If you are a healthcare leader looking to develop a culture of improvement within your organisation, you should expect several stages in the journey to introduce organisation-wide improvement. Most of the NHS Trusts in England which hold an outstanding CQC rating have implemented an organisational approach to quality and here are some ideas of what to expect and what the stages in your journey might look like, as you embed quality improvement.
Early stages of improvement – Assessing Readiness
The King’s Fund report (Embedding Culture) states: “Quality improvement methods require a fundamental change to how organisations approach their work.” To achieve a culture of quality, an organisation must have the systems and structure in place to support QI and be ‘QI-ready’. There are lots of helpful tools you can use to achieve this.
The early stage of improvement is really important in your journey towards organisational change. It’s where you put together the building blocks of change, establish how you are going to embed transformational change, and where you need to establish whether your organisation understands ‘readiness to change.’
The behaviours and attitudes of Boards hugely influence the success rate of improvement culture within an organisation. If you want to embed a culture of change and quality, you need to have your Board committed to this vision and to develop ‘distributed leadership’ across the organisation.
Distributed leadership is the process of giving team members across your organisation the opportunity to test new change ideas. By getting to know the expertise that you have within your organisation, and encouraging teams to test new change ideas, the process can be started.
You can start by assessing whether your leadership and teams are ready to build improvement capability. You will also need to identify where improvements are to be made, and this will help you determine where work needs to be done to place QI at the centre of your organisation. Improvement capability refers to an approach ‘aimed at encouraging and enabling staff to develop and deploy the skills, tools and knowledge necessary to improve the quality and safety of the care they provide.’
You will also need a structure, a framework and a vision to help you on your QI journey. You may want to create a QI roadmap or QI plan, you may also want to use a system to run and track your quality improvement work. There are also a wide range of applications you can use, such as Life QI. You might also want to coordinate a central QI team who can support your teams and QI work.
Although the first steps towards change can seem daunting, many have tried and succeeded. For example, the Board at ELFT (East London NHS Foundation Trust) have a strategic, long-term, Board-level commitment to QI and have developed a culture of improvement and organisation-wide improvement programmes. Find out more.
Mid-stage - Developing improvement skills and infrastructure
Once you have buy-in from your people and you have created a QI plan and vision, it is time to build improvement capability by developing your infrastructure and improvement skills. Studies have shown that working as a system and using a systematic approach is beneficial to achieving transformational change. By empowering your teams, sharing knowledge, insight and working collaboratively you have more chance of embedding a culture of change.
As your QI programme grows, you will need to make sure that individual projects are aligned with your organisation’s vision so that all teams are going in the same direction.
At this stage, you will also need to look at the people you work with. If you start by identifying and working with people who are interested in embedding improvement, and once a positive impact on care quality has been demonstrated, you can encourage others to emulate this success.
You will also need to ensure that you can roll out a system to track improvement and to measure and feedback on the improvement changes you are making. This is where a system such as Life QI can really help to collect and analyse data. Life QI removes barriers and helps organisations disseminate lessons learned, which in turn helps accelerate local and even national change.
There are many examples of sites who have excelled in their improvement journeys. Central and North West London NHS Foundation Trust (CNWL) took a Trust-wide comms approach to rolling out the new QI programme. They used Life QI to implement a standardised approach to improvement across the organisation and build on sharing and spreading improvement. They were able to set up a new CNWL QI microsite and a new series of monthly newsletters. Divisional leads were in place to do face-to-face engagement and central events were held to encourage staff commitment. (Read more about their journey here).
Advance levels of improvement – sustaining an organisation-wide approach
There is no doubt that it takes time, energy and focus to embed a quality improvement programme within an organisation. Once you are on your way, you will need to keep momentum going by keeping teams engaged and encouraged. Working as a system, working to a vision and sustaining this can be challenging – but you can look at the great work done by other organisations to inspire you.
Many organisations who have been successful in embedding quality change have benefitted from external support. Whether you draw on local peer support or draw on expertise from renowned international organisations like the IHI or Virgina Mason Institute, it is always helpful to include an outside influence to maintain momentum and bring new ideas.
Time is required for new service configurations to stabilise so that staff are able to overcome barriers and develop the necessary facilitators for quality care provision.’ However, once you’ve had some wins, by focusing on those who are engaged and supportive, you can build on these experiences and use momentum to reach and engage those who are less open to quality improvement.
The path to improved patient outcomes and experience is not going to be an easy one. But the benefits – improving practices, pathways, services, treatment and care – are worth it!
The challenges of leading improvement
When trying to bring about organisational change and develop improvement capability, you may encounter barriers. These obstacles can come in many forms. In the report ‘What’s getting in the Way, Barriers to Improvement in the NHS’, four possible barriers that limit transformational change were identified: Initiative Barriers, Individual Barriers, Organisational Barriers and System Wide barriers. These were all broken down to include barriers such as: resistance to change, culture of blame rather than improvement, lack of transformational and supportive visible leadership etc. – all different reasons that could stall change.
Other barriers that could get in the way range from: lack of staff, lack of money and lack of engagement reaching to goals seeming unrealistic or too ambitious. Usability barriers can sometimes occur when people find it difficult to apply a model.
However, there are real success stories coming out of healthcare organisations that demonstrate it is possible to overcome hurdles and move towards change.
The challenge is to persuade others across the organisation of the case for quality improvement and to create a compelling improvement vision. Positioning your change will be important – it must not be seen to be driven by cutting costs or as a top-down programme. If you can make small, incremental steps whilst building teams and engagement, you will be in a good position to lead your team to successful change.
 Weiner B. A theory of organizational readiness for change. Implementation Science. 2009; 4: 67.
 See above note 4; page 18.