OvercomingChallengesToImprovingQuality Fullversion

Evidence:
Overcoming
challenges
to improving
quality
Lessons from the Health Foundation’s improvement
programme evaluations and relevant literature
April 2012
Identify Innovate Demonstrate Encourage

This research was commissioned and funded by the Health Foundation to help identify where and how
improvements in healthcare quality can be made. The views expressed in this report do not necessarily represent
the views of the Health Foundation.
This research was managed by:
Emma Henrion, Senior Evaluation Manager and

Jonathan Riddell Bamber, Research and Development Manager
The Health Foundation
jonathan.bamber@health.org.uk
020 7257 8000
An article based on this research, ‘Ten challenges in improving quality in healthcare: lessons from the Health
Foundation’s programme evaluations and relevant literature’ by Mary Dixon-Woods, Sarah McNicol and Graham
Martin, is published in BMJ Quality & Safety, http://qualitysafety.bmj.com (doi:10.1136/bmjqs-2011-000760)
Authors Organisation Contact

Mary Dixon-Woods, Social Science Applied to University of Leicester,
Sarah McNicol, Healthcare Improvement Research Adrian Building, University Road,
Graham Martin (SAPPHIRE) Group, Department Leicester LE1 7RH.
of Health Sciences, University of
md11@le.ac.uk;
Leicester
0116 229 7262
© 2012 Health Foundation

Evidence: Overcoming challenges to
improving quality is published by the
Health Foundation, 90 Long Acre, London
WC2E 9RA
ISBN 978–1–906461–38–6
Foreword
For nearly ten years, the Health Foundation – The Safer Patients Initiative heightened
has been working with the NHS to deliver managerial awareness of, and commitment
improvement through service and staff to, patient safety and created organisational
development programmes. Our programmes understanding about how to implement safety
test out new ideas for improving the quality of improvement efforts.
healthcare. Our aim is to take the best ideas –
those that we can prove really make a difference to – The two Engaging with Quality programmes
improving the quality and safety of patient care – showed that peer-led improvement processes
and encourage uptake throughout the NHS. secured effective clinician engagement. The
Engaging with Quality Initiative secured the
Almost uniquely, we believe, we have consistently attention of the royal colleges and professional
evaluated these improvement programmes and the bodies, which reported immediate consequences
difference they make. We evaluate our programmes in organisation and practice, and also that the
to provide sound evidence of their impact, and programme had either ‘catalysed’ or supported
to better understand how the impact has been longer-term trends towards involving them in
achieved – or not. These evaluations have provided quality improvement.
important insights into the interventions being
tested, and have demonstrated many successes As those actively involved in improvement work
achieved by the programmes. For example: will know, bringing about the change in behaviour
– Co-Creating Health’s self management and practice necessary to improve quality can be
programme for patients improved their hard and slow. Despite the many successes of the
activation (knowledge, skills and confidence for programmes we have supported, teams frequently
self-management), as well as their use of self- encounter obstacles to achieving their original
goals. The question this posed for us was whether,
management skills. There were also improvements
by identifying and better understanding some
in condition-specific outcomes and quality of life.
of the common challenges, it would be possible
– Participation in our leadership programmes to develop a set of evidence-based approaches
has catalysed improvements. For example, the for successfully overcoming these challenges to
Shared Leadership for Change programme improving quality. Our interest was not in the
meant that a team from Carmarthenshire pros and cons of different technical methods of
Diabetes Network successfully moved routine improvement, but on the factors that affect the
diabetes care from secondary to primary care, likelihood of methods being applied and new
resulting in dramatic reduction in waiting times interventions adopted.
from 12 months to no wait for new secondary
care appointments.
OVERCOMING CHALLENGES TO IMPROVING QUALITY i

To answer this question, we commissioned to enable those at all levels in the organisation
Professor Dixon-Woods to conduct a review of to devote time to improvement projects. They
our evaluations to date and identify the barriers need to nurture a culture that motivates a multi-
commonly encountered by project teams when professional approach to improvement and strikes
doing improvement. The resulting report provides the right balance between appealing to people’s
an engaging and cogent analysis of the key internal motivators and using externally defined
challenges facing people doing improvement – and requirements to drive improvement.
what has been shown to work, both in practice and
in the wider literature, to overcome them. For many, these findings won’t be new. However,
they may well resonate with tacit knowledge about
Debate about the contribution improvement improvement work. The value of this report is
approaches can make to the quality and value of that it provides an evidence base for the factors
healthcare is ongoing. Improvements in safety, contributing to successful improvement.
effectiveness and patient experience are seen
as necessary to meeting the resource challenge As a major funder of improvement programmes,
facing healthcare. Yet, too often, the benefits The Health Foundation itself has found much
improvement interventions demonstrate in ‘study’ here to inform our future work. The findings
conditions have fallen short of expectations when are shaping both how we support individual
applied at scale. This report highlights the factors improvement programmes, as well as the wider
that need to be addressed in order to increase strategic focus of our work. In our improvement
the success of improvement efforts. As such, it programmes we are placing a much greater
should be required reading for anyone leading emphasis on the need for projects to have a clear
improvement work. theory of change, a strong evidence base and for
active senior leader engagement and commitment.
So, what might be done differently as a result of the We are building in much more time for planning
insights presented here? and set-up, and for an objective and critical
analysis of the nature of the challenge being
The findings emphasise the importance of those addressed by each project.
leading improvement work taking time to reflect
before starting an improvement programme. They Part of our strategic focus is to contribute to
need to plan carefully and recognise the multiple developing the emerging academic disciplines of
inter-dependent factors that need to be taken improvement science in order to build a stronger
into account for improvement programmes to be evidence base for what works in improving quality.
effective. It is also necessary to ensure that project We also have a number of improvement programmes
language and structures do not inadvertently that explicitly set out to change the wider
alienate those that will be depended upon for organisational context for improvements in quality.
success. Of particular importance is the time
needed to establish the evidence base for change, With the major challenges currently facing
allowing space for participants to debate and to healthcare, improving quality is more important than
build genuine ownership. Getting measurement ever. However, there can be extra pressure to make
right is also vital, but always takes more time than change happen immediately, as well as the health
people anticipate. system’s cultural bias to jump to implementation.
This report shows that if you take the time to get
The report concludes that structured improvement an intervention’s theory of change, measurement
is complex and takes time and, unless the and stakeholder engagement right, this will deliver
conditions for success are in place, is unlikely the enthusiasm, momentum and profound results
to fully achieve set objectives. This reinforces that characterise improvement at its best.
the importance of the role that organisation and
system leaders play in supporting successful Stephen Thornton,
improvement efforts. They need to ensure that Chief Executive,
sufficient time and resource is provided The Health Foundation
ii THE HEALTH FOUNDATION

Contents
Executive summary v
Chapter 1: Introduction 1
Chapter 2: Approach and methods 3
Chapter 3: Findings: factors affecting improvement 5

Theme 1: Design and planning 6
Theme 2: Organisational and institutional contexts, professions and leadership 11
Theme 3: Sustainability, spread and unintended consequences 19
Chapter 4: Key issues in overcoming the challenges to improvement 23
Chapter 5: Conclusions 29
Appendix: Summary of reports reviewed 31
References 34
OVERCOMING CHALLENGES TO IMPROVING QUALITY iii

iv THE HEALTH FOUNDATION
Executive summary
Improving quality in healthcare is intrinsically Theme 1: Design and planning

a good thing to do and efforts to make Rigorous design and planning of improvement
improvements should be commended. However, interventions is crucial to their prospects of success.
improvement is not easy. Though there are
some examples of demonstrable, real and lasting Challenge 1: Convincing people that
improvements in the care provided to patients,1 there is a problem
the effectiveness of improvement initiatives is
more often inconsistent and patchy. Over time, the Use hard data to demonstrate the extent of the
Health Foundation has assembled an impressive problem and patient stories and voices to secure
portfolio of improvement programmes and, in a emotional engagement. Use peer-led debate and
perhaps unique contribution to advancing the field discussion.
of improvement, has ensured that each is evaluated –
mostly independently. We report here a synthesis of Challenge 2: Convincing people that the
learning from the Health Foundation’s evaluations solution chosen is the right one
of its improvement programmes. We set this in the Come prepared with clear facts and figures, have
context of the broader academic literature, seeking to convincing measures of impact, and be able to
draw out lessons for those engaged in improvement demonstrate the advantages of your solution.
activities in the NHS and other health systems. Involve respected senior figures.
The evaluation reports are necessarily defined Challenge 3: Getting data collection and
by the nature of the improvement programmes monitoring systems right
themselves, which can be broadly categorised as
ones which aim to improve: This always takes much more time and energy than
anyone anticipates. It’s worth investing heavily
– leadership in data from the outset. External support may be
– clinical engagement required. Assess local systems, train people, and
– patient safety have quality assurance.
– integrated approaches to self-management Challenge 4: Excess ambitions and

of long-term conditions. ‘projectness’
Although our findings are limited by the scope Over-ambitious goals and too much talk of
of these evaluations, a number of important ‘transformation’ can alienate staff if they feel the
lessons emerge that are likely to be useful for most change is impossible. Instead, match goals and
improvement efforts. Within three main themes, ambitions to what is realistically achievable and
we have identified 10 challenges to improvement focus on bringing everyone along with you. Avoid
that consistently emerge, and have suggested ways giving the impression that the improvement activity
to overcome them, summarised below. is unlikely to survive the time span of the project.
OVERCOMING CHALLENGES TO IMPROVING QUALITY v

Theme 2: Organisational Challenge 8: Balancing carrots and
and institutional contexts, sticks – harnessing commitment through
professions and leadership incentives and potential sanctions
Organisational and institutional contexts, Relying on the intrinsic motivations of staff for
including leadership and professional behaviour quality improvement can take you a long way,
and culture, can have a profound impact on the especially if ‘carrots’ in the form of incentives are
prospects of improvement efforts. It is important provided – but they may not always be enough.
to ensure that these enhance, rather than inhibit, It is important to have ‘harder edges’ (sticks)
improvement. to encourage change, but these must be used
judiciously and are likely to require the support of
Challenge 5: The organisational context, senior executives, professional bodies and those
culture and capacities designing reward structures.
Staff may not understand the full demands of
improvement when they sign up, and team Theme 3: Sustainability, spread
instability can be very disruptive. Explain and unintended consequences
requirements to people and then provide ongoing Sustainability and spread of improvement
support. Make sure improvement goals are aligned initiatives are key challenges. Improvement is
with the wider goals of the organisation, so people vulnerable to an ‘evaporation effect’, particularly
don’t feel pulled in too many directions. It is once projects have been completed.
important that the organisational culture supports
learning and development. Challenge 9: Securing sustainability
Sustainability can be vulnerable when efforts are
Challenge 6: Tribalism and lack of staff
seen as ‘projects’ or when they rely on particular
engagement
individuals. From an early stage, projects need to
Overcoming a perceived lack of ownership and identify future funding sources, or identify ways to
professional or disciplinary boundaries can be use resources more efficiently in order to sustain
very difficult. Clarify who owns the problem and improvements. Successful outcomes should be
solution, agree roles and responsibilities at the written into standards, guidelines and procedures
outset, work to common goals and use shared to ensure they are embedded in routine activities.
language. Intermediaries, such as training staff, are
likely to have a role here. Protected staff time may Challenge 10: Considering the side
help to secure engagement. effects of change
It’s not uncommon to successfully target one
Challenge 7: Leadership
issue but also cause new problems elsewhere. This
Getting leadership for quality improvement right can cause people to lose faith. Be vigilant about
requires a delicate combination of setting out detecting unwanted consequences and be willing
a vision and sensitivity to the views of others. to learn and adapt.
‘Quieter’ leadership, oriented towards inclusion,
explanation and gentle persuasion, may be more
effective. This may require additional training.
vi THE HEALTH FOUNDATION

In overcoming the challenges to improvement, – Resist organisational impatience for quick
it is important to avoid nihilism. Improvement wins and early results, since it can have
is hard, but not impossible. Many challenges can many negative effects on the authenticity of
be overcome if they are recognised and managed improvement, and encourage poorly planned,
effectively. The following can be done to optimise poorly evidenced and unsustainable approaches
improvement efforts. to improvement.
– Recognise that there is no magic bullet. – Manage the ‘project status’ of improvement
Making progress requires negotiating many interventions carefully.
cramped channels. – Account for the ways in which organisational
– Secure the engagement of multiple stakeholders and institutional contexts can pose ongoing
using numerous approaches, many of them threats to improvement activity, particularly
apparently contradictory: strong leadership when they involve personnel changes or
alongside a participatory culture; direction and organisational stresses that erode the time and
control but also flexibility according to local enthusiasm for activities.
need in implementation; critical feedback – Balance the temptation to focus on settings
on performance without attaching blame. most likely to be receptive to improvement with
– Tame the urge to action by ensuring that time the risk that such an approach may reproduce
is dedicated to planning and design, and inequities by increasing delay to improvement
recognise that knowing that there is a need to in less fertile settings.
improve care does not mean knowing how to – Gain consensus and build coalitions. Obtaining
improve care. the support of one group of stakeholders may
– Make careful assessment of organisational risk alienating another; finding agreement
readiness, resource requirements and the on the problem to be addressed and creating
commitments needed from staff. All of these are coalitions of multiple professional groups are
vital at the outset of projects, as this is a period important tasks of improvement. Interventions
of development, piloting and testing. However, that ‘go with the grain’ and offer a clearly
they continue to be important throughout demonstrable advantage over current practices
implementation to avert disenchantment are especially likely to succeed.
and disengagement as the scale of the tasks – Coordinate actions at multiple levels, seeking
becomes apparent. to influence multiple stakeholders, to ensure
improvement that engages, incentivises and
endures.
– Remain vigilant about the potential unwanted
effects of improvement, and respond to them
flexibly and appropriately.
OVERCOMING CHALLENGES TO IMPROVING QUALITY vii

Chapter 1
Introduction
Improvement in healthcare poses important The improvement field is replete with examples
challenges. Even the definition of what of interventions, initiatives and programmes that
‘improvement’ means escapes consensus. Perhaps worked well in some settings but floundered when
the most useful definition is that offered by introduced elsewhere. Organisational context is
Batalden and Davidoff: often the deal-breaker in making positive change
happen in healthcare. As scientific understanding
Many in healthcare today are interested of improvement has developed, attention has
in defining ‘quality improvement’. We turned increasingly to trying to explain what
propose defining it as the combined and causes this variability in organisational response.3-6
unceasing efforts of everyone – healthcare
Over time, the Health Foundation has assembled
professionals, patients and their families, an impressive portfolio of improvement
researchers, payers, planners and programmes and, in a perhaps unique contribution
educators – to make the changes that will to advancing the field of improvement, has ensured
lead to better patient outcomes (health), that each is evaluated – mostly independently.
better system performance (care) and The programmes have diverged in their scope and
better professional development.2 remit, but all are united by their focus on technical
skills, leadership, capacity, knowledge and the will
These authors use the term ‘quality improvement’. for change. They therefore meet the definition of
This is a term that tends to be used in different ‘improvement’ that we offer above. The evaluation
ways by different people in different contexts, and reports represent a valuable resource, providing
is often associated with particular methodologies. insights into the challenges and opportunities
Because we are interested in improvement in of improvement and how they are influenced by
healthcare broadly, and in keeping with the spirit different healthcare organisational contexts.
of Batalden and Davidoff ’s definition, we will use
the term ‘improvement’ to encompass the whole In this report, we provide a synthesis and review
range of purposeful, directed attempts to secure of the findings of these evaluations as they relate to
positive change in health systems. factors that constrain and facilitate improvement.
We set the learning from the evaluation reports
Though there are some examples of demonstrable, in the context of the wider literature, and seek
real and lasting improvements in the care provided to draw out the lessons for those responsible for
to patients,1 the effectiveness of improvement designing and implementing improvement in
initiatives is more often inconsistent and patchy. the NHS.
OVERCOMING CHALLENGES TO IMPROVING QUALITY 1

Chapter 2
Approach and methods
Review of the Leadership programmes (2003–08)

Health Foundation’s – A review of the Health Foundation’s leadership
programmes 2003–07 (Leadership review),
evaluation reports October 2008
We reviewed 14 Health Foundation evaluation – Leadership Fellows pilot scheme (LF pilot),
reports, as follows (further details are provided September 2006
in the appendix). The abbreviation in brackets
after each report is the one we use to refer to the – Leaders for Change evaluation report (Leaders
evaluation in our review. for Change), August 2006
Safer Patients Initiative (SPI) Engaging with Quality Initiative

– Safer Patients Initiative phase 1 (SPI I), – How do you get clinicians involved in quality
February 2011 improvement? (EWQI), August 2010
– Safer Patients Initiative phase 2 (SPI II), – An evaluation of the Health Foundation’s
February 2011 Engaging with Quality Initiative (EWQI 2009),
March 2009
– Learning report: Safer Patients Initiative
(SPI Lng), February 2011 – An evaluation of the Health Foundation’s
Engaging with Quality Initiative (EWQI 2007)
– The journey to safety: a report of 24 NHS October 2007
organisations undertaking the Safer Patients
Initiative (Journey to safety), unpublished Engaging with Quality in
Primary Care (EWQPC)
Leadership programmes (2008–11)
– Engaging with Quality in Primary Care:
– What’s leadership got to do with it? evaluation of the Leading Improvement Teams
(Leadership), January 2011 Programme (EWQPC), March 2011
– Evaluation of the Shared Leadership for Change
programme (Shared Leadership), June 2009 Co-creating Health
– Co-creating Health evaluation (Co-creating
Health), in press

We began by reading each report carefully. The For the literature review, we:
reports varied in quality, length and level of detail,
but we did not make any decisions about inclusion – treated the review question as a compass, not an
or exclusion of data based on these characteristics. anchor, so that the question was open to being
We thus make no comments about the strength of refined as the review proceeded
evidence that we present, though generally we have – used iterative, intuitive searching of literatures
sought to ensure that all claims are well supported combined with more formal systematic
by both the findings from the analysis of reports searching techniques
and by a corresponding research base.
– engaged in selective, judicious sampling of
To undertake the analysis and synthesis, we relevant literatures
initially generated a thematic framework for
– sought to integrate the various literatures
coding based on Damschroder et al.’s consolidated
framework for implementation science.7 through a narrative argument.
The areas of literature in which we searched
This framework was selected to enable a rapid included: organisational studies; medical,
preliminary classification of the material, and economic and institutional sociology; social and
our approach thus has a number of similarities community psychology; critical development
to ‘best fit’ evidence synthesis, which is based studies; social movements; and innovation and
on the framework analysis technique.8,9 The diffusion studies. We examined original empirical
preliminary framework was modified substantially research, theoretical and conceptual work, and
as we began to refine our analysis, discuss the reviews (both systematic and narrative). On
emergent findings within the project team and every topic that we discuss, there is an extensive
integrate relevant literature. The final framework associated literature, and we make no claim to
is represented by the thematic headings and comprehensiveness. Given the potential for a vast
subheadings of the report presented here. and overwhelming presentation, and a concern
with making this review accessible for non-
Review of literature academic audiences, our review is necessarily
selective and only sufficient literature to support
We conducted a rapid narrative review
the points made is cited.
of organisational factors likely to hinder
improvement, with the primary aim of
illuminating and deepening understanding of
the findings in the evaluation reports through
linking to the relevant academic literature. We
built on a previous literature review in a related
area,10 which included systematic searches of the
Scopus database using keyword terms. This search
was updated using a combination of professional
expertise,11 reference chaining, and expert
recommendation.
4 THE HEALTH FOUNDATION

Chapter 3
Findings: factors affecting
improvement
The evaluation reports are necessarily defined – design and planning

by the nature of the improvement programmes
– organisational and institutional contexts,
being evaluated. The programmes varied in the
professions and leadership
interventions they used and the outcomes sought.
The interventions used in the programmes might – sustainability, spread and unintended
broadly be categorised as: consequences.
– leadership development There are other ways in which the same material
could be organised and our choice of presentation
– clinical engagement here does not represent any attempt to impose a
– organisational and systems-based approaches to hierarchy on the importance of particular themes,
patient safety but rather an effort at clarity.
– promoting integrated approaches to self- In general, we have focused on commonalities
management of long-term conditions. across the reports. Where appropriate, we have
also commented on silences or absences in
The programmes, taken in the round, intervene the reports. The nature of the reports and the
at many different levels, from the individual programmes studied do not easily allow for an
to the team, and from organisation to system. assessment of the extent to which factors might
Synthesising the evidence across the programmes interact, or of which factors are likely to exert the
helps to provide an integrated perspective that most powerful influences on improvement efforts.
recognises both the importance of individuals However, we would expect many of the factors
(their skills, competencies and qualities) but also to be contextually specific and to link together in
the contexts in which they work. ways that may be difficult to predict.
Our findings reflect and are constrained, of
course, by the nature of the programmes and their
interventions, and by the nature and reporting of
the evaluations. However, a number of important
themes emerge across the reports that are likely
to be useful for most improvement efforts. We
organise our analysis into three broad themes:

Theme 1: Design and planning The literature is replete with examples of
interventions where clinicians insist that the
Our analysis suggests that in the design and service being provided is already good. Trying to
planning of improvement interventions, it is convince clinical teams that are already doing well
important to: to change what they are doing is likely to be futile.
– establish with the key audiences that there is a Those designing and planning an intervention
real problem to be addressed and that it matters therefore must be careful to target problems
locally that are likely to be accepted as real and that the
improvement activity will offer relative advantage
– ensure that the evidence-base is of sufficient over the status quo.12,13
quality to convince people that the proposed
intervention will work The evaluation reports and the wider literature
suggest various possible strategies for establishing
– understand the mechanisms through which the problem as a problem. First, hard data to
the interventions are intended to achieve their demonstrate its existence, including variability
effects between the worst performing and best
performing units, are critical.14 The power of
– design data collection and feedback systems that
using data both ‘passively’ to ‘make transparent’
help to track progress and stimulate engagement
discrepancies in performance15 and more ‘actively’
and learning in enforcing clinical change16 is now clear. Some
– address the ‘double-edged sword’ of project examples of using data in this way are evident
status in the evaluation reports: for example, the
EWQI programme used a double audit cycle to
– ensure that ambitions are consistent with demonstrate that comparative performance data
available resources and likelihood of change. can be used to promote improvement. Second,
patient stories can be used to secure emotional
Challenge 1: Convincing people engagement with the impact of poor quality. There
that there is a problem were few reports in the evaluations of the use of
One of the most fundamental, but often least well patient stories, but those that were used ‘seemed
met, challenges in improvement is to first convince to have powerful effects and helped to engage
healthcare workers that there is a real problem to healthcare economy leaders in the worth of the
be addressed. programme for patients’ (Co-creating Health).
In the SPI programmes, many aspects were A further important strategy involves engaging
already good at baseline, leaving little room for clinicians themselves in defining what it is that
improvement (SPI I/II). This was also true in they would like to improve in their service;
EWQI, where some units were already performing clinicians are usually able to identify defects that
so well that they were unlikely to improve they would like to fix, although there are risks that
significantly further. Clinicians and others may such defects will be attributed to causes outside
argue that the problem being targeted by an the control of individual teams.17 Interesting
improvement intervention is not really a problem, work using methods such as video ethnography
that it is not a problem ‘around here’ or that is now showing considerable promise in helping
there are many more important problems to be practitioners to engage actively in recognising both
addressed before this one (EWQI; SPI). problems and their own role or contributions in
the resolving of those problems.18

Challenge 2: Convincing Changes in practice are more likely where there
people that the solution is correspondence between the probabilistic,
chosen is the right one statistical proof offered by the research evidence
base and clinicians’ own reasoning about what is
A second fundamental challenge is to convince
likely to work in practice.22 This can mean that
people that the right approach to tackling
even those quality standards that appear relatively
the problem has been selected. Improvement
well established in scientific terms may be open to
interventions are often ‘essentially contested’:
contest if they do not align well with people’s own
everyone may agree on the need for good quality,
reasoning, if they threaten people’s interests, or if
but not on what defines good quality or how it
they cause too many conflicts of priorities. Further,
should be achieved. Both the wider literature19
different forms of evidence may have varying
and evidence from the evaluation reports suggest
degrees of credibility with different professional
that having a sound scientific evidence base
and managerial groups.19,23,24 Several Health
for improvement interventions is likely to be
Foundation awards found that what was accepted
important to the chances of success.
as best practice in one profession or discipline was
Two aspects of evidence need to be distinguished. disputed in others.
On the one hand, evidence is required to support
Thus a sound evidence base is important,
particular interventions – for example, the five
but does not of itself ensure engagement and
elements of practice known to reduce infection
implementation. Active work to secure credibility
rates in central venous catheter insertion20 – and
is needed. This is likely to imply working with a
on the other, evidence is also needed for how
variety of professional groups on their own terms,
best to implement those practices. Weaknesses
and aligning the project with each group’s values
in the evidence base for either can negatively
and notions of best practice. Interventions that ‘go
impact on projects.21 The evaluation reports show
with the grain’ and are consistent with the values
that the leadership projects, for example, faced
and internal motivations of healthcare professionals
challenges in demonstrating the relationship
(SPI Lng), and do not clash with wider changes in
between particular leadership behaviours and
healthcare systems (EWQI), may be more likely to
anticipated improvement outcomes (Leadership
succeed.16 In the absence of such alignment, staff
review). Similarly, in EWQI, involvement of
may push back and fail to engage.12,13,15 Connecting
patients in improvement and service development,
with established ways of working in a particular
and the best ways to engage clinicians, suffered
organisation may also play a role; for instance early
from a weaker evidence base. The SPI programme
warning scores in the SPI programme (SPI I) were
included interventions for which the evidence base
evidently connected to long-standing traditions
was contested; one of these (beta blockade) was
of monitoring vital signs, and thus were seen as
dropped from the second phase.
more acceptable than more disruptive innovations
Challenging the evidence base can be an effective such as Situation, Background, Assessment,
strategy of resistance for clinicians who want to Recommendation (SBAR).
avoid cooperating with an intervention, as several
There is, however, a danger that being too
of the evaluation reports (including SPI) have
deferential to existing norms, values and
found. If professional consensus is lacking on the
behaviours may result in failure to challenge
evidence base for a given intervention, time and
poor quality practices. Norm-disrupting tactics
energy can be dissipated on debates about the
may be needed to confront institutionalised
legitimacy or otherwise of seeking to achieve a
complacencies.14 Further, designing interventions
particular standard for care. Reducing the number
that are too similar to those already in use may
of areas to be tackled and avoiding areas which are
risk, as the EWQI programme found, non-
disputed or scientifically contested may help make
adoption and wasted effort. One approach for
interventions more achievable (SPI II).
ensuring the acceptability of interventions is to
make strategic use of forums involving the relevant

stakeholders to discuss and debate the evidence found that some clinicians were reluctant to take
and expose it to challenge, rather than hoping that part because they had not been consulted in
the evidence will ‘speak for itself ’ in convincing the development of a care bundle. Taking more
clinicians of the need for change.25,26 account of prior skills and experience would also
have helped in implementing the intervention in
Recent years have seen growing emphasis on the the Shared Leadership programme. Similarly, the
need to know not only whether improvement SPI programme might have benefited from more
interventions succeed, but also why.14,27 The pre-intervention work to identify how it would
wider literature supports the idea that having an work and in what circumstances.
explicit theory of change – that is, an account of
the activities undertaken, and of the causal links Though considerable effort needs to be invested
between these activities and the outcomes sought28 in the theory of change at the outset, it should not
– is key to ensuring clarity of focus and strategic be regarded as fixed and immutable. It needs to be
direction and to convincing people that the chosen able to develop over time in response to learning:
solution is likely to work. retaining flexibility and a commitment to learning
are important aspects of enabling improvement
The evaluation reports demonstrate the challenges initiatives to work.14 Having a good understanding
that can arise when aspects of intervention design of how the intervention really functions, and
lack sufficient detail at the outset, and when being able to articulate this in a meaningful way,
the theory of change is difficult to articulate is critical to avoiding ‘thin simplifications’ that
because the intervention continues to develop reproduce superficial outer appearances of an
during implementation. Sometimes, there was intervention. However, this can be particularly
a lack of clarity about fundamental aspects challenging. In the Co-creating Health
of the intervention and award terms, such as programme, for example, there was a perception
agreed definitions of ‘shared leadership’ and that over-‘manualisation’ and scripting of tutors’
‘quality’ (EWQI 2009) and confusion about interactions with patients was damaging to the
the nature of the award (whether it was in the establishment of more authentic relationships.
form of cash or professional support ‘in kind’)
(Shared Leadership). In SPI, a more explicit When real-time adaptations were made in Health
theory of change might have helped to focus Foundation projects, they appear to have been
attention on clinical engagement and the role very helpful if they were carefully and thoughtfully
of middle managers (SPI II). The Co-creating undertaken. For example, revisions to the EWQPC
Health evaluation found that the programme was programme, which was felt to have been initially
hindered by programme theory that had not been too inflexible, allowed it to adapt better to meet
explicitly articulated as clearly as it might have team needs.
been at the outset, and a disconnection between
programme aims and measures of impact at site Challenge 3: Getting data collection
level. In the Leadership schemes, participants and monitoring systems right
tended to focus on personal development unless
the focus on improving quality was very clearly Designing and supporting data collection and
articulated (Leadership review). The absence of feedback systems needs to be one of the earliest
a requirement to apply learning in the workplace tasks undertaken in any improvement effort. Data
limited the support that participants could expect collection and feedback are essential elements of
from employers (Leadership review). the process of improvement. Good quality data are
the key both to demonstrating the problem and
Plenty of early consultation and trialling can showing that it is being addressed and, as we noted
help not only to refine the theory underlying the earlier, is therefore critical in engaging investments
intervention, but also to engage key stakeholders of emotion, effort and resource. Transparent
and help them to feel included and valued. For monitoring systems facilitate learning, and enable
example, one project in the EWQI programme clinicians to challenge and support each other in

pursuit of improved quality.12,13,16 Monitoring has Measures that are excessively burdensome or do
an important role both in securing compliance in not enjoy credibility with the target community
real time and in providing evidence of success, and risk alienating, rather than engaging, clinicians and
contributes to establishing shared norms of quality. producing confusion about the extent to which
Regular feedback on performance can motivate any changes are real. Choosing measures that can
sustained efforts by providing a sense of progress reliably capture relevant quality issues is critical to
or keeping participants ‘on task’ – particularly avoid gaming, where participants are incentivised
when it is gauged against the performance of to produce the desired numbers without the
comparable settings.29,30 Indeed, one of the features intended changes in practice.33 Common targets
that distinguishes improvement from research and measures across all participating teams are
is the real-time feedback of improvement data generally preferable.34 However, gaining consensus
to clinical teams, rather than being used solely on these and setting up systems for centralised
to generate research reports.31 But in driving data collection is far from straightforward,
improvement, data (and their source) need to be and is resource-intensive and demanding of
seen as credible by potential participants, while organisational support.
at the same time not too irksome or burdensome
to collect.32 If data collection can help rather than It is clear from some of the evaluation reports that
interfere with workflow, and replace rather than collecting improvement data was a stretch too
duplicate previous systems, it may be more likely far for some organisations. In some cases, setting
to succeed. up the systems and collecting the data not only
produced resentment but also undermined the
Data collection, monitoring and feedback systems improvement effort as a whole. Existing systems in
therefore need to be explicitly designed into an most organisations have been designed for clinical
improvement activity from the start, and need to needs or to capture data to report to national
be adequately resourced. But they are remarkably targets: they are not well-suited to gathering the
hard to get right: the evaluation reports type of data required by improvement initiatives
consistently demonstrate that many improvement (SPI Lng). Quality measurement systems, where
projects stumble over this aspect of the process. they do exist, are often unstable and underfunded
There are no standard established methods for (EWQI 2007). Substantial investment in training
assessing some of the types of interventions and is required to ensure that people are able to
activities, yet often little investment is made in collect, record and interpret data correctly. Even
developing them before the start of activities. well-informed and committed teams may require
Requirements for evaluation, and its benefits additional support to measure, validate and learn
and limitations, are often poorly understood from activities (EWQI 2009).
(EWQI; Co-creating Health). The SPI programme
highlighted the need to recognise differences in Challenge 4: Excess ambitions
context when importing interventions from other and ‘projectness’
healthcare systems, for example, allowing for
differences in data collection systems in the US One challenge for certain types of improvement
compared to the UK (SPI Lng; Journey to safety). activities, no matter how well designed, is that
In the leadership programmes, there was a reliance they can acquire a ‘project’ status that can bring
on retrospective self-reporting (Leadership), which opportunities but also threats. In the private sector,
is prone to multiple biases. Baseline measures are projects are seen as key tools for introducing
not always collected, or were not done well (Shared novel work practices.52 Project status can mean
Leadership; SPI; Co-creating Health). Local key benefits, including a distinctive focus, identity
teams and project managers may lack expertise and drive that helps to set an improvement
and experience in collecting and interpreting activity apart from the routine of day-to-day
data, and thus introduce biases or draw incorrect activities. Projects also have the potential to
conclusions (Co-creating Health). introduce working practices unconstrained

by existing organisational divisions, and for Without adequate financial support, infrastructure,
generating excitement and interest. However, their improvement and managerial skills and capacity,
transferability to public sector contexts such as the training, and managerial and clinical time,
NHS is not straightforward.41 improvement efforts can quickly run into
difficulties.27
A changing policy context can make it difficult
to align time-limited projects with wider These difficulties can be compounded by an
organisational goals. If projects lack ongoing senior impatient organisational culture that does not give
managerial support, it can be difficult to make the new initiatives sufficient time for a diagnosis phase
transition from project to institutionalisation as (Co-creating Health) or to allow interventions
part of wider organisational policies, procedures enough time to ‘bed in’.12 The time required for
and norms. Perhaps most corrosively, activities interventions to penetrate to the ‘sharp end’ and
seen as time-limited risk simply being tolerated result in measureable improvements may be
or ignored until they go away by coming to an much greater than anticipated at the outset. Some
end. The evaluation of the EWQI found that activities, such as team- and relationship-building,
improvement ‘is often not regarded as a part of the can take significant time to achieve, especially
core business of the NHS and has to be undertaken when they start from a low base. It may also be
at the margins of mainstream activities’. Given hard to sustain enthusiasm and effort over long
this, improvement projects can be disregarded by periods and to maintain focus when interests and
those who did not have the time or will to engage, priorities move elsewhere (EWQI). Ultimately, the
safe in the knowledge that, in time, the projects literature suggests that mismatches of ambitions
would ‘go away’. At the other extreme, projects and resources can give rise to ‘change fatigue’,
risk becoming the ‘chief executive’s favourite’, and making people and organisations more resistant
resented for how they draw away attention and to subsequent improvement initiatives,12 and
resources from other activities. Further, there is cause frustration, disillusionment and ultimately
some evidence in the SPI of hostility towards those exhaustion as efforts to improve flounder.27,42
who reap praise and reward from being associated
with project teams, while others are left with the The scale and demands of improvement
drudgery of implementation. This points to a need interventions therefore need careful assessment
to find a compromise between harnessing the at the outset and the implications of involvement
distinctiveness of improvement projects as a tool need to be explained to participating teams. In the
for change, and ensuring that such projects are Leading Improvement Teams Programme, teams
also aligned with the wider ‘direction of travel’ of started with no real appreciation of the scale of the
organisations and government policies. work involved or the amount of time engagement
would require (EWQPC). It may be difficult to
Enthusiasm for improvement is very natural, but protect participants’ dedicated time (EWQI;
it can easily overwhelm the available resources. Leadership review), especially if they are involved
Being over-ambitious may be risky in a number in a number of projects or have multiple other
of ways, not least because ambitious ‘stretch goals’ demands. Therefore this needs to be clearly and
and talk of ‘transformation’ may risk alienating explicitly negotiated before the intervention gets
people early on, and later lead to disillusionment underway. Clarity about the contributions expected
if the aims are not realised. The balance between of each team member, including service users
ambitious aims and availability of resources (EWQI), is essential.
to support change is a frequent concern in the
evaluation reports (SPI; Leadership review; Shared Staffing and skill mix required to deliver on
Leadership; EWQI), and both the literature and the goals of the intervention requires especially
the evaluation reports suggest that the scale of careful assessment. Research on improvement
resource required to support improvements is has highlighted lack of capacity as a consistent
often underestimated (SPI I; Shared Leadership). problem.12,43 Leadership, finance, management,

communication, clinical skills, administration, Challenge 5: Organisational
relationship building, data analysis, database cultures, capacities and contexts
design and the ability to train others are among the
array of skills required by the programmes covered Organisational cultures
in the evaluation reports (EWQI; Leadership), Not surprisingly, organisational cultures supportive
reflecting many of the findings in the literature on of personal and professional development, and
this point.12,44 All may be in short supply in NHS committed to improvement as an organisational
organisations. priority,15 are more likely to provide an environment
where improvement can flourish (Leadership
Bringing together a team with the range of skills review; LF pilot). The evaluations demonstrate
required is challenging, especially when people how morale, leadership and management in
lack basic meeting skills and team working skills organisational settings may lead to variation in
(Shared Leadership). In some Health Foundation outcomes (EWQI), reflecting wider findings on how
awards, lack of resourcing was evident at a very organisational culture impacts on performance,
basic level, such as the inability to provide all quality and outcomes.45,46 One key challenge is to
clinical staff with a workbook (EWQI). The ensure that organisational objectives are aligned
importance of dedicated administrative support for with an improvement activity (LF pilot).13 Some
improvement activities also needs to be strongly healthcare organisations do not appear to value
emphasised (Shared Leadership). If structures improvement (EWQI), sometimes because the
and systems are not already in place to support improvement activity has to compete with many
activities such as data collection, the problem of competing demands on organisational attention,
excess ambition may be compounded (SPI). resource and support.
Theme 2: Organisational The motives of organisations for participating

in improvement activities are often important
and institutional contexts, determinants of the likely success of an initiative.47
professions and leadership Organisations may sometimes participate in
programmes for reputational reasons – because
A second theme evident from evaluation reports not to do so would be unacceptable and damaging
and the literature relates to the profound impact – but their engagement with the programme may
on improvement efforts of organisational and not be authentic.48 If reasons for participation vary,
institutional contexts, including: organisational then variations in response may also occur.
cultures; organisational capacity; user involvement;
and outer contexts, such as the surrounding policy The internal politics of organisations are often
environment. deeply implicated in cultural support for
improvement, and may not be easily detectable
The evaluation reports and the wider literature from a simple inspection of organisational
offer clear evidence of the role of professions and structures.49 Within organisations, relationships
leadership in enabling improvement to function between clinical teams and managers are crucial
most effectively. Harnessing professionalism, to success, but the evaluation reports suggest that
supporting and nourishing leadership, ensuring some managers appeared to be too busy to take an
ownership, engaging senior staff and other interest in the project or felt personally threatened
stakeholders, engaging middle managers and ward (Leadership review). Attempts by teams to secure
staff, overcoming silos, securing effective user resources such as budgets and release of time to
involvement, and incentivising participation support improvement may be seen by managers
all emerge as important. (or other colleagues) as political acts, and
handled accordingly.49 Sometimes key individuals
– described vividly in one research report as
‘constipators’50 – are all it takes to stop a change
process or data collection system in its tracks.

A lack of organisational engagement in initiatives Some organisations failed to learn as much as they
can mean that highly committed staff are left to might have done from involvement in projects
take on responsibilities for delivering improvement because the capacity to apply the learning was
on top of their existing commitments (EWQI). lacking. The greatest potential to learn came
It can be difficult to find and protect time to when participants were able to work with senior
focus on improvements that are not viewed as managers to build local capacity (Leadership
priorities by the wider organisation (Leadership review). Effectiveness of dialogue and quality of
review; EWQPC). Lack of emotional and logistical relationships were the foundations for making
support for clinical engagement tends to result in tangible improvement (Leadership). Others have
unsustainable activity that fades out through time.27 noted elsewhere the need for joint work between
the ‘blunt and sharp ends’ of organisations to
A history of involvement in improvement can ensure that learning is bedded in and to avoid
provide an advantage in terms of organisational ‘organisational amnesia’,16,27 but also point out that
readiness43 – but can also be a source of potential organisational structures can sometimes militate
strain if activities are not well-integrated and against the capacity of practitioners to solve
aligned with organisational goals (Journey to problems by taking a top-down approach to the
safety). Even though flexible, risk-taking hospitals implementation of evidence that leaves no space
are more likely to succeed in improvement,45,51 for creativity and learning.51,52
organisational cultures may be oriented towards
stability rather than innovation, and be reluctant Organisational capacity
to allow for failures and consequent learning. This
The importance of organisational capacity to
can influence the extent to which clinicians are
support improvement has been repeatedly
risk-averse when adopting new practices (EWQI).
recognised in the literature.27,44,45 A shared
When attempting to implement innovative
sense of ‘readiness’ is difficult to achieve across
projects, there is a need to be open to new ways
organisations.53 Considerable variations in local
of learning (Shared Leadership), and to accept
capability have been found (Journey to safety) in
that not all interventions will succeed; some may
areas that are critical to improvement, including
take considerable time to yield positive results.
around implementing process measures and
Implementing new methods requires a good pre-
reliably collecting and reporting data. An academic
existing level of staff morale and motivation.
paper arising from the Journey to safety work
A further cultural challenge is ingrained commented that:
individualism in some areas of the health service
(Shared Leadership). Safety may be seen as the The implementation of data collection
responsibility of individual clinicians rather than and reporting structures for microsystems
as an organisational issue (SPI Lng), yet a barrier level clinical data on this scale provides
for clinicians is that NHS clinical career structures certain resource and practical challenges
do not typically lend themselves to progression for organisations, where such processes
through involvement in improvement (Leadership have not existed before. Review of process
review). In general, improvement work may metrics from SPI revealed that speed
be held in lower esteem than medical research,
and ease of uptake, along with final
especially among clinicians. Clinicians often have
to look beyond their daily work for opportunities
capability for process measurement was
to apply their learning, for example by taking on highly variable between sites. This was
committee roles (LF pilot). Such disincentives to evident from a number of data quality
clinician involvement are an important barrier to limitations arising in the first phase of
improvement, especially given research findings the programme, including: insufficient
that emphasise the importance of clinical (and data points and lack of sufficient baseline
particularly medical) leadership in improvement periods, changing samples or sampling
processes.12,19,25,42 strategies mid-time series, inadequate

or missing annotation describing which knowledge and expertise from organisations
changes were implemented and when, such as the Institute for Healthcare Improvement
amongst others.54 or other technical providers; support from
professional bodies (though some are better
Lack of adequate structures to support equipped/more experienced than others (EWQI));
improvement activities often means creating technical input and coaching from specialists,
new systems and processes from scratch (SPI I; such as clinical improvement experts and
Journey to safety). Without such an infrastructure, leadership development consultants; and trained
organisations lack the capacity to benefit fully from patients acting as critical friends – though they
the awards (Leadership review), but developing need to be involved at an early stage and receive
new systems can be extremely costly in services effective support/training (EWQI 2009). Such
that lack the experience and infrastructure to outside consultants and membership of structures
support improvement (EWQI). such as quality improvement collaboratives have
been noted elsewhere as an important resource in
The complexity of many interventions can also
improvement initiatives.16,49 The involvement of
pose significant challenges for organisations.
patients as consultants in driving improvement
‘Whole organisation’ approaches require alignment
is a promising, though as yet under-researched,
and coordination across departments, professions
approach.55,56 However, the extent to which
and levels, and is far from straightforward
external support can compensate for major
(EWQI; SPI). More complex improvement work
structural and resource deficits (such as inadequate
necessitates the blending of task- and people-
nursing levels) or adverse organisational cultures
related leadership skills (Leadership), which may
is still unclear.
be especially challenging. There may be substantial
problems of staff feeling helpless in the face of User involvement
problems outside their direct control, for example
arising in other departments or wards, or in The wider literature supports the notion that the
relation to tasks undertaken by other teams.17 involvement of service users in organisational
change can increase its legitimacy and its
Trying to implement improvement in situations chances of success, though evidence that user
where organisational capacity is inadequate involvement improves quality and outcomes
and culture is hostile can result in emotional remains limited.52,53 There was evidence of the
exhaustion and evaporation of support for value of user involvement in at least some of the
improvement activities.49 Securing organisational evaluation reports. However, key challenges face
support is particularly testing when organisations those leading improvement initiatives as they seek
are undergoing periods of instability including to incorporate the voices of service users into their
changes in senior personnel, financial difficulties projects, including unresolved debates about the
and reorganisation. These distractions can mean appropriate role for involved service users and the
lack of senior leadership buy-in.12,15 Unstable question of their ‘representativeness’ of the wider
staffing is a further risk to improvement patient population.54 The challenges that are faced
projects, resulting in stalled progress, especially when working across disciplinary silos, considered
when a team leader leaves and there has been above, are also faced in working effectively with
no succession planning (Shared Leadership). service users, who can easily be marginalised
Instability of teams, including rotating staff, despite commitments to ‘work in partnership’.55,56
shift patterns and the use of agency staff, makes Clarity about aims and purpose and flexibility in
it difficult to sustain collective knowledge of an implementation is vital to ensure that involved
implementation (SPI I; Safer Systems). users are able to participate actively in the
development and refinement of the intervention
External support may be important in
through time.
overcoming limitations of local expertise and
capability. In the evaluation reports, teams trying
to undertake improvement valued: support,

Outer contexts This volatility is likely to remain a feature of
The wider policy context has an important impact the English NHS context for the medium-term
on the likely success of improvement initiatives. future at least. One notable additional challenge
External, mandated requirements for meeting of rapidly evolving outer contexts is that it has
targets, policy objectives, payments, inspection made it difficult to isolate the impact of the
or accreditation, revalidation and data collection Health Foundation’s work, as skills and knowledge
all weigh heavily on improvement initiatives generally tended to increase as a result of national
by consuming energy, attention and resources. developments concurrent with the project
Sanctions for non-compliance with certain activities – the so-called rising tide phenomenon.58
activities may depress support for other, non- Besides the distraction and disruption associated
mandated activities, such as improvement. with policy turbulence, changes in the organisation
Many national policy documents, reports and structure of the NHS may give rise to more
and guidelines are aligned with the aims of fundamental shifts in the context that improvement
improvement initiatives supported by the Health projects have to face. This is already notable from,
Foundation. Government policy has placed a for example, comparing the EWQI and EWQPC
notable emphasis on quality, safety and leadership programmes, where strategies that were effective
in the NHS over the last decade. Researchers in in acute care were not always effective in primary
the wider improvement literature have noted how care. In acute care, physicians saw improvement in
the nature of this ‘outer context’ can be crucial quality as sufficient motivation in itself; in primary
in supporting or undermining improvement care, financial incentives were often required to
initiatives.12,57 Some interventions in the motivate change among general practitioners.
evaluation reports were more well supported by This reflects a wider cultural change in primary
the outer context of policy developments than care detected by social scientists, where policy
others. For example, improved hand hygiene changes such as new general practice contracts
was both a goal of the SPI and of national policy and the introduction of the Quality and Outcomes
over the same period, and thus the two were well Framework have meant that general practitioners’
aligned. By contrast, leadership development, time and even clinical decision making is
though emphasised in national policy, is often increasingly driven by financial considerations.59
ad hoc and incoherent in the NHS generally It is difficult to anticipate with certainty how
(Leadership review), and much less consistently current changes – the abolition of primary care
supported within organisations. trusts and the introduction of general practitioner-
Turbulence in policy direction and organisational led commissioning, for example – will affect
structure in the English NHS has often constituted improvement, but it is likely that approaches
a significant obstacle for improvement projects will need to be adaptable. While professional
funded by the Health Foundation. Constantly motivations may be resistant to such changes,60
shifting policy agendas during the award periods much will depend on the question of how the issue
of many of the improvement projects have proved of quality is integrated into expectations around
to be a major barrier to improvement. While commissioning, choice and regulation – and the
teams in Wales and Scotland had the advantage detail of how it is measured and valued.
of a reasonably stable environment, in England
ongoing policy instability, and consequent major Challenge 6: Tribalism and
organisational upheavals, affected the ability to lack of staff engagement
complete projects or sustain commitments (Shared
Harnessing professionalism
Leadership; Leadership review). Significant
changes which impacted on projects included the The professional status of so many of the
reorganisation and merger of primary care trusts stakeholders involved in healthcare is
and the transfer of services from secondary to simultaneously one of the greatest challenges
primary care. and richest opportunities for improvement.

Resistance to improvement based on ideals of effectively.23,74 Consequently, tapping into
professional autonomy, impermeable boundaries profession-specific networks, norms and values
between professional groups, and resistance of can be crucial.12,16,19
professional cultures to change led from outside
have all impeded efforts to improve quality Peer support was highlighted as an important
by the Health Foundation and others.67 Yet feature in several projects, especially those
professional norms, values and networks also offer concerned with the development of leadership
an important resource that can be drawn on in skills (Leadership review; EWQI; Leaders for
seeking to change individuals’ behaviour; the trick Change). This took the form of collaborative
is to mobilise them in the right direction. learning experiences, buddying, sharing tools
and data, and benchmarking. Although it was
Sociologists have increasingly moved away resource intensive, the ongoing interaction was
from a view of professions as self-interested seen as highly valuable and helped to sustain
cabals,68 towards a more nuanced view which momentum (EWQI; Shared Leadership). It was
recognises the way in which the professional especially important for frontline staff who have
ethos can be instrumental in promoting values few such opportunities (Journey to safety). Peer
of quality and patient centredness.69,70 Central support could build confidence and provide a
to this renewed interest in the progressive source of encouragement and motivation through
potential of professionalism is a recognition of sharing common problems. The opportunity
the social function of professions as providing for staff to work with peers from outside their
strong norming effects on members’ conduct and organisation was important, as it provided a safe
behaviour. Professions can secure conformity to space for honest and frank discussions (Leaders
certain standards and expectations of behaviour – for Change). This was an important aspect of the
and are generally much more effective in this than EWQPC programme, which included specialist
organisational and managerial efforts to change meetings for particular groups such as project
behaviour.71,72 The EWQI evaluation, for example, managers. Findings from other improvement
reported that peer-led audit can achieve high initiatives suggest that this approach can be very
participation and trusted results; the fact that a valuable, noting a particular role for ‘outside
project was initiated by clinicians helped increase experts’ and communities of practice in supporting
its appeal to colleagues as the goals were perceived those leading improvement, and emphasising
as being common to the profession as a whole, the need for such forms to be cross-professional
reflecting findings elsewhere.61 (bridging the silos between professions and
disciplines) and interactive.16
Issues of professional legitimacy repeatedly
surface in the evaluation reports and the wider Indeed, in evaluations of some of the initiatives
literature. In promoting the legitimacy of focusing on leadership, the multidisciplinary
improvement interventions, some evaluations approach of the projects was felt to be successful
found that clinical staff may be more influenced and a particularly useful feature (Leadership
by personal and professional networks than by review; LF pilot). Bringing together individuals
hospital management (SPI II). Professional bodies from a range of organisational and professional
and royal colleges can not only confer legitimacy, backgrounds exposed participants to a variety of
but also influence attitudes through training, skills, perspectives and knowledge to broaden their
leadership and organisational support (EWQI; thinking and horizons (LF pilot). These groups
SPI II). Clinician-led approaches to identifying did, however, require expert help in teamwork
standards, auditing and developing improvement and relationship management to realise their full
plans may be important in successfully potential (Shared Leadership). One issue was that
engaging other clinicians (EWQI). As others the language used by clinicians and managers
have noted, healthcare organisations comprise differed, hindering relationship building (LF pilot).
‘multiple professions socialized elsewhere’,73 and Another challenge was a lack of understanding
different groups do not always share knowledge and appreciation of each other’s roles (LF pilot).

Ingrained hierarchical attitudes and behaviours Engaging senior staff and
were evident too, especially in difficult situations other stakeholders
(LF pilot). Ensuring that joint working between Obtaining engagement at all levels, from the
professions and managerial groups takes place ‘sharp end’ of the practice of frontline staff to the
effectively – and that improvement does not ‘blunt end’ of senior managers in organisations
become a ‘battleground on which professions is critical to improvement efforts. Getting buy-
compete for ownership and definition of quality’74 in from frontline clinicians and senior managers
– would seem critical. simultaneously can be particularly challenging:
the first phase of SPI, for example, secured a great
Ownership
deal of managerial enthusiasm, but was sometimes
Engaging staff and overcoming a perceived lack of perceived by staff on the frontline as being ‘top-
ownership is acknowledged as one of the biggest down’ and ‘imposed’. For example, there was
challenges in making organisational changes such as enthusiasm for the SPI at a strategic level and here
improvement.75 It requires, as already noted above, features such as the leadership walk-rounds were
top-level and local-level leadership, alignment with viewed positively. They were not, however, viewed
staff priorities, and active work among staff to foster as so effective by some ward staff.
collaboration and engagement with improvement
aims.12,15,67,76 In the SPI programme, medical The evaluation reports chime with much of the
engagement was one of the biggest challenges (SPI wider literature in suggesting that engagement
Lng). Perceptions of interventions vary between of senior stakeholders is a necessary, but not
stakeholder groups involved in the improvement sufficient, condition for getting improvement
projects. The emphasis on measurement and interventions to work.42,61,62 In contrast to the
reporting up the organisational hierarchy in SPI SPI, the support of senior staff in some Health
gave the impression of a top-down approach Foundation programmes appeared sometimes
despite local staff involvement in Plan-Do-Study- to be little more than nominal. Although
Act (PDSA) cycles (Journey to safety), affirming interest from trust executives was most likely
the need noted above for measures that make when a project accorded with a national or
local ownership seem real rather than tokenistic.15 local priority, such support was fragile (EWQI).
Some frontline staff felt the focus needed to be on The need for mutual understanding between
structure and resources rather than processes (SPI). fellows and employers was highlighted in the
Disciplinary groups also vary in their attitudes: Leadership review.
doctors and nurses have different approaches to Tellingly, projects that worked best were those
change and leadership, making engagement across where a steering group member had a significant
groups difficult (EWQI). Inter-group differences in leadership role in the organisation (EWQI).
educational cultures and preferred learning styles Respected individuals could play a vital role in
have been noted as an impediment to improvement encouraging colleagues across different professions
elsewhere.16 and affording credibility to activities (EWQI).
Others have suggested that clashes between Conversely, in one EWQI project where the team
professional and managerial models of change operated as a satellite, it was especially difficult to
– command and control versus influence and influence senior stakeholders (Shared Leadership).
persuasion, for example – can be an impediment Some projects needed to do more in terms of
to improvement. Avoiding a situation where developing strategic thinking and establishing
improvement is seen as an illegitimate managerial links not just with medical directors, but with a
intrusion into professional concerns is important.12,77 range of senior executives and board members
Nevertheless, some evaluations indicated that the (Shared Leadership; Safer Systems). For senior-
methods introduced enabled staff in particular level support to count, then, it needs to be realised
locales to understand and measure the progress through strategic integration of the goals of
and impact of clinical interventions. Helping staff improvement with wider organisational objectives
to understand cause and effect in this way had the and priorities.78
potential to engender local ownership (SPI Lng).

Engaging and supporting middle positive outcomes compared to frontline staff.
managers and ward staff Communicating candidly and frequently is important
Non-engagement of middle managers was to secure the engagement of clinicians (EWQI).
identified as an issue in the evaluations of several
Silos
of the programmes, including various leadership
projects and the first phase of SPI. Preoccupied The gaps between professional and disciplinary
with the maintenance of stability and the need to groups, and between professions and management
ensure reliable service delivery, and responsible more broadly, have also been an important
for implementing strategic changes led from impediment to change in the Health Foundation’s
the top of organisations, middle managers often programmes. Award holders often find it difficult
had little opportunity to engage proactively with to develop strong working relationships with
the improvement initiatives sponsored by the stakeholders across professional and managerial
Health Foundation. Where middle managers boundaries, reflecting wider social scientific
were themselves the recipients of awards, they characterisations of hospitals and other healthcare
sometimes struggled to obtain time away from environments as ‘tribal’ organisations, in which
operational responsibilities. The wider literature relationships between different professional
suggests that support from middle managers groups are often strained.82 Consensus and
can be important in multiple ways: for example trust within one profession do not necessarily
in helping to ensure that particular projects and extend to processes led by other clinical groups.
initiatives are aligned with wider organisational Professional silos can be an important impediment
aims,79 and in integrating improvement efforts into to improvement uptake.23,75 The EWQI evaluation
broader performance monitoring and management also found that disciplinary boundaries within
systems.80 Middle managers who are sympathetic to professions can also be important: the involvement
changes may become important internal advocates, of clinicians from different specialisms, with
and may be crucial in providing not only the different values, norms, and conceptions of the
resources but also the justifications for activities.81 evidence base, can obstruct engagement.
Middle managers and ward staff can be difficult Successful strategies in some of the programmes
to engage in new interventions because they included opportunities for coaching and reflecting
already face numerous, complex and often on the nature of these professional silos, which
competing clinical and organisational demands, offered a rare chance to escape the day-to-day
often with inadequate staffing, limited resources pressures of roles into which award holders had
and equipment shortages. Since they are already been socialised over many years. Multidisciplinary
balancing multiple competing priorities, initiatives learning – both among award holders and in the
that generate further paperwork are likely to settings in which improvement projects were
be especially unwelcome (SPI I). Complex being undertaken – also showed some promise in
interventions might be viewed as daunting (SPI I), mediating the boundaries between professional
so making the implementation appear manageable and disciplinary groups. This finding is in line
is important in securing the support of frontline with suggestions from both the literature on
staff (SPI I). Others have noted the importance improvement and broader social scientific theory
of ensuring that the information infrastructure and evidence.34,83,84 However, this evidence also
supports, rather than deters, staff engagement.12 indicates that a multidisciplinary community,
covering multiple professions and specialties and
Factors found to affect medical engagement in the including managers, is not something that can
SPI include: improvement track record; resource be imposed. Rather, if it is to be sustainable and
allocation; perceptions of purpose of intervention; effective, it needs to be driven by the volition of
evidence of efficacy; external expertise; local those groups themselves, and thus needs to be
programme champions; and management viewed as legitimate and worthwhile by different
involvement (Journey to safety). In the same stakeholders and according to the standards of
programme, managers were more likely to report different professions.

Challenge 7: Leadership There are risks that individuals aspiring to be
The wider literature on improvement finds an seen as ‘inspirational’ or ‘transformational’ in fact
important role for leadership, especially clinical alienate others and perhaps are seen as claiming
(often medical) leadership, which can be crucial credit for efforts made by people in the middle
in ensuring that initiatives gain traction at a layer and the sharp end. This implies not just
local level.12 The Health Foundation evaluations collective responsibility for leadership across
found that leadership of complex improvement clinical and managerial groups, but also a broad
interventions requires a combination of technical set of strategies that are credible at different levels
skills, facilitation skills and personal qualities in the organisation and with different professional
(Leadership review). In line with findings in the groups, and which are thus most likely to wield
wider literature,42,61,62 leaders are required at all influence and change policy and practice.34
levels, from the frontline to executives. Time and The improvement leader might perhaps best
space to develop leadership capacity is noted as a be characterised as an enabler, rather than a
crucial success factor in several of the evaluations figurehead, and this role involves enabling
of the Health Foundation’s programmes, others to contribute views, expertise and ideas,
especially given the diverse backgrounds and creating networks, facilitating cooperation and
limited leadership experience of many of those collaboration, building confidence and trust in
awarded funding. Also prominent is the breadth others (Leadership), and sparking enthusiasm
and diversity of leadership qualities needed, and maintaining momentum (EWQI). ‘Quieter’
and the particular importance of facilitative, leadership, which is less about bombastic
enabling forms of leadership in achieving the declarations and more about working to
aims of improvement, given the position of most facilitate collaboration among key stakeholders,
award holders in the ‘middles’ of organisations. may be key.66
Leadership of improvement needs to be confident,
but not overly dominant (Shared Leadership).
Of particular importance are the interpersonal,
Challenge 8: Balancing
relationship and engagement skills needed carrots and sticks – harnessing
to involve and encourage others (Leadership commitment through incentives
review). Bradley et al., for example, found that and potential sanctions
‘uncompromising clinical leaders’, who were willing Busy clinicians may need incentives in order to
to make things happen but also sensitive to the prioritise improvement. The literature suggests
needs of team members, were a crucial component that the more indirect and dispersed the benefits
in the improvement project they studied.15 of an intervention are perceived to be, the less
likely clinicians are to become involved,15,16 and
Given the focus, aims and recipients of its
the evaluations support this view (EWQI 2009).
improvement awards, the Health Foundation’s
Visible improvements and unequivocal evidence
conceptualisation of leadership is well supported
that patients will benefit from improvement
by the wider social scientific evidence base.
activities can act as an incentive for greater clinician
However, this evidence base also highlights
involvement in what is generally seen as a relatively
the need for a plurality of leadership roles,
low status activity with poor rewards (EWQI 2007,
distributed throughout the different levels of the
2009). One suggestion is developing audit as an
organisational hierarchy and across the multiple
activity that can be used as evidence for engagement
groups that need to be engaged.63 This reflects
in continuing professional development and
the findings of a growing body of research on
revalidation (EWQI). Linked to this, monitoring
leadership in public sector organisations, which
systems could act as an incentive by imbuing staff
emphasises the importance of more distributed
with a sense of accountability (SPI I). Similar
forms of leadership across organisations where
efforts have been reported in the wider literature to
organisational aims are ambiguous, and power is
have generated some success.15,16,62
located across multiple professional groups.64,65

Peer pressure and peer esteem generated through Support from professional associations can thus
activities such as comparative audits, regional offer powerful backing to an improvement project,
meetings and peer-review visits (EWQI) may be but projects also need to develop for themselves
important drivers of change, while incentives for a clear theory of change that sets out how they
managers might include cost-benefit evidence and plan to shift behaviour in pursuit of improvement,
delivery of key targets (EWQI 2007). which draws in both softer and harder tactics in a
complementary manner.28
Although the SPI was seen as enhancing the career
prospects of a select few, attaching reputational
incentives to improvement programmes was Theme 3: Sustainability,
recommended as a ‘strategy for the future’ spread and unintended
(SPI I). Similarly, the Shared Leadership scheme
evaluation argued that career management and consequences
the reward system should be organised to keep A final theme relates to sustainability, spread
the team together and increase sustainability. and the potential for the intervention to produce
Certainly, the wider literature suggests that unintended – and unwanted – consequences. The
alignment with clinicians’ values and motivations evidence from the evaluation reports on these topics
can facilitate engagement with improvement.13,16 is relatively limited, as most of the evaluations
coincide with the periods of the programmes
To a large extent, many of the improvement
themselves, and do not include follow-up studies.
projects funded by the Health Foundation seek
Extending evaluations to look at the longer-term
to draw on the intrinsic motivation of healthcare
effects of programmes may be something for
professionals to maximise the quality and
the Heath Foundation to consider in the future,
effectiveness of the care they provide for patients.
especially given that sustaining and spreading
However, professional commitment and the
improvements within and beyond organisations
public service ethos only go so far in securing
is a well known challenge: the ‘improvement
change. Where projects come up against hostility
evaporation effect’ can mean that initial gains in
or indifference, ‘softer’ modes of persuasion
quality and safety diminish over time.87
may be inadequate to make changes to practice.
If intrinsic motivation is lacking, then harder
tactics may be needed in addition to softer forms Challenge 9: Securing sustainability
of encouragement. Some of the more successful The available evidence suggests a need for
projects in the EWQI learned this lesson early on, an explicit model for spreading learning
and applied a combination of soft persuasive tools and sustaining change from the outset (SPI;
and ‘harder edges’ to achieve change across systems Leadership review). Involvement in improvement
– for example, some projects deployed a system of programmes may act as a stabiliser in times of
peer review and audit early on as a means of both uncertainty (Shared Leadership), but may also
supporting change, and reminding participating enable improvements to be better sustained in
sites that they were being ‘checked up on’. the future, especially when the policy focus has
moved elsewhere (SPI I). Yet unless measures are
The key here appears to be to find a combination
embedded in wider mechanisms, clinicians’ and
of strategies, in which the harder approaches that
managers’ interest is likely to waiver when they
rely on extrinsic motivation do not undermine
are faced with new, competing priorities (EWQI).
the intrinsic will to improve quality that most
‘Locking in’ changes by changing performance
healthcare professionals will possess.85 The medical
management policies and organisational
profession offers a sophisticated example of this,
infrastructure to accommodate them can be
in which the assumed professional commitment of
crucial in sustaining change.27
individuals is backed up by a system of regulation,
support and potentially admonishment from peers
if an individual professional should deviate.86

The EWQI evaluation noted that improvement The appropriateness of transferring successful
activities appeared to have more traction when they interventions to different contexts is another
are pulled into routine activities. A key problem was issue raised in the evaluation reports. There are
the over-reliance on certain individuals, rather than significant dangers of assuming that because an
institutionalised processes such as the adaptation of improvement intervention has been found to
standards and guidelines and the building of local work in one context, it is possible to transplant it
capacity to lead change. Relying on individuals elsewhere. The evaluations do contain some reports
is a threat to stability as impact, support and of successful transfers within specific clinical
commitment can quickly be lost if they move on areas. In the EWQI programme, for example,
(EWQI). Equally, organisational change can quickly methods from Scottish National Audit Project-
destabilise progress and reverse achievements Community Acquired Pneumonia (SNAP-CAP)
unless improvements are fully embedded (SPI Lng). were transferred to other infection areas and the
Senior executive support may be required to sustain care bundle was adopted at sites in other regions
progress in the face of such challenges. (EWQI). There were also examples of projects and
individuals contributing to the development of
An obvious challenge to embedding is the lack of national standards and strategies and informing the
ongoing resources, especially when organisations design of future programmes and campaigns (SPI
face challenging financial situations. In many Lng, EWQI). However, broadly speaking, transfer
Health Foundation programmes, individuals of complex, multifaceted improvement approaches
have continued to commit time beyond the is not a straightforward matter, but important
end of the initiative to ensure improvements learning can migrate from one setting to another.88
are maintained. Some projects have secured
Organisational contexts may mean that effects vary
additional funding through subscriptions or other
considerably (EWQI). The successes of complex,
awards programmes. In the case of individuals
multifaceted approaches to improving quality
on leadership schemes, some had been successful
can be especially hard to replicate beyond the
in attracting additional resources from their
original sites, requiring patience and adaptability.88
employing organisation. However, in most cases,
In particular, it may be difficult to transfer
projects have to be resource neutral, or use existing
interventions from defined and distinctive clinical
resources more efficiently, if they are to continue
areas such as intensive care, where there is greater
(EWQI). Not all projects will become sustainable
scope to address people and context issues, a
services; they need to be able to demonstrate
stronger team culture and day-to-day leadership
clinical effectiveness and efficiency in order to
(SPI Lng). The ‘tribal’ nature of many hospitals,
become part of mainstream services (SPI Lng).
with ‘subcultures [living] out their lives in glorious
In the leadership schemes, examples could be isolation one from the other’,82 can also make
found of individuals applying learning in a transfer between directorates, wards and even
practical context. These included introducing an teams difficult.75 This is consistent with the social
accountability framework and altering the trust’s science finding that internal cohesion works to
plans to implement cuts. Others had gained reinforce behavioural changes, making it difficult
buy-in from senior leaders for a countywide for individuals to deviate from initiatives embraced
leadership development strategy (Leadership by their colleagues.89
review). Despite these successes, a major limiting
factor was that leading improvement did not The reach of some interventions is only ever likely
always fit with standard professional roles to be localised, given the size of the team and the
(Leadership). In addition, exemplar and advocate size of the domain (Shared Leadership), and the
roles are only sustainable in an organisation where time and resources available, which may mean
the culture supports leadership development that only a limited number of people are ever
(LF pilot). This reflects points made above about exposed to the intervention (SPI I; Leadership
the limited degree to which advancement along review). Even with a well-founded and conducted
clinical career pathways is enhanced by leadership programme, impact is likely to be patchy and
of improvement.16 limited (EWQI).

Challenge 10: Side
effects of change
Any intervention risks unintended consequences
and supporting positive side effects while mitigating
for negative ones can be a challenge. Although
none of the evaluations attempt to explicitly capture
the side effects of change caused by improvement
efforts, some of the evaluation reports discuss the
risk of unintended consequences, including the
prospect of clinicians becoming disenchanted with
improvement. The Co-creating Health report,
for example, identifies the risk of existing good
practice being disrupted. In a few projects, there
were unexpected opportunity costs, which were
felt by some to outweigh any benefits (for example,
non-provision of backfill costs in the Shared
Leadership programme). The need to be alert to
the side effects of improvement is now increasingly
recognised,90,97,98 but the methods for their detection
remain poorly developed.

Chapter 4
Key issues in overcoming
the challenges to improvement
Poor understanding of how organisational In addition to identifying some of the key

contexts and other challenges affect improvement challenges faced in improvement, our analysis
remains a stubborn obstruction to getting both has highlighted some of the ways in which the
the design and implementation of improvement evaluations and the wider literature suggest
efforts right. In this report, we have sought to overcoming them. Table 1 summarises the main
synthesise learning across the evaluation reports lessons of this analysis, placed under the three
of improvement projects and programmes broad themes. We then offer a short discussion
undertaken by the Health Foundation, which of some of the important issues arising from this
seek to improve quality by building leadership for analysis.
quality and through wider supporting mechanisms.
Table 1: Practical lessons in overcoming challenges to improvement

Challenges that affect improvement Ways to overcome challenges
Theme 1: Design and planning

Problem being addressed not seen as ‘real’ by staff Peer-led debate and discussion; use of hard data to
demonstrate extent of problem
Weak evidence base means intervention Avoid areas where the evidence base is weak or
lacks credibility professional consensus cannot be reached
Involvement of respected senior figures (expert opinion
leaders)
Approaches inappropriate for local context Piloting of approaches and revision (or rejection)
as appropriate
Over-ambitious aims given timescale and/or resources Better recognition of the scale of resource, effort and
support required
Focus on more defined area
Trialling to help identify support needed

Lack of clarity about definitions/nature of award Ensure basic details agreed at outset
Methods of evaluation not built in/baseline Consider evaluation at planning stage

measures not collected
Difficulty isolating impacts of interventions and Build in evaluation methods from outset eg collect
attributing change appropriately baseline measures
Control group
Counterfactual approach
Importance of evaluation not well-understood External support may be required; needs to be built in
eg difference from improvement/performance from the beginning
management Local teams need strong support
Data collection oriented towards research rather Focus on ways in which data can be used to benefit
than improvement patients
Not a significant improvement because already Target those sites/individuals with greatest potential
good at baseline to benefit
Lack of administrative support Factor in costs of administrative support to project budget
Unexpected opportunity costs or other unwanted Make limits of funding as clear as possible at start eg
consequences whether backfill costs met
Theme 2: Organisational and institutional

contexts, professions and leadership
Lack of organisational structures to support Need to identify support required and allow time/
implementation resources within project to establish systems if these are
not in place eg to collect data
Improvement valued less highly than medical research Support of senior executives, professional bodies, reward
structures
Limited capacity for organisational learning Involvement of senior managers required

Culture needs to support learning and development
Need to align departments, professionals, levels Reduce number of areas to be tackled
Shifting agendas/priorities in the ‘outer context’ Map interventions to core themes as well as specific
policies

NHS career structures not suited to progression via Support of senior executives and professional bodies
improvement eg clinicians need to look beyond daily Reputational incentives (raise status of improvement)
work to apply or change careers
Peer pressure/peer esteem (eg peer-review visits,
comparative audit)
Personnel changes Embed in institutional structures rather than relying on

individuals
Lack of incentives to encourage participation Highlight visible improvements

Use as evidence for continuing professional development/
revalidation
Reputational incentives (raise status of improvement)
Peer pressure/peer esteem (eg peer-review visits,
comparative audit)
Improvements seen as management-led/imposed Clinician-/staff-led approaches

Involvement of professional bodies
Differing views between various professions, clinical Involve representatives from all areas/professions involved
areas and stakeholder groups in design of intervention
Focus on defined clinical areas
Language barriers between clinicians and managers and More opportunities for cross-professional working
lack of understanding of roles Use of intermediaries eg training staff
Mix of skills required to deliver improvements Multidisciplinary teams and draw on external support
Lack of staff skills (eg teamworking, networking) Include training as part of the project
Inappropriate leadership style Training for leaders at all levels in

enabling/subtle leadership
Roles not clearly defined eg service users, boards Establish stakeholder involvement and roles
at an early stage
Lack of engagement of ward staff and middle managers Ensure paperwork associated with project is not excessive
Make sure intervention appears manageable
Ensure early and full support of clinical leaders
Peer-led interventions/peer opinion leaders
Build in rewards for middle managers and ward staff
Lack of staff time Protect dedicated staff time to work on improvements,

including reflection
Ensure activities recognised as a priority

Theme 3: Sustainability, spread and unintended consequences

Reach of interventions highly localised Need to be realistic about likely reach at start
Longitudinal monitoring to allow time for effects to reach
‘sharp end’
Lack of continued funding Identify future funding sources eg subscriptions,

other funders
Identify ways to use resources more efficiently
Projects not embedded in wider Need to write into standards, guidelines, procedures etc
mechanisms/routine activities Need involvement of senior managers
No specific requirement to apply/spread learning Specify in award documentation
Improvements not transferred successfully Identify areas to which improvement can be transferred
successfully (likely to be closely allied)
Need to take account of organisational context when
transferring (may need to adapt)
Needs involvement of professional bodies and those
developing national strategies
Perhaps the overriding message is that there deficit of care is revealed. Yet needing to improve
is no magic bullet in improvement. This does care and knowing how to do it are two very
not mean that nihilism has a place, but it does different things.90 A feature of improvement for
mean a need to accept the challenges and adopt perhaps the last decade has been pressing on to
a solution-focused approach. Much of what we action without enough of an evidence-base for
have found concerns tensions and balances, so intervening, or enough planning, assessment and
solutions need to be nuanced, sensitive, and consultation, and then looking for impressive
sensible, while maintaining a firm focus on the results in a short period of time. An important
benefits of improvement for patients. Securing lesson for future initiatives may be the need
the engagement of multiple stakeholders in for much more extensive project development
improving quality requires multiple approaches, periods. Significant investment is needed in
many of them apparently contradictory: strong specification of the theory of change, consultation
leadership alongside a participatory culture; with stakeholders, designing and selecting
direction and control but also flexibility according the appropriate measures and setting up data
to local need in implementation; critical feedback collection systems, and assessing organisational
on performance but without the attachment of capacity. At the same time, improvement design
blame.15 Making progress in addressing challenges needs to supply a framework for change rather
to improvement will require negotiating many than a rigid specification; adaptability is a crucial
cramped channels. component of improvement.
One tension is between action and evaluation. Another, related tension is that of project status.
There is an understandable urge to action On the one hand, it can provide excitement and a
improvement, particularly when evidence of a clear impetus for change, but it can also hamper

effectiveness in a number of different ways. such as administrative support, and high-level
The sheer complexity of healthcare organisations, buy-in from senior management, is likely to have
with their multiple tribes of professionals and a significant effect on the likelihood of success
managers, changing policy imperatives, and of an improvement project. Senior level buy-in
divergent accountabilities to patients, regulators needs to be backed up by active support, two-
and accountants, means that most improvement way communication and strategic alignment.
initiatives are but a small contribution to activity. Leadership styles also need to take account
There is a need to consider, in the early stages of of the need to facilitate collaboration across
planning, how well improvement projects align multiple professional groups to secure success in
with national policy pressures. Projects that run improvement. There are some suggestions that
counter to national pushes, or that are introduced creating ‘celebrity’ leaders for improvement within
into environments already suffering organisational organisations may ultimately prove alienating,
stress from mandated requirements, will face while under-resourcing of apparently unglamorous
challenges in achieving success. roles such as clerical support may prove fatal to an
improvement effort.
Tensions also arise in relation to the excitement
surrounding projects, especially when, as is Even in organisations where there is capacity
usually the case for the Health Foundation, awards and senior-level support, personnel changes,
for projects are awarded through a competitive particularly if they involve senior sponsors
process and are seen as highly prestigious. and ‘mentors’ of award, can seriously disrupt
Improvement project leaders can easily be carried improvement progress. In some organisations,
away by enthusiasm or a perceived need to impress improvement activities are perceived as a
the funder, fail to set goals that are reasonable, peripheral activity outside the mainstream
or drain resources and energy from other business of providing healthcare. Some of the
important activities. This can be compounded aspects of awards most valued by award holders,
by organisational impatience for quick wins and such as learning sets, coaching and ‘time out’
early results and so needs to be managed carefully. for reflection, may be most vulnerable to
Projects are particularly challenging when they are erosion if organisations are not fully supportive.
complex, involve multiple priorities, and stretch Consequently, significant attention is needed to
structures and goodwill too far. Ambitious projects help ensure that organisational support does not
with ‘stretch’ targets can easily underestimate wane. This may include closer links between these
the resources required, and indeed the amount aspects of interventions and funding arrangements
of work needed to achieve change throughout a and making clear the connection between these
ward, department or hospital. Explicit assessments improvement processes and patient outcomes.
of the effort required by participants need to be
undertaken, and participants need to make explicit Given our analysis of organisational challenges
commitments to deliver on this effort. Allied to this, to improvement, one tempting option is to
it is likely that specific kinds of project management focus intensely on the contexts that are most
skills for improvement interventions need to be receptive to change, and thus where the return
developed, to ensure that the dangers of goal on investment in improvement is likely to be
displacement – where, for example, meeting pre-set greatest. The experiences of projects under both
targets or milestones becomes more important than SPI and EWQI show that improvement is achieved
achieving positive change – are averted. much more easily in some settings than others:
for example, the highly contained and culturally
The evaluations and the wider literature repeatedly cohesive setting of the intensive care unit seemed
find differential capacity across organisations a more fertile environment in which to achieve
to support improvement initiatives. The degree behavioural change than other departments.
of readiness, in terms of physical infrastructure Focusing efforts on units characterised by strong,
such as information systems, human resourcing reciprocal ties between staff, where there is greater

acceptance of group norms and more opportunity of change. Engaging so many constituencies
for self-monitoring and informal social sanction, takes time and energy, and is no guarantee of
may be more likely to reap the rewards of success; unexpected events or turbulence in the
improved quality and safety.89,91 However, even this outer context can easily take the wind from the
approach involves a tension – since it may well be sails of an improvement initiative. However, if
that the ‘stony ground’ units, wards or practices an improvement project can be aligned with the
are those most in need of improvement. The risk interests of multiple stakeholders, and tied into
then is that focusing efforts on easy wins simply enduring policy foci, then it has a better chance of
increases inequity. securing wider influence over time.
A further tension is the need to appeal to multiple Coordinated actions at multiple levels, seeking
different audiences; gaining the support of one influence through multiple professional networks
stakeholder group may mean alienating another. covering all stakeholders,94 are needed to secure
Getting relationships and engagement right is change in organisations. Clear leadership on
one of the most important building blocks of what needs to change must be combined with
an improvement effort. Securing and retaining sensitivity to local particularities and adaptability
engagement of staff towards improvement ends in implementation to secure a sense of ownership
requires, as Bradley et al. put it, the ‘ability to pursue and reduce the level of perceived threat. However,
simultaneously contrasting approaches and balance efforts to engender ownership can be viewed as
the tensions between them’.15 Gaining agreement tokenistic if they take place within a management
on the problem to be addressed is perhaps the most culture that is perceived as top-down and
important first step in building consensus and authoritarian, and if staff feel that important issues
coalition. A clear finding across the reports is that are being marginalised.
both the problem to be addressed by improvement,
and the evidence for the effectiveness of the means Sustaining progress over time presents a further
to address it, need to be seen as legitimate by the challenge. With appropriate engagement with
staff affected by it. Care is needed in deciding where professional associations and royal colleges,
to focus improvement interventions and in ensuring improvement activities can potentially become
that they offer clear advantage over what is already mainstreamed through training and revalidation
in place. processes. Improvement interventions are much
more likely to succeed when they are developed
Efforts that go ‘against the grain’ of wider with rather than imposed on healthcare
professional, organisational and policy aims are professions. Projects seeking to change behaviour
likely to face significant difficulties in realising without some form of professional endorsement
their ambitions. At a senior management level, at a local or national level are often on a hiding to
fit with wider organisational aims means that nothing: professional groups continue to remain
improvement projects are more likely to be met crucial actors in the acceptance or refusal of
with active enthusiasm rather than indifference.92 efforts to change practice.23,95,96 Improvements in
At the frontline, fostering a sense of ownership is quality are vulnerable to changes in organisational
crucial, so that the stakeholders whose practice context and to declining interest and enthusiasm,
is likely to be affected directly have had a chance especially if they are not incorporated into
to participate in refining the improvement wider performance management systems and
intervention.93 Middle managers are very often organisational policies. Again, however, the risk of
neglected, yet their role in improvement is crucial resentment and ritualised displays of compliance
and they require better recognition and support. increases once an improvement activity becomes
This means achieving a balance between fit with part of a performance management system.
broad aims that will secure the crucial sponsorship
of senior managers, and a degree of flexibility that
enables those whose behaviour is to be changed to
be participants in the process, rather than objects

Chapter 5
Conclusions
The Health Foundation is committed to Many of the factors identified in this review
supporting improvement that will enhance are inter-related and are part of wider, complex
the quality, safety and experience of patients systems. Successfully intervening to overcome
in the NHS. Many leaders of those who have one challenge may give rise to others; as noted
received Health Foundation support have been above, the unintended consequences of efforts to
innovative in negotiating the challenges in the improve quality are insufficiently studied. More
complex organisational and professional context explicit acknowledgement of the complexity of
of healthcare. But change is hard and slow.99 the challenge facing those improving quality may
Many challenges are deep-set and structural in help to trim ambitions, avert disappointment, and
nature, and resistant to even the most determined maximise learning.
leader of change. Some aspects of organisational
context may not be amenable to change through This is not to suggest pessimism about the efforts
individual or team efforts, no matter how ‘heroic’, of the Health Foundation and others committed
‘transformational’ or determined the leadership, to achieving change through the agency of
and no matter how generous the support. At least clinicians and others working at the coalface
some failures are to be expected, and may not be of healthcare. While some challenges may
attributable to any deficiencies on the part of award seem impossible to overcome, others become
holders and their teams; they should, instead, be more amenable to intervention as we learn
treated as learning opportunities and contributions more about them. Many achievements in the
to improvement science. evaluation reports are testament to how much
can be improved with financial backing and the
right training and support. The evaluations as
a whole also highlight the potential for refining
and honing the science of quality improvement
through rigorous evaluation and careful synthesis
of the lessons produced by this. We hope that our
analysis may help to define further strategies.

Appendix
Summary of reports reviewed
Safer Patients Initiative These trusts had two stretch aims: a 30% reduction
in adverse events and a 15% reduction in mortality
The Safer Patients Initiative ran from 2004–08. over a 20-month timescale.
It was set up to test practical ways of improving
hospital safety and to demonstrate what can be Learning report: Safer Patients Initiative
achieved through an organisation-wide approach (SPI Lng), February 2011
to patient safety.
This learning report provides an overview of
Safer Patients Initiative phase 1 (SPI I), the Safer Patients Initiative (phases 1 and 2) and
February 2011 its evaluation, and highlights the impact of the
programme, key lessons and further issues for
The first phase of the Safer Patients Initiative began
exploration.
in 2004, when four UK hospitals were selected
through a competitive process. Each of the trusts The journey to safety: a report of 24
undertook improvement in leadership in the four NHS organisations undertaking the Safer
clinical areas using a predefined measurement Patients Initiative (Journey to safety),
framework. They were given an ambitious stretch unpublished
goal of halving the number of adverse events
across their organisation over two years. This programme examined five core issues
essential for any safety programme:
An organisation-wide focus on patient safety
underpinned the improvement work in each clinical – the role of the patient in patient safety
area. This involved developing better communication, – raising awareness of safety issues across
training staff in improvement methods, creating organisations
new systems for measuring process and outcomes,
– the improvement of clinical processes
and reporting and learning from adverse incidents.
Chief executives and senior teams were fully – high reliability units and the transformation of
involved in the programme, ensuring that patient whole organisations
safety remained a top strategic priority. – how safety is addressed at each level of an
organisation in a series of nested steps (focusing
Safer Patients Initiative phase 2 (SPI II),
on the Safer Patients Initiative).
February 2011
A second phase of the initiative began in 2006.
Phase 2 saw 20 further hospitals join the scheme,
working in pairs so as to learn from each other’s
successes and challenges.

Leadership programmes Leadership programmes
(2008–11) (2003–08)
What’s leadership got to do with it? A review of the Health Foundation’s
(Leadership), January 2011 leadership programmes 2003–07
This is an in-depth evaluation of the Health (Leadership review), October 2008
Foundation’s leadership programmes, including In 2003, when the Health Foundation started
an exploration of the links between leadership and investing in leadership development for clinicians
improvement. The three core enquiry questions for and managers in UK healthcare organisations,
the study were: there was insufficient funding for developing
leaders and limited learning from what was being
– What are the links between improvement and undertaken. The aims were to produce more and
leadership behaviour? better leaders, to learn what works and to share it
– Do different types of improvement require widely. This review describes the history, evolution
different leadership behaviours? and impact of this investment.
– What are the lessons for leadership Leadership Fellows pilot scheme (LF pilot),
development generally and for the Health September 2006
Foundation specifically?
This report identifies lessons from a formal
This report presents a detailed account of the evaluation of the pilot of the Health Foundation
two-year study and the conclusions that Leadership Fellows Scheme 2003–05. The aim
emerged. It contains insights into how leadership of the pilot was to inform the development of a
development can support improvement in the scheme to identify and develop a cadre of leaders
NHS. with the potential – collectively and individually
– to bring about improvements in the quality of
Evaluation of the Shared Leadership for healthcare. The 16 award holders involved in the
Change programme (Shared Leadership), pilot were provided with coaching, mentoring,
June 2009 action learning sets and master classes.
This scheme was designed to test a hypothesis
that provision of structured support to teams to Leaders for Change evaluation report
improve functioning, using a model called ‘shared (Leaders for Change), August 2006
leadership’, would lead to improvements in team The aim of the scheme was to equip middle and
processes and patient outcomes. The scheme senior professionals who have a leading role in
focused on diabetes managed clinical networks. service improvement with the necessary skills and
Six multidisciplinary diabetes teams took part in knowledge in managing and implementing change.
the scheme between October 2005 and July 2007. The award involved:
– undertaking a project (which forms the context
for development during the period of the award)
– attending three action learning sets
– attending a modular Change Agent Skills
programme
– undertaking a personal development
programme
– using an e-learning resource.

Engaging with Engaging with Quality
Quality Initiative in Primary Care
The three objectives of the Engaging with Quality Engaging with Quality in Primary Care:
Initiative were to: evaluation of the Leading Improvement
Teams Programme (EWQPC), March 2011
– engage clinicians in leading improvement
projects that would achieve measurable This is a major demonstration and examination
improvements in clinical quality of how to engage primary care clinicians from a
variety of disciplines in improving the quality of
– identify effective strategies for clinical the healthcare that they provide. The study was
improvement that could be replicated and premised on the argument that actively engaging
spread across the healthcare system clinicians provides a sustainable and cost-effective
– increase capacity for clinical quality means to improve outcomes for patients.
measurement and improvement in the UK by
developing the infrastructure. Co-creating Health
An evaluation of the Health Co-creating Health evaluation
Foundation’s Engaging with Quality (Co-creating Health), in press
Initiative (EWQI 2007) October 2007
This programme aims to achieve measurable
This is the second annual report evaluating this improvements in the quality of life of patients
initiative. with a long-term condition and to improve their
experience of the healthcare system by embedding
An evaluation of the Health self-management support within mainstream
Foundation’s Engaging with Quality health services. The evaluation report will look at
Initiative (EWQI 2009), March 2009
how successfully this aim has been met.
This is the third annual report evaluating the
initiative.
How do you get clinicians involved in

quality improvement? (EWQI), August
2010
This is the final evaluation report of the initiative.

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Evidence:

Identify Innovate Demonstrate Encourage

This research was managed by:

Emma Henrion, Senior Evaluation Manager and

Authors Organisation Contact

© 2012 Health Foundation

OVERCOMING CHALLENGES TO IMPROVING QUALITY i

ii THE HEALTH FOUNDATION

Chapter 2: Approach and methods 3

Chapter 3: Findings: factors affecting improvement 5

Chapter 4: Key issues in overcoming the challenges to improvement 23

Appendix: Summary of reports reviewed 31

OVERCOMING CHALLENGES TO IMPROVING QUALITY iii

Improving quality in healthcare is intrinsically Theme 1: Design and planning

– integrated approaches to self-management Challenge 4: Excess ambitions and

OVERCOMING CHALLENGES TO IMPROVING QUALITY v

vi THE HEALTH FOUNDATION

OVERCOMING CHALLENGES TO IMPROVING QUALITY vii

OVERCOMING CHALLENGES TO IMPROVING QUALITY 1

Review of the Leadership programmes (2003–08)

Safer Patients Initiative (SPI) Engaging with Quality Initiative

OVERCOMING CHALLENGES TO IMPROVING QUALITY 3

4 THE HEALTH FOUNDATION

The evaluation reports are necessarily defined – design and planning

OVERCOMING CHALLENGES TO IMPROVING QUALITY 5

6 THE HEALTH FOUNDATION

OVERCOMING CHALLENGES TO IMPROVING QUALITY 7

8 THE HEALTH FOUNDATION

OVERCOMING CHALLENGES TO IMPROVING QUALITY 9

10 THE HEALTH FOUNDATION

Theme 2: Organisational The motives of organisations for participating

OVERCOMING CHALLENGES TO IMPROVING QUALITY 11

12 THE HEALTH FOUNDATION

OVERCOMING CHALLENGES TO IMPROVING QUALITY 13

14 THE HEALTH FOUNDATION

OVERCOMING CHALLENGES TO IMPROVING QUALITY 15

16 THE HEALTH FOUNDATION

OVERCOMING CHALLENGES TO IMPROVING QUALITY 17

18 THE HEALTH FOUNDATION

OVERCOMING CHALLENGES TO IMPROVING QUALITY 19

20 THE HEALTH FOUNDATION

OVERCOMING CHALLENGES TO IMPROVING QUALITY 21

Poor understanding of how organisational In addition to identifying some of the key

Table 1: Practical lessons in overcoming challenges to improvement

Theme 1: Design and planning

OVERCOMING CHALLENGES TO IMPROVING QUALITY 23

Methods of evaluation not built in/baseline Consider evaluation at planning stage

Lack of administrative support Factor in costs of administrative support to project budget

Theme 2: Organisational and institutional

Limited capacity for organisational learning Involvement of senior managers required

Need to align departments, professionals, levels Reduce number of areas to be tackled

24 THE HEALTH FOUNDATION

Personnel changes Embed in institutional structures rather than relying on

Lack of incentives to encourage participation Highlight visible improvements

Improvements seen as management-led/imposed Clinician-/staff-led approaches

Inappropriate leadership style Training for leaders at all levels in

Lack of staff time Protect dedicated staff time to work on improvements,

OVERCOMING CHALLENGES TO IMPROVING QUALITY 25

Theme 3: Sustainability, spread and unintended consequences