I first learnt about quality improvement (QI), when I took a year out of training to join the chief medical officer’s clinical advisor programme at the National Patient Safety Agency. Before that I had never heard about quality improvement, nor been taught about it, or seen it applied in practice, despite having studied to become a doctor and then specialised for 12 years. Maybe it passed me by, but I don’t recall any mention or evidence of quality improvement being used as a way to solve some of the complex quality and safety issues I could see every day in the workplace.
When we began laying the ground for our QI work at East London NHS Foundation Trust in 2012-13, it was still perceived as relatively novel, particularly within the fields of mental health and community health. My efforts to seek support from national bodies to embark upon an organisation wide improvement approach was met with silence. Writing a long term business case was difficult in light of little published evidence of the outcomes from applying QI at scale within mental health and community health.
Fast forward to today, and the world of healthcare improvement has moved on significantly. Belief in QI has grown. Most healthcare providers in the UK would say that they are using quality improvement, although the reality is that this is highly variable. Most medical and nursing trainees are taught formally about quality improvement, and often have to demonstrate involvement as part of professional development portfolios. Even our regulators now inspect for signs of an improvement approach, and actively encourage organisations to adopt quality improvement.
All of which is great news for the world of healthcare improvement, and great news for our healthcare workforce who now have a way to influence and improve the complex systems in which they work. However, this progress also brings with it the very real risk that leaders feel they have to adopt QI, or misunderstand what it really means for an organisation. I see far too many organisations paying lip service to quality improvement—expecting results without proper investment from leadership, without truly undertaking the shift in leadership behaviour that is required, and without investing in the infrastructure and capability to support a transition towards experimentation, innovation, and local problem-solving.
Quality improvement involves a method and tools. But if we view it as purely a mechanistic way to work through projects and problems, we are missing the true opportunity to harness the benefits of becoming a continuously improving organisation. Quality improvement is also about a mindset and a philosophy—a deep belief in the value of involving people in the change process, of flattening hierarchies, of shifting power to the point of care, of a systematic and consistent approach to problem solving, of discovering rather than mandating our way to excellence.
The path for healthcare systems and providers to embed and sustain a culture of continuous improvement involves integrating it fully into the way the organisation is run. This is why the quality management system is so important. If quality improvement lives by itself, parallel to how teams manage their work day-to-day, it stands little change of truly being incorporated into the organisational culture and sustaining beyond an initial burst of effort.
For those of us charged with leading our system’s improvement efforts, we need to work towards the goal of embedding quality improvement alongside quality assurance (occasional checking to ensure we are delivering core standards), quality control (real-time management of the system using a range of data, visual management and clear escalation processes) and quality planning (an annual process of deeply understanding the needs of your customers or end users, and designing how you will meet these). Try removing the word “quality” and develop a system of holistic management that integrates the four approaches of improvement, assurance, control and planning. When we approach all of our work with a consistent system of management that brings together control, assurance, improvement and planning, and can determine how we are using each of these in a complementary way to achieve the best outcomes for those we serve, we will have a better chance of both utilising quality improvement at the right time for the right problems, and also embedding a sustainable system for continuous improvement.
Amar Shah is Chief Quality Officer at East London NHS Foundation Trust, the national improvement lead for the mental health safety improvement programme, quality improvement lead at the Royal College of Psychiatrists and faculty member with the Institute for Healthcare Improvement. Twitter: @DrAmarShah
Competing Interests statement: None declared.