Organisation-wide improvement in health care is an important element of the provision of patient safety. Whereas in the past, capabilities and metrics have tended to drive improvement within the NHS – organisations now need to provide strategies to create the infrastructure and the knowledge required to give high quality care. These strategies lead to effective and successful organisational improvement programmes. Having staff with the right skills and having the right culture within an organisation are also seen as vital when looking at transforming care and embedding quality improvement (QI).
What does an organisation approach to QI include?
In its report ‘The Improvement Journey’, the Health Foundation sets out six recommended steps which should ease the way for an organisational approach to improvement. These steps range from: assessing readiness of the organisation and securing board support, to the final step of sustaining an organisation-wide approach.
Why is organisation-wide improvement important?
In the paper ‘Building the business case for quality improvement: a framework for evaluating return on investment', Dr Amar Shah and Steven Course of East London NHS Foundation Trust (ELFT) set out the trust’s quality journey. They report that there are ‘complex challenges in healthcare, yet little published literature to help leaders develop a business case and evaluate return on investment from QI.’
By implementing a robust QI strategy across the trust, ELFT has reported some excellent QI wins. Among their successes are the following:
‘The teams have reduced the number of days people wait from referral to first appointment by 20% over 2 years and reduced non-attendance at first appointment by 36% over 2 years, while seeing a 26% increase in the number of referrals received during the same time period.
They also evaluated the cost avoided through reducing physical violence on acute adult mental health wards and older adult mental health wards. Both economic models involved finance teams working with clinicians to understand what happened when someone became violent on the ward, and evaluating the costs over the period of time related to violence (including medication costs, additional staff costs, repairs to the estate etc). The older adult case study demonstrated costs related to violence reducing from £120,000 over a 9-month period before the intervention, to £60,000 over a similar period after the intervention. A 36% reduction in number of incidents of violence led to a 49% reduction in costs associated with violence.’
These are fantastic wins and demonstrate what can be achieved with organisation-wide improvement.
Preconditions for success in organisation-wide improvement: line up the key elements to underpin success
Within trusts in England that have been successful with their Care Quality Commission (CQC) ratings, it would seem that there were already in place champions who have helped to line up the required resources for quality improvement. They have also made sure that the key elements are in place to underpin the organisational approaches to improvement.
The Health Foundation says that QI ‘consists of an overarching improvement vision that is understood and supported at every level of the organisation,’ which would imply that to ensure organisation-wide improvement in healthcare, buy in from the board and support from staff is needed.
As one of the goals of QI is ‘to reduce unwanted variation and remove waste from the system, through supporting teams to focus on what matters to their patients'. you also need the culture in the organisation to be right.
What are the barriers to organisation improvement and successful QI?
In England, the sheer size of NHS trusts can be a barrier – that and the complex way they are set up, often with many sites for one trust. Pressures on finance can also be a barrier, while the pressure on services, the rise in demand for care and shortages in, say, nursing staff can cause problems when trying to deliver an organisation-wide approach to improvement. QI can be overlooked, as it may not demonstrate immediate evidenced financial benefits.
The team at ELFT explain that if there are difficulties involved in the QI journey, this can be because of ‘the task of applying QI at scale within a healthcare organisation is not just about developing a new service or creating a new project, but about developing a new operating model for the entire organisation'.
Three case studies about key QI strategies
Here are some really successful projects taken from the Health Foundation report1, that have achieved organisation-level improvement while overcoming organisational improvement barriers.
East London NHS Foundation Trust (ELFT)
East London NHS Foundation Trust (ELFT) provides community health, mental health and specialist services to a population of 1.5 million people in East London, Bedfordshire and Luton. The trust’s QI programme began in 2014 and was given an outstanding rating by the CQC in September 2016. It managed this by getting a strategic, long-term, board-level commitment to QI, board-level leadership of quality, and investment in partnership with the Institute for Healthcare Improvement.
The team developed the ‘ELFT QI method’ to enable multidisciplinary teams, patients and carers to focus on the quality issues that mattered most to them. The team has trained over 3,500 people in four years at many different levels of the organisation. They have also used IT systems, such as Life QI, to give staff better access to the data they need to understand quality and performance and to support their QI projects effectively.
Northumbria Healthcare NHS Foundation Trust
Northumbria Healthcare NHS Foundation Trust employs more than 10,000 staff and provides care from 11 main sites, as well as from community sites and in people’s homes across North Tyneside and Northumberland. The trust was given an outstanding rating by the CQC in May 2016.
The trust has flourished in its QI improvement journey, by creating an ‘executive lead’ for QI, who is supported by clinicians and managers with formal QI training as well as ‘flow coaches’. The trust also created a QI strategy which seeks to balance local and national guidelines. It also set up a ‘quality lab’ and each year focuses on a small number of core priorities in the quality sphere. During 2018 and 2019 these were: sepsis, frailty, patient flow, falls, and patient and staff experience.
Western Sussex Hospitals NHS Foundation Trust
Western Sussex Hospitals NHS Foundation Trust operates three hospitals and a range of community services, including GP surgeries. It employs 7,000 staff and has an annual income of £435m. It was given an outstanding rating by the CQC in December 2015. In addition, in 2016, the trust’s chairman, chief executive and executive directors also took on the leadership of neighbouring Brighton and Sussex University Hospitals Trust, whose CQC rating has since risen from inadequate to good.
The trust created a trust-wide transformation programme called ‘Patient First’, with an aim to make continuous improvement part of all staff members’ everyday role, to empower them and enable them to drive change. They also established a ‘Kaizen Office’ (a concept of the Toyota Production System) which has a dedicated team to ensure a consistent, sustainable, trust-wide approach to improvement.
The trust aligned its workforce strategy with its QI approach using a patient-first concept and developed a capability-building programme to equip staff with the skills to deliver continuous improvement, with training available for every staff member.
These excellent examples of organisational-wide improvement demonstrate exactly what is possible – as well as the challenges which can be overcome – when adopting an organisational approach to improvement. The culture within an organisation is rightly also recognised as vital to embedding quality improvement, as well as having the right staff with the right level of skills. There are systems in place that can help you on your journey – and you can also learn from other health care organisations from their successful improvement programmes.