Common challenges to improving quality

Today we’re launching a new report that gives a cogent and engaging analysis of what we’ve learnt from funding improvement leaders and projects over the last 10 years. Overcoming challenges to improving quality synthesises the wealth of learning from our evaluations into 10 recurring themes, making links with the wider literature.   

There is much that I found resonated with my experience of leading improvement initiatives. While there is plenty written about barriers and facilitators to improvement, I wish I had been able to refer back to this analysis in my previous roles – my colleagues and I intend to make sure we learn from this for the Health Foundation’s future work. 

As well as being struck by the usefulness of seeing all these factors explored in one place, I also saw a reinforcing cycle – all too familiar from my personal experience of doing improvement work – that links the different factors together.

In my experience, improvement leaders often begin new areas of work with a compelling personal vision of the potential for quality to be much improved. I think there’s a cultural bias in health management of action over reflection, and often a strong temptation to give insufficient time to the initial challenges which our report identifies: convincing people there is a real problem and that the solution you have chosen is the right one, based on sufficiently robust evidence. 

Having set off, we can then start to encounter resistance. Faced with this, leaders of improvement projects may be tempted to argue more strongly using whatever evidence is available. However, our analysis suggests that allowing the space for evidence to be debated may be a more productive route to genuine engagement.

Existing measurement systems often don’t help, until or unless you put the time in to get the definition, systems and the skills in place (which often takes much longer than anyone anticipates). While it’s important to get to the position where you have data and can start demonstrating results, I know I’ve inadvertently pushed staff and systems too hard, or increased workload with parallel systems. As our report notes, this can alienate those who signed up for improving quality, not what they may see as further bureaucracy for which they lack the time and experience. 

Improvement leaders are also often faced with numerous practical and cultural challenges that threaten to drain the momentum of the improvement work – we think 'if only we can push on to start getting some results, then progress will start getting easier'. While this may speak well to some stakeholders, including senior sponsors, it risks alienating many of those people we ultimately depend on for lasting success.

The pattern of feverish activity and energy that characterises many of the people doing improvement work I’ve had the privilege of knowing can, however, tip over into being a hindrance. Sometimes I wonder if this drive to action is fuelled not only by admirable passion for patient care, but perhaps also the sneaking suspicion that improvement work is not valued or is seen as ‘easy work’, distracting busy staff from the day job. 

Given the challenges of leading improvement I’ve described here, we need to be more confident in asserting the critical role leaders play in enabling change processes, the multi-faceted complexity of which comes across strongly in this report. A key message for those leading organisations is to make sure that people running improvement initiatives are valued and get the support they need.

Without this support from the top of organisations, including boards, we will continue to see the negative reinforcing cycle where lack of regard and sufficient practical support for improvement activities fuels scepticism which, in turn, undermines the engagement needed for success and sustained results. 

Given the major and urgent challenges of our financial situation, driving teams to deliver ambitious, fixed-term task and finish projects is especially appealing. But addressing some of the underlying contextual factors that limit the success and wider uptake of improvement projects is still critical. Organisation and system development work should be seen as a priority for action, just as much as individual service improvement objectives. 

I really hope that you’ll find this report useful – it gives practical advice from the experiences of others on what to try next in your improvement work. Ultimately, I would encourage you to take the time to reflect on the patterns that connect/underpin the challenges described, rather than just diving in to action when you (hopefully) spot a new idea for tackling a problem.

Penny is an Assistant Director of Improvement Programmes at the Health Foundation.