What do 'outstanding' trusts tell us about how to improve care?

The NHS Long Term Plan set out a series of positive ambitions for improving patient care. There is little doubt that turning these ambitions into reality will be difficult, funding increase or not. As the Plan itself highlighted, delivery ‘will rely on local health systems having the capability to implement change effectively’.

Having a sustained, organisational approach to improvement can help. The principles and steps we set out in our report The Improvement Journey are drawn from our knowledge of what has worked at trusts across the country and beyond.

Nearly all of those trusts in England that have been given an ‘outstanding’ CQC rating have implemented a programme of organisational capability-building to support their improvement. For some, such as East London NHS Foundation Trust, quality improvement has been at the centre of their work for years. Others, like Newcastle Hospitals NHS Foundation Trust, say that a focus on continuous quality improvement is likely to be key to them retaining their outstanding rating.

And this belief in the importance of improvement capability is shared by the Care Quality Commission, who say they have ‘confidence’ in the ‘long-term sustainability of the quality of care’ at those NHS trusts with an established quality improvement culture across the organisation.

So what does an organisation-wide quality improvement approach look like?

An organisational approach to improvement amounts to much more than individual improvement initiatives or simply training staff in how to use quality improvement approaches and tools. It requires an integrated approach throughout an organisation – not just from board to ward, but across corporate as well as clinical services – along with a series of interdependent elements that support and enable initiatives to thrive.

Building the improvement skills and capability of staff is central to such an approach, but it must go hand-in-hand with the infrastructure to support and coordinate the improvement work they do. Individual initiatives are important, but there must be a mechanism to align them with a trust’s overarching strategy. And a commitment to improvement within teams won’t go far without the data systems to help them understand the impact of their intervention and refine it over time.

The improvement journey

The Improvement Journey draws together the key ingredients for successfully embedding an overarching quality improvement approach. We identify four key elements that underpin successful approaches:

1. Visible and focused leadership that ensures all improvement activities are aligned with an overarching improvement vision.
2. The infrastructure and resources needed to plan and deliver sustained improvement, such as data, equipment and permissions.
3. A programme to build the skills needed to lead and facilitate improvement work, such as expertise in QI approaches and tools.
4. A supportive, collaborative and inclusive culture and environment in which teams have time and space for reflective thinking and feel comfortable raising concerns and trying out new ideas and approaches.

Hard but worth it

It’s no surprise that only a handful of trusts have been able to build and sustain such an approach – an undertaking on this scale isn’t easy. It can take several years to build up enough support and get the right finances, people and systems in place to make it a reality. It also helps enormously if the trust has a stable board and workforce in place – a rare luxury in today’s climate – and they must stay focused and supportive in the face of external pressures.

And it isn’t only in the UK that we find this hard. In the US – while there are some much vaunted success stories (such as the Virginia Mason Production System and ThedaCare Accountable Care) – one recent study found that only 12% of hospitals surveyed had reached ‘a mature system hospital-wide stage of implementation’ of their improvement approach.

However, the benefits of making this improvement journey can be significant even beyond improving the quality and experience of patient care.

The act of empowering front-line staff to plan and deliver improvement means having more engaged and fulfilled staff, making it easier to both retain and attract staff. We are also increasingly seeing trusts with established improvement pedigree become central players in their local health and care systems – collaborating with neighbouring providers to drive improvement across their communities.

From the few to the many

The challenge now is to ensure that more trusts are ready to develop an organisational approach to improvement.

While local providers and health and care systems are ultimately responsible for building their own capabilities, they can face significant barriers in terms of resources and expertise. Policymakers and system leaders therefore have a responsibility to help them get started.

So it was positive to see the Long Term Plan recognise the importance of capability building, and commit to working with the Health Foundation to help build improvement capability at a local level.

The improvement journey can be a long one, fraught with challenges, but achieving a step-change in the quality of care across the NHS is ultimately going to require a step-change in providers’ ability to deliver it.

Bryan Jones is an Improvement Fellow at the Health Foundation.

This blog previously featured in the HSJ.