2. What are ‘quality’ and ‘quality improvement’?


The terms ‘quality’ and ‘quality improvement’ mean different things to different people in different circumstances. This can be confusing. This section looks at common definitions of both terms, and summarises how they are broadly understood.

What is quality?

Within healthcare, there is no universally accepted definition of ‘quality’. However, the following definition, from the US Institute of Medicine, is often used:

[quality is] the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

The Institute of Medicine has identified six dimensions of healthcare quality.3 These state that healthcare must be:

  • safe
  • effective
  • patient-centred
  • timely
  • efficient
  • equitable.

The dimensions of quality


Avoiding harm to patients from care that is intended to help them.


Reducing waits and sometimes harmful delays.


Providing services based on evidence and which produce a clear benefit.


Avoiding waste.


Establishing a partnership between practitioners and patients to ensure care respects patients’ needs and preferences.


Providing care that does not vary in quality because of a person’s characteristics.

The Health Foundation regards quality as the degree of excellence in healthcare. This excellence is multi-dimensional. For example, it is widely accepted that healthcare should be safe, effective, person-centred, timely, efficient and equitable.

Therefore, leaders need to actively consider these six dimensions when setting their priorities for improvement. Often the dimensions are complementary and work together. However, there can sometimes be tensions between them that will need to be balanced. It is also important to take into account different stakeholders’ views about what they feel matters and what the priority areas of focus should be within an organisation.

What is quality improvement?

There is no single definition of quality improvement. However, a number of definitions describe it as a systematic approach that uses specific techniques to improve quality. One important ingredient in successful and sustained improvement is the way in which the change is introduced and implemented. Taking a consistent approach is key.

This guide draws its definition of quality improvement from that provided by Dr John Øvretveit, a leading expert on quality in healthcare, in his report Does improving quality save money?, which states:

The conception of improvement finally reached as a result of the review was to define improvement as better patient experience and outcomes achieved through changing provider behaviour and organisation through using a systematic change method and strategies.

The key elements in this definition are the combination of a ‘change’ (improvement) and a ‘method’ (an approach with appropriate tools), while paying attention to the context, in order to achieve better outcomes.

How can we improve quality?

The Health Foundation believes that a combination of approaches is needed to ensure sustained improvements in healthcare quality.

There are a number of external influences that need to be considered and used, where possible, to drive improvements in quality. These include professional requirements, centralised government initiatives and economic drivers, such as the Commissioning Quality and Innovation (CQUIN) payment framework.

There are also a range of models and methods that individual organisations can put in place themselves. These were originally developed within an organisational or industrial context. Organisations develop and set their own goals, with full staff engagement, and employ a systematic approach to implementing change and monitoring progress.

The focus of this guide is on these organisational or industrial approaches to quality improvement. We believe they have an important part to play in transforming services and driving up quality.

What would improve quality?

Quality improvement draws on a wide variety of methodologies, approaches and tools. However, many of these share some simple underlying principles, including a focus on:

  • understanding the problem, with a particular emphasis on what the data tell you
  • understanding the processes and systems within the organisation – particularly the patient pathway – and whether these can be simplified
  • analysing the demand, capacity and flow of the service
  • choosing the tools to bring about change, including leadership and clinical engagement, skills development, and staff and patient participation
  • evaluating and measuring the impact of a change.

Regardless of the approach used, how the change is implemented – including factors such as leadership, clinical involvement and resources – is vital.

The NHS Change Model highlights the following key areas for consideration:

  • leadership for change
  • spread of innovation
  • improvement methodology
  • rigorous delivery
  • transparent measurement
  • system drivers
  • engagement to mobilise.

How the implementation is managed will depend very much on the context of the particular organisation making the change, and requires careful consideration. For more information about the underlying principles of quality improvement, see Section 5.

Quality improvement approaches and sustainable change

Only around two-thirds of healthcare improvements go on to result in sustainable change that achieves the planned objective. Therefore, leaders need to think carefully about how they can embed positive change and make it sustainable.

There is evidence that sustainable change is more likely to result from a model that involves patients and staff in developing, designing and implementing changes than from a ‘command and control’/top down model.

Quality improvement in commissioning

There is growing awareness among healthcare providers of how industrial quality improvement approaches can benefit healthcare providers. But it is also important that commissioners have an understanding of these methods. Commissioners have a specific role to play in contracting for quality and ensuring that quality improvement approaches are being used to redesign and improve services.

The commissioners’ role includes:

  • building measures of quality and safety into commissioning specifications and, where appropriate, incentives and penalties
  • putting in place monitoring and management regimes that assess quality and patient safety processes
  • putting the emphasis on assuring quality and safety in evaluating current and potential providers
  • looking at governance and leadership on these issues, rather than merely policies and procedures
  • assessing for themselves how care is provided on the ground, and how the culture and values of the organisation are expressed in behaviour
  • using the CQUIN payment framework as a route to reward providers for quality improvement.

At the heart of every commissioner–provider interaction should be discussions about what is being done to improve quality.

By developing a better understanding of quality improvement approaches, commissioners will be better placed to ask the right questions about providers’ focus on improvement and the progress they are making. This will help commissioners ensure that quality is the driving factor in their relationships with providers.

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