Public Hospital Services > Counties Manukau Health >

Counties Manukau Health Library Database & Resource Directory

Public Service, Other

Innovation and Improvement Spotlight: an archive of MUST reads

*The Innovation and Improvement Clearinghouse is a Ko Awatea resource supporting health system innovation and improvement.






Quality Improvement Coaching
Life QI

Quality improvement projects can be rewarding, however, they can also be difficult and you can run into challenges along the way. By coaching QI teams, you can talk through their difficulties and clarify the next steps. We’ve put together a cheatsheet for you to use during your QI coaching sessions. This QI coaching cheatsheet gives you a guideline and we provide you with some useful questions to ask during the coaching to facilitate your work.


'Sustaining quality improvement efforts: emerging principles and practice'

BMJ Editorial

Do we care if a quality improvement (QI) innovation is effective, if it is not sustained? This uncomfortable question is increasingly important as healthcare is judged (and reimbursed) on ‘quality’ and ‘value’. Often, a sentinel safety event or dip in performance on a quality measure tied to reimbursement spurs a ‘quick fix’ mentality. However, considering how to ‘fix the problem’ in such a way that it is permanently fixed—in other words—that the ‘fix’ becomes part of everyday practice routines, is essential. This is not easy. Reviews of the extant literature point out how little we know about how to do this successfully and conceptual models drawing on this literature also vary widely in what they consider to be important key contributors to sustainability.  When empirical literature does exist, it often demonstrates the lack of sustainability of QI interventions, and almost no studies describe how QI interventions became adopted in practice and why.




We are in a 'hospital-at-home' revolution. How do we prevent it from becoming 'hospital 2.0?'

The Advisory Board

Despite decades of global evidence, hospital-at-home models remained in “pilot phase” until last year. But Covid-19 changed that: providers everywhere are now rushing to implement and scale models of their own. Read on to learn about the biggest pitfall acute providers run into when scaling their programs, and three tips on how to avoid it.


Five things we learned from our work on NHS productivity

Health Foundation

Maximising productivity is critical if the NHS is to survive the pressures it faces in the aftermath of COVID-19 and from the long-term growth in demand for health care. Our new long read highlights practical changes that can improve productivity, and suggests policy also needs to pay attention to whether health care organisations are ready and able to shift to new ways of working. Here we summarise the key learning points. 


Editorial: Sustaining quality improvement efforts: emerging principles and practice (Robert E Burke, Perla J Marang-van de Mheen)

BMJ Quality & Safety

Do we care if a quality improvement (QI) innovation is effective, if it is not sustained? This uncomfortable question is increasingly important as healthcare is judged (and reimbursed) on ‘quality’ and ‘value’. Often, a sentinel safety event or dip in performance on a quality measure tied to reimbursement spurs a ‘quick fix’ mentality. However, considering how to ‘fix the problem’ in such a way that it is permanently fixed—in other words—that the ‘fix’ becomes part of everyday practice routines, is essential. This is not easy.

Reviews of the extant literature point out how little we know about how to do this successfully1–4 and conceptual models drawing on this literature also vary widely in what they consider to be important key contributors to sustainability.5–9 When empirical literature does exist, it often demonstrates the lack of sustainability of QI interventions,10 11 and almost no studies describe how QI interventions became adopted in practice and why.


Evaluating diabetes care quality improvement strategies used by clinical teams in five primary care practices in New Zealand

New Zealand Medical Journal

Despite the rapid growth of evidence on quality improvement (QI) strategies for improving diabetes care, much research has focused on single strategies, whereas, in typical practice, multiple strategies are used concurrently.




Setting up an emergency medical task force to manage the demands of COVID-19: experiences of a London teaching hospital

BMJ Leader

A centralised COVID-19 team was established on 16 March within the postgraduate medical education (PME) centre to address varied facets of the redeployment response. The ‘COVID-19 PME task force’ consisted of doctors from multiple specialties and different levels of training. Initially tasked with leading the design of COVID-19 rotas for over 400 junior doctors, it became apparent that the group could lead on many aspects of the hospital’s response. The task force developed a comprehensive, collaborative and adaptable leadership approach, aiming to empower each member to realise solutions to matters arising in real-time regardless of seniority.




Making Sense of Multiple Frameworks: How to Enable Whole System Quality


The recent IHI white paper provides a more holistic approach to quality management that enables organisations to close the gap between the quality that customers are currently receiving and the quality that they could be receiving.

Based on the Juran Trilogy, the whole system quality (WSQ) approach provides guidance for integrating quality planning, quality control, and quality improvement activities across multiple levels of the system.

Two pre-requisites are needed for the integrated WSQ operating system to be successfully deployed:

A well-aligned quality strategy that provides a clear line of sight to customer needs, a vision of a future state of quality, and a commitment to methods and resources that ensure quality; and

A learning culture that supports an organization-wide pursuit of quality through leadership and management practices that facilitate knowledge exchange and foster a culture of learning.


Nine Lessons Learned From the COVID-19 Pandemic for Improving Hospital Care and Health Care Delivery 

As the COVID-19 pandemic passes (in many locations) from a crisis phase into one of increasing vaccination rates and a focus on variants a number of “lessons learned” or “building back better” pieces have been appearing. This piece written from a New York City perspective offers 9 lessons for improving hospital care and health care delivery. The authors acknowledge the advent of telehealth and offer these nine in addition:

  1. Prepare for Unexpected Increases in Demand for Services
  2. Maintain Line of Sight
  3. Mind the Air
  4. Emotionally Support Health Care Workers
  5. Masks Forever (at Least for Some)
  6. Use Technology to Connect Families Near and Far
  7. Maintain Caches of Supplies and Diversify Supply Chains
  8. Reduce the Burden of Unnecessary Documentation
  9. Address Persistent Racial and Ethnic Disparities in Health.


Connecting care: Improving service transitions – Top tips
The national mental health and addiction (MHA) quality improvement programme is working with Connecting care project teams from New Zealand district health boards to improve transitions between services for MHA consumers and support a change in reporting requirements. Some providers are making great progress but there is more to be done. To support those engaged in ongoing improvement work in service transitions, the Health Quality & Safety Commission has summarised some top tips and examples from provider project teams in this document.




Putting improvement in everyone's hands: opening up healthcare improvement by simplifying, supporting and refocusing on core purpose'

Healthcare Management

Quality improvement is increasingly being used within healthcare as an operating model to empower and enable teams of staff and service users at the point of care to find solutions to complex quality and safety issues. Adopting quality improvement methods in healthcare poses several challenges, and many healthcare providers have faced barriers in embedding a culture that nurtures and supports a systematic approach to problem-solving at the point of care. This article proposes a simple framework with three components to help healthcare systems avoid the common barriers to introducing quality improvement interventions. First, simplify the language and accentuate the similarities between methods. Second, support those applying quality improvement with skilled, accessible improvement expertise and applying evidence-based adult education theories. Third, design quality improvement interventions so that they strengthen a shared purpose by allowing teams to decide what to prioritise and involving patients and family members as equal partners in quality improvement work.


Posters presented at the 2021 Sustainable Healthcare and Climate Health Aotearoa conference. (2021)

Biophilic design in healthcare and rehabilitation
Collaborative research on climate change health impacts as a mitigation tool
Developing an Australian Glossary on Health and Climate Change 
Empowering the New Zealand frontline
Reducing desflurane usage at the Sunshine Coast University Hospital
Room Service, Mercy Hospital’s journey to introduce a sustainable, waste reducing model of food service for in-patients 
Towards environmentally sustainable healthcare: a new frontier for dietitians


Reducing the MRI outpatient waiting list through a capacity and demand time series improvement programme

New Zealand Medical Journal

In 2018 an additional magnetic resonance imaging (MRI) machine was purchased, bringing the Counties Manukau District Health Board (CMDHB) total to three. This increase in physical capacity had not reduced the waiting list as expected and, despite outsourcing 60 scans per week to private providers, the backlog and waiting times for MRI scans were increasing




General resources for quality improvement projects on diabetes [Health Quality & Safety Commission]
Resources from around the country that providers may find useful to assist them in their work to improve the management of diabetes.


Case study: Improving health services to meet the needs of Māori [Health Quality & Safety Commission]
This case study looks at the work of Chadwick Healthcare in Tauranga to improve health services to better meet the needs of the Māori population and improve health outcomes for Māori. By working in partnership with Māori patients and local Māori service providers, Chadwick Healthcare was able to increase engagement with Māori and its enrolled Māori patient population


Virtual sessions from the February 2021 Quality improvement scientific symposium

Health Quality and Safety Commission

In lieu of an in-person symposium in 2020, the Health Quality & Safety Commission hosted a series of virtual one-hour webinars during February 2021. Each session featured a keynote speaker, a rapid-fire presentation and an opportunity for Q&As. Includes an excellent keynote presentation by Pat Snedden, Board Chair, Auckland DHB:  ‘Should we still be arguing about equity?


Leadership and innovation during Covid-19: lessons from the Cardiff and Vale Health System


Early in the Covid-19 pandemic, clinicians at the Cardiff and Vale University Health Board realised that they would have to make rapid changes to prevent the widespread cancellation of elective surgery. A core team of staff started meeting in a lecture theatre every morning and evening to work on the redesign. They fell into a particular ‘battle routine’: identifying problems in the morning, coming up with solutions by lunchtime and presenting the proposals back to colleagues in the evening.


Views: David Oliver: The pandemic has delivered clinical service innovations worth keeping


“The NHS’s response to the covid-19 pandemic has shown how necessity can be the mother of innovation. Although plenty has gone wrong in national policy,1 and while frontline services have experienced considerable difficulties,2 the crisis has also accelerated and enabled the adoption of some practices we might actually like to keep”


Sustaining quality improvement efforts: emerging principles and practice

BMJ Quality and Safety

Do we care if a quality improvement (QI) innovation is effective, if it is not sustained? This uncomfortable question is increasingly important as healthcare is judged (and reimbursed) on ‘quality’ and ‘value’. Often, a sentinel safety event or dip in performance on a quality measure tied to reimbursement spurs a ‘quick fix’ mentality. However, considering how to ‘fix the problem’ in such a way that it is permanently fixed—in other words—that the ‘fix’ becomes part of everyday practice routines, is essential.

Improving our understanding how to successfully sustain QI improvements

Although not explicitly requested as part of SQUIRE guidelines, we recommend QI interventions report with a description of the intervention and also how it was designed to be sustainable, ideally by using a sustainability framework that can help teams explicitly address this requirement.4 Second, we encourage QI interventionists to ensure that the duration of study is long enough to assess sustainability— something unfortunately uncommon.1 If reported systematically, it will improve the evidence base and understanding on the underlying mechanisms by which QI interventions will become fully integrated in practice and sustained. However, what ‘counts’ as sustainment?2 We recommend evaluation similar to the Schechter et al study, to monitor sustainability at least 6 months and preferably a year following the active intervention. Such early data are likely sufficient to suggest if the intervention will not be sustained, giving a clear signal in this timeframe or recovery after an initial drop-off.

Evaluating how QI interventions are sustained is not just an academic exercise and does not just apply to individual practitioners. All health systems are increasingly measured and reimbursed based on ostensible quality or value. As others have aptly put it, ‘if we want more evidence-based practice, we need more practice-based evidence’.29 More publications like Schechter et al are needed to provide practice-based evidence that add to our understanding of how successful QI interventions are sustained over time. Such study is essential to healthcare systems becoming the high-quality and high-value systems so desperately needed.



Innovations during COVID

BMJ Innovations Journal
It is impossible to predict the impact of the innovations during the time of COVID-19. In addition to the paradigm shift in vaccine development, we have seen the widescale adoption of telemedicine and significant leaps forward in the application of artificial intelligence in disease prediction and diagnosis. Many innovations will fail, but many others will also have a lasting impact on health long after we have brought the COVID-19 pandemic under control.




Innovations in care for chronic health conditions. Productivity Reform Case Study

Productivity Commission
Canberra: Productivity Commission; 2021. p. 214.

Every so often the Productivity Commission ventures into the realm of health care. While such ‘intrusions’ may not always be welcomed by some in the health sector, they can include some interesting observations. This latest report from the Productivity Commission looked into chronic disease, particularly innovative approaches to managing chronic health conditions. Many Australians have chronic conditions and they can come at a high cost to individuals and the health system (and those who fund it). This report uses a number of case studies to examine how chronic disease may be better managed for both better outcomes, less complications and lower costs. The Productivity Commission considers that these innovations improve people’s wellbeing and reduce the need for intensive forms of health care, such as hospital admission. They achieve this through improved responsiveness to consumer preferences, greater recognition of the skills of health professionals, effective collaborative practices, better use of data for decision making by clinicians and governments, and new funding models that create incentives for better management or prevention of disease. One of the points of the report is that these case studies reflect local highlights and that, as the William Gibson quote has it, “The future is already here – it's just not evenly distributed.” The hope of the report then is that these particular futures are more widely distributed. The report notes that substantial barriers exist to the development and broader diffusion of healthcare innovations. These include that innovation too often relies on dedicated individuals and that funding does not always encourage investment in innovation and improvement.




Life QI Blogs



Collaborative working and communication in healthcare

Collaboration and communication are really important in healthcare, and in this article, we look at why teamwork is so important in successful QI projects.

Read more.


Reward and recognition as motivators in healthcare

Recognising and rewarding team members for their participation, hard work and going ‘above and beyond' can be a powerful motivating factor. See how you can use it in healthcare. 

Read more.


How QI training plays part in building engagement

Training for Quality Improvement might seem like a daunting task, but there are different methods and  tools you can use for shared learning and to get your team engaged and motivated.

Read more.


Creating a culture of continuous improvement

Building a culture of improvement requires consistency and dedication, but provides great rewards, including a range of improved patient safety and quality outcomes.

Read more.


How to motivate staff for quality improvement

There is a wide range of tools and methods, such as intrinsic motivation, purpose, autonomy and mastery, all of which will help motivate colleagues to improve.

Read more.


January / February


IHI Forum 2020: Three Big Ideas

This year's Institute for Healthcare Improvement Forum covered a range of topics, including quality improvement, health equity, population heath, patient safety, joy in work, and telemedicine.

There are six primary factors that impact the adoption of quality improvement initiatives such as end-user participation and resource availability.

To help ensure success, the first step in quality improvement initiatives should be engaging frontline staff as well as patients and their families.

During a crisis, healthcare organizations should provide "psychological personal protective equipment" for individual staff members and team leaders.


Developing improvement skills, aligning activities and sustaining an organisation-wide approach to QI

An organisational approach to QI is proving ever more important in healthcare today. This approach aims to embed a culture of continuous improvement and learning across the organisations to achieve sustained improvement in the quality and experience of care. 

This month the team at LifeQI show you how an improvement vision shared by every level of the organisation can help you gain traction and show a lasting impact.


The importance of organisation-wide improvement in healthcare

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).


QI Readiness - How do you know you are ready for Quality Improvement?

With Quality improvement (QI) rightly being a key focus in health care today, how do you know when you and your organisation are ready for real change? In B Weiner’s article, ‘A theory of organizational readiness for change’[1], QI readiness is described as ‘a shared psychological state in which organizational members feel committed to implementing an organizational change and confident in their collective abilities to do so.’ This might seem like quite a feat – but there are tools and processes available to you which will help you assess your organisational readiness for change.


Board support for the improvement journey

Recent studies have shown the link between board commitment to quality improvement (QI) and better patient outcomes, demonstrating that if you want to be successful in embedding transformational change within your organisation, securing board support for your improvement journey is absolutely crucial.

In our last article we explored approaches to finding gaps in organisational skills before starting your QI journey. Now we’re going to be looking more specifically at ways you can secure your board support for improvement, in order to achieve QI success.






Avoiding unnecessary hospitalisation for patients with chronic conditions: a systematic review of implementation determinants for hospital avoidance programmes

Implementation Science. 2020;15(1):91.

 The issues of avoidable or ‘potentially preventable’ hospitalisations has interested many, particularly policymakers. If only there was a way of identifying and then reducing these hospitalisations, then the costs of operating hospitals could be curtailed (apparently). A glib answer may be to enable better provision and access to primary care. This study sought to examine the implementation of those programmes that have been attempted to reduce ‘unnecessary hospitalisations’. The systematic review focused on 13 articles covering 14 studies with thematic synthesis identifying 23 determinants of implementation. The authors found that ‘Availability of resources’, ‘compatibility and fit’, and ‘engagement of interprofessional team’ were the most prominent determinants and that the most interconnected implementation determinants were the ‘compatibility and fit’ of interventions and ‘leadership influence’ factors.


Enhancing patient involvement in quality improvement: How complaint managers see their roles and limitations

Patient Experience Journal

Patient involvement is a priority for healthcare organizations seeking to improve the quality of care and services. The contribution that complaint handling can make towards quality improvement has remained underexplored, while healthcare organizations are implementing strategies to effectively involve patients in quality improvement. We conducted a qualitative study to understand how complaint managers see their roles and limitations in enhancing patient involvement in quality improvement. A convenience sample of eleven complaint managers was selected from nine Canadian healthcare organizations with various annual volumes of complaints and situated in different settings (urban, rural, and semi-urban). The data were analyzed using a hybrid deductive-inductive approach with QDA Miner. The complaint managers saw themselves as having multiple roles that enhanced patient involvement in quality improvement: ensuring mediations with patients and clinical teams, monitoring improvements following a complaint, and informing the quality improvement and operations teams about the patients’ experiences. The complaint managers also reported limitations in their roles, such as the need to respect confidentiality that excluded patients from decisions about improvements and their hierarchical independence in the organization that kept them away from continuous quality improvement activities. Interestingly, the participants reported using new, promising practices that helped integrate, both retrospectively and proactively, the patients’ perspectives on quality improvement. Complaint handling can be effective, though it is a seldom-used gateway for integrating the patient’s voice in quality improvement. Several challenges need to be addressed to make complaint handling a more substantial element in the strategies for involving patients in healthcare organizations


An overview of reviews on strategies to reduce health inequalities

International Journal for Equity in Health (2020)

The strategies that facilitate the reduction of health inequalities must be intersectoral and multidisciplinary in nature, including all sectors of the health system. It is essential to continue generating interventions focused on strengthening health systems in order to achieve adequate universal health coverage, with a process of comprehensive and quality care.




Reflections on organisational development during Covid-19: restoring purpose and driving change

KingsFund (blog)

The King’s Fund’s Advanced Organisational Development (OD) programme brings together experienced OD, leadership and HR professionals to develop OD capability in the health and care system. During the peak of the Covid-19 pandemic, we hosted bi-weekly meetings with alumni participants of the programme, offering the group space to make sense of their experience.

Some of the reflections we heard are shared in this blog – the unexpected outcomes of the pandemic, which, amid the disruption, served to remind the group that change really can happen; the crucial future focus for OD; and the determination for OD to create a future based on social justice.

A Guide to Patient Safety Improvement: Integrating Knowledge Translation & Quality Improvement Approaches
Canadian Patient Safety Institute (2020)
When it comes to patient safety, a substantial body of evidence exists to demonstrate interventions (leading practices and processes) that lead to improved patient outcomes for numerous healthcare conditions. Despite available evidence, practice changes are not implemented consistently and effectively to support organizations and teams to address patient safety challenges.

This resource has been designed to support teams across all healthcare sectors in using a Knowledge Translation and Quality Improvement integrated approach to change that will impact patient safety outcomes. This Guide for Patient Safety Improvement is intended to accompany current best available evidence change ideas, and tools and resources for your specific project. It includes ideal practice changes “the what” and strategies “the how” that creates the evidence-based intervention. Adaptations are expected and important considerations for implementation will be provided in this guide.


September / October


What influences improvement processes in healthcare? A rapid evidence review

 RAND Corporation

The Healthcare Improvement Studies (THIS) Institute commissioned RAND Europe to conduct a rapid evidence review of the academic and grey literature, to draw out initial learning about what influences quality improvement processes in healthcare, and to inform potential themes to explore in future research.

Key Findings

We identified and reviewed 38 academic and 16 grey literature publications covering diverse improvement approaches. Some examples include Six Sigma, Lean, Business Process Reengineering, Plan-Do-Study-Act, clinical audits and feedback, quality improvement collaboratives and peer-learning communities, training and education interventions, and patient engagement and feedback-related interventions.

Key influences on improvement processes in healthcare

Based on the reviewed literature, six key factors influence the implementation of improvement efforts:

Relationships and interactions that support an improvement culture
Skills and competencies
Use of data
Patient and public involvement, engagement and participation

Working as an interconnected system of individuals and organisations, influenced by internal and external contexts
This review also attempted to go beyond identifying these high-level influences by explaining what specific aspects of the influencing factors are important for quality improvement. The report provides a detailed analysis of influencing factors across the six categories outlined above, as well as summary tables for each.


von Thiele Schwarz, Ulrica, et al. "How to design, implement and evaluate organizational interventions for maximum impact: the Sigtuna Principles." European Journal of Work and Organizational Psychology (2020): 1-13.

This paper presents ten principles that could contribute to the transformation of how organizational interventions are researched, and thereby increase the potential real-world impact. We hope these principles spark interest in the entire intervention process, from the design and implementation to evaluation, and towards a mutually beneficial relationship between the need for robust research and the flexibility needed to achieve change in practice.


Hill James E., Stephani Anne-Marie, Sapple Paul, et al. "The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: a systematic review". Implementation Science 15.1 (19 Apr.2020): 1-14.

Current evidence suggests the benefits of CQI in improving health care are uncertain, reflecting both the poor quality of evaluations and the complexities of health services themselves. Further mixed-methods evaluations are needed to understand how the health service can use this proven approach.




Examining innovation in hospital units : a complex adaptive systems approach .

BMC health services research

This study tackles the debate about the influence of complexity on healthcare delivery, particularly innovation. Instead of being subject to the influence of complexity with no means of making progress or gaining control, hospitals looking to implement innovation programmes should provide guidance to teams and departments about the type of innovation sought and provide support in terms of time and management commitment.



Personalized Medicine, Disruptive Innovation, and “Trailblazer” Guidelines: Case Study and Theorization of an Unsuccessful Change Effort

The Milbank Quarterly. 2020 [epub].

Personalised medicine has been viewed as a possible future of medicine that can deliver more targeted and appropriate care. This piece in The Milbank Quarterly uses a particular case study – an ‘a so‐far unsuccessful attempt by academic respiratory medicine researchers to pave the way for a precision medicine approach to asthma using a government‐endorsed national guideline’ – to examine how change could be brought to care. The authors note that precision medicine approaches can be ‘disruptive’ and require ‘radical changes to clinical practice and service organization’. They discuss how ‘Clinical practice guidelines (theoretically, at least) can act as “trailblazers” to introduce tests and treatments that reflect precision medicine discoveries’ but advise caution and offer that: ‘“Trailblazer” guidelines, in which new technologies are recommended, may succeed as catalysts of change only in a limited way for interested individuals and groups. In the absence of a wider program of professionally led and adequately resourced change efforts, such guidelines will lack meaning, legitimacy, and authority among intended users and may be strongly resisted.’




10 leaps forward: innovation in the pandemic 

London South Bank University. School of Health and Social Care

We asked a broad mix of frontline, senior, board and middle leadership across different NHS sectors to reflect on their experiences. 

What we have heard is astounding. Almost overnight, for some people, the NHS has turned into a high performing health system. Within all the things staff want to keep are the key conditions of the very effective health systems around the world that we have aspired to be like for years. Many described digital innovation and that is part of it, but in reading the responses to the survey we found so much more. 


COVID-19: Patient Safety and Quality Improvement Skills to Deploy during the Surge 

International Journal of Quality in Health Care 

The COVID-19 pandemic has suddenly challenged many healthcare systems. To respond to the crisis, these systems have had to reorganize instantly, with little time to reflect on the roles to assign to their Patient Safety (PS) and Quality Improvement (QI) experts. In many cases, staff who had a background in clinical care was called to support wards and critical care. Others were deemed “non-essential” and sent back to work from home, while their programs were placed in hibernation mode. This has meant that many QI and PS experts with skills to offer in their field have ended up carrying out tasks unrelated to the current crisis. 

We believe that the skillset of patient safety and quality improvement personnel is essential for the successful implementation of the changes required to achieve the desired outcomes. An understanding of systems theory and the complexity of healthcare systems, human factors and reliability theories, and change methodologies is key to the success of any transformation program. 

Here, we suggest a five-step strategy and actions through which PS and QI staff can meaningfully contribute during a pandemic by employing their core skills to support patients, staff, and organizations.


How and under what circumstances do quality improvement collaboratives lead to better outcomes? A systematic review

Implementation Science


Quality improvement collaboratives are widely used to improve health care in both high-income and low and middle-income settings. Teams from multiple health facilities share learning on a given topic and apply a structured cycle of change testing. Previous systematic reviews reported positive effects on target outcomes, but the role of context and mechanism of change is underexplored. This realist-inspired systematic review aims to analyse contextual factors influencing intended outcomes and to identify how quality improvement collaboratives may result in improved adherence to evidence-based practices.

We built an initial conceptual framework to drive our enquiry, focusing on three context domains: health facility setting; project-specific factors; wider organisational and external factors; and two further domains pertaining to mechanisms: intra-organisational and inter-organisational changes. We systematically searched five databases and grey literature for publications relating to quality improvement collaboratives in a healthcare setting and containing data on context or mechanisms. We analysed and reported findings thematically and refined the programme theory.

We screened 962 abstracts of which 88 met the inclusion criteria, and we retained 32 for analysis. Adequacy and appropriateness of external support, functionality of quality improvement teams, leadership characteristics and alignment with national systems and priorities may influence outcomes of quality improvement collaboratives, but the strength and quality of the evidence is weak. Participation in quality improvement collaborative activities may improve health professionals’ knowledge, problem-solving skills and attitude; teamwork; shared leadership and habits for improvement. Interaction across quality improvement teams may generate normative pressure and opportunities for capacity building and peer recognition.

Our review offers a novel programme theory to unpack the complexity of quality improvement collaboratives by exploring the relationship between context, mechanisms and outcomes. There remains a need for greater use of behaviour change and organisational psychology theory to improve design, adaptation and evaluation of the collaborative quality improvement approach and to test its effectiveness. Further research is needed to determine whether certain contextual factors related to capacity should be a precondition to the quality improvement collaborative approach and to test the emerging programme theory using rigorous research designs.




Guide for hibernation of quality improvement programmes

Health Improvement Scotland

Q’s partners at Healthcare Improvement Scotland have created a draft guidance document on the hibernation of programmes. It outlines processes and good practice to close programmes down well, so that they are easier to get back up and running when the time is right.

It has been shared as a Word document – allowing you to edit and customise it for your teams.



Why Improvement Needs Nurturing


Leaders often direct people — which is part of any leadership role — but with improvement, we also need to nurture. When we invest time and support the people doing the work of improvement, we get much better results than if we just tell people what to do and expect them to work miracles.

Prioritising quality improvement


QI is a team sport, best played by those making the improvements.

With so many possible areas where improvements might be made, it can feel like an impossible task to choose which should take priority. Improvement often needs several iterative cycles before solutions that work emerge. Sustained improvement takes time and effort, and it is easy to get demoralised if practices or individuals take on too many projects and can’t follow them through. It is tempting to prioritise the areas that affect practice income or please regulators rather than projects that matter more to patients and staff.

High quality care develops when an organisational culture promotes curiosity, experimentation, and continuous small cycles of change, particularly when changes are designed and driven by the people delivering care, in full collaboration with patients.7 Quality improvement is a team sport and is played best when owned by those making the improvements. Projects work best when priorities are set locally unless external benchmarking data show problems with patient safety or quality of care or practice viability is being affected by poor performance in financially driven targets.




Walking the tightrope : how rebels “do” quality of care in healthcare organizations.

Journal of health organization and management

This paper explores and conceptualizes how healthcare professionals and managers give shape to the call for more compassionate care as an alternative for system-based quality management systems. The research demonstrates how quality rebels craft deviant practices of good care and how they account for them. 


Deepening our Understanding of Quality in Australia

International Journal for Quality in Health Care

This supplement focuses on the Deepening our Understanding of Quality in Australia (DUQuA) study. Articles in this supplementary issue of International Journal for Quality in Health Care include:

Bending the quality curve ;
Deepening our Understanding of Quality in Australia (DUQuA): An overview of a nation-wide, multi-level analysis of relationships between quality management systems and patient factors in 32 hospitals ;
Organization quality systems and department-level strategies: refinement of the Deepening our Understanding in Quality in Australia (DUQuA) organization and department-level scales ;
Do organization-level quality management systems influence department-level quality? A cross-sectional study across 32 large hospitals in Australia ;
The relationships between quality management systems, safety culture and leadership and patient outcomes in Australian Emergency Departments ;
The clinician safety culture and leadership questionnaire: refinement and validation in Australian public hospitals
Do quality management systems influence clinical safety culture and leadership? A study in 32 Australian hospitals
Validation of the patient measure of safety (PMOS) questionnaire in Australian public hospitals ;
Implementation and data-related challenges in the Deepening our Understanding of Quality in Australia (DUQuA) study: implications for large-scale cross-sectional research ;
Can benchmarking Australian hospitals for quality identify and improve high and low performers? Disseminating research findings for hospitals ;
Using accreditation surveyors to conduct health services research: a qualitative, comparative study in Australia
Conclusion: the road ahead: where should we go now to improve healthcare quality in acute settings?


Bridging the Diversity Canyon: Your next level of patient experience depends on it [case study]

The Beryl Institute

In direct alignment with safe, high quality, and patient-centric care, highly effective communication is the foundation for superior care delivery outcomes. However, when taking language, culture, and socio-economic variances into account, there can be a huge disconnect, which can lead to medical errors, confusion, implicit biases, and sometimes intentional disparities in care. It is the organization’s responsibility to provide diverse cultural, linguistic, and essential social initiatives that will enhance effective communication and understanding, thereby reducing or eliminating confusion, and ultimately improving the safe delivery of care, which leads to successful patient outcomes and experiences.


Pae tū, pae ora: Pathways to pae ora 

Ministry of Health

Nāu te rourou nāku te rourou, ka ora ai te iwi.
With my basket and your basket, the people will live.

This publication features diverse case studies of activity and innovation happening in our public health sector.

The stories of Pae tū, pae ora highlight leadership, innovation and local solutions which together will help drive better outcomes for health and disability across Aotearoa New Zealand.

Feature articles include the fight against hepatitis C; the skilled work of pharmacists and nurse practitioners; the mahi of local communities and the reclaiming of traditional Māori birthing practices.


Improving behavioural health care in the emergency department and upstream


This paper provides actionable guidance for hospital emergency departments and their community partners to create a compassionate, seamless and effective system of care that respects and works with patients with mental health conditions and substance use disorders who present to the emergency department. The paper includes: a framework for a better system of care that comprises four key components: processes, provider culture, patients, and partnerships; high-leverage changes and specific change ideas; suggested measures; practical tips and examples; and resources and tools. Free registration is required to access the document.


January / February


Adapting Lean methods to facilitate stakeholder engagement and co-design in healthcare


Quality improvement approaches drawn from industry can go beyond traditional concepts of value and deliver improvements in healthcare services, argue Iain Smith and colleagues.

Healthcare systems internationally face quality and productivity challenges and calls have been made for them to focus on delivering better value.123 However, in healthcare, value is a debated concept. Value is often viewed in terms of health outcomes per spend for a given population4 or in terms of clinical efficacy, focusing on interventions with a robust evidence base and reducing the use of interventions of low benefit.2 But it can also be considered at the level of the microsystem, and systematic quality improvement (QI) approaches can help provide better value through action on quality, safety, and productivity.1

The Lean method is one approach that is being increasingly used to enhance value in healthcare.567 In the UK, for example, NHS Improvement (which regulates NHS care providers) has embarked on a programme to embed Lean in English NHS trusts—some with support from the Virginia Mason Institute, a US based healthcare consultancy,8 and others with support from an NHS Improvement consulting team.9 Lean has drawn criticism for assuming that production efficiency techniques can apply directly to healthcare1011 and for lacking methods to integrate clinical knowledge and expertise with patients’ preferences and needs in defining value.12 We examine how it can be used to engage stakeholders in both defining value and designing systems and processes to deliver value.


Value-Based Healthcare Toolkit

Canadian Foundation for Healthcare Improvement

Value-Based Healthcare (VBHC) is becoming a leading approach to improving patient and health system outcomes around the world. It is one-way of organizing healthcare to transform health outcomes.

VBHC is about linking the dollars spent to outcomes that matter to patients, rather than to the volumes of services, processes or products that may or may not achieve those outcomes.

VBHC aims to deliver services that are high value, scale back or drop those that do not, and/or re-balance the mix of services to improve the ratio of outcomes to overall costs. The goal is better outcomes at the same or lower total cost.

The purpose of this toolkit is to provide information and guidance to those who are interested in learning about value-based healthcare (VBHC); those who are thinking about implementing it; and those who are ready to assess and improve their current VBHC initiatives.


Digital health technology: global case studies of health care transformation 

Deloitte Insights 

This report contains case studies that explore how different countries around the world are utilising technology to make progress within their health care systems, and what this development means for the future of digital health care internationally. 


Practical solutions to improve care: An interactive guide to support practitioners to improve services for people living with both mental and physical health problems.

Q Improvement Lab

An interactive guide to support practitioners to improve services for people living with both mental and physical health problems 

Supporting people living with both mental and physical health problems is a priority for the UK health and care system. Someone living with a long-term physical condition is 2-3 times more likely to experience mental health problems than the rest of the population,1 affecting the care and support that’s needed for them to live well. The interrelationship between mental and physical health presents challenges for how health and care services – and the people working within them – currently operate. 

To help address this, the Q Lab and Mind have produced a practical guide to support practitioners to improve health care services for people living with mental and physical health problems. The findings come from a 12-month project exploring how care can be improved for people living with mental health problems and persistent back and neck pain. The insights from this topic are relevant to the broader mental and physical health debate, and particularly transferrable to other long-term conditions (such as fibromyalgia, ‘medically unexplained symptoms’ and other types of persistent pain).






12 innovations that will change health care and medicine in the 2020s 


Pocket-size ultrasound devices that cost 50 times less than the machines in hospitals (and connect to your phone). Virtual reality that speeds healing in rehab. Artificial intelligence that’s better than medical experts at spotting lung tumors. These are just some of the innovations now transforming medicine at a remarkable pace. 

No one can predict the future, but it can at least be glimpsed in the dozen inventions and concepts below. Like the people behind them, they stand at the vanguard of health care. Neither exhaustive nor exclusive, the list is, rather, representative of the recasting of public health and medical science likely to come in the 2020s.


3 Ways Health Care Leaders Can Encourage Experimentation


Every week, medical journals bring us news of astounding scientific discoveries: CRISPR gene editing, or CAR-T cell therapy for cancer. And yet just as frequently we hear, “Why can’t health care be more innovative?” The resolution of this paradox lies in recognizing that when people lament health care’s lack of innovation, they’re referring to how we deliver services to patients. That distinction makes the paradox even starker: “So, you’re telling me that you can reprogram T cells to find and kill cancer cells, but it took four months to get my mother an appointment with a neurologist; she spent two hours in the waiting room; and then she got an exorbitant bill that read, ‘This is not a bill’?” 

Improving patient scheduling, service, or billing should not be as hard as harnessing clustered regularly interspaced short palindromic repeats to edit nucleotide sequences. And yet it seems to be. Why is that, and what can we do about it? 




Understanding organisational culture for healthcare quality improvement


Russell Mannion and Huw Davies explore how notions of culture relate to service performance, quality, safety, and improvement

Key messages:
Organisational culture represents the shared ways of thinking, feeling, and behaving in healthcare organisations;
Healthcare organisations are best viewed as comprising multiple subcultures, which may be driving forces for change or may undermine quality improvement initiatives;
A growing body of evidence links cultures and quality, but we need a more nuanced and sophisticated understandings of cultural dynamics;
Although culture is often identified as the primary culprit in healthcare scandals, with cultural reform required to remedy failings, such simplistic diagnoses and prescriptions lack depth and specificity.

Providers deliver: better care for patients

NHS Providers

This report considers both the leadership approaches and frontline initiatives that underpin improvements in quality. Through 11 case study conversations, it considers some of the frontline work that has contributed to trusts’ improvements in Care Quality Commission ratings. The report also explores the role of trust leaders in providing an enabling, supportive environment in which this work has been possible.


How to improve healthcare improvement—an essay by Mary Dixon-Woods

BMJ Open

As improvement practice and research begin to come of age, Mary Dixon-Woods considers the key areas that need attention if we are to reap their benefits.

 “QI has been advocated in healthcare for over 30 years13; policies emphasise the need for QI and QI practice is mandated for many healthcare professionals (including junior doctors). Yet the question, “Does quality improvement actually improve quality?” remains surprisingly difficult to answer.14 The evidence for the benefits of QI is mixed14 and generally of poor quality. It is important to resolve this unsatisfactory situation. That will require doing more to bring together the practice and the study of improvement, using research to improve improvement, and thinking beyond effectiveness when considering the study and practice of improvement.”


Track the ROI of your improvement work-work

 Life QI

Despite the increasing prevalence of QI [quality improvement] teams, programmes and senior quality executives, there remains little guidance and defined mechanisms for tracking the ROI of QI work. This article presents insights from Life QI  into how this can be done based on the literature and their experiences of working with healthcare organisations around the world. 

Some key messages include: 

Not all returns are financial 

Return on Investment (ROI) is the commonly used term for measuring the impact of initiatives that have been invested in. It typically has a financially focused lens with which return is measured. Less commonly understood is the VOI (Value on Investment) concept, first introduced by Gartner (the world’s leading information technology research and advisory company). Gartner propose that a wide range of factors influence value and can play a pivotal role in contributing to an organisation’s performance and can in turn contribute to traditionally financially focused ROI. 

VOI encompasses aspects such as staff engagement, staff morale, knowledge sharing, the ability to collaborate, clear processes and systems, customer perceptions and experiences, productivity, and efficiency. 

Use a unified progress scoring system 

When assessing the impact and trends of a range of improvement projects it is useful to have a universal guide to denote progress towards whatever improvement goal has been set. This allows multiple projects to be rapidly assessed and grouped to easily identify those demonstrating improvement, not yet demonstrating improvement, and those focusing on implementation of proven improvements. 

The IHI project progress score scale does just this. As a 10-point scale it allows teams to grade their progress right from ‘intent to participate’ in a project through to ‘outstanding sustainable results’. This article explains the scale in more detail. 

Effective use of this scale allows managers and execs to accurately monitor progress of improvement efforts on a project by project basis. Dashboards can be used to track key metrics at the relevant levels within the organisation. 

Track at the levels that matter 

Some, but a relatively small number of people within the organisation, will be interested in what is happening at the organisation-level. Most people are primarily concerned about what is happening at their more local, divisional or departmental level. So, setup a monitoring infrastructure that provides people with the information relevant to their parts of the organisation. 

They will use this to drive further improvement locally and be able to see the impact on their local improvement metrics. The overall ROI/VOI of the organisation’s improvement efforts will be enhanced if those responsible for specific operational areas can monitor and evidence their specific results. With operational responsibility and monitoring structures in place locally, the total effect at the organisational level can be profound. 


A holistic approach to health and care

King’s Fund  

Writing about Why the Dutch are different, Ben Coates describes how distinctive cultural practices of directness, tolerance and co-operation in the Netherlands are (at least partly) rooted in a history that required different communities to work together to establish and maintain drainage systems to rescue these lowlands from the sea. So perhaps it is not surprising that this is the nation that has cultivated a model of health and social care provision in which professionals work collaboratively in non-hierarchical teams to provide holistic care. 

The Dutch have developed a model where health professionals work in non-hierarchical teams to provide holistic care. How does this work and what would it look like in England? Jo Maybin reflects on what happened when this approach was adopted in West Suffolk.


Improving healthcare quality in Europe: Characteristics, effectiveness and implementation of different strategies

European Observatory on Health Systems and Policies; 2019.

The WHO’s European Observatory on Health Systems and Policies and the OECD have published this substantial piece (400+ pages) that summarises much of the evidence on quality improvement in health care. While focusing on the situation in and across Europe this has much wider relevance. Many of the topics covered will be familiar to those active in safety and quality efforts. 

The reports seeks to provide an overall conceptual framework for understanding and applying strategies aimed at improving quality of care. It summarises evidence on different quality strategies and provides recommendations for their implementation. This book is intended to help policy-makers to understand concepts of quality and to support them to evaluate single strategies and combinations of strategies. 

This book elucidates the concepts behind multiple elements of quality in healthcare policy (including definitions of quality, its dimensions, related activities, and targets), quality measurement and governance and situates it all in the wider context of health systems research. It is designed to help policy-makers prioritize and align different quality initiatives and to achieve a comprehensive approach to quality improvement. 

The volume includes the following chapters:

  1. An introduction to healthcare quality: defining and explaining its role in health systems
  2. Understanding healthcare quality strategies: a five-lens framework
  3. Measuring healthcare
  4. International and EU governance and guidance for national healthcare quality
  5. Regulating the input: health professions
  6. Regulating the input – Health Technology
  7. Regulating the input – healthcare facilities
  8. External institutional strategies: accreditation, certification, supervision
  9. Clinical practice guidelines as a quality strategy
  10. Audit and feedback as a quality strategy
  11. Patient safety culture as a quality strategy
  12. Clinical pathways as a quality strategy
  13. Public reporting as a quality strategy
  14. Pay for Quality: using financial incentives to improve quality of care




A new kind of A&E

Kings Fund

With accident and emergency performance reaching new lows across England, Siva Anandaciva explains how one NHS hospital is taking an innovative approach to meet the needs of its older patients. 

“An organisation in special measures that is losing £60 million a year could have easily been risk averse and stuck with the existing way of doing things. Instead they looked at the needs of their patients and the assets they had, and with a sense of purpose and agency they tried to improve services for their patients. That’s the story.”


Course corrections: how health care innovators learn from setbacks to achieve success

Commonwealth Fund 

This report examines new models for delivering and paying for health care to better serve vulnerable patients, including people with multiple chronic conditions, serious illnesses, or functional limitations, as well as those at risk of developing health problems because of their social circumstances or behavioural health conditions. It also showcases models that improve the quality of care and health outcomes while lowering costs or reducing unnecessary health care use.



6 Leadership Lessons Learned from Around the World


I’d like to share six key ideas I’ve learned over the past 15 years while working with people in various parts of the world: 

1.Have a vision and keep it simple..

2.Learn by measuring.

3.Use the best approach for your team.

4.Care for the people who care for others

5.Respect and empower your team members.

6.Remember to learn as much as you teach


Don’t Put a Digital Expert in Charge of Your Digital Transformation


Although a digital guru may understand how to create a digital business from scratch without the constraints faced by an established business, when you put them in a real company setting, they will often fail simply because they don’t understand the business. Typically their downfall starts early, as soon as they start broadcasting their vision for the complete transformation of the company, without listening carefully to how the business operates and to the real needs of leaders and customers. This is typically followed by a period when the guru castigates the rest of the company for slowness and inertia, culminating in spinning digital off into a separate unit where the team has the freedom to create what it envisions, which in the end is too disconnected from the core organization to succeed. And that was what we saw at nearly all of the companies we’ve studied that chose a digital guru. 

By contrast, insiders with little digital experience who are placed at the head of digital initiatives succeeded about 80% of the time (of the 50 cases we studied). Why? Because ultimately digital transformation is as much about organization change as it is about technology. Insiders who are willing to learn have an advantage because they understand how the business works, they have the relationships to get things done, and, most important, they understand what they don’t know. They also understand when they need help: Smart insiders hire digital expertise into their team and then lead them to success based on their understanding of how to use digital to serve the business. 


Developing a framework of quality indicators for healthcare business cases: a qualitative document analysis consolidating insight from expert guidance and current practice

BMC Health Services Research  


To our knowledge, this is the first framework of business case quality indicators designed specifically for use in a healthcare context. The framework presented in this study has implications for how business cases are developed and evaluated by decision makers. In the future it would be beneficial to investigate how the framework could be used in practice as a tool for critical appraisal.


Spread tools: a systematic review of components, uptake, and effectiveness of quality improvement toolkits

Implementation Science 


The review documents publicly available toolkits and their components. Available uptake data are limited but indicate variability. High satisfaction with toolkits can be achieved but the usefulness of individual tools may vary. The existing evidence base on the effectiveness of toolkits remains limited. While emerging evidence indicates positive effects on clinical processes, more research on toolkit value and what affects it is needed, including linking toolkits to objective provider behavior measures and patient outcomes.





Why Leaders Shouldn’t Fear Changing Their Minds | Don Berwick


At the 2019 International Forum on Quality and Safety in Healthcare in Glasgow, IHI President Emeriti Don Berwick and Maureen Bisognano shared examples of experiences that led them to change their minds throughout their careers as leaders in health care. In a new interview, Berwick reflects on this joint talk in Glasgow, why he and Bisognano felt it was important to model vulnerability and growth, and the importance of leaders listening to others.


Do We Make QI Too Complicated?


At home, it’s natural to run small tests and improve incrementally over time. (If you try a new recipe and the dish comes out too salty, next time you’ll use less salt.) At work, where many people operate in a complex system, it isn’t as easy to make small adjustments to standard procedures ― but it can help to tap into our natural tendency to make things better.





How One Health System Overcame Resistance to a Surgical Checklist 

IHI via Harvard Business Review 

Research and the experiences of some organizations suggest that embracing those who resist change the most — empathizing with them, identifying the sources of their resistance, and helping them see change as positive — is far more effective than resisting them. This article describes three mindshifts for overcoming resistance to change and provides an example of one health system that used this approach to overcome resistance to employing a surgical safety checklist. 


Innovating the Patient Experience: Trends, Gaps and Opportunities

Beryl Institute 

The white paper identifies examples of innovation through review of submissions from the inaugural Patient Experience Innovation Awards.  

With discoveries and opportunities transferrable to many healthcare settings, the paper examines innovation through The Beryl Institute’s Experience Framework. This includes eight strategic lenses through which organizations can address experience improvement and excellence. 

Submissions are shared through the eight lenses of the Experience Framework as a means to recognize where work has already been explored and can be replicated as well as highlight inactive areas with a need for strategic approaches to improvement. 


The improvement journey : why organisation-wide improvement in health care matters, and how to get started.

The Health Foundation

This report is provides a practical guide to developing an organisation-wide approach to improvement. It outlines the benefits of such an approach and the key elements and steps that NHS trust leaders should adopt when pursuing this agenda. 

Evolving quality improvement support strategies to improve Plan–Do–Study–Act cycle fidelity : a retrospective mixed-methods study. McNicholas, C., Lennox, L., Woodcock, T. BMJ quality & safety 28(5), 2019, p.356-365. Although recommended as an effective approach to quality improvement, the Plan–Do–Study–Act (PDSA) cycle method can be challenging to use and low fidelity of published accounts of the method has been reported. There is little evidence on the fidelity of PDSA cycles used by front-line teams, nor how to support and improve the method’s use. This study identifies support strategies that may help improve PDSA cycle fidelity.




The improvement journey: Why organisation-wide improvement in health care matters, and how to get started

The Health Foundation

The Health Foundation in the UK has produced this report as a practical guide to developing an organisation-wide approach to improvement. It summarises the benefits of such an approach and outlines the key elements and steps that leaders should adopt when pursuing this agenda. The authors emphasise that building an organisation-wide approach to improvement is a journey that can take several years and requires corporate investment in infrastructure, staff capability and culture over the long-term. They note that an essential early step is securing the support and commitment of the board/governance structure for a long-term programme, including their willingness to finance the skills and infrastructure development needed to implement it. The report includes case studies of three English NHS trusts that have implemented an organisational approach to improvement. 


Spreading and scaling up innovation and improvement


Disseminating innovation across the healthcare system is challenging but potentially achievable through different logics: mechanistic, ecological, and social. 

Key messages:

Spread (replicating an intervention) and scale-up (building infrastructure to support full scale implementation) are difficult

Implementation science takes a structured and phased approach to developing, replicating, and evaluating an intervention in multiple sites

Complexity science encourages a flexible and adaptive approach to change in a dynamic, self organising system

Social science approaches consider why people act in the way they do, especially the organisational and wider social forces that shape and constrain people’s actions

These approaches may be used in combination to tackle the challenges of spread and scale-up


Workforce stress and the supportive organisation: A framework for improvement through reflection, curiosity and change


Health Education England HEE commissioned the development of a resource to get employers to rethink how they deal with workforce stress. This framework encourages employers to take a closer look at the systems they currently have in place for managing staff wellbeing, challenges them to give greater consideration to the impact workforce stress has on staff and look at the role they can play in providing better support to staff who may need it.


How organisations contribute to improving the quality of healthcare


Naomi Fulop and Angus Ramsay argue that we should focus more on how organisations and organisational leaders can contribute to improving the quality of healthcare

Key messages

The contribution of healthcare organisations to improving quality is not fully understood or considered sufficiently

Organisations can facilitate improvement by developing and implementing an organisation-wide strategy for improving quality

Organisational leaders need to support system-wide staff engagement in improvement activity and, where necessary, challenge professional interests and resistance

Leaders need to be outward facing, to learn from others, and to manage external influences. Strong clinical representation and challenge from independent voices are key components of effective leadership for improving quality

Regulators can facilitate healthcare organisations’ contribution by minimising regulatory overload and contradictory demands




Creating space for quality improvement


Clinicians already have the motivation; now they need time, skills, and support

The BMJ and the Health Foundation are launching a joint series of papers exploring how to improve the delivery of healthcare ( ).12 The series aims to discuss the evidence for systematic quality improvement, provide knowledge and support to clinicians, and ultimately to help improve care for patients.


Quick Reference Guide to Promising Care Models for Patients with Complex Needs

Commonwealth Fund 

Many pioneering programs have reduced avoidable utilization of care and lowered costs while improving health outcomes for adults with complex needs. The most promising models target high-risk populations and provide key elements of person-centered care, including individualized care plans, interdisciplinary care teams, active care coordination, and continuous information-sharing with providers and patients. 

The Quick Reference Guide to Promising Care Models offers summary information on 28 programs for adults with complex needs, specifically: 

•Target population and subpopulations served by the model

•Key features of the model associated with person-centered care

•Outcomes and impact 

Although the evidence base is evolving, we know many existing care models meaningfully improve a person’s quality of life. It is important to continue testing promising care models in different settings, from the health care system to the home, and to develop better measures of person-centered outcomes on total cost of care. The resulting information will help guide the development of financially sustainable and scalable models of care for people with complex needs. 


Lack of robust data analysis impedes care improvement efforts

Quality, outcome, and cost data should be shared with clinicians clearly and consistently. 

“"Most hospitals have cost-variance reduction efforts in the supply chain or pharmacy, where they have good data," Stowell said. "But they struggle on the clinical end with proper cohorts or outcome-based data that is comparable." 

Increasing physician engagement can begin with assessing how data is systematically shared with physicians, researchers recommended. Leaders should develop a strategy that guides the appropriate amount and type of data to share. 

Quality, outcome and cost data should be benchmarked on evidence-based guidelines and regularly shared with physicians on a consistent and usable format. The data should account for patient acuity and be broken down by unit price for specific patient cohorts. 

Ideally, transparency creates a self-propelled, value-based culture.”


Medication Safety: Quality improvement toolkit

Health Quality and Safety Commission

This toolkit was originally developed for the age related residential care (ARRC) sector. The common example used is the prevention and investigation of falls. While falls may not be a common occurrence in a pharmacy, most people can relate to a fall being an undesirable event, often with poor consequences for the person that fell. The techniques for reviewing an event and implementing change and improvements are universal.





Can we import improvements from industry to healthcare?


Exhortations to learn from other industries have been common in the world of healthcare improvement since the inception of the discipline.1 These are not always helpful. Recounting oversimplified improvement examples from other industries (often aviation) can provoke considerable frustration and scepticism among clinicians exposed to the unique challenges and everyday complexities of trying to improve healthcare. Patients are not aeroplanes, and hospitals are not production lines. Nonetheless, many successful efforts to improve the quality and safety of healthcare have taken inspiration from other industries. Here we re-examine some familiar exemplars from the aviation industry to show what is (still) to be learnt, even in areas that have made substantial improvements. 


Evolving quality improvement support strategies to improve Plan–Do–Study–Act cycle fidelity: a retrospective mixed-methods study

BMJ Quality and Safety

Although widely recommended as an effective approach to quality improvement (QI), the Plan–Do–Study–Act (PDSA) cycle method can be challenging to use, and low fidelity of published accounts of the method has been reported. There is little evidence on the fidelity of PDSA cycles used by front-line teams, nor how to support and improve the method’s use. Data collected from 39 front-line improvement teams provided an opportunity to retrospectively investigate PDSA cycle use and how strategies were modified to help improve this over time.

Although modest, statistically significant improvements in PDSA fidelity occurred; however, overall fidelity remained low. Challenges to achieving greater fidelity reflected problems with understanding the PDSA methodology, intention to use and application in practice. These problems were exacerbated by assumptions made in the original QI training and support strategies: that PDSA was easy to understand; that teams would be motivated and willing to use PDSA; and that PDSA is easy to apply. QI strategies that evolved to overcome these challenges included project selection process, redesign of training, increased hands-on support and investment in training QI support staff.

Conclusion This study identifies support strategies that may help improve PDSA cycle fidelity. It provides an approach to assess minimum standards of fidelity which can be replicated elsewhere. The findings suggest achieving high PDSA fidelity requires a gradual and negotiated process to explore different perspectives and encourage new ways of working.

The Answer to Culture Change: Everyday Management Tactics


New research from IHI suggests certain management tactics can be game-changing when it comes to creating the type of culture that supports meaningful improvement over time. .In this article, we discuss the results of two pilot initiatives, led by IHI, that resulted in sustained, significant improvements in quality and value in two very different contexts — outpatient care in the U.S. and acute inpatient care in the U.K. — through management interventions that resulted in significant cultural change.


Improving the quality of health services: tools and resources. Turning recommendations into practice

World Health Organization

The World Health Organization (WHO) has released this document that compiles together a range of WHO resources with the aim of supporting the implementation of quality improvement approaches to make health services more effective, safe and people-centred. The compilation lists the main quality improvement tools and resources currently used within WHO’s Department of Service Delivery and Safety. However, as is noted, this compendium is not an exhaustive list of quality improvement interventions. 


Quality improvement for patient safety: a chance to steady the ship?


“A small number of outstanding health systems – Intermountain, Virginia Mason, Jönköping – have harnessed quality improvement to deliver significant improvements in performance. But research on the impact of quality improvement projects at large numbers of sites generally points to quite small gains. Leaders from some successful systems have argued that healthcare organisations need to pass a ‘minimum investment threshold’, to train a sufficient number of staff and complete a sufficient number of projects, before they start to see the accumulation of incremental gains from using quality improvement methods.” 


How not to waste a crisis: a qualitative study of problem definition and its consequences in three hospitals

The Institute 

Despite an increased focus on quality and safety in recent years, certain problems in healthcare get more attention than others.

Efforts to make surgery safer, for example, have led to significant improvements, while safety issues in mental healthcare haven’t seen the same research and policy attention. It remains unclear how healthcare organisations identify problems, define them, prioritise them, and match them with solutions.

So how does a problem of quality or safety become a problem? And what implications does this have for what organisations do about it? 

“We suggest that those in senior-level roles should not simply identify patient safety as a challenge: they also need to attend carefully to how they frame it as a problem, and how that process influences the choice of therapies. ‘Burning platforms’ – crises that recentre challenging issues and highlight the need for swift action – may be useful devices for those who seek to prioritize quality and safety in health care contexts overwhelmed by ‘priority thickets’.25 But these crises may be wasted in the rush to solutions. An approach that promotes shared construction of the problem and solutions, on the other hand, may yield significant benefits. This requires caution and courage, but our data suggest that it may secure a more sustainable re-problematization of quality and safety – rather than creating short-term commotion that quickly becomes part of the noise of competing priorities. 


Tech Tips: Four Top Health Systems Share Novel Approaches to Improve Patient Engagement


Hospitals and health systems across the United States are seeking ways to better engage patients with a variety of handheld and home-based technologies to improve patient experience and health outcomes. How do you use technology to transform the hospital bedside? Increase medication adherence for hypertension? Control diabetes? Reduce distress in patients with cancer? 

Four health care organizations, including UC San Diego Health, Ochsner Health System, Sutter Health and Stanford Health Care, have all developed answers to these questions. All have created diverse models of care that incorporate use of patient-centered technologies with measureable outcomes





Making Process Improvements Stick


Starting with Frederick Taylor and W. Edwards Deming, managers have long been obsessed with ways to improve business processes. And in the past 20 years a host of improvement initiatives, including lean production, Six Sigma, and agile, have swept through a range of industries. Studies show that companies embracing such techniques may enjoy significant improvements in efficiency and costs. But when the University of North Carolina’s Brad Staats and the University of Oxford’s Matthias Holweg and David Upton looked at the benefits, they noticed a gap. “These things always work well initially, but often the gains fade very quickly,” Holweg says. “It’s always felt like researchers were telling only half the story. It’s not just about putting the programs in place—it’s also about making them stick.” 


A teachable moment: delivering perioperative medicine in integrated care systems

Royal College of Anaesthetists

This report showcases a number of innovative and award-winning programmes in hospitals across England that are improving patient care before, during and after surgery. The time preparing for, undergoing and then recovering from an operation is known as the perioperative period, and the College believes that tailored care throughout this time will improve long-term outcomes for patients after surgery.


What does ‘rapid evaluation’ in health care mean in practice? 

Nuffield Trust

Following our conference last month, Chris Sherlaw-Johnson and Jean Ledger (UCL) have written a blog on the challenges and benefits of rapid evaluation. They argue that rapid and rigorous go hand in hand, but we “should be realistic about what can be measured, and what cannot, within the timescales given”. 


Using data for improvement: Practice essentials 


What you need to know

•-Both qualitative and quantitative data are critical for evaluating and guiding improvement 

•-A family of measures, incorporating outcome, process, and balancing measures, should be used to track improvement work 

•-Time series analysis, using small amounts of data collected and displayed frequently, is the gold standard for using data for improvement 




Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies

BMJ Quality & Safety
Thirty studies (33 articles) from multiple countries and settings (eg, acute care, outpatient) with a diverse range of interviewees (eg, nurses, leadership, staff) were included in the final analysis. Five domains characterised struggling healthcare organisations: poor organisational culture (limited ownership, not collaborative, hierarchical, with disconnected leadership), inadequate infrastructure (limited quality improvement, staffing, information technology or resources), lack of a cohesive mission (mission conflicts with other missions, is externally motivated, poorly defined or promotes mediocrity), system shocks (ie, events such as leadership turnover, new electronic health record system or organisational scandals that detract from daily operations), and dysfunctional external relations with other hospitals, stakeholders, or governing bodies.

The challenges of safety improvement in New Zealand public hospitals 

Kōtuitui: New Zealand Journal of Social Sciences Online 

Patient Safety is central to the New Zealand (NZ) health strategy. However international experience shows that safety improvement work frequently fails to meet its objectives. This article provides a qualitative account of the challenges of safety improvement from the perspective of nurses, doctors, and managers in three departments in two NZ public hospitals. These staff described significant tensions in relation to engagement and organisational capacity. An analysis of their perspectives through the Organising for Quality model [Bate et al. 2008, Organising for quality: The improvement journeys of leading hospitals in Europe and the United States, Oxford & New York, Radcliffe Publishing] highlights the significance of failures at the level of structure, culture, politics, motivation and infrastructure. 


Effective quality systems: implementation in Australian public hospitals
International Journal of Health Care Quality Assurance. 2018;31(8):1044-57.

This paper reports on a study that used a literature review and interviews and focus groups to examine “quality systems” in hospitals in one Australian state. Here, they define quality system as encompassing ‘the safety, quality management, improvement system and clinical governance’ or as ‘A systematic, coordinated, organisation-wide program of planning, governance, mindset, behaviours, tools, change, measurement, evaluation and action to achieve and maintain the organisation’s vision of a great experience for each consumer’. For such a broad-ranging system they then identify seven key components: leadership, policy and strategy, staff focus, education and training, patient focus, performance results, and process improvement.  

Perhaps it is unsurprising that the 350 health service managers, staff and board members that participated in the study were hard-pressed to agree on how successfully such systems had been implemented with ‘a gap in the rhetoric from the top of the organisations, and what middle managers and health professionals were experiencing’.


Instructions to Implement Experience-Based Co-Design


Few health care organizations deeply involve patients in improving or redesigning services. Experience-based co-design (EBCD), developed in the UK, brings together research techniques such as interviewing and observation with service design methods to improve patient and staff experiences of care. A new Implementation Guide is a tool to help you adapt and adopt the innovative EBCD method.


If at First You Don’t Succeed: Meeting the Ongoing Challenge of Continuous Improvement


It’s not easy to reinvigorate quality improvement work when previous efforts didn’t last. Facing this dilemma, team members at a London hospital asked each other, “What would need to be different this time?” Here’s how they learned from the past to sustain improvement in the future .


Leveraging the Psychology of Change


Understanding why people resist change — and how to activate people to change — is essential to advance and sustain improved care. A new article in Healthcare Executive presents a concise overview of the IHI Psychology of Change Framework with key takeaways and tools for leaders. 


Opening the door to change: NHS safety culture and the need for transformation

Care Quality Commission

The Care Quality Commission in the UK has released this report examining the issues that contribute to the occurrence of ‘never events’ and wider patient safety incidents in England. The review sought to help understand the barriers to delivering safe care and to identify learning that can be applied to improve patient safety. The report found that too many people are being injured or suffering unnecessary harm because staff are not supported with sufficient training, and because the complexity of the current system makes it difficult for staff to ensure that safety is an integral part of everything they do.





Blueprint for complex care


Health care organisations across the United States are developing new models for complex care, yet innovators often pursue these initiatives in isolation from one another. This report offers a strategic plan with recommendations to advance the field of complex care. It assesses the current state of the complex care field and presents recommendations to help the field reach its full potential for improving care delivery for the nation’s most vulnerable patients. Please note that free registration is required to access these documents. 


IHI’s 10 Picks from 2018

This year, IHI created hundreds of blog posts, videos, white papers, tools, and other content. Some you may remember, and some you may have missed. Here are our 10 picks from 2018 content that deserve a second look. Thank you for joining IHI in improving health and health care around the world.


How "Flipped" Discharge Can Help Your Largest Patient Population


“Penn Medicine was inspired to improve the length of stay and the transition home for older adults when they participated in the IHI International Innovations Network and saw “flipped" discharge in action in Sheffield, England. The model involves “flipping” the traditional approach to discharge. Instead of using the “assess to discharge” approach, providers in Sheffield follow the “discharge to assess” model. This means that — rather than hold patients in the hospital to assess needs before they leave — providers discharge patients as soon as they are medically ready and assess their needs at home. This process not only reduced length of stay, but — more importantly — improved the accuracy of determining patients’ true post-acute needs.”








Understanding organisational culture for healthcare quality improvement


Ideas of culture are also central to quality improvement methods. From basic clinical audit to sustained improvement “collaboratives,” business process re-engineering, Lean Six Sigma, the need for cultural reorientation is part of the challenge.6 Yet although the language of organisational culture—sometimes culprit, sometimes remedy, and always part of the underlying substrate at which change is directed—has some immediate appeal, we should ask deeper questions. What actually is culture in health services? How does culture relate to healthcare quality, safety, and performance? And can changing culture lead to improvements in care and organisational performance?



Bring Your Breakthrough Ideas to Life


Digital advances in the past two decades have enabled more people than ever before to express creative intelligence. Yet apart from the transformation of services powered by mobile apps and the internet, few sectors have seen spectacular surges of innovation—and only 43% of companies have what experts consider a well-defined process for it. In this article the authors present a five-part framework to guide the development and ensure the survival of breakthrough ideas: Focus attention closely and with fresh eyes, step back to gain perspective, imagine unorthodox combinations, experiment quickly and smartly, and navigate potentially hostile environments outside and within the organization. The elements of this framework are not unique, but collectively they capture the critical role of reflection in conceiving opportunities, the ways in which digital tools can advance them, and the level of organizational reinvention needed in the final push to market.



Using 'nudges' to co-design improvements in patient care


Raising the bar on the national patient experience survey is a report which responds to the national adult inpatient experience survey results by investigating the lower scoring areas of the survey and recommending interventions to improve these results. The report details 'quick wins' and 'big wins' to improve the patient experience of care.

The second report Phase two: Co-designing nudges is now available.

We are seeing some positive changes to the lower-scoring areas of the national survey. The Partners in Care and medication safety programme teams have been working with the behavioural science team at Ogilvy, to develop low-cost interventions called 'nudges' to improve these lower-scoring areas.

What is a 'nudge'?

Vishal George, head of behavioural science at Ogilvy, explains that a nudge (a term coined by Richard Thaler and Cass Sunstein in their 2008 book Nudge) is a change to an environment, which alters the behaviour of individuals without changing their incentives.

Examples include an improved discharge summary for patients, follow-up phone calls about medications and a 'home safety' checklist.

What has this got to do with improving care?

Using insights from behavioural science, the new report details how Nelson Marlborough, Northland and Waikato district health boards (DHBs) worked with Ogilvy and the Commission to develop interventions to improve the inpatient experience.



Approaches to better value in the NHS: Improving quality and cost

Kings Fund

“While there are differences in how organisations are approaching value improvement, there are also several common conditions for success. These include fidelity to a clearly defined strategy that brings the various strands of value improvement work together; recognition that value improvement is a long-term commitment that will require considerable staff time and resources; and a new leadership approach that requires continuous engagement with frontline clinicians and managers.”


Improving access and continuity in general practice

Nuffield Trust

The report describes our key findings on the impact of improved access upon continuity of care, and provides a series of recommendations for commissioners and policy-makers. It sets out the evidence on continuity of care, its impact on clinical outcomes and wider health services, its importance to patients and GPs, and the relationship between improved access initiatives and continuity of care within general practice. It examines how to achieve the optimal balance between these two dimensions of care when redesigning services for local populations.


Understanding how and why the NHS adopts innovation 

NHS Innovation Accelerator

Each year the NIA has a research focus to inform how to scale  innovations successfully in the NHS. The focus of the research to date has concentrated on the innovator and innovation - the supply side of innovation. This research, in contrast, focussed on the role of adopting organisations. It aimed to understand the key factors enabling the uptake of innovation and to determine how decisions are made within NHS organisations.

The areas it aimed to address were:

• How and why organisations take up an innovation 

• The enabling factors which facilitate the uptake and embedding of the innovation 

• The impacts of adopting the innovation on organisational practices


Tool: Quality Improvement Project Management


Managing a quality improvement project is a critical skill for anyone interested in making care delivery — and systems of care — better in their health care organization. To successfully manage improvement, team leaders need specialized skills in QI project management, which has not typically been part of the improvement curriculum.

This tool describes strategies to effectively manage quality improvement projects, specific ideas to try within each strategy, and offers a workspace for you to note your next steps to implement the strategy. 


IHI Psychology of Change Framework 


This white paper is a guide for all leaders interested in understanding the underlying psychology of change and leveraging its power to impact quality improvement efforts: to achieve breakthrough results, sustainably, at scale. 

Improvement science has given health care improvers a theoretical framework and the applied technical skills to understand variation, study systems, build learning, and determine the best evidence-based interventions (“what”) and implementation strategies (“how”) to achieve the desired outcomes. 

Yet, health care improvers worldwide still struggle with the adaptive side of change, which relates to unleashing the power of people (“who”) and their motivations (“why”) to advance and sustain improvement — two commonly cited reasons for the failure of improvement initiatives. 

The paper presents a framework and set of methods for the psychology of change — five interrelated domains of practice that organizations can use to advance and sustain improvement:

•Unleash Intrinsic Motivation

•Co-Design People-Driven Change

•Co-Produce in Authentic Relationship

•Distribute Power

•Adapt in Action 

Building on the legacies of W. Edwards Deming, Everett Rogers, and many others, a renewed focus on the human side of change increases the likelihood that efforts to improve health and health care will succeed in the short term and be scaled and sustained over time. ​



Q: The journey so far 

The Health Foundation

Connecting improvement across the UK – insights and progress three years in

Widespread change is necessary to make the health sector fit for the future. Organisations need to be able to reduce waste and unhelpful variation, while developing new models of prevention-focused care. And it is vital that the health sector makes good use of the improvement ideas and expertise that already exist in every part of the UK.

Three years after it started, the Q initiative is growing rapidly and providing an insightful picture of the range and location of people involved in improvement efforts.

This report reflects the commitment of the Health Foundation and NHS Improvement to share progress and learning from the Q initiative as it develops. It accompanies the publication of RAND Europe’s interim evaluation of Q and the report on the first Q Lab project


Approaches to better value: improving quality and cost

The King's Fund

The NHS is increasingly focusing on how it can improve the value of its services, to deliver the highest quality health outcomes for patients at the lowest possible cost. This report shares learning and insight from three NHS hospital trusts that have developed organisation-wide strategies for value improvement.
While there are differences in how organisations are approaching value improvement, there are also several common conditions for success. These include fidelity to a clearly defined strategy that brings the various strands of value improvement work together; recognition that value improvement is a long-term commitment that will require considerable staff time and resources; and a new leadership approach that requires continuous engagement with frontline clinicians and managers.


The spread challenge

The Health Foundation

While the invention of new technologies, practices, and models of care are exciting moments in health care, invention is only half the story. Taking a health care intervention that has worked successfully in one location and then making it work in a new context is not simple. They are more likely to succeed if the new context is better understood and those adapting it better supported to do so.
The report highlights key recommendations for practitioners involved in spreading health care improvement, including:
• Innovators should be trained in the various theoretical approaches that exist for describing innovations in ways that can better support those adopting an idea from elsewhere to adapt them for new contexts and should be part of the innovator’s ‘toolkit’.
• There should be more opportunities for real-world testing of innovations and improvements in health care before trying to spread them. The need to compare performance across different contexts should be a recognised stage of the innovation cycle for new practices, processes and pathways, just as it already is for new drugs and devices.

Snakes & Ladders: The Journey to Primary Care Integration

The George Institute

This report presents the arguments as to why all political and other leaders must act now to transform Australia’s health system to ensure it is sustainable, effective, efficient, and leads to greater satisfaction for both consumers and service providers. The recommendations have been synthesised and derived from expert discussions and reflect established evidence that health systems with strong primary health care are more efficient, have lower rates of hospitalisation, fewer health inequalities and better health outcomes including reductions in rates of people dying.





Emergency department crowding: A systematic review of causes, consequences and solutions 


Emergency department crowding is a major global healthcare issue. There is much debate as to the causes of the phenomenon, leading to difficulties in developing successful, targeted solutions.

The aim of this systematic review was to critically analyse and summarise the findings of peer-reviewed research studies investigating the causes and consequences of, and solutions to, emergency department crowding.


Getting more health from healthcare: quality improvement must acknowledge patient coproduction—an essay by Paul Batalden


Modelling healthcare as either a product or a service neglects essential aspects of coproduction between doctors and patients. Paul Batalden shares his learning from 10 years of studying change. 


Rethinking outpatient services: Learning from an interactive workshop

Nuffield Trust

Outpatient services in England have experienced a sharp rise in activity, leading to many STPs outlining ambitious plans to reduce activity and cut costs. This briefing, in collaboration with health leaders across the country, reveals opportunities to improve the design of services and challenges if some services should be delivered in their current form.



Safer care saves money: How to improve patient care and save public money at the same time 

Grattan Institute 

Australia could save $1.5 billion a year on health spending by improving the safety of patient care in hospitals. Safer hospital care doesn’t just reduce harm to patients, it also saves money for taxpayers.


Reduction in surgical site infections in the Southern Cross Hospitals network, 20042015: successful outcome of a long-term surveillance and quality improvement project.


In summary we have shown that surveillance and reporting SSIs and the introduction of an intervention programme can make a significant contribution to the reduction of SSIs resulting in reduced healthcare costs and patient morbidity. There is scope however to reduce the rate further by greater adherence to our surgical prophylaxis and skin antisepsis interventions. The integration of an ‘anti-staph bundle’ into our patient pathway for orthopaedic surgery offers another opportunity to reduce SSIs.


Guiding the Flock: 3 Simple Rules to Improve Hospital-wide Patient Flow


W.E. Deming, influential management thinker behind QI, once described a few ways to achieve big goals without system improvement. Unfortunately, they had to do with lying, cheating, and overspending. To improve hospital-wide flow without distortion, IHI experts recommend three simple rules inspired by the flocking behavior of birds.

Innovation Labs in Healthcare - A Review of Design Labs as a Model for Healthcare Innovation [Thesis]

Healthcare is facing an uncertain future. People are living longer, costs are rising and patients are demanding a different experience. Over the past 15 years, a growing number of health systems have built in-house innovation labs to survive (and thrive) in this emerging world. Often enabled by design, it was the emergence of these labs that prompted interest in examining them further. Using a qualitative approach including expert interviews, this research explored 17 hospital based design labs around the world. It is hoped that this research may be used by others seeking to advance health design in their own organizations and to provoke discussion and thought on the use of design in the context of healthcare innovation. Outputs of this research include a Synthesis Map of the findings and a Health Design Lab Canvas. The Health Design Lab Canvas is accompanied by design principles for consideration when building a health design lab in a healthcare organization.





White Paper: IHI Innovation System

Develop an Innovation System in Your Organization

This white paper describes how a health care organization might create its own internal innovation system, based on the needs of the organization, that focuses on improving health care delivery. We share our nearly 30 years of experience with innovation at IHI, using examples to highlight how to move through this process, determine what is right for your organization, and balance innovation activities with ongoing operations. 

The paper provides a detailed description of the IHI innovation system and includes guidance on:

•Determining the innovation system architecture: goals, priorities, and dedicated resources for innovation

•Creating a disciplined innovation process, which includes an in-depth description of IHI's 90-Day Learning and Testing Cycles

•Establishing ongoing management of the innovation system: identifying innovation drivers, developing processes, and integrating operations and innovation

Applying Community Organizing Principles to Restore Joy in Work


1) Know why you care
2) Start with your people, not your problem
3) Do "with" and not "for"
4) Share power

In a recent article published by NEJM Catalyst, Institute for Healthcare Improvement (IHI) President and CEO, Derek Feeley, DBA, and Executive Director, Jessica Perlo, MPH, share their thoughts on applying community organizing principles to restore joy in work.

The Participatory Zeitgeist: an explanatory theoretical model of change in an era of coproduction and codesign in healthcare improvement

BMJ Journal of Medical Ethics

Healthcare systems redesign and service improvement approaches are adopting participatory tools, techniques and mindsets. Participatory methods increasingly used in healthcare improvement coalesce around the concept of coproduction, and related practices of cocreation, codesign and coinnovation. These participatory methods have become the new Zeitgeist—the spirit of our times in quality improvement. The rationale for this new spirit of participation relates to voice and engagement (those with lived experience should be engaged in processes of development, redesign and improvements), empowerment (engagement in codesign and coproduction has positive individual and societal benefits) and advancement (quality of life and other health outcomes and experiences of services for everyone involved should improve as a result). This paper introduces Mental Health Experience Co-design (MH ECO), a peer designed and led adapted form of Experience-based Co-design (EBCD) developed in Australia.


Strategies for building capacity for improvement at scale

The Health foundation

Deputy Director of Improvement, Penny Pereira , chaired a session at the Health Foundation’s annual event to explore how the UK health and care sector can build the improvement capability it needs. David Fillingham from the Advancing Quality Alliance (AQuA), Ruth Glassborow from Healthcare Improvement Scotland, and Adam Sewell-Jones from NHS Improvement shared their expertise. We spoke to Penny to capture some of the key themes from the discussion.




The Participatory Zeitgeist: an explanatory theoretical model of change in an era of coproduction and codesign in healthcare improvement 

BMJ Journal of Medical Ethics

Healthcare systems redesign and service improvement approaches are adopting participatory tools, techniques and mindsets. Participatory methods increasingly used in healthcare improvement coalesce around the concept of coproduction, and related practices of cocreation, codesign and coinnovation. These participatory methods have become the new Zeitgeist—the spirit of our times in quality improvement. The rationale for this new spirit of participation relates to voice and engagement (those with lived experience should be engaged in processes of development, redesign and improvements), empowerment (engagement in codesign and coproduction has positive individual and societal benefits) and advancement (quality of life and other health outcomes and experiences of services for everyone involved should improve as a result). This paper introduces Mental Health Experience Co-design (MH ECO), a peer designed and led adapted form of Experience-based Co-design (EBCD) developed in Australia.

Strategies for building capacity for improvement at scale

The Health foundation

Deputy Director of Improvement, Penny Pereira , chaired a session at the Health Foundation’s annual event to explore how the UK health and care sector can build the improvement capability it needs. David Fillingham from the Advancing Quality Alliance (AQuA), Ruth Glassborow from Healthcare Improvement Scotland, and Adam Sewell-Jones from NHS Improvement shared their expertise. We spoke to Penny to capture some of the key themes from the discussion. 


Simple rules for evidence translation in complex systems: A qualitative study

BMC Medicine 

This research aimed to advance empirical and theoretical understanding of the reality of making and sustaining improvements in complex healthcare systems. 

By recognising how agency, interconnectedness and unpredictability influences evidence translation in complex systems, SHIFT-Evidence provides a tool to guide practice and research. The ‘simple rules’ have potential to provide a common platform for academics, practitioners, patients and policymakers to collaborate when intervening to achieve improvements in healthcare.

Primary care home: community pharmacy integration and innovation

National Association of Primary Care

This report aims to inspire further integration of community pharmacy within primary care homes to improve patients’ health and support them to manage their conditions. The paper concludes that by learning from those leading the way and exploring innovative ways of working together they could have a bigger impact on improving the health and care needs of their local population.

Building the business case for quality improvement: a framework for evaluating return on investment

RCP Journal

This paper presents a framework to help identify, understand and evaluate return on investment from large-scale application of QI in healthcare providers. The framework has been developed at East London NHS Foundation Trust (ELFT), a provider of predominantly mental health and community health services to a population of 1.5 million people, which has been undertaking QI at scale since 2014. This paper presents case studies and examples from ELFT to illustrate return on investment from QI at multiple levels: improving outcomes for patients and service users, improving the experience of staff, improving productivity and efficiency, avoiding costs, reducing costs and increasing revenue. 

A Nationwide Approach to Improvement

This paper shares the story of the Scottish Improvement Journey, starting with its innovative beginnings, encompassing 50 years of clinical audit and various improvement programmes, then focusing on the introduction of the world’s first national patient safety programme, and exploring the spread of quality improvement into new social policy areas such as children’s services, education, and justice. 

The Scottish Improvement Journey describes NHSScotland’s 10-year effort to apply QI on a national scale to improve patient safety and “make Scotland the best place to live in.”

Innovative models of general practice


General practice is in crisis. Previous work from The King’s Fund found general practitioners (GPs) dealing with a rising, more complex workload. Funding has not been growing at the same rate as demand, leading to a profession under enormous strain and facing a recruitment and retention crisis.

New clinical delivery models are needed to meet demand, altering the way in which general practice operates and interacts with individuals, families and local communities.

In this report, we look at innovative models of general practice from the UK and other countries and identify key design features we believe will be important in designing effective GP services in the future.

We set out five attributes that underpin general practice: person-centred, holistic care; access; co-ordination; continuity and community focus. Models that focus on access at the expense of other attributes may not provide the most effective and comprehensive care for patients.

Successful new models of general practice often focus on building relationship –between patients and professionals, between professionals within general practice and beyond, and between general practice and wider communities.
Making radical changes to the model of general practice is complex and takes time, leadership and resources. General practice often has less access to the financial or human resources needed to undertake change than other NHS organisations. External support for improvement will be critical.



Changing how we think about healthcare improvement


The BMJ has, in conjunction with The Health Foundation, launched a joint series of paper on how to improve the quality of healthcare delivery.


How Do We Learn about Improvement?

International Journal for Quality Improvement

Experts from around the world convened at the Salzburg Global Seminar to address fundamental questions for health care improvement: To what extent can results be attributed to the changes implemented? Are these changes generalizable and ready for broader dissemination? Follow the discussion in an International Journal for Quality in Health Care special supplement.

Primary care home: community pharmacy integration and innovation

National Association of Primary Care

This report aims to inspire further integration of community pharmacy within primary care homes to improve patients’ health and support them to manage their conditions. It argues that by learning from those leading the way and exploring innovative ways of working together general practice and community pharmacy could have a bigger impact on improving the health and care needs of their local population.

Cutting emissions in healthcare 

Counties Manukau Health

by Dr David Galler .  [ This is the story of a long term project at Counties Manukau Health ]

"In late November 2017 a small group of people at Middlemore Hospital celebrated a remarkable achievement – a reduction in the Carbon footprint of the Counties Manukau DHB by 21.2% in just 5 years.

That work which began in 2011 was fuelled by the good will of a small group of ordinary people: doctors, nurses and others who took it upon themselves to take action on Climate Change by doing the same simple things at work that so many were already doing at home; conversations about small stuff in the main, recycling and reducing waste, then a growing desire to learn more about our own Carbon footprint and the relationship between Climate Change and healthcare more generally... "

Don Berwick and Dr Mike Evans talk about quality improvement in health care


This video features Dr. Mike Evans and Don Berwick discussing quality improvement in health care.

The Montefiore Health System in New York: integrated care and the fight for social justice


The Montefiore Health System in the Bronx, New York, has found ways of helping even the most deprived by stepping beyond the bounds of conventional health services. 

This case study is based on interviews with more than 25 senior leaders, doctors, nurses, managers and other staff within the Montefiore Health System.

Transformational change in health and care: reports from the field

The King'sFund

We interviewed 42 people across four case study sites who were involved in leading, supporting, delivering, receiving or witnessing transformational change. This new report shares their experiences and reflections.

Do These 4 Things When You’re Scaling Up Improvement


Not all improvement projects are part of national initiatives, but leaders involved in countrywide efforts have hard-won insights that can apply to all levels of scale-up. 

Have a Scale-up Plan from Day 1 

Build Improvement Capability and Engagement at the Local Level

Use Stories to Accelerate Scale-Up
Support New Teams as You Scale Up
Building Improvement Capacity and Capability: A "Dosing" Approach

Healthcare Executive

This article describes IHI's "dosing" approach that establishes and deploys targeted levels of improvement knowledge and skills throughout an organization to build improvement capacity and capability. The key point of the approach is that not everyone in the organization needs to have the same depth of knowledge about science of improvement concepts, methods, and tools.

Readiness for Delivering Digital Health at Scale: Lessons From a Longitudinal Qualitative Evaluation of a National Digital Health Innovation Program in the United Kingdom

Digital health has the potential to support care delivery for chronic illness. Despite positive evidence from localized implementations, new technologies have proven slow to become accepted, integrated, and routinized at scale. 

Although there is receptiveness to digital health, barriers to mainstreaming remain. Our findings suggest greater investment in national and local infrastructure, implementation of guidelines for the safe and transparent use and assessment of digital health, incentivization of interoperability, and investment in upskilling of professionals and the public would help support the normalization of digital health. 



Developing new models of care in the PACS vanguard: a new national approach to large-scale change?

The King’s Fund

The primary and acute care system (PACS) model is an attempt to bring about closer working between GPs, hospitals, community health professionals, social care and others. This report offers a unique set of first-hand perspectives into the experience of those leading a major programme at the national level and those living it at the local level. The insights shared will be invaluable to those constructing future national support programmes intended to facilitate transformation in local health and care systems.


The promise of healthtech: how digital innovators are transforming the NHS 


Technological innovation is one way in which the NHS can sustainably relieve the demographic and financial pressure it faces. This report surveys the digital health market and identifies the trends that are contributing to its growth. It also highlights major barriers to innovation in the NHS.


We analysed 25 population health interventions—and these 2 give the best 'bang for your buck' 

Advisory Board

Determining which investments to make in care delivery transformation is a difficult task without good data on initiatives with demonstrated success. To make the right investments that change the care delivery model, population health managers should prioritise initiatives proven to move target metrics related to cost, utilisation, and quality.

Here are three surprising lessons we learned from that nearly year-long study.

1. Not all chronic disease management programmes are created equal—without proper implementation, some could cost you money in the long term.

2. Be strategic when investing in under-studied interventions. The results may not be what you expect and may require you to initially narrow the scope of your services.

3. To get the most comprehensive 'bang for your buck,' two care innovation interventions stand out among the rest.

Out of the 25 interventions reviewed to date, we found that only two have been studied over a long period of time and consistently demonstrate improvements on cost, quality, utilisation, access, and patient satisfaction metrics: high-risk care management and community health worker programmes.




Experience-Based Co-Design: Tackling common challenges

Journal of Health Design 

There has been a surge in experience-based co-design (EBCD) efforts for quality improvement in health care and systems design globally. The authors identify common, shared challenges with using EBCD and their subsequent impact.  


Highly Adoptable Improvement: A Practical Model and Toolkit to Address Adoptability and Sustainability of Quality Improvement Initiatives

IHI / Joint Commission Journal on Quality and Patient Safety

Health care quality improvement initiatives that increase staff workload and have low perceived value are less likely to be adopted. This article presents the Highly Adoptable Improvement Model, a practical model and supporting tools developed on the basis of existing theories to help quality improvement (QI) programs design more adoptable approaches that lead to more sustainable improvement. 


From PES to PDSA: A guide to using the patient experience survey portal for quality improvement


Written collaboratively with the Commission's quality improvement team, this document breaks down Plan, Do, Study, Act cycles into well-defined steps so you can streamline quality improvement activities within your primary health organisation or general practice.


Learning from the Vanguards: Spreading and Scaling Up


This briefing explores the ten key factors that the vanguards have identified are crucial to encourage the spread of initiatives. These include the importance of involving clinicians in change, building shared goals across systems, and creating the time, space and resources for large scale change.

This briefing points to how the vanguards have benefitted from the co-ordinated support of the arm’s-length bodies and their permission to ‘fail fast and learn faster’. It also highlights how investing heavily in different ways of sharing learning, building networks and bringing people together, have been critical to the vanguards


Why Focusing on Burnout Isn’t Enough


In a new article, IHI’s Derek Feeley and Jessica Perlo say it’s essential to shift the focus from “burnout” to “joy in work” in health care. Delivering exceptional patient care and improving the health of our communities, they suggest, require more than preventing and treating caregiver burnout.

For Better Outcomes at Lower Cost, ‘Flip’ the Discharge Process


Hospitals usually assess patients’ post-discharge needs in the hospital, before sending them home. Sheffield Teaching Hospitals in the UK reversed this process with great results: increased satisfaction for patients, families, and employees; shorter hospital stays; and lower costs.


Pathology of poverty: the need for quality improvement efforts to address social determinants of health

BMJ Quality and Safety 

A massive body of literature characterises the impact of poverty on health outcomes. In 1817, Rene Villermé, a young French surgeon (and later economist-cum-social commentator), demonstrated stark differences in life expectancy across Parisian neighbourhoods or arondissements.1 This demonstration of disparities in basic health outcomes across income levels helped configure our early understanding of the ‘social determinants of health’. These determinants refer to the conditions in which people are born, grow, live, work and age, including income, housing and education, among others. Even 200 years after Villermé, with so many technological advances both within and outside of healthcare, the unequal distribution of resources across society continues to exert tremendous influence on the health outcomes of individuals and their communities. 

In this issue of BMJ Quality and Safety, two papers draw attention to just some of the ways in which poverty directly affects the types of issues many in quality improvement (QI) aim to address


Six steps for communications with impact

100 Lives improvement

1000 Lives Improvement has developed a framework to put strategic communication at the heart of improvement and change projects. This animation illustrates the steps of the framework. Individuals don’t need prior knowledge or skills in communication: the steps provide a starting point to develop a strategy to support improvement work.




Improving Health Equity: 5 Guiding Principles for Health Care Leaders


In January 2017, a team from IHI argued that health care organizations must make health equity a strategic priority. The authors identified five key steps for health care organizations: make health equity a leader-driven priority, develop structures and processes that support equity, take specific actions that address the social determinants of health, confront institutional racism within the organization, and partner with community organizations.


Deprescribing: Is Less Medicine the Best Medicine?


Deprescribing is a practice that all clinicians and pharmacists understand, yet guidelines on how and when a patient should stop taking a medication remain rare. The focus of this practice is to reduce or stop medications that may harm or no longer benefit a patient. When physicians can discontinue or decrease the number of medications a patient is prescribed, it both decreases the likelihood of an adverse event, and reduces the financial burden of paying for a multitude of medications.

How can health care providers get back to basics to stop the medications that may be unnecessary or even harm patients?

An innovative program out of Ottawa, Canada demonstrates how simplifying deprescribing can help providers incorporate the basics back into their routine. 


A Simple Way to Involve Frontline Clinicians in Managing Costs


While there have been significant strides in providing frontline clinicians with quality information, these clinicians still lack the tools they need to play an active role in controlling the costs of the care they provide. To date, only small steps have been taken at most health care systems (for example, clarifying the costs of specific tests during the test-ordering process), and new clinical analytics systems that offer better insights into costs and efficiency often aren’t integrated into day-to-day clinical care. Worse, discussions at health care organizations about how to increase “overall value” too often degenerate into conversations about cost reduction, with participants forgetting that delivering value means both improving outcomes and lowering costs.

In 2016 the Scottish National Health Service (NHS Scotland) piloted an approach to value improvement that took both cost and quality into account and turned the management of value into the basic task of the point-of-care manager. Value ceased to be a side initiative or something driven solely by top-level finance and executive leaders.

The “lean accounting” method for measuring real, unallocated costs used came from the Institute for Healthcare Improvement and one of us (Brian). IHI had partnered with him to combine a version of lean accounting that had been used in manufacturing with a point-of-care management system. 



Navigating the sustainability landscape: a systematic review of sustainability approaches in healthcare 

Implementation Science

Improvement initiatives offer a valuable mechanism for delivering and testing innovations in healthcare settings. Many of these initiatives deliver meaningful and necessary changes to patient care and outcomes. However, many improvement initiatives fail to sustain to a point where their full benefits can be realised. This has led many researchers and healthcare practitioners to develop frameworks, models and tools to support and monitor sustainability. This work aimed to identify what approaches are available to assess and influence sustainability in healthcare and to describe the different perspectives, applications and constructs within these approaches to guide their future use.


Promising Practices for Improving Hospital Patient Safety Culture 

Agency for Healthcare Research and Quality (AHRQ) 

Patient safety culture has a positive influence on the effectiveness of patient safety and quality improvement interventions. A study was conducted to gain knowledge about promising best practices used by hospitals to improve patient safety culture hospitalwide.


Against the odds: successfully scaling innovation in the NHS 

The Health Foundation 

This report, written in partnership with the Health Foundation, calls for new approaches to scaling tried and tested health care innovations. It highlights the need to create the right conditions to spread these successfully across the NHS and identifies a shortlist of ten innovations that have successfully spread across the NHS in recent years.

Some assembly required: implementing new models of care

Health Foundation 

“The report identifies additional implications of the new care models programme for local health and social care leaders embarking on cross-organisational change. Taking time to understand and adapt to the local context is essential for new care models. Sites should focus on care redesign and its intended aims, and reserve time for people to collaborate to support co-design. Finally, evaluation must be seen as a core component of any plan, and teams must be given the time and support to collect and analyse data.” 

Falling short: Why the NHS is still struggling to make the most of new innovations

Nuffield Trust 

“The idea that the NHS is slow to adopt seemingly well-evidenced innovations is not new and, for the most part, is accepted as fact. The reasons for this have been extensively studied. Last year, the Accelerated Access Review set out the barriers once again – proposing a number of useful solutions that, if implemented as envisaged, could go a long way to improving the situation.” 

Growing innovative models of health, care and support for adults

Social Care Institute for Excellence 

This briefing explains that innovative, often small-scale models of health, social care and support for adults could be scaled up to benefit as many people as possible. It argues that the challenge is to make scaling up successful. 

No hospital is an island: learning from the acute care collaboration vanguards


This report covers the learning from 13 acute care collaborations that were established in September 2015 as part of the new care models programme. It highlights six common strategies that have emerged, including the way clinical practices are being standardised; how vanguards are making better use of clinical support services; and how the skills of health care professionals are being used more creatively and flexibly.

Adoption and spread of innovation in the NHS


This article aims to make a pragmatic contribution to the discussion of how to speed up the adoption of service innovation in the NHS. It draws on eight examples of successful spread of innovation supported by academic health science networks (organisations set up by NHS England in 2013 to identify and spread health innovations, including through connecting the NHS with academic organisations, local authorities, the third sector and industry). We interviewed the originators of the innovations wherever possible and the AHSN staff responsible for supporting adoption and spread, to understand the approach they had taken and the challenges they had encountered.






Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies / by Trisha Greenhalgh et al

J Med Internet Res. 2017 Nov; 19(11): e367.

Many promising technological innovations in health and social care are characterized by nonadoption or abandonment by individuals or by failed attempts to scale up locally, spread distantly, or sustain the innovation long term at the organization or system level.

Our objective was to produce an evidence-based, theory-informed, and pragmatic framework to help predict and evaluate the success of a technology-supported health or social care program.

Subject to further empirical testing, NASSS could be applied across a range of technological innovations in health and social care. It has several potential uses: (1) to inform the design of a new technology; (2) to identify technological solutions that (perhaps despite policy or industry enthusiasm) have a limited chance of achieving large-scale, sustained adoption; (3) to plan the implementation, scale-up, or rollout of a technology program; and (4) to explain and learn from program failures.

Additional comment from Dr Robyn Whittaker published in the latest NZ Digital Health Research Review

Comment (GH): This paper is an important piece in the ongoing discourse of health technology pilots presenting good evidence but still resulting in a lack of sustained uptake and adoption into business as usual. The authors have distilled a large amount of information through extensive methodology modes to create a framework (NASSS) that aims to help inform and evaluate the success of technology-supported health programmes. The paper lays out nicely questions to use to assess each of the seven domains. They place each response into a matrix of Simple, Complicated and Complex, which then helps set the tone for assessing the difficulty a health technology programme may have in becoming embedded and sustained into service delivery. The authors highlight that the framework could be used retrospectively and prospectively. However they advocate that prospectively using it can inform the implementation and help with lining up the wider system variables that would be needed to support success. However, it is not a deterministic or formulaic tool where if you tick all the boxes you will have success. The authors suggest that the framework is more iterative and should be used to help identify the challenging domains (which will be different depending on the implementation programme) at a (preferably) early stage and therefore set a realistic plan for adoption, spread and sustainability, or contrarily, whether to embark on the programme at all.

Falling short: Why the NHS is still struggling to make the most of new innovations

Nuffield Trust

There is an overly supply-driven and top-down approach to innovation. Shifts towards the co-production of solutions between clinicians and industry are encouraging, but initiatives such as the Innovation and Technology Tariff (while useful in some regards) do little to move the NHS away from a supply-driven approach, which starts with products first.

Identifying the most pressing problems and looking for solutions is rarely built into anyone’s day job – least of all clinicians. This is further compounded by a lack of clarity around how far chief executives should be involved in adopting innovation. Chief innovation officers with board oversight of the innovation process could make a fundamental difference.

Evidence generation (and the bodies that support it such as NIHR) are often not conducive to assessing real-world innovations in a timely way – particularly where there is a focus on cost effectiveness (rather than cost benefit).
Too often procurement departments and organisations as a whole look to innovations to produce short-term cash-releasing savings, rather than identifying where innovations can transform care pathways and lead to more efficient services. This requires adaptive leadership that can work across boundaries.

There is a tension between the policy push towards large-scale organisations (such as accountable care systems) and the capacity of SMEs to fulfil the needs of large contracts. 


Leading Large Scale Change: A guide to leading large scale change through complex health and social care environments


Leading Large Scale Change: a practical guide has been produced by the NHS England Sustainable Improvement Team and the Horizons Team, NHS England, to help all those involved in seeking to achieve transformational change in complex health and care environments. 

A comprehensive round-up is provided of all the latest thinking and practical approaches and tools that can be used in advancing large scale change. This publication refresh includes:

Updates on the leading transformational change models
The latest thinking from national and global improvement experts and change leaders
New tools, techniques and tips to help effectively progress large scale change programmes
Case studies and learning that will help leaders and change agents in health and care and across public services
Signposting to a host of new online resources including videos, presentations and digital media links. 


Meeting the quality challenge: sharing examples of best practice from clinical leaders in emergency departments

Care Quality Commission

This report provides practical examples of positive action that some trusts are taking to help meet the challenges of managing capacity and demand. The examples cover a range of areas including ambulance arrivals, initial patient assessments, staffing, managing deteriorating patients and specialist referrals.


Some assembly required: implementing new models of care - Lessons from the new care models programme  

Health Foundation   

The Health Foundation has captured some of the experiences of those working on the vanguard sites of the new care models programme in England. Drawing on the experiences of those leading the vanguard sites of the new care models programme, this report sets out 10 lessons for those seeking to systematically make improvements across local health and care services for those patients who are in most need of joined up care.
It emphasises the value of local co-creation and testing of new care models, and offers useful learning for those seeking to drive the development of new models of care within sustainability and transformation partnerships and accountable care systems.

Key findings

The report sets out 10 lessons for those seeking to systematically make changes across services in their area. These are based on first-hand accounts of clinicians and managers from the new care models programme’s vanguard sites. These sites have worked through the complexities of bringing together professions and organisations to develop place-based models of better coordinated care for people with complex health and social care needs.

The report finds that assessing and understanding what change efforts have come before, and what organisations and relationships currently exist is vital when developing new models of care. It emphasises the value of local co-creation and testing.

Collaborative action for the delivery of effective person-centred coordinated care 

South West Science Academic Health Network

A paper published in the journal Health Research Policy and Systems, reports on an approach to improve health service delivery using a collaborative approach between researchers, health care organisations, commissioners, and patients and the public to introduce and evaluate innovative approaches to person-centred coordinated care (P3C).

Multi-faceted challenges within the care/health environment are the catalyst for new and sometimes radical thinking about how care is delivered. This has resulted in a move away from disease-based models to an effective and integrated person-centred approach – person-centred coordinated care.

For people with complex health needs, their experience is often of fragmented care which results in poor outcomes. P3C is seen as a potential solution, but the dilemma for care providers is there is an absence of accessible evidence or scalable guidance – resulting in services ‘experimenting’ with new models of care with little support on implementation or evaluation.

This collaborative action is being used to support and accelerate the spread and adoption of P3C in UK primary care environments, with a focus on closing the gap between research and practice.

This publication highlights examples of P3C service model innovations and organisational links.


Six Steps for Communications with Impact
Watch a short animated video from 1000 Lives Improvement in Wales that describes how to use communications strategies to meet your QI goals.  see also


Behavioural design teams: the next frontier in clinical delivery innovation?

Commonwealth Fund

This briefing examines how embedded behavioural design teams could help providers rethinking the delivery of care in their organisations. Using interviews with experts in clinical delivery innovation and members of behavioural design teams, it highlights best practice in embedded behavioural design teams within health care organisations.

Are quality improvement collaboratives effective? A systematic review

BMJ Quality and Safety

Collaboratives reporting success generally addressed relatively straightforward aspects of care, had a strong evidence base and noted a clear evidence-practice gap in an accepted clinical pathway or guideline.

QICs have been adopted widely as an approach to shared learning and improvement in healthcare. Overall, the QICs included in this review reported significant improvements in targeted clinical processes and patient outcomes. These reports are encouraging, but most be interpreted cautiously since fewer than a third met established quality and reporting criteria, and publication bias is likely.

Embedding a culture of quality improvement

The KingsFund 

Quality improvement refers to the use of systematic tools and methods to continuously improve the quality of care and outcomes for patients. This report explores the factors that have helped organisations to launch a quality improvement strategy and sustain a focus on quality improvement. 

The report draws on a roundtable event attended by senior local and national NHS leaders, semi-structured interviews with NHS leaders and senior stakeholders involved in quality improvement initiatives, and a literature review.  

We identified three common themes for successfully launching a quality improvement strategy: having a clear rationale; ensuring staff are ready for change; understanding the implications for the organisation’s leadership team in terms of style and role. 

Key enablers for embedding a culture of quality improvement included: developing and maintaining a new approach to leadership; allocating adequate time and resources; ensuring there is effective patient engagement and co-production; maintaining staff engagement. Fidelity to a chosen approach is critical to sustaining and embedding quality improvement in an organisation’s culture. 

The report finds that NHS leaders play a key role in creating the right conditions for quality improvement. Leaders need to engage with staff, empower frontline teams to develop solutions, and ensure that there is an appropriate infrastructure in place to support staff and spread learning. 




10 IHI Innovations to Improve Health and Health Care


About 10 years ago, IHI established a Research and Development team and a systematic process of 90-day innovation cycles to tackle some of the vexing issues in health care. A new publication, 10 IHI Innovations to Improve Health and Health Care, curates some key ideas that have emerged from this systematic approach, and reshaped how and what IHI has committed itself to over the years — including the Triple Aim, the concept of a health care Campaign, the Breakthrough Series Collaborative model, among others

Achieving Hospital-wide Patient Flow


The culmination of approximately two decades of IHI’s research, innovation, and learning about hospital-wide patient flow, this white paper guides leaders and quality improvement teams through an in-depth examination of a systems view of patient flow, theories for improvement, and high-leverage strategies and interventions to achieve hospital-wide patient flow.

New care models: Harnessing technology


This publication explores how five vanguards are implementing innovative digital technology solutions at the heart of a new approach to care. They are:

East and North Hertfordshire
Better Care Together Morecambe Bay
Better Together Mid Nottinghamshire
Salford Together
East Midlands Radiology Consortium

The report describes how the starting point for any project introducing new technology should be the perspective of the end users. Technological solutions should be co-produced with people who use services and clinicians to ensure that the solutions are anchored in their needs and experiences. 

Engaging staff in the development process, understanding how they work and want to work in future, and providing ongoing support and training, is crucial to the successful implementation of new digital technologies.

The experiences of these vanguards demonstrate that it is possible to overcome the many challenges to adopting digital technology in health and care, and use it to enable more efficient, integrated, precise and personalised care.

In light of the national policy emphasis on enabling supported self-care and the shift towards out of hospital service provision, it is more important than ever before for health and care services to provide tools and information to support people and communities to have greater control over their own health and wellbeing. 

Digital technologies can drive, and underpin, care that is truly integrated around the needs of people – breaking down the barriers that have historically existed between primary, secondary and social care services.

When it comes to harnessing technology, local areas should ‘steal with pride’ and make use of learning and evidence from other areas. However new technological solutions need to be considered in the context of local needs, and anchored to wider change programmes across organisations and whole health and care systems. 

In isolation, small-scale technology projects will not bring about the fundamental shift envisioned in the Five year forward view. Teams should consider how they can make use of local place-based approaches that encourage collaboration across public services and capitalise on existing strengths and resources in the community.




Making the case for quality improvement: lessons for NHS boards and leaders 

Kings Fund

This briefing makes the case for quality improvement to be at the heart of local plans for redesigning services. By quality improvement, we mean the use of methods and tools to try to continuously improve quality of care and outcomes for patients.

The briefing does this by drawing on existing literature and examples from within the NHS of where quality has been improved and describing how this was done. It describes the potential benefits from investing in quality improvement – including for patients, staff and the financial sustainability of the system.

Key messages

Quality improvement – the use of methods and tools to continuously improve quality of care and outcomes for patients – should be at the heart of local plans for redesigning services. Leaders have a vital role to play in making this happen – leadership and management practices have a significant impact on quality. Studies have shown that board commitment to quality improvement is linked to higher-quality care, underlining the leadership role of boards in this area.

Improving quality and reducing costs are sometimes seen as conflicting aims when they are in fact often two sides of the same coin. There are many opportunities to deliver better outcomes at lower cost (improving value), for example by reducing unwarranted variations in care and addressing overuse, misuse and underuse of treatment. There are many examples across the NHS showing that even relatively small-scale quality improvement initiatives can lead to significant benefits for patients and staff, while also delivering better value.

The potential benefit is even greater if quality improvement techniques are applied consistently and systematically across organisations and systems. To deliver the changes that are needed to sustain and improve care, there needs to be a move from pockets of innovation and isolated examples of good practice to system-wide improvement.


Partnerships for improvement: ingredients for success: briefing

Health Foundation

This briefing looks at a range of current organisational partnerships. It focuses on five different partnering arrangements, as well as interviews with national leaders, and draws out learning to help inform and guide policymakers and providers.

Improving Diagnostic Quality and Safety Final Report

National Quality Forum 

The (US) National Quality Forum convened an expert Committee to develop a conceptual framework for measuring diagnostic quality and safety and to identify priorities for future measure development. The Committee’s seven themes and recommendations are intended to apply broadly to those researching or wishing to develop measures related to reducing diagnostic harm.

Accomplishing reform: successful case studies drawn from the health systems of 60 countries

International Journal for Quality in Health Care 

Healthcare reform typically involves orchestrating a policy change, mediated through some form of operational, systems, financial, process or practice intervention. The aim is to improve the ways in which care is delivered to patients. In our book ‘Health Systems Improvement Across the Globe: Success Stories from 60 Countries’, we gathered case-study accomplishments from 60 countries. Common factors linked to success included the ‘acorn-to-oak tree’ principle (a small scale initiative can lead to system-wide reforms); the ‘data-to-information-to-intelligence’ principle (the role of IT and data are becoming more critical for delivering efficient and appropriate care, but must be converted into useful intelligence); the ‘many-hands’ principle (concerted action between stakeholders is key); and the ‘patient-as-the-pre-eminent-player’ principle (placing patients at the centre of reform designs is critical for success).

Another meta-message centers on the extent of the change people try to enable. With time and focused effort, small scale, purpose-designed, local initiatives can and often do lead to system-wide improvements. Another overarching lesson learned is that the method by which information is captured, analysed and communicated throughout a systems change is fundamental. No reform can stick unless stakeholders are informed, information is exchanged and communication occurs at the right time, in the right place, between the right people, through the right medium. The book also teaches that implementation predicated on relationships between key stakeholders, using evidence on which to base decisions, and adopting clear principles of reform design provide a strong opportunity to deliver system improvements.

A final meta-lesson is the most crucial of all: placing the patient, their experience and well-being, at the centre of an initiative, anchors it to the point of the whole reform enterprise, whichever country is involved. That is the obvious, bedrock test for any reform: does it make care better for patients?

Embedding quality improvement skills: guides to build improvement capacity and capability  

NHS Improvement 

These guides are for organisations seeking to begin or build on their improvement capacity and capability. 

The guide builds on 2012 work from the NHS Institute of Innovation and Improvement and draws on the experience of healthcare providers. NHS Improvement has worked with the Institute for Healthcare Improvement (IHI) which have provided subject matter expertise in the development of this co-produced document.

It outlines the IHI ‘dosing’ approach to embedding quality improvement (QI) skills that several NHS trusts have found useful. It:

• outlines the scale of training and development required to embed quality improvement into the fabric of your organisation

• introduces some of the challenges leaders face around building capacity and capability

• introduces the concept of ‘dosing’

• makes recommendations on how to frame and plan the development of a system-wide strategy to build improvement capacity and capability.

Building capacity and capability for improvement is grounded in experiential learning and the application of the concepts, tools and methods to daily work. Both classroom and virtual learning are part of the design principles.


Ethical Guideline for Quality Improvement (Ko Awatea)

Ko Awatea

These guidelines and practical tools have been developed as a resource to support staff of Counties Manukau Health to consider ethical implications of quality improvement.

The tools (checklist and decision tree) are intended to:

build knowledge and awareness of potential ethical issues encountered in Quality Improvement
build knowledge to respond to ethical issues arising in Quality Improvement work
provide further resources to support ethical conduct of Quality Improvement.

New care models: harnessing technology


This report explores how digital tools can help to address rising demand, constrained funding and workforce challenges, and it demonstrates how technology has the potential to revolutionise the way health and care is delivered. It focuses on how five vanguards are implementing innovative digital technology solutions at the heart of a new approach to care. 

Rising demand for services, constrained funding and a multitude of workforce challenges require us to think differently about the way we deliver health and care services to meet people’s needs and expectations. Digital tools are key part of the answer to this set of challenges, and the NHS Five year forward view outlined ambitious plans to deliver a step-change in how health and care services use technology. 

The report describes how the starting point for any project introducing new technology should be the perspective of the end users. Technological solutions should be co-produced with people who use services and clinicians to ensure that the solutions are anchored in their needs and experiences. Engaging staff in the development process, understanding how they work and want to work in future, and providing ongoing support and training, is crucial to the successful implementation of new digital technologies. 


Leading Large Scale Change

NHS Horizons 

The refreshed guide provides a vital and comprehensive round-up of all the latest thinking and practical approaches and tools that can be used in advancing large scale change programmes.

Leading Large Scale Change: A Practical Guide brings you:

Updates on the leading models that will enable you to address the challenges in achieving transformational change;
The latest thinking from national and global improvement experts and change leaders;
New tools, techniques and tips to help you effectively progress large scale change programmes;
Evidence-based insights and learning that will help leaders and change agents in health and care and across public services;
Thought-provoking content that will help you successfully take forward your STP, vanguard, new care model, accountable care system or other large scale change programme;
Signposting to a host of new online resources including videos, presentations and digital media links.

Learning from our improvement heritage

We have collaborated with NHS Horizons Group and the Health Foundation to produce 8 interviews with key inspirational leaders about their experience of introducing quality improvement changes across health and care.

Our collaboration offers an inspirational insight into 8 leaders, each giving a detailed account on what enabled them to cope with highly stressful factors such as complexity, difficult relationships up and down the NHS and across other care providers, as well as unpredictability in policy shifts. 

They provide an unparalleled opportunity to learn from a diverse group of people with diverse experiences.  We find out about their successes, mistakes, and how they learnt to use improvement skills in their daily work. 


What role does performance information play in securing improvement in healthcare? a conceptual framework for levers of change

BMJ Open 

In this paper the authors identify and describe eight different levers for change in healthcare that are each enabled by performance information. Their framework structures these levers in terms of the source of motivation (internal/external) and whether change is planned or emergent.

The eight levers identified are:

cognitive – a means to gauge one’s own performance
mimetic – inform about the performance of others
supportive – provide facilitation, implementation tools or models of care to actively support change
formative – develop capabilities and skills through teaching, mentoring and feedback
 normative – set performance against guidelines, professional standards, norms, certification and accreditation processes
coercive – use policies, regulations incentives and disincentives to force change
structural – organisational constraints
competitive – attract patients or funders.
These have then been mapped in a matrix of quadrants each quadrant representing a different way in which change occurs (source of motivation and origin of change).

In any given context (and context matters) multiple levers may operate; but there are also instances whether different levers may act in different directions.

The authors make a number of apposite observations, including:

Measuring performance in healthcare is …about quantifying what healthcare systems, organisations and professionals are really achieving;
Routine release of information can guide planned efforts to improve and provide formative feedback according to agreed regular schedules. However, routine reporting can also lose salience if too many measures or too frequent reporting generates indicator chaos or fatigue;
Levers are the way to harness the power of data to secure improvement. However, a lever rarely operates in isolation—any system, organisation or healthcare professional is subject to multiple levers simultaneously; Meaningful and sustained change is more likely to be secured when different levers work in concert—aligning and reinforcing efforts to improve;
the efficacy of levers is context dependent… there is a need informed and often nuanced application



Primary Care Home: Evaluating a new model of primary care

Nuffield Trust 

This is an evaluation report for the Primary Care Home (PCH) model – a way of organising care for groups of 30,000 to 50,000 patients. It was developed by the National Association of Primary Care (NAPC), which commissioned this report.

Established last year, the model seeks to link staff from general practice, community-based services, hospitals, mental health services, social care and voluntary organisations to deliver joined-up care. The model was piloted in 15 rapid test sites, each of which qualified for £40,000 of start-up funding from NHS England. Since then another 170 sites have signed up.  

Our formative evaluation was based on reviews in 2016/17 of 13 rapid test sites’ plans and priorities for building the PCH model, and an in-depth look at the progress and early successes in three case study areas.

The report looks at how sites can make early progress with implementing and evaluating their local PCH models, examines what might stand in the way of change and offers a number of broader lessons for the NHS as a whole.  


Advances in Patient Safety and Medical Liability 


In October 2009, AHRQ launched the Patient Safety and Medical Liability (PSML) Initiative to address four goals: (1) putting patient safety first by reducing preventable injuries, (2) fostering better communication between doctors and patients, (3) ensuring fair and timely compensation for medical injuries while reducing malpractice litigation, and (4) reducing liability premiums. Under the PSML initiative, AHRQ funded 13 planning grants and 7 demonstration grants; the goal was to help States and health systems seek comprehensive solutions that improve patient safety and address the underlying causes of the malpractice problem. 

This publication, Advances in Patient Safety and Medical Liability, presents contributions and findings from the AHRQ-funded projects. In addition to a prologue, the volume includes two commentaries and nine papers, organized into two primary themes: improving communication and improving patient safety.

Developing accountable care systems: lessons from Canterbury, New Zealand



The health system in Canterbury, New Zealand, has undertaken a significant programme of transformation over the past decade. As a result of the changes, the health system is supporting more people in their homes and communities and has moderated demand for hospital care, particularly among older people.
Change was achieved through developing a number of new delivery models, which involve better integration of care across organisational and service boundaries, increased investment in community-based services, and strengthening primary care.

The experience in Canterbury offers useful lessons in terms of how to redesign care in this way. Key approaches include the development of a clear, unifying vision of ‘one system, one budget’; sustained investment in giving staff skills to support them to innovate and giving them permission to do so; and developing new models of integrated working and new forms of contracting to support this.

A multi-state, multi-site, multi-sector healthcare improvement model: implementing evidence for practice

International Journal for Quality in Health Care 

Paper reporting on a project undertaken in nine Australian hospitals seeking to improve the management of inadvertent peri-operative hypothermia. This paper focuses less on the intervention and more the approach or model adopted (or more accurately, adapted). The authors discuss taking the models developed by the Institute of Healthcare Improvement and the Johns Hopkins Quality and Safety Group and developing a ‘hybrid model’. This model focused on engaging those most affected by the intervention so as “to engage the hearts and minds of healthcare clinicians, and others in order to empower them to make the necessary improvements to enhance patient care quality and safety.” In a sense this is an example not so much of developing models but being aware of the importance of context. Transferability is often not so much a case of simply importing a solution but understanding the local context and making adjustments and modifications to suit the local setting.


Managing patient flow and improving efficiencies: The role of technology

Nuffield trust 

Having witnessed tracking technology first hand in two American health care organisations, in a new long read Sophie Castle-Clarke sets out its strengths and how to implement it successfully.


Case studies: Focus on improving patient flow

NHS Improvement
This series of case studies explains how selected providers are delivering effectively against good practice priorities.




Is There a Way to Prevent Quality Improvement Burnout? [blog] 


Even the most dedicated quality improvement champions get overwhelmed sometimes. How do we avoid wasting time and resources on improvement initiatives that don’t succeed or “stick”? How can we prevent overwork, resentment, and burnout related to QI? IHI faculty member Chris Hayes says one way to do this is to use the “Highly Adoptable Improvement” model that he helped develop. According to this model, change initiatives that don’t add to workload and have high perceived value are most likely to be adopted, cause less workplace burnout, and achieve their intended outcomes.


Use [of] improvement science to test approaches to improving joy in work in your organization [Step four]

In IHI  Framework for Improving Joy in Work 

There are many ways to take a systems approach to improving joy in work. The aim is to make the change process rewarding and effective. Using principles of improvement science, organizations can determine if the changes they test are leading to improvement; if they are effective in different programs, departments, and clinics; and if they are sustainable. In IHI’s prototype initiative, teams used the Model for Improvement27 or another improvement method that was standard in their organization. In all cases, the teams set an aim for their work, decided on measures that would tell them if they were making progress, and selected components of the Framework for Improving Joy in Work as areas in which to test changes.


The State of Patient Experience 2017: A Return to Purpose

Beryl Institute

The full research report from the Institute's latest benchmarking study provides insights into trends in structure and practice, leadership and measurement and offers core considerations for organizations looking to lead in experience excellence. The largest research of its kind, the study engaged almost 1,700 respondents from 26 countries representing six continents sharing the challenges and opportunities they are facing and the steps they are taking to address the patient experience.

According to the research:

Experience efforts are expanding and are now an integral part of the fabric of our healthcare efforts.
Patient experience remains a top priority with a focus on employee engagement now seen as a central driver in experience efforts.

Leadership and culture are now the significant motivators versus the historic focus on mandates and requirements, and there is a recognition of the impact that patient/family voice and caregiver engagement has on the work of healthcare.

Patient experience itself continues to establish presence with the role of patient experience leaders, experience team size and the use of a formal definition on the rise.

Patient experience is now being recognized as an integrated effort touching on much of what we do in healthcare and one that drives clear and measurable outcomes

Good practice guide: Focus on improving patient flow


The guide outlines areas for providers to focus on to improve the safety, efficiency and effectiveness of their urgent and emergency care programmes. Each section contains links to supporting resources that provide further detail.

Good patient flow is central to patient experience, clinical safety and reducing the pressure on staff. It is also essential to the delivery of national emergency care access standards. Experts consistently advocate focussing on patient flow as a key factor in providing effective health care.

The good practice guide is also accompanied by a series of case studies that offer examples of how providers have implemented some of the principles in the guide. 


Advancing Care: Research with care homes. Themed review

National Institute for Health Research

The UK’s National Institute for Health Research (NIHR) have produced this themed review focusing on three themes relating to the care of older people in care homes

Living well – maintaining good health and quality of life
Ageing well – managing long term conditions associated with ageing (Noting that 70% of people in care homes have dementia or severe memory problems)
Dying well – ensuring a good quality end of life (Noting that 18% of the people who die in England each year die in a care home). 


Quality improvement in mental health 

The King’s Fund

Quality improvement approaches – increasingly well-established in NHS acute hospitals – could play a key role in improving the quality of mental health care.

A growing number of mental health providers (in the UK and beyond) are beginning to embed quality improvement across their organisations, with some encouraging results. The approach is based on the concept that sustained improvement is best achieved by empowering frontline teams, service users and carers to design, implement and test changes to services.

This report describes the quality improvement journey of three mental health organisations (two in England and one in Singapore). It provides key insights and lessons for others considering embarking on a similar journey.


Holding the gains: sustaining change in quality improvement 

Ko Awatea

Sustaining change is one of the biggest challenges in quality improvement. Studies estimate that up to 70 per cent of change initiatives fail to stick.[

How, then, can you maximise the sustainability of your quality improvement project? This article shares eight tips for sustainability factors that are often overlooked. 



HEALTH SYSTEM IMPROVEMENT GUIDE Folau I Lagi-Ma – Journey to Wellness 

Ko Awatea 

The Folau I Lagi-Ma collaborative project brought together project manager and improvement advisor expertise from Ko Awatea with the clinical expertise of frontline healthcare staff. Together, they created an innovative new model of selfmanagement support that integrates occupational therapy and peer support into primary care to help people living with long-term conditions in Counties Manukau to manage their own health and achieve a better quality of life.


Evaluating Complex Health Interventions: A Guide to Rigorous Research Designs


Perhaps the more difficult aspects of an intervention or innovation in health care are the implementation and evaluation. This short (29-page) guide offers some suggestions on possible project/research designs that permit clearer evaluation of the intervention. The guide includes flowcharts to suggest which designs are better suited to the question or intervention being studied.

The guide is aimed at program managers and other stakeholders implementing innovations in public health and community settings who are involved in evaluation but may not themselves be evaluators. The evaluation designs covered included a mix of experimental, quasi-experimental and observational designs. For each design there is an illustrated description, examples, discussion of strengths and weaknesses and more, including discussion of the compromises involved in design selection.



Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health

National Academy of Medicine 

According to this report from the [US] National Academy of Medicine, “the top 1 percent of patients account for more than 20 percent of health care expenditures, and the top 5 percent account for nearly half of the nation’s spending on health care”. The National Academy of Medicine, with guidance from an expert planning committee, was tasked with convening three workshops and summarizing the presentations, discussions, and the relevant literature. This resulting document, reports and reflects on the following issues:

Key characteristics of high-need patients
Use of a patient categorization scheme—or a taxonomy—as a tool to inform and target care
Promising care models and attributes to better serve this patient population, as well as insights on “matching” these models to specific patient groups
Areas of opportunity for policy-level action to support the spread and scale of evidence-based programs. The publication concludes by exploring common themes and opportunities for action in the field.
The Academy argues that “Improving care for high-need patients is not only possible–it also contributes to a more sustainable health system. But progress will take a coordinated effort from policy makers, payers, providers, and researchers, as well as patients and their loved ones.”


Learning from Scotland’s NHS 

Nuffield Trust

This report looks at Scotland’s unique health care system, and explores how other parts of the UK might be able to learn from it.

It looks at how health care in Scotland is different, where its approach seems to solve problems being faced elsewhere in the UK, and whether that approach could be transplanted to England, Wales and Northern Ireland. It also assesses whether there are areas where Scotland could learn from its peers.

Scotland has a unique system of improving the quality of health care. It focuses on engaging the altruistic professional motivations of frontline staff to do better, and building their skills to improve. Success is defined based on specific measurements of safety and effectiveness that make sense to clinicians.

Scotland’s smaller size as a country supports a more personalised, less formal approach than in England. The Scottish NHS has also benefited from a continuous focus on quality improvement over many years. It uses a consistent, coherent method where better ways of working are tested on a small scale, quickly changed, and then rolled out. This is overseen by a single organisation that both monitors the quality of care and also helps staff to improve it. 


Quality Improvement Essentials Toolkit


IHI’s QI Essentials Toolkit includes the tools and templates you need to launch and manage a successful improvement project. Each of the ten tools in the toolkit includes a short description, instructions, an example, and a blank template.

What we know about designing an effective improvement intervention (but too often fail to put into practice)

BMJ Quality & Safety

It is temptingly easy to treat improvement interventions as if they are drugs—technical, stable and uninfluenced by the environment in which they work. Doing so makes life so much easier for everyone. It allows improvement practitioners to plan their work with a high degree of certainty, funders to be confident that they know what they are buying and evaluators to focus on what really matters—whether or not ‘it’ works.

But of course most people know that life is not as simple as that. Experienced improvers have long recognised that interventions—the specific tools and activities introduced into a healthcare system with the aim of changing its performance for the better1—flex and morph. Clever improvers watch and describe how this happens. Even more clever improvers plan and actively manage the process in a way that optimises the impact of the improvement initiative.

The challenge is that while most improvers (the authors included) appreciate the importance of carefully designing an improvement intervention, they (we) rarely do so in a sufficiently clever way. In this article, we describe our attempts as an experienced team of practitioners, improvers, commissioners and evaluators to design an effective intervention to improve the safety of people living in care homes in England... 


Tackling variations in clinical care: Assessing the Getting It Right First Time (GIRFT) programme


The Getting It Right First Time (GIRFT) programme aims to bring about higher-quality care in hospitals, at lower cost, by reducing unwanted variations in services and practices.

It uses national data to identify the variations and outcomes, shares that data with all those concerned with a service – not only clinicians, but also clinical and medical directors, managers and chief executives – and monitors the changes that are implemented.

The programme began with orthopaedics and is now being rolled out to 32 different surgical and medical specialisms across the English NHS. Through an informal assessment of the programme, this paper sets out what the programme is, why it is needed, what is different about it, what it has achieved, what challenges it faces and what potential it has. It also contains vignettes illustrating hospitals’ experiences of the programme.



Enabling change through communities of practice: Wellbeing Our Way

National Voices

In June 2014, National Voices set out to explore and test how communities of practice could facilitate the spread of large-scale change across England’s voluntary sector working for health and wellbeing.

This publication reflects on our experiences over the last 3 years, and in the spirit of communities of practice, aims to share reflections in order that others can use our learning.


Reinventing innovation: Five findings to guide strategy through execution: Key insights from PwC’s Innovation Benchmark  

In an era of digital business and rapid technology change,  virtually no company can ignore the imperative to innovate.  Failing to do so is an invitation to lose business.

To learn how companies are responding to this mandate, PwC conducted a major global study. We surveyed over 1,200 executives in 44 countries and spoke in depth with individuals charged with managing innovation initiatives at leading companies.  Our goal was to understand how these leaders view innovation and what they are doing to better reap its rewards. We looked at innovation across a complex set of challenges, including innovation strategy, operating models, culture, metrics, and more to understand how innovating companies are seeking to create business value and financial returns on their efforts. 


Open4 Results - A Window on the Quality of New Zealand's Health Care 2017  

The latest snapshot of the quality of New Zealand’s health care shows continuing improvements, but also highlights ongoing inequity in treatment.  

A qualitative formative evaluation of a patient-centred patient safety intervention delivered in collaboration with hospital volunteers

Health Expectations 

Evidence suggests that patients can meaningfully feed back to healthcare providers about the safety of their care. The PRASE (Patient Reporting and Action for a Safe Environment) intervention provides a way to systematically collect feedback from patients to support service improvement. The intervention is being implemented in acute care settings with patient feedback collected by hospital volunteers for the first time.




Building a Better Operating Room: Views from Surgery and Architecture

The operating room is the single most important place in the hospital for surgeons. Despite enormous innovation in surgical practice, relatively fewer advances have been made to the actual operating room itself. New technology and devices have been introduced to crowd the space, but changes to the actual lay out and how to organize the room remains largely unchanged. Indeed, many of the design shortcoming described by surgeons 4 decades ago—“faults in equipment, inaccessibility of necessary items, problems in communication, inefficient handling of materials, unconscionable delays … that are an expression of a hazardous environment”1—could readily be identified by surgeons today.

The problem of building a better operating room is not new and arises largely from knowledge gaps between architects and users of the operating room. Many surgeons and nurses who have been involved in operating room planning and are around to occupy that space afterwards are often disheartened by the gap between their suggestions and the result. The architects, however, are faced with enormous constraints—budgets, regulatory codes, materials limitations—that they cannot or do not communicate well. Revisions made to accommodate these constraints can often make the initial plan unrecognizable leaving care providers wondering why they ever offered their input to begin with.

In this perspective, we take both an architectural and surgical view to outline current limitations of operating room design and emerging solutions to facilitate improvement

Driving improvement: Case studies from eight NHS trusts

Care Quality commission

We spoke to staff, patients and local patient representative groups at eight trusts that have shown significant improvement.

We set out to explore what a selection of NHS trusts had done to become 'well-led'. We chose eight trusts that had shown significant improvement since a previous inspection.

We asked people in those trusts how they had achieved improvements, looking at the steps their leaders had taken and the effect of those actions on staff and patients.

We interviewed a range of people from each trust, including chief executives, medical and nursing directors, non-executives, heads of communications, frontline staff, patient representatives and external stakeholders.


Mindshift: activities for teams, innovators and change agents

BC Patient Safety & Quality Council

This resource is intended to facilitate working with groups to accelerate improvement through interactive team-building activities. It is designed to develop communication skills, model adaptive systems, shift culture, and foster innovation, creativity, and thought diversity.

For each of the activities in this resource, we outline the purpose, category, instructions, time commitment/range, number of participants, resources required, and debriefing notes.


David Oliver: Should practical quality improvement have parity of esteem with evidence based medicine?  


As I qualified in 1989, my career has coincided with the growing evidence based medicine movement. It’s been a major advance in evaluating clinical interventions, defining best practice, and moving beyond a reliance on expert opinion or tradition. It’s given us methodologically consistent systematic reviews such as Cochrane, and evidence based guidelines such as those from NICE.123

Medics learn that good systematic reviews and meta-analyses top the evidence pyramid, then randomised controlled trials (RCTs).45 In conventional evidence based medicine, even good local observational and implementation data are ranked as less weighty evidence. This may skew our world view—making it harder for quality improvement (QI) work to find academic funding, prestige, or publication impact.

Shouldn’t we start giving QI work equal status to evidence based medicine, given its powerful ability to tackle pressing and relevant problems in individual systems and services in real time? Read more


Raising the Bar on the National Patient Experience Survey: Report Findings and Recommendations 

Health Quality and Safety Commission 

Raising the Bar on the National Patient Experience Survey responds to the national inpatient experience survey results by investigating the lower scoring areas of the survey and recommending interventions to improve these results. Four DHBs participated and provided opportunities for staff and patients to explore the reasons behind the responses to information about medication side effects and discharge from hospital through interviews, observation and focus groups. The results suggest there are interventions that could improve the experience for patients and staff and lead to improved patient outcomes, reduced readmission rates, and reduced health care costs associated with these readmissions.



Pushing the frontiers of improvement research

Health Foundation

Since 2010 the Health Foundation has been investing in and promoting improvement research; the work they have supported has improved care and altered national policy. We are delighted that the Foundation is now investing around £40 million in the establishment of an improvement research institute. This new organisation is being set up and run by the University of Cambridge, working closely with a wide range of partners including the health service, university and charity sectors and from other sectors across the UK.

Our vision for the institute is bold and ambitious: we want to create the enabling infrastructure for the NHS to become the world’s largest producer of systematic learning about how to improve health care for patients. To do this, we will use innovative approaches ranging from citizen science through to large-scale research capacity building, and we will be working directly with patients themselves as partners.

The basic principle behind the institute is a simple but important one: we need to get better at getting better at delivering healthcare, and one way to make that happen is by creating a better evidence-base for improvement.  Read more


Fresh thinking about the evidence needed for a healthier UK

Health Foundation

The Health Foundation is working with Dr Harry Rutter from the London School of Hygiene and Tropical Medicine to develop a new model of evidence that will inform the policy and action needed to make our population healthier. We spoke to Dr Rutter about the challenges inherent in generating and using evidence in new ways, and how traditional measures alone don’t capture the complexity of work in this area.

Enabling self management support

Ko Awatea 

Ko Awatea has published a guide to enabling self-management support which describes programme options to deliver this type of support and the patient, clinician and service activators that enable these options.

The guide, Enabling self-management support, is based on learning from Ko Awatea’s Manaaki Hauora – Supporting Wellness campaign, which aimed to provide self-management support for people living with long-term conditions in Counties Manukau.

The Manaaki Hauora – Supporting Wellness campaign covered 16 collaborative teams in different settings and clinical contexts, each of which worked towards a unique aim that contributed to the overall campaign goal. Ten of the teams, whose projects demonstrated the greatest reach and impact, are featured in the guide.

Self-management support options that demonstrated reach and impact in the Manaaki Hauora – Supporting Wellness campaign include the use of peers to engage with and support patients, personalised self-management support, health passports, the use of health coaches, generic and condition-specific group-based self-management support, group care planning, and ongoing support.

These options work well when the patient, the clinician and the healthcare system are activated.

The campaign also identified six system-level enablers which must exist in complement with factors that activate patients and clinicians to establish and deliver self-management support services that work well and make a difference for people with long-term conditions.

“The support of senior managers to address barriers is important, as is making resources available. The use of co-design and collaborative methodology provides quality improvement teams with a framework for ensuring that services and resources meet the needs of patients and their families and putting improvement initiatives into practice. Quality improvement project teams also need passionate leadership, and they are more likely to succeed if staff turnover is low during the project period or succession planning is in place,” says Ms Dowdle.



New paper highlights national success implementing orthopaedic ERAS 

Ko Awatea 

A paper published by Ko Awatea and the Ministry of Health in the New Zealand Medical Journal shows how 18 DHBs are implementing Enhanced Recovery after Surgery (ERAS) protocols in their orthopaedic services.

The paper, Implementation and effects of Enhanced Recovery After Surgery for hip and knee replacements and fractured neck of femur in New Zealand orthopaedic services describes the implementation of ERAS for elective hip and knee joint replacement and acute fractured neck of femur, and its effects.

ERAS comprises an evidence-based, multimodal, patient-centred rehabilitation programme for patients undergoing surgery. It is known to significantly improve surgical outcomes for patients and the cost-effectiveness of care.

The National Orthopaedic ERAS Collaborative, launched in 2013, implemented ERAS protocols using IHI Breakthrough Series (BTS) collaborative quality improvement methodology.

Compliance with the elements that make up ERAS increased from 33% to 75% for knee replacements, from 31% to 78% for hip replacements, and from 29% to 51% for fractured neck of femur. The length of time patients spent in hospital for knee joint replacement fell from 5.4 days to 4.5 days, and for hip replacement from 5.1 days to 4.3 days.

“ERAS can be difficult to implement because it requires all members of a multidisciplinary peri-operative team to work together to implement identified protocols. The National Orthopaedic ERAS Collaborative shows that BTS methodology works to implement ERAS on a large scale,” says Suzanne Proudfoot, Projects and Campaign Manager, Ko Awatea.

“When you look at the success we’ve had with this and our Target CLAB Zero collaborative, which reduced the national CLAB rate in intensive care units by 96%, you can see the potential of this methodology to address other problems in healthcare.”


Leading a Culture of Safety: A Blueprint for Success


Patient safety experts and researchers have increasingly pointed to the role of organizational culture in the success of patient and workforce safety initiatives. Yet, creating a culture of safety in healthcare settings has proven to be a challenging endeavor, and there is a lack of clear actions for organizational leaders to take in developing such a culture. 

Leading a Culture of Safety: A Blueprint for Success was developed to bridge this gap in knowledge and resources by providing chief executive officers and other leaders with a useful tool for assessing and advancing their organization’s culture of safety. This guide can be used to help determine the current state of an organization’s journey, inform dialogue with the board and leadership team, and help leaders set priorities. 

The high-level strategies and practical tactics in the guide are divided into two levels:

The foundational level provides basic tactics and strategies essential for the implementation of each domain.
The sustaining level provides strategies for spreading and embedding a culture of safety throughout the organization.



Open innovation in health: A guide to transforming healthcare through collaboration 


What role can open innovation play in addressing health challenges around the world? In this report, we explore the ways that companies, governments and researchers around the world are collaborating to improve the innovation process in health, from the way that problems are identified to how new products and services are created and then adopted by providers of healthcare.

The guide is the result of a collaboration with the State of São Paulo and the UK government and involved testing open innovation methods in Brazil through two pilot projects. It identifies open innovation approaches across the innovation cycle.


Caring to change : How compassionate leadership can stimulate innovation in health care

King’s Fund

This paper looks at compassion – which involves attending, understanding, empathising and helping – as a core cultural value of the NHS and how compassionate leadership results in a working environment that encourages people to find new and improved ways of doing things.

 It also describes four key elements of a culture for innovative, high-quality and continually improving care and what they mean for patients, staff and the wider organisation: inspiring vision and strategy positive inclusion and participation enthusiastic team and cross-boundary working support and autonomy for staff to innovate.

The paper also presents case studies of how compassionate leadership has led to innovation.


How Cultural Alignment and the Use of Incentives Can Promote a Culture of Health: Stakeholder Perspectives


This report draws on interviews with Culture of Health stakeholders whose work focused on culture, incentives, or both to learn how organizations are addressing and leveraging culture and incentives to promote health and well-being. 

Key findings include the following:
Equity is often addressed in silos, which impedes progress toward a unified goal of health equity for all;
members of specific cultural groups need to be given a voice in health-related activities;
systems are built around prevailing cultural norms, making it challenging for those working with specific cultures to make cultural adaptations; and not all incentives are monetary. 

Recommendations include institutionalizing practices that ensure ongoing input from marginalized populations, identifying ways to help smaller organizations overcome structural inequalities, and institutionalizing health promotion efforts in sectors other than public health or health care to sustain collaborative efforts.



Increasing patient engagement in healthcare service design: a qualitative evaluation of a co-design programme in New Zealand

Patient Experience Journal

The Health & Quality Safety Commission New Zealand commissioned Ko Awatea, an innovation and improvement centre, to deliver a co-design programme to nine teams of healthcare providers. The co-design programme was part of Partners in Care, a broader programme developed in 2012 to support and enable patient engagement and participation across the health and disability sector.  Health professionals identified key challenges to patient engagement as capturing diverse experiences, clear communication of project details and the availability and health of the patient. Patients advised the importance of improved communication, planning in advance and providing feedback and assurance about the value of their contribution. There are several important considerations to secure and maintain patient engagement in co-design. These include tailored strategies for approaching patients and capturing their experiences, pre-existing relationships and continued rapport building between patients and health professionals, good communication throughout the project, planning, and visibility of outcomes.




Minding the gap: factors associated with primary care coordination of adults in 11 countries

Commonwealth Fund 

This briefing summarises the findings of a study which surveyed patient experience of care coordination in eleven high-income countries (incl. NZ). The dimensions of care coordination assessed for this study were: access to medical records or test results; receiving conflicting information; use of diagnostic tests that the patient felt was unnecessary; and dissemination of information between primary care doctor and specialist.


Adults with poor primary care coordination were more likely to be hospitalized and more likely to visit the emergency room for nonurgent and urgent care than people who did not report poor coordination. An established relationship with a regular physician was associated with better care coordination, indicating the ongoing benefits of strengthening primary care.


Best Practices in Patient Safety: 2nd Global Ministerial Summit on Patient Safety

This compilation of best practices illustrates the global efforts to increase patient safety. Development and implementation of patient safety measures require continuous interaction of the three areas Policy, Evidence, and Implementation. Prerequisites of feasibility and the benefits of this interaction are a close collaboration and communication between lawmakers, scientists, stakeholders, healthcare professionals, and patients. The various examples in this best practice compilation provide a good insight in working cooperation, opportunities, and challenges when improving patient safety. All these examples have in common that the long-term success depends on the synergy of policy, evidence, and implementation: the most promising evidence-based approach is only sustainable if it can be successfully implemented in healthcare settings and is supported by governmental decisions. The topics in this compilation range from global issues on patient safety efficiency to preventions of patients harm caused by infections or specific antibiotics. This booklet can finally guide governments, scientists, stakeholders, healthcare professionals, and patients to contribute to the promotion of regional and global safety culture.

Caring for Quality in Health: Lessons Learnt from 15 Reviews of Health Care Quality


Over the past four years, the OECD has conducted a series of in-depth reviews of the policies and institutions that underpin the measurement and improvement of health care quality in 15 different health systems. This synthesis report draws on key lessons from the OECD Health Care Quality Review series. The objective is to summarise the main challenges and good practices to support improvements in health care quality, and to help ensure that the substantial resources devoted to health are being used effectively in supporting people to live healthier lives. The overarching conclusion emerging across the Health Care Quality Review series concerns transparency. Governments should encourage, and where appropriate require, health systems and health care providers to be open about the effectiveness, safety and patient-centredness of care they provide. More measures of patient outcomes are needed (especially those reported by patients themselves), and these should underpin standards, guidelines, incentives and innovations in service delivery. Greater transparency can lead to optimisation of both quality and efficiency – twin objectives which reinforce, rather than subvert, each other. In practical terms, greater transparency and better performance can be supported by changes in where and how care is delivered; changes in the roles of patients and professionals; and employing tools such as data and incentives more effectively. Key actions in these three areas are set out in the twelve lessons presented in this synthesis report




An investigation of quality improvement initiatives in decreasing the rate of avoidable 30-day, skilled nursing facility-to-hospital readmissions: a systematic review

Clinical Interventions in Ageing 

Objectives: The main objective was to investigate the applicability and effectiveness of quality improvement initiatives in decreasing the rate of avoidable 30-day, skilled nursing facility (SNF)-to-hospital readmissions.

Problem: The rate of rehospitalizations from SNF within 30 days of original discharge has increased within the last decade.

Setting: The research team participants conducted a literature review via Cumulative Index of Nursing and Allied Health Literature and PubMed to collect data about quality improvement implemented in SNFs.

Results: The most common facilitator was the incorporation of specialized staff. The most cited barriers were quality improvement tracking and implementation.

Conclusion: These strategy examples can be useful to acute care hospitals attempting to lower bounce back from subacute care providers and long-term care facilities seeking quality improvement initiatives to reduce hospital readmissions.



Investigating the meaning of ‘good’ or ‘very good’ patient evaluations of care in English general practice: a mixed methods study 

BMJ Open 

Objective To examine concordance between responses to patient experience survey items evaluating doctors' interpersonal skills, and subsequent patient interview accounts of their experiences of care.

Conclusions Positive responses on patient experience questionnaires can mask important negative experiences which patients describe in subsequent interviews. The interpretation of absolute patient experience scores in feedback and public reporting should be done with caution, and clinicians should not be complacent following receipt of ‘good’ feedback. Relative scores are more easily interpretable when used to compare the performance of providers.

In patient-centred healthcare systems, patients should be enabled to reflect candidly on their experiences of care, and be certain that such experiences make a meaningful contribution to quality improvement. 


Reducing hospital admissions by improving continuity of care in general practice

Health Foundation

This briefing summarises research that analysed data from over 230,000 anonymised patient records for older people aged 62–82 years. The research found that there were fewer hospital admissions for certain conditions when the patient saw the same GP more consistently. Patients who saw their usual GP two or more times out of every ten were associated with six per cent fewer avoidable hospital admissions.

Evaluating investment in quality improvement capacity building: a systematic review 

BMJ Open  

Leading health systems have invested in substantial quality improvement (QI) capacity building, but little is known about the aggregate effect of these investments at the health system level. We conducted a systematic review to identify key steps and elements that should be considered for system-level evaluations of investment in QI capacity building.

Shifting the balance of care: Great expectations 

Nuffield Trust 

This research draws on an extensive literature review to assess the realism of the narrative that moving care out of hospital will save money. It explores five key areas: elective care, urgent and emergency care, admission avoidance and easier discharge, at risk populations, and self-care. 

Our research has shown that despite the potential of initiatives aimed at shifting the balance of care, it seems unlikely that falls in hospital activity will be realised unless significant additional investment is made in out-of-hospital alternatives. 

Where schemes have been most successful, they have: targeted particular patient populations (such as those in nursing homes or the end of life); improved access to specialist expertise in the community; provided active support to patients including continuity of care; appropriately supported and trained staff; addressed a gap in services rather than duplicating existing work. 

Implementation and contextual factors cannot be underestimated, and there needs to be realistic expectations, especially around the economic benefit of new care models. If STPs continue to work towards undeliverable expectations, there is a significant risk to staff morale, schemes may be stopped before they have had a chance to demonstrate success, and gains in other outcome measures such as patient experience may be lost.


A Model for Implementing Evidence-Based Practices More Quickly

NEJM Catalyst 

A staggering 36,000 randomized controlled trials (RCTs) are published each year, on average, and it typically takes about 17 years for findings to reach clinical practice. Proposed changes in frontline care often originate with suggestions from clinicians, but evaluating their merit can be time-consuming and expensive. Focused evidence reviews may yield inconclusive results that don’t lend themselves to clear-cut decisions; pilot studies are vulnerable to poor design, less-than-rigorous evaluation, scant evidence, and other limitations. The result: a logjam of epic proportions that slows the real-world implementation of evidence-based practices. At Kaiser Permanente Southern California (KPSC), we aimed to find a quicker, more effective, more systematic way to break that logjam in a manner that is consistent with the Triple Aim.

The result was E-SCOPE — Evidence Scanning for Clinical, Operational, and Practice Efficiencies — a system for identifying and rapidly implementing clinical and operational practices that are supported by newly published, high-quality evidence.


Why “What Matters to You?” Matters Around the World

Five years ago, Maureen Bisognano, IHI President Emerita and Senior Fellow, gave an influential keynote at IHI’s Summit. Her exhortation to ask not only “What's the matter?” but also “What matters to you?” is helping to fundamentally change the conversation between clinicians and patients. In a preview of her upcoming keynote at IHI’s April 20-22 Summit on Improving Patient Care in the Office Practice and the Community, Bisognano shares why “What matters to you?” has spread around the world. She also shares how this change in the balance of power increases patient engagement and has the potential to increase joy in work. 

Lessons from Ten Exemplary Student-led QI Projects


Every year, over 150 students submit their work in quality improvement, IHI Open School Chapter leadership, and community organizing. A group of interprofessional faculty review the submissions across the categories select three winners to present their storyboards at a special session.

This blog post highlights a few of the exceptional quality improvement projects IHI Open School learners are leading. Students and trainees tackled all types of projects in many settings — offering translation for patients with limited English proficiency, making more effective referrals from birth centers to acute care, and reducing patient wait times. They set clear aims appropriate to the context of their system, used specific improvement methods and tools, highlighted the data that demonstrated improvement, and shared a clear study of their results as they look toward future tests of change.  


Selling Social Change  

Stanford Social Innovation Review

All too often, nonprofits take a “build it and they will come” approach, focusing most of their efforts on creating services that they think are innovative or effective, and expressing surprise when those services go begging for participants. It’s time for nonprofits to develop a more sales-driven approach to social change...

There are three critical steps nonprofits need to take when creating and implementing solutions. In the sections that follow, each of these three steps will be explored in detail.

Recognize the limits of designing a service or program primarily for effectiveness and also design for “spreadability.”
Go beyond identifying a broad group of potential beneficiaries and focus first on a subgroup most likely to participate.
Develop and resource a sales and marketing capability from the outset, right alongside budgeting for program delivery.


What increases innovation capability and general performance in organisations: new research

Oxford Review 

This study looked at the level of influence the following factors have on each other: 

Organisational culture;
Leadership style;
Organisational learning 

And how they affect innovation capability and performance within organisations





Research and QI: How Can They Work Together?


As more and more health care organizations apply quality improvement (QI) methods to improve care processes, some common questions arise: What’s the difference between a QI approach and more traditional research and evidence-based medical practice? Is there “additive benefit” from bringing together these approaches? Dr. Amar Shah, Associate Medical Director and Consultant Forensic Psychiatrist at East London NHS Foundation Trust, and Dr. Robert Lloyd, IHI Vice President, make a case for bringing the best of quality improvement and traditional research together. They provide examples to illustrate how improvement-based testing of evidence-based interventions can lead to more efficient and effective implementation.


Engaging health care volunteers to pursue the Triple Aim

American Hospital Association

This report showcases how volunteer services support the Triple Aim, a framework developed by the Institute for Healthcare Improvement that outlines an approach for maximizing the performance of the health care system. This framework looks at improving the patient experience of care; improving the health of populations; and reducing the per-capita cost of health care. 


Improving communication with primary care physicians at the time of hospital discharge

 The Joint Commission Journal on Quality and Patient Safety 

One of the issues around discharge from hospital is the communication with the patient’s GP or other provider(s) about that hospitalisation. This paper describes the approach taken at a US academic children’s hospital. The quality improvement intervention used Lean methodology, engagement frontline provider s (usually residents), and redesigned workflow processes within the electronic health record to improve communication around discharge. The study reports that they achieved their goal communication with primary care physicians at discharge to 80%, and that this was then sustained for a 7-month period. 


A Framework for Safe, Reliable, and Effective Care


A new white paper from IHI and Safe & Reliable Healthcare presents a framework for achieving safe and reliable operational excellence in health care organizations and systems. The authors describe the key strategic, clinical, and operational components required to create a “system of safety” — not just a collection of stand-alone projects. The framework comprises two foundational domains — culture and the learning system — and provides definitions and implementation strategies for nine interrelated components, with patient and family engagement at the core. Organizations may use the framework as a roadmap to guide them in applying the principles, and as a diagnostic tool to assess their work to date.



Research to improve the up-take of service by people considered hard to reach: synthesis of findings and a practical guide for service innovation


This paper is a synthesis of findings from a three year research programme on “engaging with the ‘hard to reach’ to improve uptake of social and health service”. The researchers recognised that ‘hard to reach’ is a problematic way of thinking about potential clients of a service. The ‘hard to reach’ may not necessarily see themselves as ‘hard to reach’, and it may be services that are ‘hard to reach’. The project chose to focus on ‘making services reachable’. Following a typology published by Heatley (2016), the kind of programmes and agencies that have informed our findings, and for whom our findings are intended to be useful, are those that work with clients with complex needs (requiring multiple forms of support or intervention) and low capacity to “understand and manage their access to available services” (Heatley, 2016). Our data confirms that clients with complex needs tend to experience the services, rather than themselves, as being ‘hard to reach’. The research took an ecosystems approach, highlighting how uptake of service emerges from interaction between a social service, a client and the client’s family, plus the wider service ecosystem.

Six principles for designing social service engagement with those deemed hard to reach

1.    Service is not a service product delivered. Service is an experience in which a service seeker benefits by accessing resources offered by another.

2.    Service (co-)design is about reciprocal values of the parties involved, not merging or agreeing on values.

3.    Structures and processes need to be (co-)designed to enable and support negotiated meaning and empowerment.

4.    Capability and social, cultural and financial capital is needed from all parties – service needs to recognise, enhance and build capability and capital with clients.

5.    Engagement with clients with complex needs is about negotiating core assumptions with them on the purpose, course and context of service offered.

6.    Negotiation of core assumptions is needed in every key relationship in service provision, and is ongoing and dynamic.


Designing a high-performing health care system for patients with complex needs: ten recommendations for policymakers

Commonwealth Fund

In 2014, the Commonwealth Fund established the International Experts Working Group on Patients with Complex Needs to outline the prerequisites for a high-performing health system designed for high-need patients. This report outlines the working group's recommendations for tackling the challenges of delivering care that is more patient-centred, more collaborative and integrated. 


Making Sure Health Care Improvements Stick : Six key principles aid in continuous quality improvement. 


Researchers at IHI have been working to identify and test the “active ingredients” that make for continuous improvement and quality control at the front line in health care. A new Healthcare Executive article describes six management principles, leadership practices, core competencies, and mental models that all play a role in generating and sustaining improvement. For example, shaping team culture and building team capability increase the capacity for and rate of improvement and reinforce the expectation that improvement is everyone’s job, every day. 


Caring for Quality in Health: Lessons learnt from 15 reviews of health care quality


OECD Health Care Quality Reviews provide a toolkit to improve the quality of health care.

Over the past four years, the OECD has conducted a series of in-depth reviews of the policies and institutions that underpin the measurement and improvement of health care quality in 15 different health systems. Caring for Quality in Health: Lessons learnt from 15 reviews of health care quality seeks to answer the question of what caring for quality means for a modern health care system by identifying what policies and approaches work best in improving quality of care.

Despite differences in health care system priorities, and in how quality-improvement tools are designed and applied, a number of common approaches and shared challenges emerged across the 15 OECD Reviews of Health Care Quality analysed. The most important of these concerns transparency. Governments should encourage, and where appropriate require, health systems and health care providers to be open about the effectiveness, safety and patient-centredness of care they provide.

More measures of patient outcomes are also needed - especially those reported by patients themselves. These should underpin standards, guidelines, incentives and innovations in service delivery. Greater transparency can lead to optimisation of both quality and efficiency – twin objectives which reinforce, rather than subvert, each other. In practical terms, greater transparency and better performance can be supported by changes in where and how care is delivered; changes in the roles of patients and professionals; and employing tools such as data and incentives more effectively. Key actions in these three areas are set out in the 12 lessons presented in this synthesis report.


Does quality improvement improve quality?

Future Hospital Journal

Although quality improvement (QI) is frequently advocated as a way of addressing the problems with healthcare, evidence of its effectiveness has remained very mixed. The reasons for this are varied but the growing literature highlights particular challenges. Fidelity in the application of QI methods is often variable. QI work is often pursued through time-limited, small-scale projects, led by professionals who may lack the expertise, power or resources to instigate the changes required. There is insufficient attention to rigorous evaluation of improvement and to sharing the lessons of successes and failures. Too many QI interventions are seen as ‘magic bullets’ that will produce improvement in any situation, regardless of context. Too much improvement work is undertaken in isolation at a local level, failing to pool resources and develop collective solutions, and introducing new hazards in the process. This article considers these challenges and proposes four key ways in which QI might itself be improved.



The seven dimensions of an innovation culture

Ko Awatea 

Innovation is vital to deliver higher quality and lower costs in the complex, rapidly changing environment of healthcare.

While innovation exists in healthcare, it is not systematically applied, and the current rate of innovation is unlikely to achieve the change we want and need. Efforts at innovation in healthcare will continue to move at the same slow pace and yield the same mixed results unless we explicitly address the organisational culture required to support innovation.

Leaders at every level have a disproportionately large effect on organisational culture. By their behaviours, leaders create the conditions that either aid or hinder innovation.

Literature on organisational transformation suggests that leaders can support innovation by paying attention to seven key dimensions of an innovation culture.  Read more …





Sustaining Improvement

IHI White Paper

This white paper presents a framework that health care organizations can use to sustain improvements in the safety, effectiveness, and efficiency of patient care. The key to sustaining improvement is to focus on the daily work of frontline managers, supported by a high-performance management system that prescribes standard tasks and responsibilities for managers at all levels of the organization.

To inform this work, we reviewed selected literature and interviewed leading organizations. The result presented in this white paper is a description of high-performance management in theory and practice, along with recommendations for organizations interested in pursuing these methods:

A theoretical context for high-performance management, grounded in the Juran Trilogy (Quality Planning, Quality Control, and Quality Improvement) and selected current literature;
An organizational framework for a high-performance management system (HPMS), illustrating standard work for each tier of management and the integrated organizational hierarchy that reinforces, supports, and improves work at all levels;
A driver diagram that summarizes our theory of the key factors for implementing a HPMS through standardized management tasks, pervasive Quality Control (as defined by Juran to mean monitoring the system and making necessary adjustments to ensure stability over time), coordinated Quality Improvement, and development of a culture of candid transparency that encourages and sustains these activities;
Case examples that describe three health care organizations’ approaches to testing and implementing management standard work; and
Appendices containing additional guidance for organizations seeking to implement these practices.


Technical Series on Safer Primary Care

World Health Organization 

The World Health Organization has produced the Technical Series on Safer Primary Care – a series of nine short monographs exploring the magnitude and nature of harm in the primary care setting from various perspective. Each monograph describes the scope, approach, potential solutions, practical next steps, concluding remarks, and then provides links to online toolkits and manuals to provide practical suggestions for countries and organizations that have committed to moving forward this agenda.

The nine monographs cover:

Patient engagement
Education and training
Human factors
Administrative errors
Diagnostic errors
Medication errors
Transitions of care
Electronic tools.

Safe, sustainable and productive staffing: an improvement resource for adult inpatient wards in acute hospitals

National Quality Board 

This is an improvement resource to support nurse staffing in adult inpatient wards in acute hospitals which is aligned to Commitment 9 of Leading Change, Adding Value: a framework for nursing, midwifery and care staff (2016).1It is based on the National Quality Board’s expectations that to ensure safe, effective, caring, responsive and well-led care on a sustainable basis, trusts will employ the right staff with the right skills in the right place and at the right time. We have designed it to be used by all those involved in clinical establishment setting, approval and deployment– from the ward manager to the board of directors. 

The resource outlines a systematic approach for identifying the organisational, managerial and ward factors that support safe staffing. It makes recommendations for monitoring and taking action if not enough staff are available on the ward to meet patients’ needs. It builds on NICE guidelines2 on safe and sustainable staffing for nursing in adult inpatient care in acute wards. 






The challenge and potential of whole system flow

The Health Foundation 

Whole system flow is the coordination of all systems and resources, across a health and social care economy, to deliver effective, efficient, person-centred care in the right setting at the right time and by the right person. 

Improving flow is seen by both practice leaders and policymakers as having a crucial role to play in driving up service quality and productivity, as well as improving the experience of care for patients and service users. 

The challenge and potential of whole system flow introduces methods that local health and social care leaders can use to improve whole system flow. It also describes steps policymakers and regulators can take to create an environment conducive to change at this scale. 


Top 6 ways to make your improvement project succeed

We sat down with CFHI Faculty, Chris Hayes, to find out what it takes for quality improvement projects to succeed. Watch the video for some helpful tips.


Building a Culture of Improvement at East London NHS Foundation Trust

Institute for Healthcare Improvement

Brief report from the (US) Institute for Healthcare Improvement describing how a UK health ‘system’ (the East London NHS Foundation Trust (ELFT) has been able to reduce incidents of inpatient violence, medication errors, waiting times for treatment in the community, and improved staff satisfaction and engagement, among other improvements.

The ELFT provides mental health and community services to a diverse and largely low-income population. Approximately 65,000 individuals come into contact with ELFT’s services each year at more than 100 community and inpatient sites.

According to the report, ELFT leaders and staff made a concerted effort to entrench a culture of continuous improvement in the organization, and they integrated quality improvement methodology and training into every level of work.


Whole System Measures 2.0: A Compass for Health System Leaders

Institute for Healthcare Improvement

IHI developed Whole System Measures 2.0 (WSM 2.0) to provide specific guidance to health care system leaders and boards on how to measure current overall system performance and use this data to inform organizational strategy. WSM 2.0 is a set of 15 measures that help leaders better understand their organization’s current (and desired) state across three domains (the Triple Aim): population health, experience of care, and per capita cost.

This work builds on the original Whole System Measures IHI White Paper, published in 2007, and ongoing efforts to advance the Triple Aim. While directive, this small measure set creates the opportunity for health care system leaders, managers, clinicians, and staff to drill down further to understand specific performance challenges or successes, and to identify strategic opportunities for improvement.

Many efforts to develop core measures of quality have emerged in recent years. While these efforts are important and substantive in their own right, they also contribute to health care measurement complexity, highlighting the need for clarity and parsimony to enable senior leaders to understand the overall performance of their systems.

The individual measures that comprise WSM 2.0 are not new; pulling them together to gain the appropriate level of understanding of quality across the system is new. While we do need to reduce measurement burden, we also need to rationalize the measures that exist. WSM 2.0 is intended to provide specific guidance to health care system leaders and boards on how to do just that: measure overall system performance and use this data to inform organizational strategy.



Does quality improvement improve quality?

Future Hospital Journal

With this provocative title the authors pick up some of the issues raised in John Øvretveit’s piece discussed in the last issue of On the Radar. This piece poses perhaps more fundamental questions about quality improvement (QI) in healthcare – as it has been practiced – and suggests ways in which QI may be improved. 

The authors describe the issue thus “Although quality improvement (QI) is frequently advocated as a way of addressing the problems with healthcare, evidence of its effectiveness has remained very mixed. The reasons for this are varied but the growing literature highlights particular challenges. Fidelity in the application of QI methods is often variable. QI work is often pursued through time-limited, small-scale projects, led by professionals who may lack the expertise, power or resources to instigate the changes required. There is insufficient attention to rigorous evaluation of improvement and to sharing the lessons of successes and failures. Too many QI interventions are seen as ‘magic bullets’ that will produce improvement in any situation, regardless of context. Too much improvement work is undertaken in isolation at a local level, failing to pool resources and develop collective solutions, and introducing new hazards in the process.” 

The proposals for improving the quality of quality improvement include:

Act like a sector – many of the quality challenges that confront healthcare need to be solved at the level of entire systems

Stop looking for magic bullets – focus on organisational strengthening and learn from positive deviance. …Too little has been spent on the organisational strengthening needed to make improvement. …much can be learned from the characteristics, practices and behaviours that are implicated in the performance of demonstrably safe and high-quality settings.

Build capacity for designing and testing solutions, and plan for replication and scaling from the start – Developing solutions to many quality and safety problems may require high-level skills and expertise from multiple disciplines, and highly sophisticated development processes. …we need to get better at developing or selecting interventions that have a high likelihood of success, testing them rigorously in different contexts, and offering organisations solutions

Think programmes and resources, not projects – QI projects are sometimes the right answer … but where they are undertaken it should be with a commitment to sharing. … Healthcare needs to do for QI what it has done for research: build an infrastructure that enables learning about successful and less successful efforts to be curated and searched by others.


Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach

BMJ Open 

Paper evaluating the NHS (England) large-scale two-phase quality improvement programme. The programme sought to

develop a shared national, regional and locally aligned safety focus for 4 high-cost, high volume harms (venous thromboembolism (VTE), pressure ulcers, urinary tract infection in patients with urinary catheters and falls)
establish a new measurement system based on a composite measure of ‘harm-free’ care and
deliver improved outcomes, with a specific objective of ensuring that 95% of patients would be harm-free.

These aims were only partially met or met in some places better than others. However, as the authors note external events, “A context of extreme policy-related structural turbulence impacted strongly”. Many participants “saw the principles underlying the programme as attractive, useful and innovative” but “they often struggled to convert enthusiasm into change.” The development of the measurement system was “arduous” and data submission rates were “patchy throughout phase I but improved in reach and consistency in phase II.” Also reported was “Some evidence of improvement in clinical outcomes over time could be detected but was hard to interpret”. 

The authors conclude that there are “important lessons for large-scale improvement programmes, particularly when they seek to develop novel concepts and measures. External contexts may exert far-reaching influence. The challenges of developing measurement systems should not be underestimated.”


Integrated care for older people with frailty: innovative approaches in practice

British Geriatrics Society 

GPs and geriatricians are uniquely suited to lead the response to the challenges of caring for this group. As generalist disciplines, general practice and geriatrics look at the whole person and consider care within the context of the patient’s family, carers and the wider community. They take continuity of responsibility for care across many disease episodes and over time, and coordinate care across organisations. These shared holistic values provide opportunities for collaboration between the two specialisms, and this should be at the forefront of the future design and delivery of care for older people. 

However, in the past, service development has all too often taken place in isolation, leading to the creation of services in silos. Not only does this fragmentation have a detrimental impact on patient experience and outcomes, there are also negative consequences for service efficiency and effectiveness. This has been particularly true at a national level and, in this respect at least, little has changed. 

However, improvements are being made at a local level where GPs and geriatricians are providing clinical leadership in spite of the organisational barriers they face. This report has been designed to showcase examples of these new approaches that are putting the positive talk around integration of care into practice. 

The case studies were all selected as examples of collaboration between GPs and geriatricians that provide innovative and interesting ideas about the care of older people. They were also chosen to cover a range of locations across the UK, including urban and rural populations, and a range of settings, including services based in the community, in GP practices, in care homes and in hospitals. While the majority are led by GPs or geriatricians, the initiatives were selected to illustrate the vital role that many other professionals play, including nurses, therapists, pharmacists and social workers.


The digital patient: transforming primary care?

Nuffield Trust
The digital patient: transforming primary care? reviews the evidence that exists on digital technology and its impact on patients in primary care and the NHS. It explores the impact of seven types of digital services offered by the NHS: 

1.    Wearables and monitoring technology

2.    Online triage tools

3.    Online sources of health information and advice, targeted interventions and peer support

4.    Online appointment booking and other transactional services

5.    Remote consultations

6.    Online access to records and care plans

7.    Apps

The report finds that patient-facing technology is already showing promise that it can improve care for patients and reduce strain on the stretched health service – particularly for people with long-term conditions such as diabetes or COPD. However, this rapidly evolving market comes with risks. Many apps, tools and devices have not been officially evaluated, meaning that their effectiveness is unknown. In some cases, technology can increase demand for services, disengage staff and have the potential to disrupt the way that patients access care. 

Moreover, the report warns that policy-makers and politicians should avoid assuming that self-care-enabling technology will produce significant savings, at least in the short term.

The report also presents a series of lessons and recommendations to NHS professionals, leaders and policy-makers about how best to harness the potential of technology and avoid the pitfalls.


Realising the value - Ten key actions to put people and communities at the heart of health and wellbeing 

The Health Foundation

This is the final report of the Realising the Value programme, an 18-month programme funded by NHS England and led by Nesta and the Health Foundation. The programme was set up to support the NHS Five Year Forward View vision to develop a new relationship with people and communities. The programme sought to enable the health and care system to support people to have the knowledge, skills and confidence to play an active role in managing their own health and to work with communities and their assets.

This report sets out the key learning and recommendations from the programme, based on what we think it means to realise fully the value of people and communities at the heart of health and wellbeing.

Our recommendations include both what should be done and how people need to work differently. We believe that significant progress can be made through the following 10 actions:

What needs to happen:

Implement person- and community-centred ways of working across the system, using the best available tools and evidence.

Develop a simplified outcomes framework, focused on what matters to people.

Continue to learn by doing, alongside further research.

Make better use of existing levers such as legislation, regulation and accountability.

Trial new outcomes-based payment mechanisms and implement them as part of wider national payment  reform.

How people need to work differently

Enable health and care professionals and the wider workforce to understand and work in person- and community-centred ways.

Develop strong and sustained networks as an integral part of implementation.

Value the role of people and communities in their health and wellbeing, including through co-production, volunteering and social movements for health.

Make greater use of behavioural insights to increase effectiveness and uptake.

Support a thriving and sustainable voluntary, community and social enterprise sector, working alongside people, families, communities and the health and care system.




Responding to the needs of patients with multimorbidity: a vision for general practice

Royal College of General Practitioners

The prevalence and significance of multimorbidity – where patients have multiple conditions (usually chronic) – is gaining greater recognition. For example, the UK’s National Institute for Health and Care Excellence issued a Guideline on Multimorbidity: clinical assessment and management in September (available from Now the UK’s Royal College of General Practitioners has issued this document that starts by reviewing how effectively the current health system serves patients living with multiple long-term conditions before examining some innovative ways of working and the impact they have had on the quality of care received by patients with multiple long-term conditions, such as longer consultation times for those who need them, collaborative care and support planning and the role of multidisciplinary teams in caring for patients with complex needs. The report also recommends improving communication between primary and secondary care professionals, increasing exposure of delivering care to patients with multimorbidities in GP training, and the development of improved decision making tools.


The 2015 Garrod Lecture: Why is improvement difficult?

Journal of Antimicrobial Chemotherapy

The text of Peter Davey’s 2015 Garrod Lecture. The Garrod Lecture is deliver by the recipient of the British Society for Antimicrobial Chemotherapy's Garrod Medal. The Medal is awarded to individuals who are an international authority in the field of antimicrobial chemotherapy.  In 2015 Peter Davey spoke on the “urgent need to improve the design and reporting of interventions to change behaviour.”

Davey's noted that “achieving sustained improvement at scale will also require a more profound understanding of the role of context. What makes contexts receptive to change and which elements of context, under what circumstances, are important for human performance? Answering these questions will require interdisciplinary work with social scientists to integrate complementary approaches from human factors and ergonomics, improvement science and educational research. We need to rethink professional education to embrace complexity and enable teams to learn in practice. Workplace-based learning of improvement science will enable students and early-career professionals to become change agents and transform training from a burden on clinical teams into a driver for improvement. This will make better use of existing resources, which is the key to sustainability at scale.”


Power of people

Health Foundation 

We explore five inspirational examples of innovation in health care.

Our series of five short films – the Power of people – is a unique and moving take on how the lives of people using health services and their families can be improved through the determined efforts of people working in health care. 

Pills: Reviewing medication in care homes 
Flo: Telehealth with a human touch 
Bottoms up: Everyone can influence safety, quality and experience 
Recovery college: From mental health patient to recovery student 
Gold Line: Bringing health care home 

The Power of people films present different perspectives on innovative ways to provide care, which have changed the lives of both people receiving care and the people caring for them.

The demands on our health service are growing – the ideas of the people working in the health service will be essential in meeting this challenge. Our short films show the power of what can be achieved when people are given the time and support to innovate. We hope they inspire those already doing great things in the health service to think about what else might be possible. 


Turning Safety on its Head: Team Resilience for the Everyday 

Dr Carl Horsley, Counties Manukau Health

Dr Carl Horsley is a dual trained intensivist who is the current clinical head of the Critical Care Complex at Middlemore Hospital. He is a member of the Resilient Healthcare Network and recently co-authored a chapter on a project he introduced to enhance the ability of staff to adapt to changing situations within the Complex. This approach sees people as the key resource required to deal with the complexity of modern healthcare and has led to improved staff engagement, improved quality care and a more patient centred view. 

“The reality is that healthcare is a complex adaptive system which is constantly changing and thus requires constant adjustment and adaptation. In the real work environment, staff constantly have to make trade-offs between efficiency and thoroughness. This reality requires a different view of safety.

Safety-II: The new view
The ability to juggle complex dynamic situations is how we achieve normal success; it is also how things sometimes go wrong. Safety-II recognises that both good and bad outcomes stem from the same performance adjustments people make every day to get their jobs done.[1] No action is intrinsically good or bad – the outcome depends on whether the action suits the context.

In this model of safety, the system only succeeds because people can adjust to meet the conditions of work. Complexity is the problem and people are the solution…”

Read more ...


Triple Aim in Canada: developing capacity to lead to better health, care and cost

International Journal for Quality in Health Care 

Quality problem Many modern health systems strive for ‘Triple Aim’ (TA)—better health for populations, improved experience of care for patients and lower costs of the system, but note challenges in implementation. Outcomes of applying TA as a quality improvement framework (QI) have started to be realized with early lessons as to why some systems make progress while others do not.

Initial assessment Limited evidence is available as to how organizations create the capacity and infrastructure required to design, implement, evaluate and sustain TA systems.

Choice of solution To support embedding TA across Canada, the Canadian Foundation for Healthcare Improvement supported enrolment of nine Canadian teams to participate in the Institute for Healthcare Improvement's TA Improvement Community.

Implementation Structured support for TA design, implementation, evaluation and sustainability was addressed in a collaborative programme of webinars and action periods. Teams were coached to undertake and test small-scale improvements before attempting to scale.

Evaluation A summative evaluation of the Canadian cohort was undertaken to assess site progress in building TA infrastructure across various healthcare settings. The evaluation explored the process of change, experiences and challenges and strategies for continuous QI.

Lessons learned Delivering TA requires a sustained and coordinated effort supported by strong leadership and governance, continuous QI, engaged interdisciplinary teams and partnering within and beyond the healthcare sector. 


Health as a Social Movement: The Power of People in Movements


This report illuminates the power of people in movements to improve health and proposes the need for new models of engagement between institutions and social movements.

Key findings

People working together in social movements have changed how we experience health and the systems that shape it: reducing stigma around issues like breast cancer, improving end of life care, winning rights for those with disabilities, advancing clinical research and reframing health priorities.
The report identifies seven ways social movements impact health and care and illustrates the transformative potential of movements through over 20 national, international and historical examples.

Social movements put pressure on societal systems to accelerate transformation, respond directly to the experiences of people and can diffuse change widely across populations. Yet, they can be messy, turbulent and risky. They represent one approach to the  transformation so urgently needed in health and care.

It is potentially unprecedented for a major public institution like the NHS - with clear hierarchies, rules and protocols - to actively call for and nurture social movements.

Effective encounters between institutions and movements will require new models of engagement that draw on the efficiency and scale of institutions and the dynamism and agility of movements. The report also stresses that understanding how social movements behave is critical to engaging with them.

RCEM Quality Improvement Guide: a guide for clinicians undertaking quality improvement in Emergency Departments

The Royal College of Emergency Medicine

This guide is intended to assist Fellows and Members who are undertaking Quality Improvement (QI) work in their Emergency Departments. It is intended to help bridge the gap between improvement science and implementation. 


Using data to identify good-quality care for older people

Nuffield  Trust

This report describes the results of a pilot analysis of the effectiveness of using routine health care data to determine areas that have made quality improvements in the care of frail and older people over time. It focuses on a few indicators that were mainly derived from acute emergency hospital use and applies statistical analyses to them at the local authority area level.


How do we learn about improving health care: a call for a new epistemological paradigm

International Journal for Quality in Health Care 

The field of improving health care has been achieving more significant results in outcomes at scale in recent years. This has raised legitimate questions regarding the rigor, attribution, generalizability and replicability of the results. This paper describes the issue and outlines questions to be addressed in order to develop an epistemological paradigm that responds to these questions.

The complexity of health care requires a more rigorous approach to advance our understanding of methods for learning about improving health care. Additionally, the greater use of robust qualitative, quantitate and mixed methods is needed to assess effectiveness—not merely to demonstrate if an intervention works, but why and how it works—and to explore the factors underlying success or failure. 


Many Ways to Many : A brief compendium of networked learning methods.

Stanford Social Innovation Review

Donors, governments, NGOs, and other stakeholders in the social sector are increasingly interested in how to spread effective solutions and innovations to everyone who can benefit from them. A growing literature on the topic is forming, as researchers and analysts describe general principles for building collective will and setting shared aims, designing scalable and charismatic interventions, and leveraging existing networks and institutions to have bigger impact.

In our view, however, there remains a crucial gap in this collected knowledge. While the attributes of effective learning networks (i.e. structured methods to support knowledge exchange and spread new behaviors) have been described in general terms, few attempts have been made to define and distinguish the approaches that have been applied to greatest effect. Building on our work in the last two decades, mainly in international health, we attempt to address that gap here by documenting ten approaches to orchestrating networked learning at various scales.




From knowledge to action: A framework for building quality and safety capability in the New Zealand health system

From knowledge to action: A framework for building quality and safety capability in the New Zealand health system is a high-level framework to guide the development of quality and safety capability across all levels in the health and disability sector, including consumers/patients.

It has been developed at the request of the sector and informed by international models with input from an expert advisory group. 


Training healthcare professionals in quality improvement

Future Hospital Journal

The Academy of Medical Royal College's report Quality improvement – training for better outcomes sets a path for the normalisation of quality improvement as part of all health professionals’ jobs. This accompanies similar calls to action by the King's Fund and the Faculty of Medical Leadership and Management and is aligned with NHS Improvement and Health Education England future strategies. These exhortations to action come on the backdrop of increased fiscal constraints within the NHS, low morale, a burgeoning volume of research evidence and audit outputs and increasing complexity of how we deliver care in a bewildering NHS landscape. Asking the question ‘how can we do something better?’ or ‘do we really need to do this?’, and building our resilience and capability to respond effectively gives us new purpose, the right skills and a means to influence and make a difference to the safety, ­effectiveness and experience of patient care. Most importantly, we do this through harnessing the talents of ­multiprofessional teams – with meaningful patient involvement – to rediscover the joy and optimism in our work and what truly motivates us and to see this translated into improved sustainable outcomes for our patients and our working days.



Visibility: the new value proposition for health systems

World Health Innovation Network

The purpose of this paper is to propose a new strategy for addressing the seemingly intractable challenge of patient safety and the growing rates of death and injury associated with adverse events in healthcare systems. The paper examines the capacity to strengthen health system performance by improving visibility to create value for health systems, government, industry, and patients. WIN’s research has engaged four countries (Canada, US, UK and Australia), seven Canadian provinces, industry partners and leaders in the health sector. The paper’s recommendations have capacity to improve the delivery of safer, higher-quality, more efficient and sustainable health care by leveraging strategic supply chain innovation.

Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach

BMJ Open

Objectives We aimed to evaluate whether a large-scale two-phase quality improvement programme achieved its aims and to characterise the influences on achievement.

Setting National Health Service (NHS) in England.

Participants NHS staff.

Interventions The programme sought to (1) develop a shared national, regional and locally aligned safety focus for 4 high-cost, high volume harms; (2) establish a new measurement system based on a composite measure of ‘harm-free’ care and (3) deliver improved outcomes. Phase I involved a quality improvement collaborative intended to involve 100 organisations; phase II used financial incentives for data collection.

Measures Multimethod evaluation of the programme. In phase I, analysis of regional plans and of rates of data submission and clinical outcomes reported to the programme. A concurrent process evaluation was conducted of phase I, but only data on submission rates and clinical outcomes were available for phase II.

Results A context of extreme policy-related structural turbulence impacted strongly on phase I. Most regions' plans did not demonstrate full alignment with the national programme; most fell short of recruitment targets and attrition in attendance at the collaborative meetings occurred over time. Though collaborative participants saw the principles underlying the programme as attractive, useful and innovative, they often struggled to convert enthusiasm into change. Developing the measurement system was arduous, yet continued to be met by controversy. Data submission rates remained patchy throughout phase I but improved in reach and consistency in phase II in response to financial incentives. Some evidence of improvement in clinical outcomes over time could be detected but was hard to interpret owing to variability in the denominators.

Conclusions These findings offer important lessons for large-scale improvement programmes, particularly when they seek to develop novel concepts and measures. External contexts may exert far-reaching influence. The challenges of developing measurement systems should not be underestimated.

Does quality improvement improve quality?

Future Hospital Journal

Although quality improvement (QI) is frequently advocated as a way of addressing the problems with healthcare, evidence of its effectiveness has remained very mixed. The reasons for this are varied but the growing literature highlights particular challenges. Fidelity in the application of QI methods is often variable. QI work is often pursued through time-limited, small-scale projects, led by professionals who may lack the expertise, power or resources to instigate the changes required. There is insufficient attention to rigorous evaluation of improvement and to sharing the lessons of successes and failures. Too many QI interventions are seen as ‘magic bullets’ that will produce improvement in any situation, regardless of context. Too much improvement work is undertaken in isolation at a local level, failing to pool resources and develop collective solutions, and introducing new hazards in the process. This article considers these challenges and proposes four key ways in which QI might itself be improved.



Health of the public in 2040: optimising the research environment for a healthier fairer future

The Academy of Medical Sciences

Over the coming decades, the UK population will face a wide range of complex health challenges and opportunities, many of which can only be fully addressed through strategies to secure and improve the health of the public as a whole. The Academy’s report, ‘Improving the health of the public by 2040’, explores how to organise our research environment to generate and translate the evidence needed to underpin such strategies.

The report concludes that while public health research has provided fundamental insights into human health, there remains much we do not know about the complex array of interlinking factors that influence the health of the public, and about how to prevent and solve the many health challenges we face as a population.

Solving these challenges will require shifting towards a ‘health of the public’ approach, involving disciplines that would not usually be considered to be within the public health field. This is turn requires six key developments:

Rebalancing and enhancing the coordination of research;
Harnessing new technologies and the digital revolution;
Developing transdisciplinary research capacity;
Aligning perspectives and approaches between clinical and public health practice;
Working with all sectors of society, including policymakers, practitioners, the commercial sector and the public;
Engaging globally

Consumer co-creation in health: innovating in Primary Health Networks

Australian Healthcare and Hospitals Association

This evidence brief from the Deeble Institute examines how to include consumers in “value creation in health care planning and delivery”. The report refers to the growing literature on health value co-creation and its benefits in the health sector and how it suggests that value can be co-created for the individual consumer, clinical practices, health care organisations, and governments. The author offers some recommendations on how to increase the role of consumers in (co)designing healthcare services. The report includes examples of emerging models of community engagement in Primary Health Networks such as NSW’s WentWest, the Western Australia Primary Health Alliance, Capital Health Network in the ACT and North Brisbane PHN.



Patient safety: closing the implementation gap

Kings Fund [blog]

I’ve been to many conferences on quality and safety in the NHS, and never cease to be frustrated by suggestions of creating yet another policy or checklist, or by people bemoaning the difficulty of implementing improvement measures with the common complaint ‘Why is it so hard for people just to do the right thing?’

Choosing the right method of implementation is vital. Those leading change need to ensure:

an easy method of implementation;
good-quality guidance;
clear benefits – with numbers, feelings and experiences demonstrating that the change is better than status quo;
the message is delivered in person, using the right role model or opinion leader;
people are recognised and rewarded for their actions, and thanked for their contribution;
they adopt a coaching style of leadership; if leaders simply try to solve the problems themselves then people will not take ownership of the outcome.

Implementation is more often about making smaller changes that can incrementally make things easier, better, safer and more effective. And it requires ongoing maintenance. Read more …



Health system performance for the high-need patient: a look at access to care and patient care experiences

Commonwealth Fund

A pair of Issues Briefs from the same team of authors published by (US) Commonwealth Fund that discuss the characteristics and experiences of heavy or ‘high need’ users of healthcare.

The first provides an analysis of the health care needs of patients in the USA with long-term conditions and argues that health care improvement efforts should focus on the needs of those with multiple chronic illnesses and who have limited ability to care for themselves. The high need patients have rates of hospital more than twice those for adults with multiple chronic conditions only; they also visited the doctor more frequently and used more home health care.

The second Issue Brief compared the health care experience of patients with co-morbidities and a functional limitation to those with multiple conditions but no functional limitations. The authors found that patients with higher levels of need were more likely to report having unmet medical needs and less likely to report experiences of good patient-provider communication. These findings highlight the importance of tailoring interventions to meet the needs of the highest-need, most complex patients.



Improving Population Health by Working with Communities: Action Guide 3.0 

The Action Guide is a framework to help multi-sector groups work together to improve population health by addressing 10 interrelated elements for success and using the related resources as needed. Like a “how-to” manual, the Action Guide is organized by these 10 elements and contains definitions, recommendations, practical examples, and a range of resources to help communities achieve their shared goals and make lasting improvements in population health.

 The Action Guide’s 10 key elements are:

                Collaborative Self-Assessment

                Leadership Across the Region and Within Organizations

                Audience-Specific Strategic Communication

                A Community Health Needs Assessment and Asset Mapping Process

                An Organizational Planning and Priority-Setting Process

                An Agreed-Upon, Prioritized Set of Health Improvement Activities

                Selection and Use of Measures and Performance Targets

                Joint Reporting on Progress Toward Achieving Intended Results

                Indications of Scalability

                A Plan for Sustainability


The £22 billion question: how can improvement be spread in the NHS?

The Kings Fund

In the mid-1990s, the service improvement methodologies developed by Don Berwick at the Institute for Healthcare Improvement in Boston, US, were first used in the NHS. In 2001 the Department of Health established the Modernisation Agency to develop and spread service improvement skills more widely throughout the NHS. And yet there is still a mountain to climb in terms of both service improvement and productivity, and there is significant variation across the country. Why is it that the best ideas are so hard to spread?


Why the NHS needs a quality improvement strategy

Chris Ham in conversation with Don Berwick

Even simple improvements take intention and method. In complex systems such as health care, with high levels of interdependency, risk, and hard-to-see dynamics, without stewardship and active nurturance, things will decay.

A shared approach to improvement is essential. Exactly what that approach should be is open to debate, but, without a strategy, what would we expect to happen?

…Great innovation has bi-directional kinetic energy: ‘top-down’ and ‘bottom-up’ at the same time. From the ‘top’ can come resources, clarified aims, permission, and assets for collective learning. From the ‘bottom’ can come great ideas, tested, de-bugged and exciting. And local innovators can become teachers for others. Key to spreading innovation is a combination of (a) strong respect for and support of local improvement and (b) consistent, positive and generous leadership from executive and clinical leaders who believe that shared learning almost always beats central control.

The enemy of the spread of innovation is fear.  Read more …


Lean and IHI’s Approach to QI: Do You Have to Choose?

If you talk to enough people working in health care quality improvement, you sometimes get the impression there is a lot of confusion and misunderstanding about Lean and what we refer to in the white paper as “IHI-QI,” or IHI’s approach to improvement.

Traditionally, IHI has focused much attention on the Model for Improvement, developed by Associates in Process Improvement (API). IHI has worked closely with API for the last 25 years.

People working on quality improvement also hear about approaches like the Toyota Production System, or Lean. They hear about how Virginia Mason Medical Center in Seattle and ThedaCare in Wisconsin successfully apply Lean.

How do these approaches differ, and what do they have in common? How, if at all, can we use these approaches together?

What are some of the common misunderstandings about Lean and the IHI approach?

Many assume Lean is only about cutting costs or reducing waste, or that it’s basically just a set of tools. With IHI-QI, people sometimes think it only means the application of PDSA cycles or the Model for Improvement.

People sometimes see both Lean and IHI-QI as using dogmatic checklists that spell out every step, or as if you can magically fix a problem as long as you use the right tool from the toolbox.

These simplistic views ignore that — whichever approach you use — you need an organizational and leadership strategy that guides how to introduce these methods and apply them in practice.




TedTalk: A smarter, more precise way to think about public health

Sue Desmond-Hellmann is using precision public health — an approach that incorporates big data, consumer monitoring, gene sequencing and other innovative tools — to solve the world's most difficult medical problems. It's already helped cut HIV transmission from mothers to babies by nearly half in sub-Saharan Africa, and now it's being used to address alarming infant mortality rates all over the world. The goal: to save lives by bringing the right interventions to the right populations at the right time.

Innovating Beyond Bullet Points: Eight ideas on turning talking points into action-points

This article has ideas on how to push your organisation, your people and yourself to stop talking and start innovation

1. Sharpen the (organizational) saw
2. Plant thought leaders in a room: just add coffee (and seed funding)
3. Don’t just stand there… partner, invest, accelerate and scratch your own itch along the way.
4. Steal the wheel, don’t reinvent it. You’d be surprised how open and willing other innovators are to sharing ideas, methods, and tools.
5. Create space for innovation to thrive
6. Free your “Radicals” to empower real change in your organization
7. Build diverse teams who focus on innovation (from incremental to disruption)
8. Get senior leaders actively involved in the innovation process

Ten tips for running a national improvement collaborative

Ko Awatea

This article shares ten factors that are important in making a collaborative a success:

Considering population size and the structure of the health system;
Using Breakthrough Series methodology;
Proving international evidence in the national context;
A clear mandate for change;
Leveraging clinical expertise and professional respect;
Involving diverse stakeholders;
Sharing measurement data with teams promptly;
Being adaptable and responsive;
Setting clear roles and responsibilities;
Putting an effective communications plan in place.

How can health and social care employers help staff development?

The Guardian

Continuous learning is vital for those working in health and social care, but quality training resources and study time are hard to find. Is e-learning the answer?

Professional learning and development are essential parts of any career in health and social care, and leaders across both sectors want to create a culture of lifelong learning among their staff.

Despite this, 57% of health and social care staff don’t feel they have opportunities to take training to further their career and just over two-thirds (68%) don’t feel they have enough training to do their job, according to the results of a recent Guardian survey.

How can employers in health and social care improve access to training and development? What examples of innovative technologies are there and how can health and social care professionals fit training around work and other commitments?


Making things that work available to everyone

Ko Awatea

In 2014, Ko Awatea was fortunate to have Joe McCannon visit and teach. Last week, delegates from Ko Awatea had the opportunity to visit Joe at the Skid Row School for Large-Scale Change. The school was run by Joe McCannon, Dan Heath and Becky Margiotta of the Billions Institute. This article summarises the key learnings.

Ideas that work often fail to spread to everyone who could benefit. We glorify discovering new ideas over implementing them and assume that change will diffuse as if by magic to the people who need it. In addition, a marketplace crowded with ideas, variation in values and beliefs, contextual differences, logistical barriers, fear and inertia make it difficult to create large-scale change.

However, large-scale change can and does happen. The Billions Institute shows us how. Their model has five features:

Set your vision and aims;

Design your intervention;

Choose your expansion method;

Run a ‘command centre’;

Manage fear and liberate creativity for the individual and the team


How Can You Start Improving Health Equity Right Now?


Like tackling any big problem, getting involved in reducing health disparities starts with small steps. As we like to say at IHI, “What can you do by next Tuesday?”

One small step could be to examine your own reactions to people who are different from you — in race, ethnicity, gender, country of origin, age, or many other dimensions of diversity.

If you are like most of us, you have some degree of implicit bias, the attitudes and stereotypes that unconsciously affect how we perceive, respond to, and interact with others.

see also the IHI's new guide 'Achieving Health Equity: A Guide for Health Care Organizations'


Patients' experiences in Australian hospitals: An Evidence Check rapid review brokered by the Sax Institute for the Australian Commission on Safety and Quality in Health Care

This Evidence Check sought to identify factors reported in primary research as relating to positive and negative experiences of patients in Australian hospitals. From the 39 studies reviewed, the researchers identified 7 themes: ‘The care environment’, ‘Reciprocal communication and information sharing’, ‘Correct treatment and physical outcomes’, ‘Emotional support’, ‘Comfort, pain and clinical care’, ‘Interpersonal skills and professionalism’, and ‘Discharge planning and process’.

The authors’ concluded that “Tangible opportunities to enhance the patient experience are apparent. Small changes to the way that the health system operates, is resourced, and the way that health professionals engage with patients could substantially improve care. Examples include inviting patients and carers to contribute to decision making and discussions about treatment options and care preferences.


Better Ways to Pay for Health Care


“Payers for health care are pursuing a variety of policies as part of broader efforts to improve the quality and efficiency of care.  Payment reform is but one policy tool to improve health system performance that requires supportive measures in place such as policies with well-developed stakeholder involvement, information on quality, clear criteria for tariff setting, and embedding evaluation as part of the policy process. Countries should not, however, underestimate the significant data challenges when looking at price setting processes. Data access and ways to overcome its fragmentation require well-developed infrastructures. Policy efforts highlight a trend towards aligning payer and provider incentives by using evidence-based clinical guidelines and outcomes to inform price setting. There are signs of increasing policy focus on outcomes to inform price setting. These efforts could bring about system-wide effects of using evidence along with a patient-centred focus to improve health care delivery and performance in the long-run

Executive Summary

How health care providers are paid is one of the key policy levers that countries have to drive health system performance. However, health providers are still paid in traditional ways – through fee-for-service (FFS), capitation, salary, global budgets or more recently diagnosis-related groups (DRGs). These give incentives for undesirable behaviours, for instance over-provision of services or inattention to clinical needs. More should be done to align payer and provider incentives so that payment is based on delivering value to patients.



Improving Health and Wellbeing Outcomes in the Early Years

“The Institute of Public Health in Ireland partnered with the Centre for Effective Services to produce a volume linking research and practice relating to the early years. The early years have been increasingly recognised in research and policy as a pivotal time in the life course, providing the foundations for numerous health-related outcomes. The lifelong effects of the early years’ experience includes impacts across many aspects of health and wellbeing; including inter alia obesity, heart disease, mental health, educational achievement and economic status. This publication brings together academic authors to consider the rationale and evidence regarding early interventions, as well as practitioners providing on-the-ground examples of what can be achieved.” Source: Institute of Public Health in Ireland



Improving Health System Efficiency in Canada: Perspectives of Decision-Makers

“In this qualitative case study, decision-makers from 2 provinces -- British Columbia and Nova Scotia -- reflect on the main actions they have taken and the challenges they face in improving health system efficiency. This study builds on previous work from CIHI's health system efficiency project.”




Patient safety collaboratives: making care safer for all

Academic Health Science Networks

Patient Safety Collaboratives are led by Academic Health Science Networks and are made up of NHS, academic and health care experts. The aim of the collaboratives is to improve patient safety, spread examples of success and influence system leaderships. This report highlights the work of 15 teams of Patient Safety Collaboratives that aimed to improve patient safety and reduce avoidable harm in the NHS.


Quality Improvement at Counties Manukau Health: A case study evaluation 

This report is an independent evaluation of a quality improvement initiative undertaken by Counties Manukau Health. The objectives of this report are to establish if improvement within the Counties Manukau healthcare system as a consequence of the initiative was evident, how any improvement was accomplished, and if any gaps remained. Three aspects of quality improvement were examined: Counties Manukau’s System Level Measures, the establishment of comparisons and gold standards for these measures; and a case study of healthcare organisations recognised for their work on quality improvement.


What Works: Going digital to deliver wellbeing services to young people? Insights from e-tools supporting youth mental health and parenting

From online programmes to serious games, video teleconferencing and text counselling, digital platforms lend themselves to providing preventative and self-managed care options. Commonly cited benefits include consumer empowerment, scalability, possible efficiency gains, reduced burden and social cost, standardisation of programmes and access to usage data.

But how confident are we that such initiatives actually work?

The publication draws out high-level findings on the most established types of digital tools for delivering wellbeing support, then digs deeper to learn about good practices from particular cases.

It looks at:

·         intended users

·         questions of safety and support

·         design forms and processes

·         challenges in implementation, uptake, and quality assurance.

We conclude there is a lot of potential for going digital in delivering services, if done the right way.



Co-design programme evaluation and case studies 2015–16

Prepared by Ko Awatea for the NZ Health Quality & Safety Commission


These findings have highlighted a high level of passion and enthusiasm for the co-design approach across programme participants. Participant responses suggest that application of the co-design approach to future projects is the main avenue through which others, through observation and ‘doing’, learn about co-design and its role in health care transformation.

The lack of systemic or structural integration of the co-design approach into organisational training and development, policy or strategy leaves the co-design approach open to the risk of poor sustainability. This is compounded by competing organisational priorities and need for increased senior leadership or management knowledge of co-design and expected benefits of the approach. These findings suggest that knowledge about co-design needs to filter to higher organisational levels.

 Future considerations for the Co-Design Programme

This report has identified a number of learnings. These offer potential future opportunities to increase the sustainability of co-design approaches through:

1. embedding co-design within existing organisational training at DHBs, for example, the improvement advisor programme, safety programmes and other general improvement training

2. delivering focused workshops on areas of the co-design process participants have found challenging, such as effectively engaging with consumers

3. identifying programme participants who may need additional support to train or teach colleagues and connect them to existing training or mentorship in their organisation that can assist in developing these skills

4. considering different modalities for the delivery of programme content which teams can access within timescales that suit their needs, for example, e-learning programmes

5. increasing support for senior leaders to understand co-design and expected benefits, and how co-design can fit within their organisational strategy, values and priorities, potentially through targeted training or communications to senior leaders

6. support senior leaders and sponsors to play a more active role in sharing the co-design methodology, in particular, advocating for co-design to be embedded within broader organisational policies or strategy.



Clinical leadership and hospital performance: assessing the evidence base

BMC Health Services Research

Paper reporting on a review of the literature on clinical leadership, clinician involvement in governance and hospital performance that focused on ‘quantitatively-oriented studies’ or ‘scientific papers’ with a final selection of 19 papers published in English language journals. The authors report that “In general terms, the findings show a positive impact of clinical leadership on different types of outcome measures, with only a handful of studies highlighting a negative impact on financial and social performance. Therefore, this review lends support to the prevalent move across health systems towards increasing the presence of clinicians in leadership positions in healthcare organisations.”



Challenges, solutions and future directions in the evaluation of service innovations in health care and public health

Health Services and Delivery Research

Another substantial report (164 pages) in the NHS National Institute for Health Research’s Health Services and Delivery Research. Rather than being a single report this is a collection of essays from some of the ‘thought leaders’ that provide a ‘state of the art’ view of the evaluation of complex interventions. AsJennifer Dixon noted in one of the report’s forewords, “It is clear from the contributions in many essays that the task of evaluating complex interventions is almost as complex as the systems being evaluated.” In her Foreword, the English Chief Medical Officer, Sally Davies, observed that “The volume provides a clear and authoritative explanation for the range of methods that can now be brought to bear to evaluate services. A wide spectrum of methods are described from novel forms of randomised trials to innovative statistical techniques for analysing data about services, outcome measures focused on patients’ priorities, and new focuses of research such as how to implement best practice. An impressive range of experts were mobilised to contribute to the debates out of which the position papers emerged. As well as providing accessible state-of-the-art explanations of best methods for evaluative research, the volume contains other important messages. These messages are that evaluation involves partnership between health professionals, providers, commissioners and researchers; and that innovation will best emerge from early and close dialogue between these different partners.”


Qualitative analysis of the in-hospital patient experience survey (2016)

Health Quality & Safety Commission 

The Health Quality & Safety Commission’s in-hospital patient experience survey was implemented on 1 July 2014.

Since the survey began, there are three questions which consistently rate lower than others. In early 2016, the Commission undertook qualitative analysis of comments in the quarterly survey results for August and November 2015, to get a better understanding of why those three questions continue to be the lowest rated.

To date quantitative data has formed the basis of results. Some district health board (DHBs) have analysed the patient experience survey comments to guide their own improvement initiatives, however, this is the first attempt to collate comments collectively from all 20 DHBs.


Sustaining Improvement


How can health care organizations sustain improvements in safety, effectiveness, and efficiency of patient care? According to the new IHI White Paper, Sustaining Improvement, the key is to focus on the daily work of frontline managers, supported by a high-performance management system that prescribes standard tasks and responsibilities for managers at all levels of the organization. The white paper presents a theoretical context for high-performance management, grounded in the Juran Trilogy (Quality Planning, Quality Control, and Quality Improvement); a framework for high-performance management; a driver diagram for implementing the framework; and case examples describing three organizations’ approaches to testing and implementing management standard work.


Harnessing organizational energy for transformational change

Presentation by Helen Bevan

Transforming Health Care: A Compendium of Reports from the National Patient Safety Foundation’s Lucian Leape Institute

Lucian Leape Institute at the National Patient Safety Foundation

The Lucian Leape Institute of the [US] National Patient Safety Foundation have compiled this short (32 page) compendium of the executive summaries and recommendations from five of their reports as a resource for health care leaders. As is noted in the Introduction:
“The series of reports has revealed how much the issues overlap and intersect. It is difficult to imagine robust patient and family engagement without greater transparency, for example. Likewise, greater patient and family engagement is essential if we are to work together to improve care integration.
What has become particularly clear is the fact that strong leadership and a culture of safety are essential for lasting improvement in patient safety. But changing culture takes time, and not all leaders know where or how to begin. This compendium should be referenced to inform discussions, set work priorities, and make what may sometimes be difficult decisions.” 

The five reports that are drawn together here include:

Shining a Light: Safer Health Care Through Transparency (2015)
Safety Is Personal: Partnering with Patients and Families for the Safest Care (2014)
Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care (2013)
Order from Chaos: Accelerating Care Integration (2012)
Unmet Needs: Teaching Physicians to Provide Safe Patient Care (2010)

Strategic quality improvement An action learning approach

Kings Fund

The King’s Fund was commissioned by Oxleas NHS Foundation Trust to work with their Quality Board to facilitate an assessment of its existing approaches to quality improvement and to develop a strategy for future work. This case study details the approach and philosophy behind this work, which involved working with the trust’s five directorates to develop their ability to appraise their own approach to quality improvement with a view to improving performance, achieving better clinical outcomes and building further on the trust’s capacity as a learning organisation.


Primary health networks and leadership for quality improvement

Australasian Medical Journal

The organisation of primary health care in Australia through supportive meso-level PCHOs, the PHNs, holds enormous potential, but a critical success factor will be the successful and appropriate engagement of frontline clinicians and GPs.

This requires a structured and systematic approach to developing an engagement plan. The evidence from the international experience and past Australian experience may inform what should be included in such a plan, but adaptation to the local context will be paramount. To successfully adapt it to the local context, PHNs should consider the level of engagement required from its membership, measure the level of engagement they have ,and then develop and implement a multi-faceted strategy to improve the degree of engagement. In doing so they will need to consider the heterogeneity of general practices and the four levels of quality improvement to produce an appropriately segmented engagement strategy. Co-designing the strategy with GPs will stack the deck of cards in their favour and to achieve all of this will require a vision, will ,and resources. However, in doing so they will achieve the collective and distributed leadership required for quality improvement to achieve their objectives of improving effectiveness and efficiency of health services.

Disruptive Innovation - Considerations for health and health care in Europe

European Commission

“Disruptive innovation is a concept that has been developed for analysing ways to improve health outcomes and reduce costs in the US health care system. The Expert Panel on Effective ways of Investing in Health (EXPH) was requested to focus on the implications of disruptive innovation for health and health care in Europe. The Expert Panel understands “disruptive innovation” in health care as a type of innovation that creates new networks and new organisational cultures involving new players, and that has the potential to improve health outcomes and the value of health care. This innovation displaces older systems and ways of doing things.”

A Framework for Improving Health Equity

Healthcare Executive

While communitywide efforts and coalitions are key to achieving health equity, health care organizations and systems have tremendous potential to directly influence numerous underlying societal inequities that contribute to health disparities and poor health. This article presents an overview of a framework developed by IHI to help guide leaders in improving health equity by making it a system-level priority for their organizations.

Building Q: Learning from designing a large scale improvement community

The Health Foundation

This report looks at the first year of the Q initiative and the extensive co-design process used to create it.

Q is a diverse and growing community of people, with experience and understanding of improvement, committed to improving the quality of health and care across the UK.

To ensure Q meets the needs of those in improvement, the Health Foundation worked in partnership with 48 organisations to recruit 231 founding members to help design and test Q during 2015. The Health Foundation believe the process to design Q is the largest collaborative design process of its type undertaken in improvement in health care.

The report identifies lessons for anyone seeking to support improvement work across organisations or through networks, as well as those engaged in designing initiatives with many diverse stakeholders. It draws on a variety of sources including the independent real-time evaluation of Q undertaken by RAND Europe.

Key lessons:

·  Q needs to be first and foremost about connecting people involved in improvement. During 2015, members were supported to build many new connections and relationships with people from other professional backgrounds and geographies. There are early signs to support the hypothesis that these connections can boost the effectiveness and confidence of those doing improvement, enable innovations to flow more easily across the system and allow new collaborations.

·  Multiple enablers need to be in place for people to be able to design, implement and measure improvements effectively. These include time, access to information and resources, and support in a system that is often fragmented and turbulent. Members supported the idea that Q should provide a long-term infrastructure that will offer development opportunities and make members more visible to each other, encouraging connections and helping people work together to support each other.

·  The scale of the co-design process enabled broad-based engagement in shaping Q. Collaboratively designing Q with such a large and diverse range of people was complex and challenging. Members were very engaged in debates around what Q should deliver, but with many divergent views synthesising and deciding how to move forward was often hard. However, the scale of the process enabled a broad-based community of improvers to be established. A significant majority of founding members report a positive attitude to Q, perceive the initiative as important and want to stay involved and shape the strategy further. Q is now broadly at the stage intended, with an agreed operating model that will now be tested in practice on a larger scale as the community grows.

Outpatient services and primary care: scoping review, substudies and international comparisons.

Health Services Delivery and Research

This report sets out findings from a scoping review of the literature to update what we know about interventions designed to improve the effectiveness and efficiency of the outpatient referral system. We also provide substudies on a range of more recent innovations taking place in England, which are not yet adequately covered in the published literature. Finally, we include data on international experiences in this area, which may provide lessons for the UK.

Aims and objectives
Identify and review what is currently known about strategies involving primary care that are designed to improve the effectiveness and efficiency of outpatient services.
Comment on the impact of such schemes on the organisation of primary care, the primary care workforce, access, clinical outcomes for patients and patient experience.
Identify and comment on the potential for innovative models of care to be replicated more widely.
Identify the needs for future research in this area in terms of both primary research and systematic reviews that might be needed.
Summarise the findings in a way that will be readily accessible to policy-makers and managers.


For many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.

What is improvement science anyway?

Maxine Power [blog]

This post follows Maxine’s first blog ‘Improvement is a contact sport’ packed with top tips when facing challenges as an aspiring improver.



Exploring the links between quality improvement strategies and organisational outcomes in four New Zealand district health boards

(2016). Ministry of Health, the Treasury, and the Health Quality & Safety Commission.
Participating DHBs provide real-life examples of what customer-centric models of care look like in practice. Elements that contributed to the success of programmes in these DHBs are relevant to other services delivered by the Government. 

Executive summary

A number of New Zealand District Health Boards (DHBs) are using quality frameworks and concepts as core elements of their organisational strategies to improve patient outcomes and manage healthcare costs. The successes and challenges of these strategies can provide useful insights for other DHBs and the broader health system.

During 2015, the Ministry of Health (Ministry), the Treasury (Treasury) and the Health Quality & Safety Commission (the Commission) undertook a collaborative project with Auckland, Bay of Plenty, Canterbury and Whanganui DHBs to explore the links between quality improvement (QI) strategies and organisational outcomes.

The four participating DHBs were retrospectively evaluated using two frameworks. Their organisational strategy and overall approach to quality were summarised using a framework based on the Institute for Healthcare Improvement’s (IHI) Seven Leadership Leverage Points for Organization-Level Improvement in Health Care1 and the New Zealand Quality Guide2. Concurrently, their performance was measured against the dimensions of the Triple Aim. This approach provides a comprehensive overview of each DHB, both from the qualitative and quantitative perspectives.

Analysis carried out for the project found that all four case study DHBs showed clear improvements in some measures, and for some measures the improvement was greater than for non-case study DHBs. There is no evidence that a focus on specific outcomes had a negative impact on outcomes elsewhere. Rather, the general direction of QI in the studied DHBs in areas not covered by specific local initiatives was similar or better than the country as a whole.

QI programmes undertaken by the four DHBs were all significantly different in nature, approach and scale. However, there were common success factors across most or all of the case study DHBs including alignment to strategic goals, executive and clinical leadership, culture and capability, measurement and results, and consumer engagement and patient experience.

In addition to providing an overview of each DHB and their approach to QI, the case studies offered a number of useful lessons for DHBs seeking to include QI elements in their organisational strategy. The case studies also offer a number of valuable insights for the centre.

Lessons in Leadership for Improvement: Kaiser Permanente’s Improvement Journey Over 10 Years.

Institute for Healthcare Improvement

Over the past decade, Kaiser Permanente (KP) has achieved impressive improvements in quality of care — halving its hospital standardized mortality ratio and reducing hospital-acquired pressure ulcers by more than 80 percent, among other achievements. These accomplishments are all the more remarkable for the size and complexity of the organization in which they occurred, and a testament to what can be accomplished in health care with engaged and effective leadership and staff. Kaiser's achievements also owe a great deal to a unique 10-plus-year collaboration with IHI — a strategic partnership that accelerated improvement at KP, greatly informed IHI’s own learning, and helped KP build system-wide capacity for improvement.

Lean interventions in healthcare: do they actually work? A systematic literature review

International Journal for Quality in Health Care

Lean is a widely used quality improvement methodology initially developed and used in the automotive and manufacturing industries but recently expanded to the healthcare sector. This systematic literature review, published in the International Journal for Quality in Health Care, seeks to independently assess the effect of Lean or Lean interventions on worker and patient satisfaction, health and process outcomes, and financial costs.

A scoping review of online repositories of quality improvement projects, interventions and initiatives in healthcare

BMJ Quality & Safety

Quality improvement (QI) activities occur widely across health care. Much of this activity goes unreported. There are a number of sites/repositories that do allow QI activities to be reported on and searched (such as BMJ Quality Improvement Reports at This article reports on a review of 13 publicly available, web-based QI repositories. The authors report that the 13 sites “used different terminology (eg, practices vs case studies) and approaches to content acquisition, and varied in terms of primary areas of focus. All provided some means for organising content according to categories or themes and most provided at least rudimentary keyword search functionality. Notably, none of the QI repositories included evaluations of their impact.”


Essentials for improving service quality in cancer care


This commentary, drawing on site visits to cancer care centres and interviews with cancer patients, family members, clinicians, and health care leaders in the USA, proposes six “essentials” for improving service quality in cancer care. The six factors are:

1.     Embrace team-based care

2.     Offer concurrent palliative care

3.     Prepare family members for caregiving

4.     Facilitate continuous connection

5.     Broaden the geographic reach of clinical excellence

6.     Adopt payment-system reforms.


Governing for quality: A quality and safety guide for district health boards

This guide will help district health boards (DHBs) put quality and safety at the centre of governance and drive improvement in their organisations. While the guide has been written with DHBs in mind, the principles and guidance are relevant and can be applied to all health care providers.

It includes:

• an outline of the role of boards as agents for quality and safety improvement

• the seven essential steps boards can take to improve the quality and safety of health care services:

1. Lead and set clear goals

2. Gather information and seek out patient stories

3. Establish system-wide measures and monitor them

4. Put a high quality and safety culture in place

5. Ensure the right mix of people and encourage discussion

6. Commit to ongoing learning at all levels

7. Define roles and establish clear accountability at all levels


The Health of the Nation: Averting the demise of universal healthcare

London: Civitas; 2016

The UK think tank Civitas has published this collection of essays that examine that the background to the current pressures on the UK’s National Health Service and some of the ideas that have been proposed for reform. The publication features contributions from eleven authors from across the political spectrum and covers a wide range of suggestions covering public health and behaviour change; change management; technological innovations; and the future of commissioning.


Review of after-hours service models: Learnings for regional, rural and remote communities

Deeble Institute Issues Brief No 15

This issues brief offers an evaluation of current delivery models of after-hours primary health care nationally and internationally. It identifies a number of innovations and program elements that could be commonly applied by Primary Health Networks throughout Australia. Recognising that local setting is important and there is a need to tailor after-hours services appropriately, each model must be assessed in terms of suitability in the local context. As such, this Issues Brief describes individual program elements and options for innovations in after-hours service delivery which may be adaptable and transferrable across PHNs. Key principles common across the options proposed are:

  • Services are flexible, responsive and tailored to regional circumstance
  • Efficient and effective use is made of the broader health workforce
  • Innovative service delivery is promoted
  • Data is used to inform policy change
  • Communication with patients and providers is key to success


Who cares? The future of general practice

London: Reform; 2016.

Primary care (or general practice) is often seen as the hope for reducing the pressures on hospitals. However, primary care faces its own challenges. This report form the UK’s Reform think tank reviews the current model of general practice in the UK and asserts that the model needs to change to address the future needs. The authors believe that British general practice would benefit from economies of scale and better integration. Creating such large practices will entail quite a different model of care, including much more multidisciplinary work in which “GPs could pass 50 per cent of appointments they currently conduct to other professionals. A more diverse workforce could, for instance, see pharmacists or nurses administering the estimated 57 million appointments (15 per cent of the total number of appointments) consumed by common conditions and medicines-related problems each year. This alone could deliver up to £727 million of savings per year.” The approach also calls for a significant change in commissioning of services.




Competencies for Patient Safety and Quality Improvement: A Synthesis of Recommendations in Influential Position Papers

Joint Commission Journal on Quality and Patient Safety

This paper reports on a study that examined 22 “position papers published by national and international professional associations, expert panels, consortia, centers and institutes, and convened committees, in the domain of patient safety and QI.” The list of bodies is heavily focused on North America and some of the sources are a tad dated. The authors reveal a concern about the breadth of competencies and “instead encourage development of an international consensus on the essential KSA [knowledge, skills and attitudes] for patient safety and QI [quality improvement] across all health professions and all levels of skill acquisition.”


Transformational change in healthcare: an examination of four case studies

Australian Health Review

In this article, the characteristics of success for transformational change in healthcare are explored through four case studies from the US, UK and Australia. Multiple sources of evidence were used to investigate each case study. Some common observations between case studies are:

  • In most case studies, there was a clear case for change because the preceding health system was very poor
  • A well-communicated narrative existed for each case study with evidence-based rationale for why change was needed
  • In most cases, health professional and patient engagement and consultation was paramount
  • A clear delineation of responsibility and appropriate performance measures and incentives were present
  • System redesign was essential and was facilitated by sophisticated data management
    Leadership focused on quality of care and the notion of health as a complex adaptive system.


Improving the patient experience through the health care physical environment

Health Research & Educational Trust

This HPOE guide, a collaboration with the American Society for Healthcare Engineering, explores ways hospital and health system leaders can use the physical environment to improve the patient experience. The guide describes a "people, process, place" model that will help hospital and health system leaders identify people-centered ways to improve the patient experience of care through:

establishing a culture of caring; implementing process improvements, such as processes that support patients and staff; and making improvements to the place of care, including the hospital physical environment, technology and furniture.

By working with this model, hospitals and health systems can take a more holistic approach to improving the patient experience.

The guide includes case studies; a hospital leader checklist; a template for using the people, process and place model; a detailed table outlining eight domains of care measured by the HCAHPS survey with observed relationships to the physical environment; and additional resources list. 


Achieving change in primary care—causes of the evidence to practice gap: systematic reviews of reviews

Implementation Science


Background: This study is to identify, summarise and synthesise literature on the causes of the evidence to practice gap for complex interventions in primary care.

Seventy reviews fulfilled the inclusion criteria and encompassed a wide range of topics, e.g. guideline implementation, integration of new roles, technology implementation, public health and preventative medicine. None of the included papers used the term “cause” or stated an intention to investigate causes at all. A descriptive approach was often used, and the included papers expressed “causes” in terms of “barriers and facilitators” to implementation.

We developed a four-level framework covering external context, organisation, professionals and intervention. External contextual factors included policies, incentivisation structures, dominant paradigms, stakeholders’ buy-in, infrastructure and advances in technology. Organisation-related factors included culture, available resources, integration with existing processes, relationships, skill mix and staff involvement. At the level of individual professionals, professional role, underlying philosophy of care and competencies were important. Characteristics of the intervention that impacted on implementation included evidence of benefit, ease of use and adaptability to local circumstances. We postulate that the “fit” between the intervention and the context is critical in determining the success of implementation.

Conclusions: This comprehensive review of reviews summarises current knowledge on the barriers and facilitators to implementation of diverse complex interventions in primary care. To maximise the uptake of complex interventions in primary care, health care professionals and commissioning organisations should consider the range of contextual factors, remaining aware of the dynamic nature of context. Future studies should place an emphasis on describing context and articulating the relationships between the factors identified here.


Invited Essay: A Collaborative Approach to a Chronic Care Problem       

Longwoods Healthcare Papers

Quality improvement collaboratives (QICs) are popular vehicles for supporting healthcare improvement; however, the effectiveness of these models and the factors associated with their success are not fully understood. This paper presents a QIC in the Canadian context, where provincial healthcare systems have historically faced difficulty in transcending their structural and political limitations as well as moving from reactive models of care (prioritizing illness treatment in a hospital-reliant system) to more proactive ones (prioritizing population health in a primary care-based system). In March 2012, in a move that has been described as "unprecedented," 17 health regions across four provinces in Atlantic Canada, together with the Canadian Foundation for Healthcare Improvement (CFHI), developed a collaborative to improve chronic disease prevention and management.

This paper introduces the Atlantic Healthcare Collaboration for Innovation and Improvement in Chronic Disease (AHC), reflecting on the experience of developing and implementing the model, which involved teams of front-line clinicians and managers working with CFHI faculty, coaches and staff to assess, design, implement, evaluate and share healthcare improvements for people living with chronic diseases. The paper shares key results and lessons learned from the AHC QIC experience, thus far, for improving chronic disease prevention and management in healthcare in Canada.


Patient care: a unified approach. A case study report

Royal College of General Practitioners and Royal College of Physicians

Integrated care and the coordination and continuity of care are all seen as desirable for improving the care patients receive. They all tend to place primary care as the key for achieving these improvements. This report from the UK’s Royal College of General Practitioners (RCGP) and Royal College of Physicians (RCP) presents a number of case studies “that exemplify how integration between GPs and physicians can be achieved. The case studies span a wide range of services in England and Wales, and cover a variety of learning points involving different specialties, different population groups and different ways of addressing complex issues. This report has been compiled to share learning from successful examples of integration, and to encourage GPs and physicians to reflect on their own practice. Many of the examples provided are disease specific, owing to the way in which secondary care is organised; however, around the country there are many innovative examples of more holistic treatment.

The sheer variety of integrative services show there is no ‘one size fits all’ approach, and the themes of the report include:

  • the many approaches to integration, which will vary depending on the patient population
  • improved communication and the establishment of an ongoing dialogue between GPs and physicians are vital to successful integration
  • empowering the workforce to make change, and the importance of providing an educational environment that encourages innovation
  • a supportive external environment, including commissioning and funding fit for purpose, and information and technology systems that support primary and secondary care working together
  • the difference that can be made to patients if GPs and physicians are part of a multidisciplinary team (MDT) and work across the whole health economy

Hidden in plain view: barriers to quality improvement

Physician Leadership Journal

Despite a vast amount of knowledge about the technical methods of improving quality and safety in health care, rates of success have been highly variable within and across organizations. In our work with many health care leaders and organizations, our observation has been that relational rather than technical issues are the most common barriers to improvement.

This may seem paradoxical in an industry devoted to healing relationships. But we have observed that the complexity and stress so prevalent in health care settings lead to frequent problems in working relationships at all levels of interaction: interpersonal, team, interdepartmental and inter-organizational.

Multiple research studies and analyses have suggested that contextual factors (such as quality of relationships, communication, leadership style, organizational culture, team process and behaviours, etc.) are critical facilitators or impediments for change…

Habits of thinking and action are not broken overnight. In health care, we have a long way to go to break our habit of marginalizing relational knowledge, skills and practice. The key ingredients are patience, persistence, courage and compassion for our innately human way of falling into counterproductive behaviour under stress.

Paradoxically, by recognizing this less rational side of our humanness and addressing it with compassion, we greatly enhance the chances for transformation.


Effects of organizational context on Lean implementation in five hospital systems

 Health Care Management Review

Despite broad agreement among researchers about the value of examining how context shapes implementation of improvement programs and projects, limited attention has been paid to contextual effects on implementation of Lean.

To help reduce gaps in knowledge of effects of intraorganizational context, we researched Lean implementation initiatives in five organizations and examined 12 of their Lean rapid improvement projects. All projects aimed at improving clinical care delivery.

On the basis of the literature on Lean , innovation, and quality improvement, we developed a framework of factors likely to affect Lean implementation and outcomes. Drawing on the framework, we conducted semi structured interviews and applied qualitative codes to the transcribed interviews. Available documents, data, and observations supplemented the interviews. We constructed case s studies of Lean implementation in each organization, compared implementation across organizations, and compared the 12 projects.


  • Intra-organizational characteristics affecting organization-wide Lean initiatives and often also shaping project outcomes included CEO commitment to
  • Lean and active support for it, prior organizational capacity for quality
  • improvement-based performance improvement, alignment of the Lean initiative with the organizational mission, dedication of resources and experts to Lean, staff training before and during projects, establishment of measurable and
  • relevant project targets, planning of project sequences that enhance staff
  • capabilities and commitment without overburdening them, and ensuring communication between project members and other affected staff. Dependence of projects on inputs of new information technology was a barrier to project success. Incremental implementation of Lean produced reported improvements in operational efficiency and occasionally in care quality. However, even under the relatively favourable circumstances prevailing in our study sites, incremental implementation did not readily change organizational culture.

Practice Implications:
This study should alert researchers, managers, and teachers of management to ways that contexts shape Lean implementation and may affect other types of process redesign and quality improvement.


From tokenism to empowerment: progressing patient and public involvement in healthcare improvement

BMJ Quality & Safety

There have been repeated calls to better involve patients and the public and to place them at the centre of healthcare. Serious clinical and service failings in the UK and internationally increase the urgency and importance of addressing this problem. Despite this supportive policy context, progress to achieve greater involvement is patchy and slow and often concentrated at the lowest levels of involvement.

A selective narrative literature search was guided by the authors’ broad expertise, covering a range of disciplines across health and social care, policy and research. Published systematic literature reviews were used to identify relevant authors and publications. Google and hand searches of journal articles and reference lists and reports augmented identification of recent evidence.

Patients and the wider public can be involved at most stages of healthcare, and this can have a number of benefits. Uncertainty persists about why and how to do involvement well and evaluate its impact, how to involve and support a diversity of individuals, and in ways that allow them to work in partnership to genuinely influence decision-making. This exposes patient and public involvement (PPI) to criticisms of exclusivity and tokenism.

Current models of PPI are too narrow, and few organisations mention empowerment or address equality and diversity in their involvement strategies. These aspects of involvement should receive greater attention, as well as the adoption of models and frameworks that enable power and decision-making to be shared more equitably with patients and the public in designing, planning and co-producing healthcare.

Chronic failure in primary medical care

Melbourne: Grattan Institute

This latest report from the Grattan Institute asserts that the Australian primary care is proving sub-optimal care for patients with chronic diseases. The report’s authors claim that ineffective management of chronic diseases costs the Australian health system more than $320 million each year in avoidable hospital admissions, that the primary care system provides only half the recommended care for many chronic conditions each year and that there are more than a quarter of a million admissions to hospital for health problems that potentially could have been prevented.

Chronic conditions affect many Australians and the numbers have been growing. To address these primary care needs to function well. This report argues, as have others, that the fee-for-service model is unsuited to managing and preventing chronic disease. The authors perceive a role for Primary Health Networks in helping patients receive better care for their chronic conditions.

Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices

United States Government Accountability Office

It is no secret that implementation (and sustained implementation and impact) is where some of the biggest challenges lie in safety and quality interventions. This brief (34-page) report from the US U.S. Government Accountability Office (GAO) examined how six American hospitals tried to implement a number of evidence-based safety practices. Three key challenges affected the efforts to implement evidence-based patient safety practices, including:

  • Obtaining data to identify adverse events in their own hospitals
  • Determining which patient safety practices should be implemented
  • Ensuring that staff consistently implement the practices over time.

Improving the governance of patient safety in emergency care: a systematic review of interventions

BMJ Open

At first glance it would seem that managing patient safety may be more straightforward in some settings than others. One setting that may seem more challenging is that of emergency care. This article reports on a systematic review that sought to focus on interventions that aim to improve the governance of patient safety within emergency care on effectiveness, reliability, validity and feasibility. From, the 18 included studies that authors found "The use of a simulation-based training programme and well-designed incident reporting systems led to a statistically significant improvement of safety knowledge and attitudes by ED staff and an increase of incident reports within EDs, respectively".





New care models: Vanguards – developing a blueprint for the future of NHS and care services

 In January 2015, the NHS invited individual organisations and partnerships to apply to become ‘vanguard’ sites for the new care models programme, one of the first steps towards delivering the Five Year Forward View and supporting improvement and integration of services.

In March, the first 29 vanguard sites were chosen. There were three vanguard types – integrated primary and acute care systems; enhanced health in care homes; and, multispecialty community provider vanguards.

In July, 8 urgent and emergency vanguards were announced.

In September a further 13 vanguards were announced – known as acute care collaborations, they aim to link local hospitals together to improve their clinical and financial viability.

The 50 vanguards were selected following a rigorous process, involving workshops and the engagement of key partners and patient representative groups.

Each vanguard site will take a lead on the development of new care models which will act as the blueprints for the NHS moving forward and the inspiration to the rest of the health and care system.


 Behavioural insights in health care: Nudging to reduce inefficiency and waste

‘Behavioural insights’ has been described as the ‘application of behavioural science to policy and practice with a focus on (but not exclusively) “automatic” processes’. Nudges are a particular type of behaviour change intervention that might be considered an expression of behavioural insights. Nudge-type interventions – approaches that steer people in certain directions while maintaining their freedom of choice– recognise that many decisions – and ensuing behaviours – are automatic and not made consciously. Nudges have been proposed as an effective way to change behaviour and improve outcomes at lower cost than traditional tools across a range of policy areas.

There is much evidence that suggests the potential for all of these nudge-type interventions to be successful if suitably applied. However, the evidence available is highly variable in terms of quality, relevance to health care and behaviour change impact. Further, even for those interventions with the strongest evidence base – prompts, cues and reminders, and audit and feedback – there is much that is not yet known about how to enhance and optimise them. There is a clear need for more good quality evaluation and synthesised evidence of nudge-type interventions, their behaviour change potential and their impact on inefficiency and waste.
While nudge-type interventions hold much promise for reducing inefficiency and waste in health care it is important that intervention development clearly builds on existing research and theory. If this does not happen then nudging in health care is more likely to contribute to inefficiency and waste than reduce it.

Enabling Change in Health Care

Innovation centers such as the Penn Medicine Center for Health Care Innovation — an arm of the University of Pennsylvania Health System — are using rapid, low-cost experiments to explore new approaches to improving care.

Health care reforms and market trends are stimulating local health systems to seek better and more cost-efficient ways of meeting their patients’ needs. This case study is part of ongoing research by The Commonwealth Fund to track how health systems are transforming care delivery, particularly to meet the needs of high-needs, high-cost patients and vulnerable populations.


Patient safety 2030

This report from the NIHR Patient Safety Translational Research Centre at Imperial College London and Imperial College Healthcare NHS Trust asserts that there is a need for a ‘toolbox’ for patient safety which includes using digital technology to improve safety; providing robust training and education, and strengthening leadership at the political, organisational, clinical and community levels. The report’s authors argue that interventions implemented to reduce avoidable patient harm must be engineered with the whole system in mind, and must empower patients and staff to become more involved in preventing harm and improving care.


Bringing together physical and mental health: A new frontier for integrated care

The King’s Fund in the UK have released this report claiming that the psychological problems associated with physical health conditions, and vice versa, are costing the NHS more than £11 billion a year and care is less effective than it could be. The report argues that by integrating physical and mental health care the NHS can improve health outcomes and save money.
The £11 billion a year is the collective cost of:

  • high rates of mental health issues among those with long-term conditions such as cancer, diabetes or heart disease
  • limited support for the psychological aspects of physical health, for example during and after pregnancy
  • poor management of ‘medically unexplained symptoms’ such as persistent pain or tiredness.

The authors argue that the separation between physical and mental health has a high human cost: in the UK the life expectancy for people with severe mental illness is 15 to 20 years below that of the general population.

The report identifies 10 areas where there is particular scope for improvement across the system from enhancing mental health input in acute hospitals and assessing physical health problems in mental health inpatient facilities, to increased support for GPs in managing people with complex conditions. The ten priorities identified are:

1.     Incorporating mental health into public health programmes

2.     Promoting health among people with severe mental illnesses

3.     Improving management of medically unexplained symptoms in primary care

4.     Strengthening primary care for the physical health needs of people with severe mental illnesses

5.     Supporting the mental health of people with long-term conditions

6.     Supporting the mental health and wellbeing of carers

7.     Supporting mental health in acute hospitals

8.     Addressing physical health in mental health inpatient facilities

9.     Providing integrated support for perinatal mental health

10.   Supporting the mental health needs of people in residential homes.


Improving quality in the English NHS: A strategy for action 

This report from the UK’s King’s Fund argues that the NHS in England cannot meet the health care needs of the population without a sustained and comprehensive commitment to quality improvement as a principal strategy. The authors argue that the NHS in England has lacked a coherent approach to improving quality of care. They proceed to describe key features of a quality improvement strategy and the role of organisations at different levels in realising it, offering 10 design principles to guide its development. The design principles include:

  • Expecting organisations to build in-house capacity for quality improvement
  • Supporting organisations through shared learning and regional support
  • Establishing a national centre of expertise
  • Integrating quality improvement and leadership development
  • Ensuring national bodies provide unified, co-ordinated support to the NHS as full participants in a single strategy
  • Involving frontline clinical leaders and the leaders of organisations in developing the strategy
  • Ensuring the voice of patients and the public is sought and heard in the design and implementation of the strategy
  • Being open to learning from other organisations at home and abroad
  • Working with organisations and experts outside the formal structures
  • Reflecting, measuring and learning rapidly about what is and is not working to help implementation become more successful.


Safer Healthcare: Strategies for the Real World

In their new book, Safer Healthcare: Strategies for the Real World, Professors Vincent and Amalberti set out a system of safety strategies and interventions for managing patient safety on a day-to-day basis and improving safety over the long term. These strategies are applicable at all levels of the healthcare system from the frontline to the regulation and governance of the system.

There have been many advances in patient safety but we now need a new and broader vision that encompasses care throughout the patient’s journey. We argue that we need to see safety through the patient’s eyes, to consider how safety is managed in different contexts and to develop a wider strategic and practical vision in which patient safety is recast as the management of risk over time. We need to make more use of strategies concerned with detecting, controlling, managing and responding to risk. Strategies for managing safety in highly standardised and controlled environments are necessarily different from those in which clinicians constantly have to adapt and respond to changing circumstances.

Free from harm: accelerating patient safety improvement fifteen years after to err is human

Report of an Expert Panel Convened by the National Patient Safety Foundation.
Fifteen years after the Institute of Medicine brought public attention to the issue of medical errors and adverse events, patient safety concerns remain a serious public health issue that must be tackled with a more pervasive response.

With a grant from AIG, the National Patient Safety Foundation (NPSF) convened an expert panel in February 2015 to assess the state of the patient safety field and set the stage for the next 15 years of work.  

The resulting report calls for the establishment of a total systems approach and a culture of safety, and calls for action by government, regulators, health professionals, and others to place higher priority on patient safety science and implementation. 

The report makes eight recommendations:

  • Ensure that leaders establish and sustain a safety culture;
  • Create centralized and coordinated oversight of patient safety;
  • Create a common set of safety metrics that reflect meaningful outcomes;
  • Increase funding for research in patient safety and implementation science;
  • Address safety across the entire care continuum;
  • Support the health care workforce;
  • Partner with patients and families for the safest care
  • Ensure that technology is safe and optimized to improve patient safety


What are the effective ways to translate clinical leadership into health care quality improvement?

The authors of this piece assert that “effective leaders in health care can have a stark consequence on the quality and outcomes of care. The delivery of safe, quality, compassionate health care is dependent on having effective clinical leaders at the frontline.” They proceed to explore ways of translating clinical leadership into health care quality improvement.

They argue that “Clinical leaders are effective in facilitating innovation and change through improvement. This is achieved by recognizing, influencing, and empowering individuals through effective communication in order to share and learn from and with each other in practice.” They recognise that health care organisations need to create cultures that encourage and develop clinical leaders. Openness and candour are key elements in their view.


High performing hospitals: a qualitative systematic review of associated factors and practical strategies for improvement

Health is a complex human endeavour and the factors that contribute to high performance are complex. The objective of this review was to identify methods used to identify high performing hospitals, the factors associated with high performers, and practical strategies for improvement. The review screened more than 11,000 studies before focusing on 19. From the analysis the authors report that seven themes (and 25 sub-themes) representing factors associated with high performance emerged: positive organisational culture, senior management support, effective performance monitoring, building and maintaining a proficient workforce, effective leaders across the organisation, expertise-driven practice, and interdisciplinary teamwork.




Improving the governance of patient safety in emergency care: a systematic review of interventions

BMJ Open

The objective of this study, published in BMJ Open, was to systematically review interventions that aim to improve the governance of patient safety within emergency care on effectiveness, reliability, validity and feasibility.

A Framework for Scaling Up Health Interventions: Lessons from Large-Scale Improvement Initiatives in Africa

Implementation Science

This article details a sequence of four steps for taking a health intervention to full scale: 1. Set-up, 2. Develop the Scalable Unit, 3. Test of Scale-up, and 4. Go to Full Scale. The properties that facilitate adoption of the new ideas and the infrastructure required to support the scale-up are also described. Two case studies present national-scale initiatives in Ghana and South Africa that used early iterations of this framework to scale up evidence-based interventions to improve maternal and child health.

Operational productivity and performance in English NHS acute hospitals: Unwarranted variations

The Carter Review 

An inquiry into hospital productivity released this week claims that the NHS could save £5 billion a year through running costs and reducing the number of patients unable to leave wards. Our Chief Executive Nigel Edwards warns that the government should beware top-down approaches to reducing costs.

A Best Practice Guide for Continuous Practice Improvement | Council of Medical Colleges of New Zealand 

This Guide is a framework for use when developing or reviewing programmes set up to demonstrate the competence and performance of medical specialists. The Best Practice Guide was produced as a joint project Council of Medical Colleges (CMC) and Member Colleges, the Medical Council of New Zealand (MCNZ), the Ministry of Health (MoH) and District Health Board (DHB) Chief Medical Officers.

The Best Practice Guide is accompanied by a stock take of definitions, resources, tools and additional information to assist all to implement a best practice guide for continuous practice improvement.


Economic Evaluation of Interventions for Prevention of Hospital Acquired Infections: A Systematic Review


Paper reporting on a systematic review examining economic analyses of interventions to prevent hospital-acquired infections. The review focused on 27 articles published in the period 2009 to 2014 The authors report finding highly positive cost–benefit ratios and conclude that preventing hospital-acquired infections is a cost-effective patient safety strategy.




Evaluating Investment in Quality Improvement Capacity Building: A Synthesis of the Literature

Working Paper. Toronto: Institute of Health Policy, Management and Evaluation; 2015.

Poor quality of care places a heavy financial and human burden on health care systems worldwide.
Low quality care is widespread and persists despite the fact that more organizations than ever before are actively engaged in Quality Improvement (QI) efforts.

System level assessments of the impact of QI capacity building are essential to link investments to health system performance improvement and transformation.

The objectives of this study were to explore existing QI capacity building evaluations that allow assessment of the return on investments (ROI) or other types of economic evaluations, and to gather and review the literature on the current knowledge in QI capacity building evaluation.


Beyond clinical engagement: a pragmatic model for quality improvement interventions, aligning clinical and managerial priorities

BMJ Quality and Safety

Despite taking advantage of established learning from other industries, quality improvement initiatives in healthcare may struggle to outperform secular trends. The reasons for this are rarely explored in detail, and are often attributed merely to difficulties in engaging clinicians in quality improvement work. In a narrative review of the literature, we argue that this focus on clinicians, at the relative expense of managerial staff, has proven counterproductive. Clinical engagement is not a universal challenge; moreover, there is evidence that managers-particularly middle managers-also have a role to play in quality improvement. Yet managerial participation in quality improvement interventions is often assumed, rather than proven. We identify specific factors that influence the coordination of front-line staff and managers in quality improvement, and integrate these factors into a novel model: the model of alignment. We use this model to explore the implementation of an interdisciplinary intervention in a recent trial, describing different participation incentives and barriers for different staff groups. The extent to which clinical and managerial interests align may be an important determinant of the ultimate success of quality improvement interventions.

'The problem with Plan-Do-Study-Act cycles'

BMJ Quality and Safety

Quality improvement (QI) methods have been introduced to healthcare to support the delivery of care that is safe, timely, effective, efficient, equitable and cost effective. Of the many QI tools and methods, the Plan-Do-Study-Act (PDSA) cycle is one of the few that focuses on the crux of change, the translation of ideas and intentions into action. As such, the PDSA cycle and the concept of iterative tests of change are central to many QI approaches, including the model for improvement,1 lean,2 six sigma3 and total quality management.4

PDSA provides a structured experimental learning approach to testing changes. Previously, concerns have been raised regarding the fidelity of application of PDSA method, which may undermine learning efforts,5 the complexity of its use in practice5 ,6 and as to the appropriateness of the PDSA method to address the significant challenges of healthcare improvement.7

This article presents our reflections on the full potential of using PDSA in healthcare, but in doing so we explore the inherent complexity and multiple challenges of executing PDSA well. Ultimately, we argue that the problem with PDSA is the oversimplification of the method as it has been translated into healthcare and the failure to invest in a rigorous and tailored application of the approach.


Integrating new practices: a qualitative study of how hospital innovations become routine

Implementation Science

Hospital quality improvement efforts absorb substantial time and resources, but many innovations fail to integrate into organizational routines, undermining the potential to sustain the new practices. Despite a well-developed literature on the initial implementation of new practices, we have limited knowledge about the mechanisms by which integration occurs.

We conducted a qualitative study using a purposive sample of hospitals that participated in the State Action on Avoidable Rehospitalizations (STAAR) initiative, a collaborative to reduce hospital readmissions that encouraged members to adopt new practices. We selected hospitals where risk-standardized readmission rates (RSRR) had improved (n = 7) or deteriorated (n  = 3) over the course of the first 2 years of the STAAR initiative (2010–2011 to 2011–2012) and interviewed a range of staff at each site (90 total). We recruited hospitals until reaching theoretical saturation. The constant comparative method was used to conduct coding and identification of key themes.

When innovations were successfully integrated, participants consistently reported that a small number of key staff held the innovation in place for as long as a year while more permanent integrating mechanisms began to work. Depending on characteristics of the innovation, one of three categories of integrating mechanisms eventually took over the role of holding new practices in place. Innovations that proved intrinsically rewarding to the staff, by making their jobs easier or more gratifying, became integrated through shifts in attitudes and norms over time. Innovations for which the staff did not perceive benefits to themselves were integrated through revised performance standards if the innovation involved complex tasks and through automation if the innovation involved simple tasks.

Hospitals have an opportunity to promote the integration of new practices by planning for the extended effort required to hold a new practice in place while integration mechanisms take hold. By understanding how integrating mechanisms correspond to innovation characteristics, hospitals may be able to foster integrating mechanisms most likely to work for particular innovations.


Uses and abuses of performance data in healthcare

Dr Foster

Measurement of performance in the healthcare sector is essential for transparency and accountability, and to support improvement. However, these improvements are undermined by weaknesses in the generation of data and metrics. This report outlines five steps that are not currently being addressed by policy but could significantly reduce data abuse and increase the benefit that can be gained through the use of performance dataQuality Improvement Essentials Toolkit

This page was last updated at 9:55AM on June 15, 2022.