QI Essentials: Thinking of holding a meeting for QI? Read this first…

Sometimes a 15-minutes huddle is more efficient than a 1-hour meeting… Have a read of Amar’s latest QI Essentials blog for tips on how to run effective Quality Improvement meetings.

For most of us, when we think about how to bring people together to work on something, our first thought is often to hold a meeting. So when we’re working on a quality improvement project, we might naturally default to organising our work by holding meetings. I’m hoping this blog might change the way we think about how to bring people together to work on quality improvement…

Over the 15 years that I’ve been working in the NHS, for a variety of organisations, I can’t even fathom how many hours of my life have been spent in meetings. And this just seems to keep increasing, the more senior one’s role. However, I’m fairly confident that the vast majority of meetings that I’ve sat in, or chaired, haven’t been as effective as they could be. I’m sometimes left wondering why I’ve actually been in the room, what value I’ve added, or what we’ve achieved in the time together. Leaving a meeting more energised than when I entered hasn’t usually been the norm.

With quality improvement, our task is to bring together a diverse group of people representing different aspects of the system we want to influence, in order to generate and test out new ideas aimed at achieving a shared purpose. Is the best way to do this through a series of meetings? Perhaps, but maybe not in the way we traditionally run meetings…

Quality improvement is an almost completely practical activity. The value comes from applying ideas in practice, with a little bit of planning and thinking around how we might learn and adapt. Once you’ve got going with a project, the only real reason for coming together as a team is to ask three simple questions:

• What is the data telling us?
• What did we learn from our last test of change (the study part of the PDSA cycle)?
• How should we plan our next test – what’s our theory and prediction, how might we design a test to see if this holds true, and what data would we need in order to evaluate this?

I’d suggest that a 15 minute huddle might easily be enough to work through these three questions together, as long as we’ve planned how we want to use the time. A meeting is a process, and so needs careful design. Turning up to a meeting with just an agenda and list of attendees is really only scratching the surface of how to run an effective meeting.

As with any process, we need to be clear about what objective we want to achieve, and how we’ll design the process to involve everyone in achieving this. So having a project lead or meeting facilitator is critical, in order to make sure we make most efficient use of the time we have. Whoever takes on this role will need to put in a little time before each catch-up to design how best to use the time. This might involve thinking about the room layout or seating arrangements, the equipment available, any exercises that will be needed, and other roles within the meeting (such as recording actions, or time-keeper) which will help the team be as effective as it can be.

If our tests of change are long, the pace at which we are able to learn and bring about change will be slow. So our ambition is to run tests at a quicker pace, enabling us to be more agile and nimble. It makes sense then to try to meet more frequently, but for less time. Coming together for 15 minutes a week, which helps us run a test that lasts no longer than a week, is much more effective than a one hour meeting once a month. My only caveat to this would be that in the early days of a project, when we’re trying to bring the project team together around a shared purpose, and then attempting to understand the system, we might need slightly longer sessions which allow deeper connection and more involved exercises. An hour spent as a group creating a really detailed cause-and-effect diagram or generating ideas and developing a driver diagram might be hugely valuable time well-spent.

We have an opportunity in the way that we go about quality improvement to model a better way of working that involves people more deeply, connects people to shared purpose and makes more efficient use of our most scarce resource: our time. We want to pull people towards quality improvement work, to feel energised by it, and so the way in which we go about the work needs to generate energy and excitement. A well-designed, short huddle that helps us build a rhythm around frequent tests of change is more likely to help us learn faster, solve our quality issue quicker and generate more energy within the team around the work.

Our focus and energy needs to be spent on changing the system, not administering the process – so I’d encourage us to think about how we can remove waste in the way we go about the work. Do we really need minutes for quality improvement meetings? Can we capture and distribute actions in the meeting itself, rather than leave this as a task after the meeting? Could we use a whiteboard or flipchart to capture actions as we go, take a photo and circulate, so we’re all set to work on our actions and test of change from the minute we go our separate ways? What could we do instead to create energy, involve people more deeply, tell stories to connect back to the shared purpose…?

You can read all past QI Essentials posts here.

QI Essentials: The daily practice of improvement

What does it take to make quality improvement a part of our every day habits and behaviours? Have a read of Amar’s latest QI Essentials blog…

In “Outliers – the story of success”, Malcolm Gladwell challenges the notion that success is based on innate skill, hard work or focused ambition. Or that we can ascribe the success of an individual purely down to factors related to that individual. Gladwell writes about the role of family, culture and friendship in an individual’s success, stating that “what we do as a community, as a society, for each other, matters as much as what we do for ourselves.” In studying the success of individuals across a range of disciplines, Gladwell suggests that 10,000 hours of practice are needed in order to develop world-class expertise in a particular skill, since dubbed the” 10,000-hour rule”.

Quality improvement is definitely a skill that needs to be practised in order to refine and improve one’s technique, much like my piano playing. QI isn’t simply knowledge, or a method. We know from many evaluations and studies that most people and organisations, despite knowing the theory of quality improvement, struggle to actually apply it on a consistent and regular basis in daily work. And what does it really mean, to make quality improvement part of everyday work? I hear frequently the phrase “making quality improvement business as usual”, but what does this actually mean?

For many organisations, quality improvement consists of structured projects aimed to specific improvement opportunities with multidisciplinary teams coming together to work on a goal of shared interest, using improvement tools and a systematic method. But does a programme of multiple projects equate to making quality improvement part of daily work? Organisations that have truly embraced a continuous improvement philosophy and demonstrated fidelity to this for a decade or more have found that it involves more than just projects. Of course, that’s not to say that projects aren’t important. QI projects are an absolutely vital mechanism for delivering tangible improvement on specific complex issues, bringing together a group of stakeholders to discover solutions and test them out over a period of several months. The accumulation of projects across the breadth of an organisation and over time helps transform organisational performance to new levels.

However, the downside of viewing the adoption of continuous improvement in an organisation as simply a programme with multiple projects is the risk that quality improvement becomes limited to only being practised within projects and by the small groups of people coming together around projects. The true opportunity of quality improvement lies in both tackling strategic improvement opportunities through robust project structure AND using our quality improvement skills on a daily basis to help us identify challenges and improve processes every single day, by every single person.

So, what does it take to be able to move beyond training people in QI skills and deploying these to QI projects, to using quality improvement in our every day work, no matter what our role? And will simply practising be enough to become world-class in quality improvement? Certainly, we’ve seen in our work at East London NHS Foundation Trust that it’s important to be able to try out the skills of improvement, see the effects, learn about the method through actually trying it out on real-life improvement opportunities – and that this helps build not only confidence in the approach, but also the skill in being able to use it effectively. Some of the recent evaluations of the use of Plan-Do-Study-Act cycles by Julie Reed and colleagues at North West London CLAHRC are highlighting the importance of properly learning and applying the method, practising in the real-world with skilled support to guide. So, could we consider that deliberate practise will help us become great improvers and how many of us could realistically hope to achieve this, given that it would need 20 hours of practise a week for 10 years in order to achieve Gladwell’s 10,000-hour rule?

Well, firstly, there’s increasing evidence that deliberate practise by itself may not be as important as we originally thought in improving performance within a particular domain. A meta-analysis from Princeton University in 2014 looking at practise and performance across domains such as music, sports and games have found that practice explained 26% of the variance in performance for games, 21% for music and 18% for sports, but only explained 4% of the variance in performance in education and less than 1% for professions. The theory is that deliberate practice is only a predictor of success in fields that have very stable structures. For example, in chess, tennis and classical music, the rules never change – so studying more and practicing more has a much greater effect on performance. I’d argue that the world of healthcare is much less stable – our systems our complex and ever-evolving, the use of improvement needs to be highly adaptable and dynamic. So although deliberate practise is likely to be important in becoming proficient in using quality improvement skills, it’s not going to be enough for us to become truly world-class improvers.

So, if practise isn’t enough, what else does it take? Perhaps the place where I’ve found most learning about this is from Mike Rother’s six years of research in Toyota and their management thinking and practice, that have enabled it to embed continuous improvement and adaptation into and across the organization in a way that few other organisations have been able.

Perhaps it isn’t surprising to some, but the key is… behaviour. Specific behaviours, habits and patterns of thinking and conducting oneself, that are practiced over and over, every day at Toyota. In Japan, these routine habits and behaviours are called kata. It’s a way of practising scientific thinking – moving towards a mindset of seeing our environment and work as a system, identifying opportunities, developing theories, and seeing the value of testing, learning and adapting. Avoiding jumping to conclusions, but practicing a systematic approach to understanding the world around us, comparing what we think (our theory) with what we see (evidence) and adjusting based on the difference between these two.

Kata is applicable to all, including leaders – perhaps particularly for leaders, where it is easy to feel the need and pressure to find solutions to challenges, and to believe that we have the best solutions by virtue of our expertise, experience or skill. At Toyota there are two types of kata that are key: the improvement kata, and the coaching kata. The improvement kata describes a systematic approach to being curious about the status quo, seeing the work around us as a system, bringing people together and opening our minds to different theories that would improve the system, testing these and adapting based on what we see. The coaching kata is key to the role of managers and leaders, in teaching the improvement kata and bringing it into the organization. The primary role of Toyota’s managers and leaders is about increasing the improvement capability of people, developing people who in turn improve processes and systems through the improvement kata. This involves a set of practices which have their roots in the Buddhist master/apprentice teaching method – guiding, teaching, encouraging, showing, developing, enabling the person to discover things for themselves through using the improvement kata.

In our learning at ELFT about embedding quality improvement into daily work, it’s clear that QI projects and training are absolutely key – to help us learn and practise the skills, build belief, create step-changes in performance on complex quality and safety issues. But we’ve also learnt that the real value comes in applying what we’ve learnt into our daily habits and rituals as ‘improvement kata’ –  bringing our scientific thinking into the way we understand our work and challenges on a daily basis, using our simple QI tools where and when they make sense, involving people in a more meaningful way in developing theories, using the discipline of test-learn-adapt to continually improve ourselves and the world around us. And the role of leaders and managers is key to this – in inviting ideas from a diverse range of people, in stopping us from jumping to conclusions, in encouraging the testing of creative ideas, in helping us find time to think together…

You can read all past QI Essentials posts here.

QI Essentials: What does a Chief Quality Officer do?

What is the role of a CQO?  There are still very few chief quality officers in the UK, although it’s a common role in the US. In this blog, Dr Amar Shah reflects on the role and responsibilities of a Chief Quality Officer…

I figured it was probably about time to tackle this topic, given that we’re six blogs into the series! So, what is a Chief Quality Officer (CQO), and what does one do?

It’s probably useful to start by mentioning that CQOs are very common in the US and some other parts of the world, but still pretty rare in the UK. I think I am perhaps the only CQO of a provider Trust in England (although I’ve just seen that University Hospitals Coventry & Warwickshire may be appointing their first CQO, which would be exciting!) We have the excellent Simon Watson at NHS Lothian in Scotland, but there may otherwise be no CQOs yet in any provider Trust in the UK.

But back in 2013, the Keogh review, which looked into the fourteen English hospitals with higher than expected mortality rates, recommended that healthcare organisations have people with the breadth of skills and expertise to know what data to look at, how to scrutinise it, and use it to drive tangible improvements. The review referenced the prevalence of Chief Quality Officers in the US, but stated that this may not necessarily require a new Board role. Professor Nick Black endorsed the need for a new Board role, writing that “we need Chief Quality Officers with vision to lead, inspire staff and facilitate rigorous assessment and improvement of quality throughout their trust.”

The basic argument is that as the core purpose of a healthcare provider is about quality of care, it ought to have Board-level expertise in quality, just as it does for finance in a Chief Finance Officer. That there even is such a thing as ‘expertise in quality’ remains questionable for many, who argue that simply being a clinical leader such as a doctor or nurse on the Board, remains sufficient expertise and knowledge on the topic of quality of care. Increasingly though, there is recognition of a body of scientific knowledge on continuous improvement, quality management, complex systems, human behaviour and change, that can be a major asset for organisations that are aspiring to provide the highest possible quality and moving from ‘good to great’.

Another common question that I’ve been frequently asked is ‘who is responsible for quality?’ when you have a nurse leader, medical leader and quality leader on the Board. My view is that this is a healthy tension, as when quality becomes one person’s responsibility, we’re heading in the wrong direction! Quality is so core to our mission as an organisation that it absolutely has to be a shared, collective responsibility, for us to have any chance of meeting the needs of those we serve. At ELFT, I work closely with the Chief Nurse and Chief Medical Officer on all aspects of quality, and our understanding of the best way to manage this will continue to evolve.

OK, enough about the need for CQOs. What does one actually do? Partly, I’m in the enviable position of being able to make it up as I go, as there’s such little precedent in the NHS. But I also feel the weight of having to demonstrate the value of the role, in order to encourage other leaders that they would genuinely benefit and see a return from an investment in Board-level expertise on quality.

The role of a Chief Quality Officer is about influencing the culture of an organisation to engage and activate people, leading breakthrough improvement work, building an infrastructure to support improvement at scale, and developing a holistic quality management system that incorporates rigorous planning, meaningful assurance and reliable quality control. What kind of activities do these translate to? Well, let’s take the example of planning. Usual NHS planning is fairly dull, mostly to satisfy external agencies and usually centred around paper plans. I’ve tried to influence a new approach to planning at ELFT, with one example being our new Trust strategy which we launched in 2018. The strategy itself is a simple one-pager, visualised using an improvement tool called a driver diagram.

The process of creating the strategy involved over 30 workshops and 1000 people (both staff, service users and stakeholders) over a period of four months, with the qualitative data collated and analysed systematically to build the strategy from the ground up. This took longer than the old approach might have, but it allowed people to be part of the conversation, come to terms with it over the course of a few months and feel that they really own our new promise to our population. It will give us a much better chance of delivering, I think.

Let’s take another example related to influencing culture. For six years now, I’ve met with all new starters at ELFT through a one-hour session at induction, as a very simple but effective way to influence the culture of the organisation. I had a huge amount of fun leading our Breaking the Rules campaign in 2017, which enabled all staff and service users to voice rules that they perceived were getting in the way of us doing the right thing. As a campaign, it reinforced the principles that we’re trying to encourage through our improvement philosophy of flipping the power, giving all a voice, and stopping doing things that add little value.

The CQO role has a breadth that means I have to influence across all executive portfolios, all parts of the organisation and at all levels. It also includes being the executive director for the corporate quality function, which supports the organisation through expertise in quality improvement and quality assurance.

The executive and Board role means having to tread the fine line of being an internal guide to the team, whilst being in the team. It can be a difficult place to be, as I know I’d be less effective if I didn’t retain enough objectivity to be able to guide and act as a critical friend, but also need to be an effective team player within the executive and take on collective responsibility and lead on my share of areas.

The executive team often has to grapple with meeting internally- and externally-driven aspirations or requirements, and balance the need for assurance, control and improvement. This is an entirely healthy tension for a well-functioning executive team, and surfaces precisely the kind of conversations that a maturing improvement-focused organisation ought to be engaging in. The Chief Quality Officer role helps provide guidance on these questions, internal challenge and also offers solutions.

An average week for me usually includes a mix of Executive team or Board meetings; time with our quality teams, leading on design and delivery of our Trustwide workstreams for strategic improvement priorities or quality assurance activities; leadership on Trustwide programmes of work such as staff engagement or analytics; a smattering of corporate meetings (that I do my best to only attend if I’m adding value); and visits to clinical or corporate teams as executive walkrounds or to celebrate their improvement work.

Every week always also includes clinical work, as a Chief Quality Officer is one of perhaps only a couple of people in the executive team with ongoing regular clinical responsibilities. I find this aspect of the job rewarding, as it allows me to switch attention rapidly from the individual to the whole system. Being able to continually flip between perspectives and learn from both helps me be a better leader I think.

So, that’s my best guess at what I do, or should be doing, now that I’m a year into the role. I’d love to hear your thoughts on whether you see an ongoing need for chief quality officers in healthcare. And wouldn’t it be nice if this blog inspired a chair or chief exec to consider what a CQO might bring to their organisation??

You can read all past QI Essentials posts here.

QI Essentials: Learning systems for improvement

Achieving change in behaviour and culture in complex organisations requires intentional design. In this blog, Dr Amar Shah shares some learning on key components of the design of learning systems for improvement.

The pursuit of continuous improvement helps us create a learning organisation, described by Peter Senge as “where people continually expand their capacity to create the result they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning how to learn together”.

Achieving this change in behaviour and culture in complex organisations requires intentional design. Those of us leading continuous improvement will likely have toyed with a number of different ways of supporting large numbers of teams, working in different contexts, to apply quality improvement and align this towards a common goal. In this blog, I share my learning about the seven components that I’ve found are key to the design of learning systems for improvement, shown in the image below.

Bear in mind that as we look to create a learning organisation, we will be trying to build systems of learning at multiple levels – at the level of the macrosystem (whole organisation), at the level of mesosystems (divisions or directorates), at the level of microsystems (individual teams) and even at the level of the individual. Yes, even we as individuals ought to shift towards a learning mindset, and the seven components above are just as applicable at the individual or team level, as they are at the whole-system level.

1. Shared purpose

Probably the most important of all. Having a clear purpose or goal, aligned to what really matters. Creating a deep visceral connection to emotion, rather than a set of words on the wall, is what we mean here. As a team, would everyone be able to talk passionately, and consistently, about what the purpose of the team is? As an organisation, is it clear what the mission is, and can people describe this in their own words and feel a connection to it?

2. Shared language

For us to learn and play together, we need a common way to communicate. The language of improvement can be a wonderful bridge across different professions and power hierarchies. The use of improvement tools can allow all to have an equal voice and power in determining how we improve. Improvement can bring teams together from different contexts but facing similar challenges, learning together through the common language of improvement, and building networks across the organisation that otherwise might not exist.

3. Autonomy

The application of quality improvement, in itself, shifts power outside of formal hierarchy to enable people to develop their own theories about what may make a difference, and the ability to try new ideas without fear of failure. In large-scale improvement, there’s a delicate balance between bringing teams together that are all working towards a common purpose with a shared theory of change (such as flow, or joy in work), whilst still devolving power and autonomy to each team to understand what matters most in their context, and make the changes that they believe will make a difference.

4. Collective leadership

Collective leadership is described by Professor Michael West as “the purposeful, visible distribution of leadership responsibility onto the shoulders of every person in the organisation”. The design of large-scale improvement can support this by involving a diverse range of people in the work, including patients, service users and family members. We can also intentionally redistribute power within improvement work by allocating leadership roles to those who hold no formal hierarchical role. One of the beautiful aspects of supporting quality improvement work is that it witnesses the emergence of new leaders from unexpected places, given the opportunity and permission to improve the system for those we serve.

5. Connections and relationships

Bringing people together and creating safe spaces to share with each other helps build relationships within teams and across teams. This is critical to allow the surfacing of difficult issues, the ability to explore and make sense through emotional connection, and to ensure people feel free to fail and learn in the pursuit of a common goal. Any learning system needs to develop ways for people to truly connect with each other as humans, not just as professionals. Story-telling can be a wonderful way in to this deeper connection.

6. Data and measures to understand variation

Learning systems need to support teams to understand the variation that exists within their own microsystem, and also learn from the variation across teams. Key to this is the use of data over time, shared transparently, in order to support learning and adaptation. As with all quality improvement work, no single measure can help understand how a complex system behaves, so we need a range of measures (outcome, process and balancing). For large collaborative learning systems with multiple teams working towards a common purpose, there needs to be a way to learn across teams and from the variation, so standardising the outcome measure is really important.

7. Infrastructure to support the learning system

Learning systems for quality improvement are usually built to tackle complex challenges that haven’t been solved before. Inevitably, this is going to be difficult work. Teams need close support through this journey, which will include access to improvement expertise and knowledge, leadership support to make changes that challenge the status quo and access to content knowledge about ideas and evidence that has been shown to be effective in solving the challenge. Any learning system design needs to give consideration to how teams will access this support as easily as possible, in order to accelerate the improvement work.

You can read all past QI Essentials posts here.

What it takes…

What does it take within a team to run a quality improvement project through to completion? Is it about brilliant ideas or the energy of a charismatic leader? Perhaps it’s about everyone having skills in quality improvement, or finding time to do the work?

With so many organisations now recognising the potential opportunity of applying quality improvement to solve complex issues, and increasing support for this approach from regulators and national bodies, it’s going to be pretty important to understand the key components that enable teams to own and integrate QI into their day-to-day work, particularly given the level of strain that the healthcare system is under. Everyone I talk to is already working hard, giving their best, trying to do all they can to improve the lives of those we serve. So how then to fit in quality improvement, without it becoming an additional burden?

Earlier this week, I was fortunate to hear the story told by a team of their successful quality improvement project, which was then discussed by a group of improvers from four different healthcare providers. Here’s what we heard and learnt…

First and foremost, we felt the passion from everyone involved to solve the issue. The team chose the topic for their improvement work themselves, through a conversation with staff and service users. What emerged was a general dissatisfaction that service users on the secure forensic mental health ward weren’t able to fully utilise the leave off the ward that they had been granted, for a variety of reasons. The service users were frustrated that leave often had to be cancelled or couldn’t be facilitated by staff, which often led to conflict on the ward. Staff felt as if they were letting down their service users when leave couldn’t be facilitated due to staff availability, and that the service users’ recovery was often being impaired by not utilising opportunities to connect back with the community.

This initial open dialogue between staff and service users helped create a consensus and unity across the whole ward community around a complex challenge, with multiple factors contributing to the problem, that they all had an incentive to help solve. It was a topic that mattered to all stakeholders, and surfaced from within, rather than from higher up in the organisation. It seems startlingly clear to me that successful quality improvement work often starts from a single question: “What matters most?” to those who will be directly impacted by the work.

Second, we heard a tale of genuine persistence. The team, made up of a diverse group of staff and service users, met every fortnight for a year. Every fortnight for an entire year… That takes commitment and dedication, whilst working on a busy and dynamic ward. Staff changes, increased acuity on the ward, incidents – none of these impacted on the regular rhythm of the fortnightly meetings. They became part of the routine habits within the team. But the work also needed structure.

As the team described their work, the clarity of roles shone through. The project had a clear leader, who incidentally wasn’t the formal leader of the ward team. But those with formal leadership roles within the team, the ward manager and Consultant, were fully involved in the work – attending the fortnightly meetings, ensuring the team found time for the work and supporting the integration of the work within existing spaces on the ward, such as the ward round and community meeting. This seems important to me. Both that those with formal power on the ward were actively involved, but also that the work was led by someone without a formal leadership responsibility, so she had a little more space and time to focus on the project.

Third, we heard how the team included service users at every stage of the project – from the very first conversation about what they should improve, through to understanding the problem, to considering how they might solve it. Here’s an example that left us all in awe. The team used a common quality improvement tool called a Fishbone diagram, or cause-and-effect diagram, first developed by Dr Kaoru Ishikawa, a Japanese quality expert. The tool helps identify the root causes contributing to a problem. Many of us have probably used this tool before, but we were surprised by the way in which the team created theirs.

They used one of their weekly community meetings on the ward with around 10-12 service users to understand the factors that caused leave to be unmet. The cause and effect diagram below was created by this group of service users. Pretty phenomenal – while many of us improvers use this tool routinely, I’m not sure I’ve ever seen one created by a group of patients or service users before.

At East London NHS Foundation Trust, we have recently evaluated all our completed QI projects (several hundred at this point) and compared those that have involved full partnership with service users (which we call the Big I of involvement) against others. We found that those with Big I involvement were 2.8 times more likely to have successfully completed than those that had no involvement of service users, or just occasional involvement. Even more evidence to suggest that involving service users doesn’t just help us develop better ideas, or support their recovery, or accelerate the work – it also gives the project a much better chance of actually achieving its aim.

The team spoke proudly about the ideas they had tested, which had helped them improve from an average of 3.5 unmet leaves each week a year ago, to 0.4 unmet leaves each week at present. I came away energised and inspired by their story, and with three lessons that I think we can all incorporate into the way we use quality improvement in our teams: ensure we focus on what matters most to the staff and service users involved, be persistent and develop a regular rhythm for the work, and involve our patients and service users from the very beginning through to the very end as full partners in the improvement effort.

You can read all past QI Essentials posts here.

Activating agency

Over the last few weeks I have been reminded that, at its heart, quality improvement work is really all about connections, relationships and purpose. We may need the technical skills of quality improvement and the systematic method to navigate and learn our way through some really complex problems. But the true opportunity in quality improvement lies in bringing people together and unleashing their potential around a common purpose.

The word ‘agency’ isn’t yet in common healthcare parlance, even if we see the word ‘improvement’ frequently overused for all manner of activities. And yet, agency is really what we seek most of all. Agency refers to the ability of an individual or group to choose to act with purpose.

As our health and care systems in England and across the globe face the significant challenge of having to provide high quality care year on year whilst seeing demand increase and resource remain the same, or often reduce, it can be easy to feel powerless in this struggle, or to tighten control from the centre of organisations. There are no easy solutions, and it can feel like a huge weight to bear for leaders. However, our opportunity comes from recognising the true value of our greatest asset – our people, including staff, service users, carers and citizens – in helping us find the path to better healthcare and health of the population.

A team of people with agency can achieve quite remarkable things – whether this be the #Hellomynameis campaign for more compassionate care, the global What Matters to You movement in healthcare, or even the non-violence civil disobedience led by Mahatma Gandhi in India ninety years ago. Agency can help bring positive change of previously unimaginable scale at an incredible pace, but it needs both power and courage.

For organisations that are truly on a continuous improvement journey, the use of quality improvement is fundamentally about devolving power – inviting those closest to the point of care to help us find solutions to our most complex challenges, providing them with the skills and support to change the system for the better. The unrelenting drumbeat of quality improvement, the story-telling by teams that are seeing results and the constancy of purpose that is needed from leadership may sometimes feel almost cult-like, but is so important for creating the conditions to give people courage to try something different in what can often be difficult circumstances.

Based on our last five years of work at East London NHS Foundation Trust (ELFT), I am increasingly convinced that all quality improvement needs to be designed around one simple question: “What matters to you?” If we genuinely start each improvement effort with this simple question, asked with both service users and staff together, and use this to ignite a dialogue about what truly matters, we can start to connect people and create a community with common purpose. We begin then to move away from ‘us’ and ‘them’, to simply ‘us’. Quality improvement offers a way to help us break out of our silos and start to come together, united by a shared goal and bringing the best that each of us have to offer to help us get there.

Some of my most memorable moments over the last five years have been through observing individuals, who might ordinarily have felt powerless in the system, start to feel a sense of power within themselves. Administrative staff identifying and testing change ideas to reduce waiting times and distress for young people who need access to mental health expertise; domestic staff bringing their knowledge of the ward environment to help discover ways to reduce incidents of aggression and violence; service users voicing ideas and influencing the team about what would aid their recovery and journey through the service. The flattening of the traditional hierarchy that quality improvement can bring, and the effect on an individual’s sense of agency can be startling.

There is also a collective agency that is palpable. An energy and sense of optimism as people encounter positive experiences of other people exercising power and courage. Quality improvement nurtures this through bringing people together in learning systems to share their experiences and ideas, through our focus on story-telling, which can inspire so many others to gain the courage to act, and through our intentional and frequent celebration of the amazing things we see taking place every day.

And there is agency at the level of the system. We are certainly feeling the effects of this at ELFT, where people increasingly sense that the structures and culture within which they operate are giving them permission, licence and freedom to exercise their power and courage. This needs authentic and positive reinforcement by leaders over a long period of time, to build a sense of psychological safety. It also needs tangible changes and signals to demonstrate that things can actually change in response to need, and that the power resides in all of us to bring change. Campaigns like “Breaking the Rules” can really help give people an outlet to voice their ideas, and demonstrate that leadership are intent on creating agency at the system-level.

So, if you’ve seen quality improvement so far as simply projects that help improve quality of care, I urge you to look beyond this. See the true potential of quality improvement in helping us connect more deeply to what really matters (to us and those around us), to strengthen our relationships within our teams and with those we serve, to bring people together around common purpose and discover ways to change the system for the better. And most of all, to activate agency… in individuals, in groups and in the whole system.

You can read all past QI Essentials posts here.

Top tips for starting a quality improvement project

Thinking of starting a quality improvement project? Identified something that needs improving? Here’s my three top tips on setting up your project for success…

1. Start with the end in mind.

Often, the spark for improvement comes from an idea, a realisation that things would be better if we tried this new way of doing things. This is completely natural. And yet it’s the wrong place to start for quality improvement work. QI isn’t about implementing an idea, it’s about solving a complex issue where we’ll need multiple ideas and theories about what a better system might look like. So, although our minds are curious and imaginative, and often trained to consider alternative solutions, we need to work backwards when we start a quality improvement project. What is that idea aimed at achieving? What’s the outcome that this might improve? Make this the aim of the quality improvement project, not the initial idea that might have sparked the curiosity. You’ll open up the possibilities, invite more creative thinking, engage a wider group and have a better chance of improving outcomes.

2. Focus on what really matters.

Our healthcare systems are straining to meet today’s demands, and workload for our staff is going up. To give your quality improvement project the best chance of success, forget the ‘nice to have’, and focus on the critical. Wrap your quality improvement project around what truly matters. But to whom? To senior managers? To the team? To your patients, service users and families? I’d suggest starting any quality improvement project with a conversation involving all of the above. All will be absolutely key to the work, and all should be involved from the very beginning in choosing what to focus your quality improvement effort on. It’ll help ensure your project is tackling what people care most about, and it’ll build engagement and will for the work ahead. And my guess is that you won’t find too much disparity between what your patients really care about, what the team really cares about, and what senior managers really care about.

3. Improvement is a team sport

All care is delivered in teams, and so all improvement should be done as teams. There’s something powerful about a whole multidisciplinary team coming together with their patients and service users to identify their biggest improvement opportunity, and working on this together. It helps strengthen team working, it brings people together around a shared purpose, it helps connect the staff to what really matters to those they serve, and it starts to break down some of the power imbalances – both within staff, but also between staff and service users and patients.

Successful teams come together often for short huddles, find time to reflect together, and develop habits around their work. Similarly, think about how you can bring together a small project team, with representatives from all parts of the service and service users, to meet regularly about the project. Find ways to build this into the existing spaces and rhythm within the team, rather than creating a new meeting or additional ask. Role model quality improvement in the way that the team works – keep the meetings short and efficient; try standing meetings; avoid excessive note-taking. The only real purpose of coming together as a team to discuss a quality improvement project is to reflect on how the last test of change went, and plan the next test of change. So, could you start finding new and creative ways of achieving this that don’t involve meetings?

QI Essentials blog with Dr Amar Shah comes out every month. Here you can read all previous posts.

Improving Quality ≠ Quality Improvement

In this new blog series, Dr Amar Shah – Consultant forensic psychiatrist & Chief Quality Officer at ELFT – will explore all things QI, sharing tips and tricks, demystifying QI and sharing stories to inspire everyone to improve the system in which they work. Enjoy!

Over the last few years we have seen a proliferation in the interest and use of quality improvement in health and healthcare. This represents a really promising shift in our mental models about how to solve some of our most complex quality issues. Alongside the increasing use of the word ‘improvement’ in our everyday language within healthcare, I’ve observed some difference in understanding of what exactly we mean by the term “quality improvement”.

So, what is quality improvement? And is it any different from what we’ve always done? Surely we’ve always been trying to improve quality?

In helping people try to work through these questions, I often start with the provocation that improving quality is not the same as quality improvement. This often evokes some puzzled expressions. A simple reversal in words, but two very different concepts.

For any product or service, there are many ways we can improve quality. In healthcare, we’ve used many different mechanisms and methods to improve quality for decades. One approach is planning or redesign, which involves deeply understanding the needs of the population/customer/service user, looking at the evidence and best practice across the industry in order to ascertain what structures and processes we need to put in place. This is something we might do once a year. Another way to improve quality is through assurance: occasionally checking that we are meeting a particular standard or threshold. A third way to improve quality is through quality control, which incorporates really good operational management, monitoring performance in real-time within the team, taking action when needed to bring the system back into control, and escalating rapidly when we can’t solve a problem. The fourth way to improve quality is through quality improvement: a systematic method to solve complex problems through testing and learning, involving those closest to the issue deeply in discovering new solutions.

So, quality improvement is a particular, and very specific, approach to complex problem solving that relies on testing and learning (and failing many times). Quality improvement empowers those closest to the improvement opportunity to discover a better way, and should deeply involve both staff, patients, service users and carers in understanding the issue, identifying new ideas and testing these out to see which work within the given context. As we are looking to learn whether a particular service or issue has improved, we also look at data quite differently, in order to see whether something has changed over time.

This leaves us with an exciting opportunity. The emergence of quality improvement can build on all our efforts to date, rather than replace them. The real questions are whether we are able to identify the right kind of challenges and opportunities for which quality improvement is perfectly suited, and whether we can create the appropriate conditions in which quality improvement can thrive…