Making QI business as usual for health care

With Glastonbury, Wimbledon and the World Cup over, half of 2014 is already behind us. And looking back over the last six months, there are three things which I think will play out to have significant implications for quality in the NHS over the coming years. 

The first is the shift we are finally starting to see from a focus in measuring and reducing specific harms to one of assessing and maintaining safety. The Health Foundation took a pivotal role in championing work to reduce avoidable harm, through its Safer Patients Initiative and support to the four UK governments' respective safety programmes. We are proud of the contribution we have made to helping people recognise where harm can be avoided and supporting the development of the necessary skills to do so. But we also know that this has just been the first stage in the journey.

Improving safety in health care can feel like an archaeological dig. You start by uncovering Roman remains, only to find that underneath them are more ancient remains previously obscured. In health care the prominent areas of avoidable harm – that for too long we accepted as a regrettable yet inevitable side effect of delivering care to ill and vulnerable people – have screened from view many other seemingly disparate and disconnected hazards and harm.

As we have found it possible to eliminate or radically reduce central line infections, MRSA, pressure ulcers and deterioration on in-patient wards, we have started to see other harm that was previously obscured. Harm that is not so easily attributed to a single cause and therefore cannot be addressed through our current approaches. Harm that arises because of a multitude of errors that can and do occur when working in a pressurised and shifting context.

Yet other industries have managed to make gains in these areas as well – through adopting a focus on safety rather than harm and through an emphasis on anticipating hazards and mitigating them before harm occurs.

The elegant conclusions of our report The measurement and monitoring of safety and the findings of our Safer Clinical Systems programme evaluation (to be published later this year) indicate the value that teams across the NHS can reap from shifting their focus from harm to safety. Jeremy Hunt has encouraged all NHS organisations in England to use the Vincent et al framework and we are now moving into a testing phase with three regional improvement bodies (covering six frontline NHS providers) to understand better how this framework can be applied routinely in practice. We will select sites by September and will share insights as they emerge.

The second important shift I have seen is the increasing recognition that people who use health services can no longer be viewed as passive recipients of care, but as active co-producers of their own health. Simon Stevens and Rob Webster's first speeches as the new chief executives of NHS England and the NHS Confederation respectively, and the recent reports from the All Party Parliamentary Group on Global Health and KPMG International, all make the case for health services to see patients as assets in generating health and wellbeing rather than the source of an uncontrollable demand.

The Health Foundation has made the largest combined investment in demonstration work to support people to take a more active role in their care – whether through being active in the decision making process, being supported to self manage their long-term condition or to actually administer their own care in an acute setting.

Like other industries, health care needs revolutionise the way it views the 'consumer' and put into practice tried and tested approaches to activating patients and delivering the health care that really matters to them. The body of knowledge and practical approaches that we have developed over the past seven years are available in our person-centred care resource centre. Later this summer, we will be publishing a report based on evidence from our improvement programmes and empirical literature, aiming to help those looking to implement self-management support and shared decision-making. Our next challenge will be to explore what the requirements will be for professionals and service design if we are to embrace the potential of activated patients.

Finally, over the past 10 years, the Foundation has invested heavily in building expert skills in quality improvement (QI) methods. Perhaps most notably through the year-long fellowship we have funded for 3-4 clinical leaders annually at the Institute for Healthcare Improvement in the US.

Along with other investments in QI capability at national regional and local level, I think we are starting to see a critical mass of expertise across regional bodies in England and at national level in Wales, Scotland and Northern Ireland. The Foundation is currently supporting these bodies to explore how, by sharing their approaches and expertise more formally, they can make the whole greater than the sum of the parts and build a sustainable improvement infrastructure for the NHS. An embryonic UK improvement alliance will be the first 'bottom up' improvement network and has the potential to accelerate the application of QI methods in health care.

As with all shifts in thinking and practice it is never easy to pinpoint the exact cause, but in each of these it is gratifying to see a contribution from our own investment in quality improvement. At the Health Foundation we’re in quality improvement for the long haul, but real success will be when QI is business as usual for everyone in health care.

Jo is Director of Strategy at the Health Foundation, www.twitter.com/JoBibbyTHF