OvercomingChallengesToImprovingQuality Fullversion
OvercomingChallengesToImprovingQuality Fullversion
OvercomingChallengesToImprovingQuality Fullversion
Overcoming
challenges
to improving
quality
Lessons from the Health Foundation’s improvement
programme evaluations and relevant literature
April 2012
[email protected]
020 7257 8000
An article based on this research, ‘Ten challenges in improving quality in healthcare: lessons from the Health
Foundation’s programme evaluations and relevant literature’ by Mary Dixon-Woods, Sarah McNicol and Graham
Martin, is published in BMJ Quality & Safety, http://qualitysafety.bmj.com (doi:10.1136/bmjqs-2011-000760)
For nearly ten years, the Health Foundation – The Safer Patients Initiative heightened
has been working with the NHS to deliver managerial awareness of, and commitment
improvement through service and staff to, patient safety and created organisational
development programmes. Our programmes understanding about how to implement safety
test out new ideas for improving the quality of improvement efforts.
healthcare. Our aim is to take the best ideas –
those that we can prove really make a difference to – The two Engaging with Quality programmes
improving the quality and safety of patient care – showed that peer-led improvement processes
and encourage uptake throughout the NHS. secured effective clinician engagement. The
Engaging with Quality Initiative secured the
Almost uniquely, we believe, we have consistently attention of the royal colleges and professional
evaluated these improvement programmes and the bodies, which reported immediate consequences
difference they make. We evaluate our programmes in organisation and practice, and also that the
to provide sound evidence of their impact, and programme had either ‘catalysed’ or supported
to better understand how the impact has been longer-term trends towards involving them in
achieved – or not. These evaluations have provided quality improvement.
important insights into the interventions being
tested, and have demonstrated many successes As those actively involved in improvement work
achieved by the programmes. For example: will know, bringing about the change in behaviour
– Co-Creating Health’s self management and practice necessary to improve quality can be
programme for patients improved their hard and slow. Despite the many successes of the
activation (knowledge, skills and confidence for programmes we have supported, teams frequently
self-management), as well as their use of self- encounter obstacles to achieving their original
goals. The question this posed for us was whether,
management skills. There were also improvements
by identifying and better understanding some
in condition-specific outcomes and quality of life.
of the common challenges, it would be possible
– Participation in our leadership programmes to develop a set of evidence-based approaches
has catalysed improvements. For example, the for successfully overcoming these challenges to
Shared Leadership for Change programme improving quality. Our interest was not in the
meant that a team from Carmarthenshire pros and cons of different technical methods of
Diabetes Network successfully moved routine improvement, but on the factors that affect the
diabetes care from secondary to primary care, likelihood of methods being applied and new
resulting in dramatic reduction in waiting times interventions adopted.
from 12 months to no wait for new secondary
care appointments.
Executive summary v
Chapter 1: Introduction 1
Chapter 5: Conclusions 29
References 34
Improvement in healthcare poses important The improvement field is replete with examples
challenges. Even the definition of what of interventions, initiatives and programmes that
‘improvement’ means escapes consensus. Perhaps worked well in some settings but floundered when
the most useful definition is that offered by introduced elsewhere. Organisational context is
Batalden and Davidoff: often the deal-breaker in making positive change
happen in healthcare. As scientific understanding
Many in healthcare today are interested of improvement has developed, attention has
in defining ‘quality improvement’. We turned increasingly to trying to explain what
propose defining it as the combined and causes this variability in organisational response.3-6
unceasing efforts of everyone – healthcare
Over time, the Health Foundation has assembled
professionals, patients and their families, an impressive portfolio of improvement
researchers, payers, planners and programmes and, in a perhaps unique contribution
educators – to make the changes that will to advancing the field of improvement, has ensured
lead to better patient outcomes (health), that each is evaluated – mostly independently.
better system performance (care) and The programmes have diverged in their scope and
better professional development.2 remit, but all are united by their focus on technical
skills, leadership, capacity, knowledge and the will
These authors use the term ‘quality improvement’. for change. They therefore meet the definition of
This is a term that tends to be used in different ‘improvement’ that we offer above. The evaluation
ways by different people in different contexts, and reports represent a valuable resource, providing
is often associated with particular methodologies. insights into the challenges and opportunities
Because we are interested in improvement in of improvement and how they are influenced by
healthcare broadly, and in keeping with the spirit different healthcare organisational contexts.
of Batalden and Davidoff ’s definition, we will use
the term ‘improvement’ to encompass the whole In this report, we provide a synthesis and review
range of purposeful, directed attempts to secure of the findings of these evaluations as they relate to
positive change in health systems. factors that constrain and facilitate improvement.
We set the learning from the evaluation reports
Though there are some examples of demonstrable, in the context of the wider literature, and seek
real and lasting improvements in the care provided to draw out the lessons for those responsible for
to patients,1 the effectiveness of improvement designing and implementing improvement in
initiatives is more often inconsistent and patchy. the NHS.
– Safer Patients Initiative phase 2 (SPI II), – An evaluation of the Health Foundation’s
February 2011 Engaging with Quality Initiative (EWQI 2009),
March 2009
– Learning report: Safer Patients Initiative
(SPI Lng), February 2011 – An evaluation of the Health Foundation’s
Engaging with Quality Initiative (EWQI 2007)
– The journey to safety: a report of 24 NHS October 2007
organisations undertaking the Safer Patients
Initiative (Journey to safety), unpublished Engaging with Quality in
Primary Care (EWQPC)
Leadership programmes (2008–11)
– Engaging with Quality in Primary Care:
– What’s leadership got to do with it? evaluation of the Leading Improvement Teams
(Leadership), January 2011 Programme (EWQPC), March 2011
– Evaluation of the Shared Leadership for Change
programme (Shared Leadership), June 2009 Co-creating Health
– Co-creating Health evaluation (Co-creating
Health), in press
– leadership development There are other ways in which the same material
could be organised and our choice of presentation
– clinical engagement here does not represent any attempt to impose a
– organisational and systems-based approaches to hierarchy on the importance of particular themes,
patient safety but rather an effort at clarity.
– promoting integrated approaches to self- In general, we have focused on commonalities
management of long-term conditions. across the reports. Where appropriate, we have
also commented on silences or absences in
The programmes, taken in the round, intervene the reports. The nature of the reports and the
at many different levels, from the individual programmes studied do not easily allow for an
to the team, and from organisation to system. assessment of the extent to which factors might
Synthesising the evidence across the programmes interact, or of which factors are likely to exert the
helps to provide an integrated perspective that most powerful influences on improvement efforts.
recognises both the importance of individuals However, we would expect many of the factors
(their skills, competencies and qualities) but also to be contextually specific and to link together in
the contexts in which they work. ways that may be difficult to predict.
Our findings reflect and are constrained, of
course, by the nature of the programmes and their
interventions, and by the nature and reporting of
the evaluations. However, a number of important
themes emerge across the reports that are likely
to be useful for most improvement efforts. We
organise our analysis into three broad themes:
In the SPI programmes, many aspects were A further important strategy involves engaging
already good at baseline, leaving little room for clinicians themselves in defining what it is that
improvement (SPI I/II). This was also true in they would like to improve in their service;
EWQI, where some units were already performing clinicians are usually able to identify defects that
so well that they were unlikely to improve they would like to fix, although there are risks that
significantly further. Clinicians and others may such defects will be attributed to causes outside
argue that the problem being targeted by an the control of individual teams.17 Interesting
improvement intervention is not really a problem, work using methods such as video ethnography
that it is not a problem ‘around here’ or that is now showing considerable promise in helping
there are many more important problems to be practitioners to engage actively in recognising both
addressed before this one (EWQI; SPI). problems and their own role or contributions in
the resolving of those problems.18
Middle managers and ward staff can be difficult Successful strategies in some of the programmes
to engage in new interventions because they included opportunities for coaching and reflecting
already face numerous, complex and often on the nature of these professional silos, which
competing clinical and organisational demands, offered a rare chance to escape the day-to-day
often with inadequate staffing, limited resources pressures of roles into which award holders had
and equipment shortages. Since they are already been socialised over many years. Multidisciplinary
balancing multiple competing priorities, initiatives learning – both among award holders and in the
that generate further paperwork are likely to settings in which improvement projects were
be especially unwelcome (SPI I). Complex being undertaken – also showed some promise in
interventions might be viewed as daunting (SPI I), mediating the boundaries between professional
so making the implementation appear manageable and disciplinary groups. This finding is in line
is important in securing the support of frontline with suggestions from both the literature on
staff (SPI I). Others have noted the importance improvement and broader social scientific theory
of ensuring that the information infrastructure and evidence.34,83,84 However, this evidence also
supports, rather than deters, staff engagement.12 indicates that a multidisciplinary community,
covering multiple professions and specialties and
Factors found to affect medical engagement in the including managers, is not something that can
SPI include: improvement track record; resource be imposed. Rather, if it is to be sustainable and
allocation; perceptions of purpose of intervention; effective, it needs to be driven by the volition of
evidence of efficacy; external expertise; local those groups themselves, and thus needs to be
programme champions; and management viewed as legitimate and worthwhile by different
involvement (Journey to safety). In the same stakeholders and according to the standards of
programme, managers were more likely to report different professions.
Weak evidence base means intervention Avoid areas where the evidence base is weak or
lacks credibility professional consensus cannot be reached
Involvement of respected senior figures (expert opinion
leaders)
Approaches inappropriate for local context Piloting of approaches and revision (or rejection)
as appropriate
Over-ambitious aims given timescale and/or resources Better recognition of the scale of resource, effort and
support required
Focus on more defined area
Trialling to help identify support needed
Lack of clarity about definitions/nature of award Ensure basic details agreed at outset
Difficulty isolating impacts of interventions and Build in evaluation methods from outset eg collect
attributing change appropriately baseline measures
Control group
Counterfactual approach
Importance of evaluation not well-understood External support may be required; needs to be built in
eg difference from improvement/performance from the beginning
management Local teams need strong support
Data collection oriented towards research rather Focus on ways in which data can be used to benefit
than improvement patients
Not a significant improvement because already Target those sites/individuals with greatest potential
good at baseline to benefit
Unexpected opportunity costs or other unwanted Make limits of funding as clear as possible at start eg
consequences whether backfill costs met
Improvement valued less highly than medical research Support of senior executives, professional bodies, reward
structures
Shifting agendas/priorities in the ‘outer context’ Map interventions to core themes as well as specific
policies
NHS career structures not suited to progression via Support of senior executives and professional bodies
improvement eg clinicians need to look beyond daily Reputational incentives (raise status of improvement)
work to apply or change careers
Peer pressure/peer esteem (eg peer-review visits,
comparative audit)
Differing views between various professions, clinical Involve representatives from all areas/professions involved
areas and stakeholder groups in design of intervention
Focus on defined clinical areas
Language barriers between clinicians and managers and More opportunities for cross-professional working
lack of understanding of roles Use of intermediaries eg training staff
Mix of skills required to deliver improvements Multidisciplinary teams and draw on external support
Lack of staff skills (eg teamworking, networking) Include training as part of the project
Roles not clearly defined eg service users, boards Establish stakeholder involvement and roles
at an early stage
Lack of engagement of ward staff and middle managers Ensure paperwork associated with project is not excessive
Make sure intervention appears manageable
Ensure early and full support of clinical leaders
Peer-led interventions/peer opinion leaders
Build in rewards for middle managers and ward staff
Projects not embedded in wider Need to write into standards, guidelines, procedures etc
mechanisms/routine activities Need involvement of senior managers
Improvements not transferred successfully Identify areas to which improvement can be transferred
successfully (likely to be closely allied)
Need to take account of organisational context when
transferring (may need to adapt)
Needs involvement of professional bodies and those
developing national strategies
Perhaps the overriding message is that there deficit of care is revealed. Yet needing to improve
is no magic bullet in improvement. This does care and knowing how to do it are two very
not mean that nihilism has a place, but it does different things.90 A feature of improvement for
mean a need to accept the challenges and adopt perhaps the last decade has been pressing on to
a solution-focused approach. Much of what we action without enough of an evidence-base for
have found concerns tensions and balances, so intervening, or enough planning, assessment and
solutions need to be nuanced, sensitive, and consultation, and then looking for impressive
sensible, while maintaining a firm focus on the results in a short period of time. An important
benefits of improvement for patients. Securing lesson for future initiatives may be the need
the engagement of multiple stakeholders in for much more extensive project development
improving quality requires multiple approaches, periods. Significant investment is needed in
many of them apparently contradictory: strong specification of the theory of change, consultation
leadership alongside a participatory culture; with stakeholders, designing and selecting
direction and control but also flexibility according the appropriate measures and setting up data
to local need in implementation; critical feedback collection systems, and assessing organisational
on performance but without the attachment of capacity. At the same time, improvement design
blame.15 Making progress in addressing challenges needs to supply a framework for change rather
to improvement will require negotiating many than a rigid specification; adaptability is a crucial
cramped channels. component of improvement.
One tension is between action and evaluation. Another, related tension is that of project status.
There is an understandable urge to action On the one hand, it can provide excitement and a
improvement, particularly when evidence of a clear impetus for change, but it can also hamper
The Health Foundation is committed to Many of the factors identified in this review
supporting improvement that will enhance are inter-related and are part of wider, complex
the quality, safety and experience of patients systems. Successfully intervening to overcome
in the NHS. Many leaders of those who have one challenge may give rise to others; as noted
received Health Foundation support have been above, the unintended consequences of efforts to
innovative in negotiating the challenges in the improve quality are insufficiently studied. More
complex organisational and professional context explicit acknowledgement of the complexity of
of healthcare. But change is hard and slow.99 the challenge facing those improving quality may
Many challenges are deep-set and structural in help to trim ambitions, avert disappointment, and
nature, and resistant to even the most determined maximise learning.
leader of change. Some aspects of organisational
context may not be amenable to change through This is not to suggest pessimism about the efforts
individual or team efforts, no matter how ‘heroic’, of the Health Foundation and others committed
‘transformational’ or determined the leadership, to achieving change through the agency of
and no matter how generous the support. At least clinicians and others working at the coalface
some failures are to be expected, and may not be of healthcare. While some challenges may
attributable to any deficiencies on the part of award seem impossible to overcome, others become
holders and their teams; they should, instead, be more amenable to intervention as we learn
treated as learning opportunities and contributions more about them. Many achievements in the
to improvement science. evaluation reports are testament to how much
can be improved with financial backing and the
right training and support. The evaluations as
a whole also highlight the potential for refining
and honing the science of quality improvement
through rigorous evaluation and careful synthesis
of the lessons produced by this. We hope that our
analysis may help to define further strategies.
Safer Patients Initiative These trusts had two stretch aims: a 30% reduction
in adverse events and a 15% reduction in mortality
The Safer Patients Initiative ran from 2004–08. over a 20-month timescale.
It was set up to test practical ways of improving
hospital safety and to demonstrate what can be Learning report: Safer Patients Initiative
achieved through an organisation-wide approach (SPI Lng), February 2011
to patient safety.
This learning report provides an overview of
Safer Patients Initiative phase 1 (SPI I), the Safer Patients Initiative (phases 1 and 2) and
February 2011 its evaluation, and highlights the impact of the
programme, key lessons and further issues for
The first phase of the Safer Patients Initiative began
exploration.
in 2004, when four UK hospitals were selected
through a competitive process. Each of the trusts The journey to safety: a report of 24
undertook improvement in leadership in the four NHS organisations undertaking the Safer
clinical areas using a predefined measurement Patients Initiative (Journey to safety),
framework. They were given an ambitious stretch unpublished
goal of halving the number of adverse events
across their organisation over two years. This programme examined five core issues
essential for any safety programme:
An organisation-wide focus on patient safety
underpinned the improvement work in each clinical – the role of the patient in patient safety
area. This involved developing better communication, – raising awareness of safety issues across
training staff in improvement methods, creating organisations
new systems for measuring process and outcomes,
– the improvement of clinical processes
and reporting and learning from adverse incidents.
Chief executives and senior teams were fully – high reliability units and the transformation of
involved in the programme, ensuring that patient whole organisations
safety remained a top strategic priority. – how safety is addressed at each level of an
organisation in a series of nested steps (focusing
Safer Patients Initiative phase 2 (SPI II),
on the Safer Patients Initiative).
February 2011
A second phase of the initiative began in 2006.
Phase 2 saw 20 further hospitals join the scheme,
working in pairs so as to learn from each other’s
successes and challenges.
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