Quality Improvement Basics

1. What is Quality Improvement?
2. How do we define quality?
3. The importance of Quality Improvement in health and care
4. What is a culture of continuous improvement?
5. Guiding principles for continuous Quality Improvement
6. Why stakeholder feedback in Quality Improvement matters
7. The wider Quality Improvement team: engaging staff, patients and other stakeholders in Quality Improvement
8. How to spread and sustain Quality Improvement in health and care
9. Getting started in QI: from pen-and-paper methods to digital Quality Improvement tools

What is Quality Improvement?

Quality Improvement is the process of continuously striving to improve services, products or processes. It is a systematic and coordinated process that includes:

• the identification of problems;
• the systematic use of data, methods and tools to design and select solutions; and
• real-time measurement of baseline data and improvements.

It includes the combined efforts of everyone – health and care professionals, patients and carers, partners, advocacy groups and more – in making changes that will improve patient outcomes, system performance and effectiveness, as well as patient and workforce experience.  

The linked aims of improvement:  What is QI and how can it transform healthcare?

The process is a cycle and does not end. Quality Improvement, and indeed healthcare, cannot reach its full potential unless change-making becomes an intrinsic part of everyone’s job, every day; and unless those closest to the issues affecting care are given the time, permission and resources to speak up and share solutions to the challenges faced.

As The Health Foundation points out in QI Made Simple, “Done well, Quality Improvement can deliver sustained improvements not only in the quality, experience, productivity and outcomes of care, but also in the lives of the people working in healthcare.”

There are a range of different methods and tools in Quality Improvement, from Lean Six Sigma to The Institute for Healthcare Improvement (IHI)’s Model for Improvement, but as The King’s Fund states: “There is no clear evidence that one approach is superior to others. Rather, it is the process of having a systematic approach to Quality Improvement and applying this consistently that is important.” 

As much as a set of tools and a methodology, Quality Improvement can also be thought of as a mindset. In addition to technical skills, there are behavioural ones whereby stakeholders (health and care professionals and patients alike) resist the inertia and safety net of thinking, “that’s the way we’ve always done things,” and are humble and curious to look for opportunities to learn and improve. The IHI talk more about this in this here.

How do we define quality?

In England, a single definition of quality for the NHS was first set out in High Quality Care for All in 2008, following the NHS Next Stage Review led by Lord Darzi. This definition sets out three dimensions to quality:

• clinical effectiveness: quality care is care which is delivered according to the best evidence as to what is clinically effective in improving an individual’s health outcomes;
• safety: quality care is care which is delivered so as to avoid all avoidable harm and risks to the individual’s safety; and
• patient experience: quality care is care which looks to give the individual as positive an experience of receiving and recovering from the care as possible, including being treated according to what that individual wants or needs, and with compassion, dignity and respect.

High quality care requires all three dimensions to be present.

Definition of quality, Quality in the New Health System

The definition also states that those providing services should be:

• well-led: open (collaborating internally and externally) and are committed to learning and improvement;
• sustainable: using resources sensibly and efficiently, providing fair access to all according to the needs of the population; and
• equitable: providing care that does not vary in quality because of a person’s characteristics.

In Crossing the Quality Chasm, the US Institute of Medicine defines six domains of healthcare quality – or six areas for healthcare to improve on:

• Safe: avoiding harm to patients, reducing the hazards and risk from the care itself.
• Effective: providing evidence-based care and refraining from providing services that are unlikely to be of benefit.
• Patient-centred: putting people in control of their own care and ensuring that care is responsive to individual patient preferences, needs and values.
• Timely: reducing waiting times for care and avoiding needless, harmful delays.
• Efficient: avoiding waste – from duplication to lost records, and even lost ideas.
• Equitable: ensuring that care is of the same quality regardless of patient characteristics such as gender, ethnicity, location or socio-economic status.

The importance of Quality Improvement in health and care

Quality Improvement exists in all industries, however it is most often written about and discussed within the health and care sector. Extending beyond traditional problem-solving, Quality Improvement in healthcare is important for solving complex problems where an immediate solution is not known and where the nature of the problem is not fully understood. It is a process for designing, implementing and monitoring changes in healthcare services to improve or maintain the quality of care.

A focus on Quality Improvement in health and care has many benefits. It can:

• improve patient safety, care delivery and patient outcomes;
• enhance patient experience;
• improve systems and processes, reducing inefficiencies and waste to make best use of resources (across time, finance, assets and equipment, and people);
• reduce errors;
• better prepare a team or organisation to handle large-scale emergencies or events, as illustrated during the COVID-19 pandemic;
• provide a systematic and scalable way of tackling the challenges (both large and small) faced by a team, department, or organisation;
• ensure data is used to both uncover problems and effect solutions;
• build participatory change, by using the expertise and contributions of those closest to the issues – service providers and service users – to identify issues and solutions; and
• release the creativity and innovation necessary to tackle complex issues which may have remained unsolved for many years.   

All methodologies for Quality Improvement in health and care (e.g. Lean Six Sigma, or IHI’s Model of Improvement) share a systematic approach that is both inclusive and scalable. But Quality Improvement is more than a set of tools and a methodology: it is a mindset that feeds organisational culture.

What is a culture of continuous improvement?

A culture of continuous improvement is one in which incremental positive change is built into the mindset and fabric of an organisation. It is an approach whereby everyone in an organisation – leadership, management and employees – is empowered and motivated to make tomorrow better.

McKinsey & Company lists continuous improvement as one of four recipes for superior organisational health.

Creating a continuous improvement culture requires commitment and persistence. It requires an understanding of the current mindsets influencing employee behaviour and then a clear plan for how these mindsets can be shifted to engage the entire workforce in a drive for improved performance and innovation.

This sounds like an ambitious undertaking. However, by creating an environment in which staff can provide feedback about their daily work, and then participate in improvement and decision-making processes such as providing simple feedback mechanisms for staff to voice their ideas for change, the foundations of a culture of continuous improvement can be laid.

Small practical changes such as this can make a big difference with benefits extending beyond those immediately involved. Moreover, 100% adoption in new improvement programmes is not required for the culture to begin to shift. Even starting with a small group of participants, the subsequent impact can be profound. We call this the ‘halo effect of engagement’.

With a handful of champion participants, increasing numbers of colleagues will start to:

• feel the benefit from the improvements made;
• become aware of a new way to improve;
• feel lifted by the enthusiasm of engaged participants and energised by their sense of ownership;
• feel part of a collaborative environment; and
• feel encouraged to get involved as well.

Guiding principles for continuous Quality Improvement

A key element to embedding continuous Quality Improvement is to ensure everyone has an opportunity to participate. It requires moving beyond the old model of decision-making powers being held by a few at the top, which results in overburdened leaders, unengaged followers and top-down change.

A continuous improvement model is one of collaborative change in which everyone plays a role in improving their workplace. By giving everyone a voice, 24/7, regardless of role, and enabling people at all levels to provide real-time insights, you can start to understand what matters to the workforce; create continuous, real-time touch points; and improve staff experience by creating an open and collaborative culture.

There are a few guiding principles to help teams achieve this:

• Firstly, it is important to replace top-down and project-based mentality with tools and techniques to support everyone to identify and solve problems themselves, emphasising the importance of small, incremental improvements. This may require training and a new system for ensuring everyone’s voices can be heard in real time.
• Additionally, it is important to provide ongoing communication and progress updates, celebrate successes, and ensure staff are able to take ownership and feel proud of their achievements.
• Involving patients, service users and their carers is also central to creating a continuous improvement culture.
• Getting commitment from leaders at all levels is essential, including a commitment from leaders to demonstrate the new behaviour expected from staff. It is important they understand the long-term approach needed for success, as well as how to shift behaviour away from the old model of top-down change.
• It is crucial to convey that this new way of working is not a separate job, but part of the everyday responsibilities of all staff. Leaders should still ensure there is adequate time and resources allocated for staff participation, particularly for training activities.

Why stakeholder feedback in Quality Improvement matters

Health and care delivery involves the complex coordination of a multidisciplinary group of clinical and non-clinical staff, as well as patients and their family members; and delivering safe, quality care requires effective communication and collaboration across the team, department and organisation.

Stakeholder feedback in Quality Improvement is essential so as to ensure those who are most impacted by the quality measures – whether that be patients, carers, clinicians or other members of staff – are best placed to identify problems and come up with solutions, enabling teams to tap into their collective intelligence.

Moreover, as engagement increases, so does stakeholder experience and in turn, healthcare delivery and patient outcomes. We call this the ripple effect of engagement as shown below:

If we give key stakeholders a voice, support them to suggest solutions to the challenges they face and involve them in decision-making, we can create a ripple effect; improving staff and patient experience, the quality of care delivery and patient outcomes.

As Helen Bevan, the Chief Transformation Officer at NHS Horizons, put it: “The more that people participate, the more power is created.” She uses the term “new power”, coined by authors Jeremy Heimans and Henry Timms, saying that, “New power is like a current; it surges with energy when people come together with a shared purpose.”

The wider Quality Improvement team: engaging staff, patients and other stakeholders in Quality Improvement

With any Quality Improvement initiative, early and effective communication is key to building and maintaining engagement. It’s crucial that the basics of any new initiative are communicated upfront. Take time to explain:

• Why do you want them to participate? Share programme objectives and the advantages of getting involved – there will be different motivating factors for different groups.
• What can they expect? Share the process for reviewing and actioning data, as well as providing progress updates.
• Who are the faces behind this initiative? Share group leads, champions or executive sponsors – people prefer to know where their feedback is going and who is involved. A programme championed by individuals who are known and trusted by colleagues is more likely to succeed.
• How can people get involved? Share the ways staff, service users and other stakeholders can take part, either as a participant or champion.

Consider how to spread the word by utilising popular communication channels such as email, the intranet, staff meetings and huddles, senior leadership meetings, posters in areas of heavy traffic, and social media platforms. Where possible, involve colleagues from the communications team.

In addition to communication, other key ways of building momentum and maintaining engagement include:

• Make it simple: integrating any new programme into existing processes wherever possible, so that it becomes the norm.
• Demonstrate impact: show the difference being made as soon as possible and celebrate the wins and staff achievements. No matter how big or small, progress updates and success stories are powerful tools for accelerating a programme’s implementation by reinforcing the message that the management and leadership teams are listening, and that change is happening.
• Consider running a campaign: focused campaigns or challenges are great ways to start the conversation, encourage uptake or galvanise a programme over a specific timeframe. For example, a “5 ideas in 2 weeks” campaign could kick things off, entering everyone who hits the target into a prize draw.
• Incentives and recognition: there are many ways to do this, for example: highlighting an improvement of the month, or an improver of the month; nominating a star of the month; running a thank you scheme for people who have gone above and beyond; or certificates of recognition.
• Recruit champions to help spread the word: the more people to help champion and embed this new way of working, the better. Champions are key individuals who understand the importance of these programmes and can help to spread the word and encourage others to join in.

Last, but by no means least, don’t be afraid of failure – it’s critical that we minimise blame and fear of failure when embracing frontline feedback.

How to spread and sustain Quality Improvement in health and care

Maintaining momentum to sustain the new ways of working and, if appropriate, spreading the improvement across other teams or departments is the next key step in ensuring that emerging practice becomes part of everyday routine.

Sustaining Quality Improvement

We have seen how stakeholder feedback is essential in improvement. We need to bring everyone along the journey of change – not least so that we fully understand the context of existing processes and the challenges faced so that an effective and sustainable intervention can be created. 

Improvement is not something to do for team members, it is to be done with them, and it is important to communicate this from the outset. Every member of the team must understand the role they play and feel empowered and accountable. In addition, expert patients, families, and caregivers are all key partners in designing sustainable Quality Improvement interventions.

As well as involving stakeholders, formal Quality Improvement tools such as Plan-Do-Study-Act (PDSA) cycles assist in ensuring that solutions are sustainable. In the case of PDSA cycles, by adding or removing one component at a time, this tool allows for careful isolation and refinement of the different aspects of an intervention.

It’s also imperative to continue communications consistently and on an ongoing basis to drive engagement in new processes ultimately to demonstrate success and impact. This might include:

1. Robust feedback mechanisms: ensure there is a way to capture insights and feed them back to participants. With staff, this might be in team huddles or on notice boards in staff breakrooms; whereas it may be more appropriate to feedback to service users via a different channel, such as email or a generic newsletter.
2. Structures to foolproof change: from training materials and standard work documentation(simple written or visual descriptions of current best practices in a particular process) to hospital “kits” which contain everything required for a particular intervention; these structures minimise the risk of non-adherence. 
3. Formal capacity building: ensuring staff are trained in and understand new processes is vital.
4. Performance boards & process control boards: performance boards communicate the outcome of Quality Improvement efforts to staff, and process control boards display how much work is required versus how much is completed in real time. Both of these visual management methods provide simple and transparent representation for staff.
5. Communicate early and often: communications don’t need to be complicated or sophisticated, but frequent check-ins and updates go a long way to maintaining momentum.
6. Supportive management structure:  ensure senior leaders are involved. As we have seen, successful change happens with input from the frontline and senior management: management needs to set the vision that change, innovation and continuous improvement is welcome and encouraged; plus they need to provide the infrastructure for this to happen.
7. Add to the agenda of recurring staff meetings:  this shows a commitment to improve and ensures ongoing touch points.

Always remember to communicate that there is no such thing as a bad idea. It’s crucial that stakeholders feel comfortable sharing all ideas, no matter how small or novel it might appear. This is where a digital platform such as ImproveWell can really play an important role.

The NHS Sustainability Model can be used to help identify factors that may increase or decrease the likelihood of continued project success post launch.  Developed by frontline staff, improvement experts, and organisational leaders it is a checklist of ten factors related to process, staff and organisational issues and uses a weighted scoring system to derive an overall score and outlines sustainability strengths and weaknesses across each factor.

Spreading Quality Improvement

Spread means replicating an initiative in a different environment, for example a different team, department, organisation or locality. More often than not, it will involve identification of the unique facets of the environment (e.g. related to resources, infrastructure, leadership support, or culture) and possibly adaptation of the initiative accordingly.  As management consultant Peter Drucker famously said, “context eats strategy for breakfast”.

Spreading an innovation is no easy feat – there is no simple or universally replicable way of implementing change at scale across complex systems. In their paper,  Spreading and scaling up innovation and improvement, Greenhalgh & Papoutsi discuss three theories of innovation spread:

• implementation science which takes a structured and phased approach to developing, replicating, and evaluating an intervention in multiple sites;
• complexity science which encourages a flexible and adaptive approach to change in a dynamic, self-organising system; and
• social science approaches which consider why people act in the way they do, especially the organisational and wider social forces that shape and constrain people’s actions.

In reality, these approaches may be used in combination to tackle the challenges of spread.  Either way, laying the foundation of successful spread is crucial for sure. But how? Here are seven factors to consider:

1. Leadership support: ensure you have leadership buy-in to ensure the vision is supported both in terms of culture and resource.
2. Bring people on the journey: no initiative can be lifted whole scale from one environment to another. Ensure you learn from the frontline and customise the initiative accordingly.
3. Share results of pilots: demonstrating success in terms of initial pilots goes a long way to building confidence and trust in new environments.
4. Develop the plan: think about the four Ws of your initiative – what, who, where and why? 
5. Use your organisational structure: embedding new ways of working into existing structures makes adoption much more seamless.
6. Build a communications plan: from posters to emails and social media, a new programme will never take off if no one knows about it.
7. Track and measure: what does success look like? How will you measure change and impact?

An example of spread can be seen in the use of the ImproveWell digital solution to support the implementation of the Institute for Healthcare Improvement’s (IHI) Framework for Improving Joy in Work, which started as an initiative at East London NHS Foundation Trust before being adopted at a national level by Royal College of Psychiatrists and subsequently globally by the IHI themselves.

Getting started in QI: from pen-and-paper methods to digital Quality Improvement tools

There are a range of Quality Improvement tools which can be used to support Quality Improvement in an organisation. Often a combination of tools is required depending on where an organisation sits in its improvement journey. Here we introduce both some simple low-tech Quality Improvement tools as well as digital Quality Improvement tools.

Low-tech Quality Improvement tools

• Suggestion boxes: for staff to give their feedback and suggestions for improvements.
• Marble jars: to track sentiment, asking colleagues to add a marble when they have had a good day at work.
• Huddles: daily and weekly huddles help make a positive start to the day’s work and ensure all colleagues feel involved.
• Innovation hub meetings and hackathons:  making the space for people to bring their problems and their solutions to the table, refining them together, hearing the perspectives of their colleagues.

Formal Quality Improvement tools

• Clinical audits, statistical process control & performance benchmarking: These tools all measure care against agreed standards – either pre-defined ones in the case of clinical audits and statistical process control or against peers and national targets in the case of performance benchmarking.

• Process mapping & root cause analysis: To understand underlying issues, process maps plot the patient journey to assist with identifying Quality Improvement opportunities whilst root cause analysis provides a systematic framework for understanding the causes of events affecting quality.

• Model for improvement, PDSA & Lean Six Sigma: Tools for planning and testing improvement projects include the model for improvement which assists on identifying, testing and refining Quality Improvement initiatives; PDSA (plan, do, study, act) cycles which introduce and test potential improvements on a small scale; and Lean Six Sigma which eliminates waste and redirects resources for quality and efficiency.

• Decision trees & communication tools: To promote change in practice, decision trees can be used to improve the quality and consistency of processes in health and care; and communication tools can improve quality of care through structured information exchange.

More information is provided on each of these in the Healthcare Quality Improvement Partnership’s Guide to QI Tools.

Digital tools such as ImproveWell

Giving everyone a voice, ImproveWell makes it simple for organisations to capture continuous, real-time insight to improve staff experience and the quality of patient care.

The solution is grounded in three principles: those at the frontline are best-placed to improve the systems around them; giving staff a voice and empowering them to find solutions to the challenges they face is fundamental to engagement and positive experience; and a happier workforce leads to better patient outcomes.

Developed in partnership with health and care organisations, ImproveWell’s feedback systems provide a platform for people to drive change, together. 24/7 everyone can:

• suggest ideas for improvement;
• share how their workday is going; and
• complete tailored pulse surveys.

Insights from wider stakeholder groups can also be tapped via customisable online portals.

An intelligent data dashboard helps group and organisational leads to capture real-time data, track workforce sentiment, prioritise efforts, measure change and publish reports to complete the feedback loop. Book a demo to discover how the tool can assist your organisation

Other online resources

As you progress, you will begin to build your toolkit. Any lasting, effective model for improvement must start its transformation at the roots. It requires bottom-up improvement with continuous support from leadership at the top. There are numerous resources to get started, but here are some great sources of inspiration:

• The Health Foundation: an independent charity committed to bringing better health and care to people in the UK, from grants to research and policy analysis, the Health Foundation shines a light on how to make successful change happen. Their Improvement Lab has published a great resource on Skills for Collaborative Change.

• The King’s Fund: a health charity that shapes health and social care policy and practice, provides NHS leadership development, and hosts health events and conferences. The King’s Fund publishes excellent publications incorporating research and analysis on health and social care.

• The Institute for Healthcare Improvement (IHI): this 30-year-old organisation uses improvement science to advance and sustain better outcomes in health and care across the world. Its reports and whitepapersinclude the Psychology of Change Framework to Advance and Sustain Improvement which addresses why people might resist change and how to address that resistance.

• British Medical Journal Quality & Safety: this journal encourages the science of improvement, debate, and new thinking on improving the quality of health and care. It integrates the academic and clinical aspects of quality and safety in healthcare.

• The Improver Podcast: hosted by ImproveWell founders Lara Mott and Dr Na’eem Ahmed, The Improver explores improvement and participatory change in health and care through interviews with key opinion leaders.

More resources on fostering bottom-up improvement with support from leadership at the top can be found in our guide to participatory change. 

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