spheres. They have been effective, for instance, in enabling the consistent delivery of standardised care bundles across systems and reducing variations in the management of long-term conditions, thus ensuring that all patients receive care in line with the latest evidence-based national guidance. Meanwhile, variations in the time it takes for patients to access care services have been addressed by work to match service demand with capacity. In this way, improvement approaches provide the means to narrow the gap between health care provider organisations’ performances against standard national access targets.

The central organisational benefit from the deployment of improvement approaches at scale is the delivery of safe, high-quality care due to, among other things, a reduction in patient harms and variations in care delivery, and improvements in the efficiency and reliability of care processes and pathways. There are many examples of safety and quality gains from improvement at both service and departmental levels as well as across whole organisations. A hip fracture quality improvement programme involving English NHS trusts, for example, led to a reduction in the 30-day mortality rate and an increase in the number of patients mobilised soon after surgery. Another NHS trust-based quality improvement programme in England focused on improving patient outcomes after emergency laparotomy achieved reductions in length of stay and mortality. Meanwhile, an analysis of the impact of organisation-wide lean-based improvement programmes in the US highlighted a wide range of quality-related benefits, such as lower unplanned readmission rates and improved patient experience scores.

Improvement approaches offer well-tested routes to identifying the service changes that matter most to patients, service users and front-line staff. They also help ensure that any changes get the support they need to be successfully implemented and sustained. Those practicing improvement can also use diagnostic and analytical tools to reveal ways in which staff time and equipment are not being deployed efficiently or to identify the source of chronic bottlenecks in care pathways and systems. As such, improvement approaches can ensure that existing resources are used effectively, for example, and that time is spent most usefully. By mapping and analysing existing care processes and workflows, for example, improvers have found ways to remove low-value, repetitive clinical activity and develop new process models that have reduced the use of medical products while improving care quality.

A reduction in adverse clinical outcomes and the development of a positive safety culture are key goals of many improvement interventions. As well as benefiting patients, the avoidance of patient safety incidents can have significant financial advantages for health care providers due to reduced litigation, legal and insurance fees. For example, PROMPT, a maternity safety multi-professional training intervention developed at North Bristol NHS Foundation Trust, has reduced the litigation costs associated with unsafe maternity care at the trust by 91%. In the US, meanwhile, the Mayo Clinic has had a reduction in its professional liability exposure in the 6 years following the introduction of its quality improvement programme. Embedding a safety culture can also help organisations avoid and respond effectively to crises in the quality of care, which can have a major destabilising effect and long-standing impacts on organisational viability.

Usually, direct cost savings can only happen when an asset or activity with fixed overheads or procurement costs is decommissioned. Such savings are contingent on avoiding the displacement of the activity to other parts of the organisation, which in turn requires extra resource. The de-implementation of clinically unnecessary or low-value diagnostic and treatment procedures is one area of potential cost reduction that can benefit from the application of improvement approaches. It is estimated that between 25 and 30% of all care is of low value. The presence of an established organisational improvement infrastructure is seen as a key enabler of effective de-implementation strategies. Another potential area of cost reduction is the decommissioning of permanently staffed facilities. For example, East London NHS Foundation Trust used improvement approaches to reduce bed occupancy levels on two wards sufficiently to enable one of the wards to be closed altogether – delivering an annual cost reduction of around £1m.    

The consistent application of improvement methods such as lean has been shown to deliver a more efficient use of staff time and resources. For example, the five English NHS trusts participating in the NHS partnership with Virginia Mason Institute between 2015 and 2020 achieved a collective 62% reduction in process lead times in the care pathways targeted for improvement – removing over 3,000 hours of health care process time. If organisations are able to use such time savings to increase the overall amount of care delivered using the same resources, then productivity gains can also be achieved.

The NHS is responsible for 4% of England’s carbon emissions. As such, health care organisations have important roles to play in combatting climate change by reducing their environmental harms and delivering sustainable health care. Integrating sustainability into their organisation-wide improvement agendas, and using improvement approaches to drive sustainability gains, will help organisations achieve these goals. A further benefit is that reductions in carbon emissions often go hand in hand with cost savings, as case studies collected by the Centre for Sustainable Healthcare demonstrate.

New technology has the potential to transform the way health care is provided, not least by increasing provider organisations’ diagnostic and administrative capacity and freeing up staff capacity. But effective implementation of new technology requires careful planning, a well-developed engagement strategy and the ability to review and redesign care processes and pathways. Any case for improvement should convey the ability of improvement practitioners to help harness the potential of new technology and make sure innovations are fully embedded in the fabric of organisations. 

High levels of staff turnover and absence and an inability to fill roles have both quality and financial implications. Among other things, they can affect care continuity and lead to greater reliance on expensive agency staff to maintain services. Empowering staff to undertake improvement can help tackle these challenges by increasing employee engagement and strengthening their sense of job control. Engaging staff through improvement also has performance benefits for organisations. A defining characteristic of many high-performing NHS trusts is their commitment to engaging staff and devolving decision making through improvement. A correlation has also been found between quality and staffing retention and vacancy levels in the residential and nursing home sector.

Training staff in improvement approaches can lead to significant organisational benefits, if staff are given opportunities to put their skills into practice. For example, Leeds Teaching Hospitals NHS Trust, one of the participants in the NHS partnership with Virginia Mason Institute, identified a financial benefit of over £14.2m from waste reduction in 2019/20 as a result of training staff in the Leeds Improvement Method. This training benefit was deemed robust enough to be included in the overall waste reduction figure of £54.5m reported in the trust’s 2019/20 annual accounts.   

In a highly regulated sector with organisations under intense public and political scrutiny, improvement can help demonstrate a coherent and sustainable strategy for achieving key goals. This can enable relationships with commissioners and regulators that focus on ambitions agreed with local populations, rather than external performance management expectations. Policymakers and regulators have highlighted the performance benefits associated with adopting an organisation-wide approach to improvement, noting that many of the highest-rated NHS trusts have established and comprehensive improvement strategies. There are other benefits too. For example, East London NHS Foundation Trust believes that its reputation as a quality leader has enabled it to gain new business and increase its annual revenue.

Much can be learned from improvement approaches about how to drive and support change across health care systems like ICSs. The improvement collaborative model, which has been frequently deployed across the NHS and relies on a well-organised network spanning multiple organisations, is one such source of learning. The experiences of these collaboratives in developing shared goals across professional and organisational boundaries, creating indicators and datasets to guide improvement and developing an infrastructure to convene and support members are highly relevant to the challenge of leading system-level change faced by ICSs and others. Some collaboratives have reported notable care process and outcome improvements. Furthermore, some key characteristics of effective collaboratives have been identified that can help to inform the work of system-level improvement leads. Insights can also be taken from improvement efforts involving clinical communities that cross organisational boundaries. These communities have generated a range of sustained improvements in NHS settings and have had some success delivering improvement across large, dispersed provider systems in the US.

Ensuring that patients can flow seamlessly from one care setting to another has been a perennial challenge for the NHS and other care sectors. The transition of patients from acute care to social and community-based settings has been particularly problematic, with delayed discharges common. One of the approaches used to tackle this challenge – the discharge to assess model, which is predicated on discharging patients as soon as their acute medical needs have been met – owes much to the analytical and problem-solving expertise and collaborative skills of quality improvement teams. The model was successfully piloted in Sheffield by a team that used a lean-based methodology in combination with the Big Room approach to bring together stakeholders from each point of the care pathway to identify and test potential solutions. The collaborative principles and technical skills that underpinned this success have now been codified and spread across parts of the UK via a coaching approach developed by the Flow Coaching Academy. This approach is ideally suited to help drive effective multi-professional efforts to address persistent bottlenecks along care pathways that span multiple care sectors and providers. As such, it potentially has long-term value to the NHS and other care sectors as a means of smoothing the flow of patients across systems.

One of the major challenges in health care is the slow adoption of technologies, care models and evidence. Given that the business case for most proven innovations relies on implementing them at scale in a timely and efficient manner, a pressing challenge for the NHS and other care sectors is to identify reliable mechanisms and approaches for spread and adoption. The improvement community has developed strategies that can help meet this challenge. The use of learning systems and network approaches, for example, can support teams to identify, understand and adopt key innovations developed elsewhere. Meanwhile, initiatives such as the Q community are seeking to reduce the tendency within the NHS and other care sectors towards ‘wheel reinvention’ – something that is not only a major source of waste but makes it harder to realise the potential offered by a national health system to scale up proven and impactful innovations.