Evidence:Overcomingchallengesto improvingqualityLessons from the Health Foundation’s improvementprogramme evaluations and relevant literatureApril 2012Identify Innovate Demonstrate Encourage
This research was commissioned and funded by the Health Foundation to help identify where and howimprovements in healthcare quality can be made. The views expressed in this report do not necessarily representthe views of the Health Foundation.This research was managed by:Emma Henrion, Senior Evaluation Manager andJonathan Riddell Bamber, Research and Development ManagerThe Health Foundationjonathan.firstname.lastname@example.org 7257 8000An article based on this research, ‘Ten challenges in improving quality in healthcare: lessons from the HealthFoundation’s programme evaluations and relevant literature’ by Mary Dixon-Woods, Sarah McNicol and GrahamMartin, is published in BMJ Quality & Safety, http://qualitysafety.bmj.com (doi:10.1136/bmjqs-2011-000760)AuthorsMary Dixon-Woods,Sarah McNicol,Graham Martin 2012 Health FoundationEvidence: Overcoming challenges toimproving quality is published by theHealth Foundation, 90 Long Acre, LondonWC2E 9RAISBN 978–1–906461–38–6OrganisationSocial Science Applied toHealthcare Improvement Research(SAPPHIRE) Group, Departmentof Health Sciences, University ofLeicesterContactUniversity of Leicester,Adrian Building, University Road,Leicester LE1 7RH.email@example.com;0116 229 7262
ForewordFor nearly ten years, the Health Foundationhas been working with the NHS to deliverimprovement through service and staffdevelopment programmes. Our programmestest out new ideas for improving the quality ofhealthcare. Our aim is to take the best ideas –those that we can prove really make a difference toimproving the quality and safety of patient care –and encourage uptake throughout the NHS.Almost uniquely, we believe, we have consistentlyevaluated these improvement programmes and thedifference they make. We evaluate our programmesto provide sound evidence of their impact, andto better understand how the impact has beenachieved – or not. These evaluations have providedimportant insights into the interventions beingtested, and have demonstrated many successesachieved by the programmes. For example:– The Safer Patients Initiative heightenedmanagerial awareness of, and commitmentto, patient safety and created organisationalunderstanding about how to implement safetyimprovement efforts.– The two Engaging with Quality programmesshowed that peer-led improvement processessecured effective clinician engagement. TheEngaging with Quality Initiative secured theattention of the royal colleges and professionalbodies, which reported immediate consequencesin organisation and practice, and also that theprogramme had either ‘catalysed’ or supportedlonger-term trends towards involving them inquality improvement.As those actively involved in improvement workwill know, bringing about the change in behaviourand practice necessary to improve quality can be– Co-Creating Health’s self managementhard and slow. Despite the many successes of theprogramme for patients improved theiractivation (knowledge, skills and confidence for programmes we have supported, teams frequentlyencounter obstacles to achieving their originalself-management), as well as their use of selfgoals. The question this posed for us was whether,management skills. There were also improvementsby identifying and better understanding somein condition-specific outcomes and quality of life.of the common challenges, it would be possible– Participation in our leadership programmesto develop a set of evidence-based approacheshas catalysed improvements. For example, thefor successfully overcoming these challenges toShared Leadership for Change programmeimproving quality. Our interest was not in thepros and cons of different technical methods ofmeant that a team from Carmarthenshireimprovement, but on the factors that affect theDiabetes Network successfully moved routinelikelihood of methods being applied and newdiabetes care from secondary to primary care,resulting in dramatic reduction in waiting times interventions adopted.from 12 months to no wait for new secondarycare appointments.OVERCOMING CHALLENGES TO IMPROVING QUALITYi
To answer this question, we commissionedProfessor Dixon-Woods to conduct a review ofour evaluations to date and identify the barrierscommonly encountered by project teams whendoing improvement. The resulting report providesan engaging and cogent analysis of the keychallenges facing people doing improvement – andwhat has been shown to work, both in practice andin the wider literature, to overcome them.Debate about the contribution improvementapproaches can make to the quality and value ofhealthcare is ongoing. Improvements in safety,effectiveness and patient experience are seenas necessary to meeting the resource challengefacing healthcare. Yet, too often, the benefitsimprovement interventions demonstrate in ‘study’conditions have fallen short of expectations whenapplied at scale. This report highlights the factorsthat need to be addressed in order to increasethe success of improvement efforts. As such, itshould be required reading for anyone leadingimprovement work.So, what might be done differently as a result of theinsights presented here?The findings emphasise the importance of thoseleading improvement work taking time to reflectbefore starting an improvement programme. Theyneed to plan carefully and recognise the multipleinter-dependent factors that need to be takeninto account for improvement programmes to beeffective. It is also necessary to ensure that projectlanguage and structures do not inadvertentlyalienate those that will be depended upon forsuccess. Of particular importance is the timeneeded to establish the evidence base for change,allowing space for participants to debate and tobuild genuine ownership. Getting measurementright is also vital, but always takes more time thanpeople anticipate.The report concludes that structured improvementis complex and takes time and, unless theconditions for success are in place, is unlikelyto fully achieve set objectives. This reinforcesthe importance of the role that organisation andsystem leaders play in supporting successfulimprovement efforts. They need to ensure thatsufficient time and resource is providediiTHE HEALTH FOUNDATIONto enable those at all levels in the organisationto devote time to improvement projects. Theyneed to nurture a culture that motivates a multiprofessional approach to improvement and strikesthe right balance between appealing to people’sinternal motivators and using externally definedrequirements to drive improvement.For many, these findings won’t be new. However,they may well resonate with tacit knowledge aboutimprovement work. The value of this report isthat it provides an evidence base for the factorscontributing to successful improvement.As a major funder of improvement programmes,The Health Foundation itself has found muchhere to inform our future work. The findingsare shaping both how we support individualimprovement programmes, as well as the widerstrategic focus of our work. In our improvementprogrammes we are placing a much greateremphasis on the need for projects to have a cleartheory of change, a strong evidence base and foractive senior leader engagement and commitment.We are building in much more time for planningand set-up, and for an objective and criticalanalysis of the nature of the challenge beingaddressed by each project.Part of our strategic focus is to contribute todeveloping the emerging academic disciplines ofimprovement science in order to build a strongerevidence base for what works in improving quality.We also have a number of improvement programmesthat explicitly set out to change the widerorganisational context for improvements in quality.With the major challenges currently facinghealthcare, improving quality is more important thanever. However, there can be extra pressure to makechange happen immediately, as well as the healthsystem’s cultural bias to jump to implementation.This report shows that if you take the time to getan intervention’s theory of change, measurementand stakeholder engagement right, this will deliverthe enthusiasm, momentum and profound resultsthat characterise improvement at its best.Stephen Thornton,Chief Executive,The Health Foundation
ContentsExecutive summaryvChapter 1: Introduction1Chapter 2: Approach and methods3Chapter 3: Findings: factors affecting improvement5Theme 1: Design and planning6Theme 2: Organisational and institutional contexts, professions and leadership11Theme 3: Sustainability, spread and unintended consequences19Chapter 4: Key issues in overcoming the challenges to improvement23Chapter 5: Conclusions29Appendix: Summary of reports reviewed31References34OVERCOMING CHALLENGES TO IMPROVING QUALITYiii
ivTHE HEALTH FOUNDATION
Executive summaryImproving quality in healthcare is intrinsicallya good thing to do and efforts to makeimprovements should be commended. However,improvement is not easy. Though there aresome examples of demonstrable, real and lastingimprovements in the care provided to patients,1the effectiveness of improvement initiatives ismore often inconsistent and patchy. Over time, theHealth Foundation has assembled an impressiveportfolio of improvement programmes and, in aperhaps unique contribution to advancing the fieldof improvement, has ensured that each is evaluated –mostly independently. We report here a synthesis oflearning from the Health Foundation’s evaluationsof its improvement programmes. We set this in thecontext of the broader academic literature, seeking todraw out lessons for those engaged in improvementactivities in the NHS and other health systems.Theme 1: Design and planningThe evaluation reports are necessarily definedby the nature of the improvement programmesthemselves, which can be broadly categorised asones which aim to improve:Challenge 3: Getting data collection andmonitoring systems rightRigorous design and planning of improvementinterventions is crucial to their prospects of success.Challenge 1: Convincing people thatthere is a problemUse hard data to demonstrate the extent of theproblem and patient stories and voices to secureemotional engagement. Use peer-led debate anddiscussion.Challenge 2: Convincing people that thesolution chosen is the right oneCome prepared with clear facts and figures, haveconvincing measures of impact, and be able todemonstrate the advantages of your solution.Involve respected senior figures.– patient safetyThis always takes much more time and energy thananyone anticipates. It’s worth investing heavilyin data from the outset. External support may berequired. Assess local systems, train people, andhave quality assurance.– integrated approaches to self-managementof long-term conditions.Challenge 4: Excess ambitions and‘projectness’Although our findings are limited by the scopeof these evaluations, a number of importantlessons emerge that are likely to be useful for mostimprovement efforts. Within three main themes,we have identified 10 challenges to improvementthat consistently emerge, and have suggested waysto overcome them, summarised below.Over-ambitious goals and too much talk of‘transformation’ can alienate staff if they feel thechange is impossible. Instead, match goals andambitions to what is realistically achievable andfocus on bringing everyone along with you. Avoidgiving the impression that the improvement activityis unlikely to survive the time span of the project.– leadership– clinical engagementOVERCOMING CHALLENGES TO IMPROVING QUALITYv
Theme 2: Organisationaland institutional contexts,professions and leadershipOrganisational and institutional contexts,including leadership and professional behaviourand culture, can have a profound impact on theprospects of improvement efforts. It is importantto ensure that these enhance, rather than inhibit,improvement.Challenge 5: The organisational context,culture and capacitiesStaff may not understand the full demands ofimprovement when they sign up, and teaminstability can be very disruptive. Explainrequirements to people and then provide ongoingsupport. Make sure improvement goals are alignedwith the wider goals of the organisation, so peopledon’t feel pulled in too many directions. It isimportant that the organisational culture supportslearning and development.Challenge 6: Tribalism and lack of staffengagementOvercoming a perceived lack of ownership andprofessional or disciplinary boundaries can bevery difficult. Clarify who owns the problem andsolution, agree roles and responsibilities at theoutset, work to common goals and use sharedlanguage. Intermediaries, such as training staff, arelikely to have a role here. Protected staff time mayhelp to secure engagement.Challenge 7: LeadershipGetting leadership for quality improvement rightrequires a delicate combination of setting outa vision and sensitivity to the views of others.‘Quieter’ leadership, oriented towards inclusion,explanation and gentle persuasion, may be moreeffective. This may require additional training.viTHE HEALTH FOUNDATIONChallenge 8: Balancing carrots andsticks – harnessing commitment throughincentives and potential sanctionsRelying on the intrinsic motivations of staff forquality improvement can take you a long way,especially if ‘carrots’ in the form of incentives areprovided – but they may not always be enough.It is important to have ‘harder edges’ (sticks)to encourage change, but these must be usedjudiciously and are likely to require the support ofsenior executives, professional bodies and thosedesigning reward structures.Theme 3: Sustainability, spreadand unintended consequencesSustainability and spread of improvementinitiatives are key challenges. Improvement isvulnerable to an ‘evaporation effect’, particularlyonce projects have been completed.Challenge 9: Securing sustainabilitySustainability can be vulnerable when efforts areseen as ‘projects’ or when they rely on particularindividuals. From an early stage, projects need toidentify future funding sources, or identify ways touse resources more efficiently in order to sustainimprovements. Successful outcomes should bewritten into standards, guidelines and proceduresto ensure they are embedded in routine activities.Challenge 10: Considering the sideeffects of changeIt’s not uncommon to successfully target oneissue but also cause new problems elsewhere. Thiscan cause people to lose faith. Be vigilant aboutdetecting unwanted consequences and be willingto learn and adapt.
In overcoming the challenges to improvement,it is important to avoid nihilism. Improvementis hard, but not impossible. Many challenges canbe overcome if they are recognised and managedeffectively. The following can be done to optimiseimprovement efforts.– Resist organisational impatience for quickwins and early results, since it can havemany negative effects on the authenticity ofimprovement, and encourage poorly planned,poorly evidenced and unsustainable approachesto improvement.– Recognise that there is no magic bullet.Making progress requires negotiating manycramped channels.– Manage the ‘project status’ of improvementinterventions carefully.– Secure the engagement of multiple stakeholdersusing numerous approaches, many of themapparently contradictory: strong leadershipalongside a participatory culture; direction andcontrol but also flexibility according to localneed in implementation; critical feedbackon performance without attaching blame.– Tame the urge to action by ensuring that timeis dedicated to planning and design, andrecognise that knowing that there is a need toimprove care does not mean knowing how toimprove care.– Make careful assessment of organisationalreadiness, resource requirements and thecommitments needed from staff. All of these arevital at the outset of projects, as this is a periodof development, piloting and testing. However,they continue to be important throughoutimplementation to avert disenchantmentand disengagement as the scale of the tasksbecomes apparent.– Account for the ways in which organisationaland institutional contexts can pose ongoingthreats to improvement activity, particularlywhen they involve personnel changes ororganisational stresses that erode the time andenthusiasm for activities.– Balance the temptation to focus on settingsmost likely to be receptive to improvement withthe risk that such an approach may reproduceinequities by increasing delay to improvementin less fertile settings.– Gain consensus and build coalitions. Obtainingthe support of one group of stakeholders mayrisk alienating another; finding agreementon the problem to be addressed and creatingcoalitions of multiple professional groups areimportant tasks of improvement. Interventionsthat ‘go with the grain’ and offer a clearlydemonstrable advantage over current practicesare especially likely to succeed.– Coordinate actions at multiple levels, seekingto influence multiple stakeholders, to ensureimprovement that engages, incentivises andendures.– Remain vigilant about the potential unwantedeffects of improvement, and respond to themflexibly and appropriately.OVERCOMING CHALLENGES TO IMPROVING QUALITYvii
Chapter 1IntroductionImprovement in healthcare poses importantchallenges. Even the definition of what‘improvement’ means escapes consensus. Perhapsthe most useful definition is that offered byBatalden and Davidoff:Many in healthcare today are interestedin defining ‘quality improvement’. Wepropose defining it as the combined andunceasing efforts of everyone – healthcareprofessionals, patients and their families,researchers, payers, planners andeducators – to make the changes that willlead to better patient outcomes (health),better system performance (care) andbetter professional development.2These authors use the term ‘quality improvement’.This is a term that tends to be used in differentways by different people in different contexts, andis often associated with particular methodologies.Because we are interested in improvement inhealthcare broadly, and in keeping with the spiritof Batalden and Davidoff ’s definition, we will usethe term ‘improvement’ to encompass the wholerange of purposeful, directed attempts to securepositive change in health systems.Though there are some examples of demonstrable,real and lasting improvements in the care providedto patients,1 the effectiveness of improvementinitiatives is more often inconsistent and patchy.The improvement field is replete with examplesof interventions, initiatives and programmes thatworked well in some settings but floundered whenintroduced elsewhere. Organisational context isoften the deal-breaker in making positive changehappen in healthcare. As scientific understandingof improvement has developed, attention hasturned increasingly to trying to explain whatcauses this variability in organisational response.3-6Over time, the Health Foundation has assembledan impressive portfolio of improvementprogrammes and, in a perhaps unique contributionto advancing the field of improvement, has ensuredthat each is evaluated – mostly independently.The programmes have diverged in their scope andremit, but all are united by their focus on technicalskills, leadership, capacity, knowledge and the willfor change. They therefore meet the definition of‘improvement’ that we offer above. The evaluationreports represent a valuable resource, providinginsights into the challenges and opportunitiesof improvement and how they are influenced bydifferent healthcare organisational contexts.In this report, we provide a synthesis and reviewof the findings of these evaluations as they relate tofactors that constrain and facilitate improvement.We set the learning from the evaluation reportsin the context of the wider literature, and seekto draw out the lessons for those responsible fordesigning and implementing improvement inthe NHS.OVERCOMING CHALLENGES
Debate about the contribution improvement approaches can make to the quality and value of healthcare is ongoing. Improvements in safety, effectiveness and patient experience are seen as necessary to meeting the resource challenge facing healthcare. Yet, too often, the benefits improvement interventions demonstrate in ‘study’ conditions have fallen short of expectations when applied at .