Every (improvement) system is perfectly designed to deliver the results it gets

Anyone who has been involved in improvement activity over the past 10 years will be familiar with the phrase ‘every system is perfectly designed to get the results it gets’, the premise being that both the intended and unintended consequences are designed into our systems.

Let’s take an example: healthcare in the UK has, over the last 12 years, been perfectly designed to reduce waiting times from 18 months to 18 weeks for many procedures, just as it has been perfectly designed to harm 1 in 10 patients. Reflecting on the Safer Patients Initiative (SPI), the same can be true about improvement systems: every improvement system is perfectly designed to get the results its gets and SPI is a case in point.

Over the 22 months of the SPI programme, we saw teams improving process reliability, reaching better compliance with hand hygiene and reliable clinical observations and implementation of care bundles. In some cases we saw improvements in outcomes: fewer deteriorating patients, fewer infections in ICU etc. Furthermore, it galvanised system level action, putting a practical approach to improving patient safety on the policy agenda, and we saw health systems across the UK starting to adopt and implement similar approaches.

But as the independent evaluations show, this didn’t translate into the stated programme aim of transforming a whole organisation’s approach to safety, with the expected reductions in overall levels of harm and mortality.

The independent evaluations found little penetration beyond the teams directly involved in the programme and, while whole hospital measures of harm improved in the SPI hospitals, it didn’t improve any faster or greater than in the control hospitals.

We know that we still need to improve quality further and faster, so the real question we need to be asking – and answering – is how can an improvement system be perfectly designed to deliver improvement in quality and safety at scale?

Knowing what we know now about the challenge of improving services at scale there are a number of things that we, and others leading improvement, need to design into our improvement systems:

Improvement activity needs to be built on strong foundations
You need a clear understanding about what works in improving quality, why it works and when it works. This can draw on a wide range of scientific disciplines, such as applying knowledge from statistics, engineering, management or social science.

Greater engagement with people’s intrinsic motivation
Those closely involved in SPI were really enthusiastic – the challenge is embedding system improvement as a core feature of professionalism. We also need to understand how to create the necessary dialogue to engage individuals in improvement activities. 

Embrace a wider set of methods
The model for improvement has been the staple of improvement efforts for the last decade, but we need to embrace a wider set of methods to make more wide-reaching change.

With patient safety specifically, we need to embrace the wider set of methods used by safety critical industries, such as human factors approaches (for example looking at how team behaviours can create a safe or unsafe environment for care). Creating a culture of mindfulness will encourage everyone to take a proactive approach to identifying risk.

Greater understanding of how systems and processes outside direct clinical care contribute to safety and quality
We need to move beyond approaches that are applied solely within the clinical microsystem, such as redesigning procedures for observations or debriefs. We also require solutions to the problems that arise from factors outside the control of the microsystem, such as supply chain issues, information availability or staffing rotas.

As an improvement community we have a real challenge ahead of us. With limited models for sustainability and spread, what we need first and foremost is to better understand how to create the conditions to support a culture of continual improvement.

Jo is Director of Improvement Programmes at the Health Foundation.