Underlying principles

When participating in an improvement intervention for the first time, it is not necessary to be an expert in quality improvement approaches and methods. However, before starting it is important to understand the core underlying principles that are common to most approaches and methods currently being used in health care.

Understanding the problem

Before thinking about how to tackle an improvement problem, it is important to understand how and why the problem has arisen. Taking the time to do so, preferably by using a variety of data and in collaboration with a range of staff and patients, will help to avoid the risk of tackling the symptoms of the problem instead of its root cause.

One tool that can be used to identify the causes of the problem is a ‘cause and effect’ or ‘fishbone’ diagram, which is designed to enable teams to identify all potential causes, not just those that are most obvious. After identifying the most likely causes, teams can use a range of tools to investigate them further, such as patient interviews, surveys and process mapping.

Process mapping is a tool used to chart each step of a process. It is used to map the pathway or journey through part, or all, of a patient’s health care journey and its supporting processes. Process mapping is especially useful as a tool to engage staff in understanding how the different steps fit together, which steps add value to the process, and where there may be waste or delays. Mapping patient journeys involving multiple providers is also important to identify any quality problems that occur at the interfaces between teams and organisations.

Designing improvement

It is important to allow enough time to design an improvement intervention and plan its delivery. Developing a specific aim and clear, measurable targets is essential. Another key step is to align the aim of the intervention with wider service, organisational or system goals. This can help to attract support and resources from leaders and managers for a smooth implementation.

It is also important to consider any challenges that will need to be addressed for the intervention to achieve its aims. A driver diagram is a useful way of capturing these key issues and identifying the activities required to tackle them. A logic model, which sets out a theory of change about how an intervention is supposed to work, is another helpful tool.

When identifying an intervention, it is useful to look at how other teams have addressed similar improvement challenges. As well as providing insights about what has and has not worked in other contexts, it can help to avoid the risk of ‘reinventing the wheel’ by repeating work that has already been carried out elsewhere.

Data and measurement for improvement

Measurement and gathering data are vital elements of any attempt to improve performance or quality and are needed to assess the impact against set objectives. When trying to assess the impact of a change to a complex system, a combination of measures is often used, such as process and outcomes measures. Measuring for improvement aims to identify the changes that occur while the intervention is being tested so that the intervention can be refined over time in response to these data.

To measure change it is important to capture a baseline and then carry out measurement at regular intervals to gauge whether the impact of the intervention represents an improvement or deterioration compared to the expected level of performance variation.

It is also important to measure ‘what would have been’ without the intervention, bearing in mind any potential external causes of change seen in measurement. This can be done using statistical process control (SPC), a method that examines the difference between natural variation (common cause variation) and variation that can be controlled (special cause variation). SPC uses control charts that display boundaries (control limits) for acceptable variation in a process.

Improving reliability

A key focus of quality improvement is to improve the reliability of the system and clinical processes. Ensuring reliability mitigates against waste and defects in the system and reduces error and harm. Analysis of high reliability organisations, many of which can be found in industries that have developed and sustained high levels of safety, such as commercial aviation and nuclear power industries, has identified a number of common attributes and behaviours. These include a culture of ‘collective mindfulness’ in which staff routinely look for and report minor safety problems and share a willingness to invest time and resources in identifying and learning from errors.

In health care, systematic quality improvement approaches such as Lean (see Section 4) have been used to:

  • redesign system and clinical pathways
  • create more standardised working procedures
  • develop error-free processes that deliver high quality, consistent care and use resources efficiently.

Other health care organisations have taken a proactive approach to safety by developing the capacity to detect and assess system-level weaknesses (hazards and their associated risks) and introducing interventions to address them (risk controls).

Demand, capacity and flow

Some backlogs and delays in health care services are attributable to resource shortages or increases in demand. A case in point is the backlog of appointments and procedures created by the COVID-19 pandemic. However, not all delays are the result of capacity problems. It may be that the capacity is in the wrong place or is provided at the wrong time. To understand whether there is a capacity shortfall in a service, it is necessary to measure the demand (the number of patients requiring access to the service) and the flow (how and when a need for a service is met).

For a process improvement to be made, there needs to be a detailed understanding of the variation and relationship between demand, capacity and flow. For example, demand is often relatively stable and flow can be predicted in terms of peaks and troughs. In this case, it may be the variation in the capacity available that causes the problem (for example, how work plans are scheduled, staff sickness, and planned or unplanned leave).

The relational aspects of improvement

When planning, designing and testing an improvement intervention it is important to focus not just on the technical aspects of improvement, such as how to apply quality improvement methods and tools and to measure change, but also on the relational aspects of improvement. The way in which the team of people leading the intervention work together and how they communicate with others whose support they need, is likely to have a profound influence on the success of the intervention. These relational issues are discussed in the remaining part of this section.

Involving and engaging staff

Evidence about successful quality improvement indicates that the method or approach used is not the sole predictor of success, but rather it is the way in which the change is introduced. Factors that contribute to this include leadership, effective communication, staff engagement and patient participation, as well as training and education.

Engaging the people closest to the issue being addressed is especially important, but it can be challenging. For example, many clinicians will be keen to improve the quality of the service they offer and may already have done so through methods such as clinical audit, peer review and adoption of best practice. However, they may be unfamiliar with quality improvement approaches. For this reason, capability building and facilitated support are key elements of building clinical commitment to improvement. Other important aspects include:

  • involving the clinical team early on when setting aspirations and goals
  • ensuring senior clinical involvement and peer influence
  • obtaining credible endorsement – for example, from the royal colleges
  • involving clinical networks across organisational boundaries
  • providing evidence that the change has been successful elsewhere
  • embedding an understanding of quality improvement into training and education of health care professionals.

Clinicians are more likely to engage with the process if the motivation and reasons focus on improving the quality of patient care rather than on cost-cutting measures.

Nonetheless, it is important to ensure that all relevant staff are engaged, not just clinicians. Managers, for example, can help to ensure that improvement is embedded into standard practice and non-clinical staff, who are often the first point of contact for patients, play a key role in improving care. Breaking down traditional hierarchies for this multidisciplinary approach is essential to ensure that all perspectives and ideas are considered.

Co-producing improvement

At its best, quality improvement in health care is built on an equal partnership between staff, patients, carers and the wider public. These partnerships are part of a desire to move away from a staff-driven approach to improving care, in which patients are sometimes invited to participate, to a model where staff and patients make decisions that relate directly to the patient’s care together.

Underpinning these partnerships is a shared purpose, which is informed by discussions on what matters most to patients and where they think improvement efforts should be focused. Trust, openness and an ability to listen respectfully are key to the success of these discussions. A willingness to confront any power imbalances among participants, making it difficult for some participants to contribute equally, is also important.

Creating such an environment is not always straightforward: patients may need support and training to make the transition to being ‘makers and shapers’ of services, while professionals may need guidance on addressing certain issues, such as unconscious bias.

It is important that organisations invest resources into patient and public involvement in improvement and build up the necessary skills and knowledge to maximise the time, expertise and commitment of patients, carers and the wider public.

Building effective teams

How improvement team members relate to each other and work together has a critical bearing on the success of the intervention. Treating each other with respect and courtesy, listening carefully to the views of others and valuing their ideas, regardless of their hierarchical position, are all behaviours that can help the team to work together more effectively.

Equally important are a willingness to learn together and a sense of humility, founded on an awareness that no single person has the skills and experience to solve a problem on their own. Any team disagreements should be resolved through open discussion, rather than by personal or positional power.

Other vital attributes are the ability to ask questions clearly and frequently, and to share knowledge and thoughts in a focused and timely fashion. These ‘teaming’ skills help team participants to interact effectively and efficiently.


Collaboration is an essential component of effective learning and improvement. Working collaboratively and outside of traditional organisational boundaries often provides the basis for understanding and addressing improvement challenges. Networks and partnerships such as clinical audit networks, academic health science networks, primary care networks, the Q community (see Section 6) or other similar groups enable the sharing of experiences, knowledge and expertise within local health systems.

Collaboration also provides opportunities for scaling up of techniques, learning and discussion and can drive continued developments in quality improvement. Health care quality improvement strategies developed through collaborative networks can be shared and adopted at regional or national levels and therefore have a wider uptake than those developed locally. This raises the standard of quality and consistency of care across a broader landscape.

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