Part I: Why organisational improvement matters

What is an organisational approach to improvement?

An organisational approach to improvement is one that aims to embed a culture of continuous improvement and learning across an organisation, along with the means to make it a reality, with a view to delivering sustained improvements in the quality and experience of care. Specifically, it consists of an overarching improvement vision that is understood and supported at every level of the organisation. This vision is then realised through a coordinated and prioritised programme of interventions aimed at improving the quality, safety, efficiency, timeliness and person-centredness of the organisation’s care processes, pathways and systems.

Organisational approaches to improvement are underpinned by several key elements:

  • Leadership and governance – visible and focused leadership at board level accompanied by effective governance and management processes that ensure all improvement activities are aligned with the organisation’s vision.
  • Infrastructure and resources – a management system and infrastructure capable of providing teams with the data, equipment, resources and permission needed to plan and deliver sustained improvement.
  • Skills and workforce – a programme to build the skills and capability of staff across the organisation to lead and facilitate improvement work, such as expertise in QI approaches and tools.
  • Culture and environment – the presence of a supportive, collaborative and inclusive workplace culture and a learning climate in which teams have time and space for reflective thinking and feel psychologically safe to raise concerns and try out new ideas and approaches.

Although most sustained examples of organisational approaches to improvement demonstrate these features, there are also areas of variation. For example, many organisations in the NHS choose to create a central improvement team responsible for helping front-line teams design and implement microsystem improvements, as well as for overseeing large-scale change. However, other organisations have not done so and argue that creating a central team could lead to an over-reliance on a small group of experts to drive improvement.

In the field of innovation, a US study has highlighted the range of organisational designs providers have created to innovate and identify new services and processes, as well as meeting the demands of routine care management. These vary from dedicated innovation teams working independently from executive management and existing organisational processes, to ‘cross-functional’ teams that look at both incremental improvement and disruptive innovation, through to models built on the premise that innovation is everyone’s responsibility. A further area of variation is the type of improvement method used by organisations (for example, ‘lean’, ‘six sigma’, the ‘model of improvement’), although many believe that the method chosen is not as important as the level of rigour and consistency with which it is used, and whether there is commitment to it over time.

So, there is diversity as well as similarity between the various organisational approaches that exist, and successful approaches may look different in different organisations.

Why does organisational improvement matter?

Within the NHS, most improvement work is conceived and delivered at microsystem level. That is, it relates to care processes managed by small teams within specific departments and services. Although much of this work generates significant patient and service benefits, working solely at the microsystem level has limitations. In particular, discrete, time-limited local improvement efforts may not represent the most efficient use of staff time and resources, especially if they take place without any overarching mechanism to coordinate them or provide oversight., It can lead to the same problem being solved in multiple ways by multiple teams across the organisation, and sometimes on multiple occasions if organisational memories are short. A culture in which more professional kudos is often given to those who lead their own improvement projects, even very small-scale projects, than to those who participate in large-scale programmes, or seek to replicate proven interventions, is partly responsible for a profusion of small, one-off projects.

An integrated, organisation-wide approach to improvement, through which local activities are aligned, coordinated and appropriately resourced, can help to avoid this, and enable an organisation to derive maximum benefits from its improvement capability and the enthusiasm of its staff. It also provides the strategic constancy of purpose, momentum and infrastructure needed for complex, multifaceted improvement initiatives to emerge and become embedded. Without such a supportive context, many promising interventions have found it hard to gain traction and show a lasting impact.,

In addition, it is only at the organisational level that it becomes possible to oversee the creation of a positive, collaborative and inclusive workplace culture, which recent studies have shown is closely associated with improved patient outcomes. Another advantage of organisational-level programmes is that, in contrast to many national or regional training offers, they allow local, team-based skills development and give people the chance to learn by doing in their everyday practice.

The direction of travel within the NHS is towards greater integration of care, and partnership working between provider organisations. Regional partnerships such as Surrey Heartlands, which has set up its own academy aimed at supporting clinicians to work across organisational boundaries, will become more common in the years ahead. However, the strategies and activities of these partnerships will inevitably be underpinned and influenced by organisational-level programmes and activities in their regions. One of the first projects of the Surrey Heartlands academy, for example, is to develop a QI system that connects and aligns the work of organisations within the partnership. What is more, trusts with established improvement pedigrees, such as East London NHS Foundation Trust and Northumbria Healthcare NHS Foundation Trust (Box 1), see collaboration with neighbouring providers as a way to drive improvement within their communities and as pivotal to their organisational missions. Their improvement leadership and expertise, which has been shaped by their experience of delivering improvement across the multiple institutions and services within their trusts, is likely to be critical to the success of fledgling system-level partnerships. As such, the insights and learning from organisational-level improvement programmes will be relevant to the design and delivery of initiatives to build improvement capability across whole health and care systems.

What does 'good' look like?

Most of the NHS trusts in England that have been given an outstanding CQC rating have implemented an organisation-wide improvement programme of the kind described above – a trend the CQC itself picked out in its 2017 State of Care report. Moreover, the CQC has stated that it feels confident about the ‘long-term sustainability of the quality of care’ at those NHS trusts where it finds ‘an established quality improvement culture’ across the organisation., Organisations with a ‘mature quality improvement approach’, the CQC advises, have, among other things, prioritised improvement at board level, put in place a plan for building improvement skills at all levels of the organisation, and developed structures to oversee QI work and ensure it is aligned with the organisation’s strategic objectives.,

A case in point is East London NHS Foundation Trust. According to its most recent inspection report, the trust’s ‘well-established quality improvement programme’ was an important factor in it retaining its outstanding rating. The CQC found that ‘quality improvement remained central to the work of the trust’, with a growing number of staff receiving improvement training and getting the chance to use their skills to improve care. It also reported that the trust was using QI methods to support the delivery of some of its core strategic priorities, such as improving care pathways and access to services. East London is now looking to apply its improvement approach at a system level, by working with neighbouring organisations to improve local population health.

Similarly, Northumbria Healthcare NHS Foundation Trust, rated as outstanding in 2016, has developed a capability-building programme that is being rolled out at all levels of the trust. As well as ensuring that there is a common way of working across the trust, and that an improvement ethos is shared by clinical and non-clinical staff, Northumbria is looking to build the capability needed to drive change across service and organisational boundaries. The trust aims to improve flow along care pathways by setting up a Flow Coaching Academy, bringing professionals from different services and sectors together with patients to plan and test changes on a collaborative basis.

Another trust rated as outstanding, Salford Royal NHS Foundation Trust, has had a strategic focus on QI for over a decade. It has a mature, trust-wide capability-building programme, which includes a Microsystems Coaching Programme and a Clinical Quality Academy. Salford Royal’s approach to improvement includes an emphasis on identifying and tackling unwarranted variation in practice and measuring the effects of improvement efforts over time. To this end, Salford has sought to build the digital infrastructure and capability needed to enable staff to record, extract and analyse data in a timely and efficient way. Salford also became a Global Digital Exemplar in 2016 and is the first fully digitally enabled trust in England, with over 500,000 patient records across primary and secondary care.

The approaches taken by three outstanding trusts – East London, Northumbria and Western Sussex – are summarised in Box 1. There are many striking similarities in the methods they use to build improvement capability and deliver improvement, such as a commitment to creating an open and positive culture where staff feel empowered to lead change, and a willingness to invest in long-term change.

Other outstanding trusts have only recently adopted an organisational approach to improvement. For example, Newcastle upon Tyne Hospitals NHS Foundation Trust, which was rated as outstanding in 2016, has taken steps since its inspection to expand QI capability and expertise within the trust. According to its 2018 Quality Strategy, the trust’s ‘focus on continuous quality improvement’ is designed to help it maintain its outstanding rating. An improvement collaborative has also been formed by staff who are members of the Q community, with a view to enhancing and promoting QI across the trust.

A major influence on the strategic direction of many of these trusts has been the work of leading provider organisations in North America and Europe. Examples include the Virginia Mason Institute Production System,, which has already worked with a number of English trusts, Intermountain Healthcare Delivery Institute, Johns Hopkins Medicine, Thedacare Accountable Care and Jönköping County Council’s QI programme in Sweden. All these organisations have mature, organisation-wide improvement programmes that have delivered sustained improvements in quality over many years.

There is also much to learn from the improvement work of health and social care organisations in other parts of the UK. For example, South Eastern Health and Social Care Trust, an integrated provider in Northern Ireland, has a long-established, trust-wide, programme to build improvement capability that involves both health and social care staff. It offers useful learning for integrated care systems seeking to build improvement capability in a coordinated way in acute, community and social care settings.

Box 1: Summary of key QI strategies and programmes delivered by three English trusts rated as outstanding

East London NHS Foundation Trust

East London NHS Foundation Trust provides community health, mental health and specialist services to a population of 1.5 million people in East London, Bedfordshire and Luton. It operates from over 150 community and inpatient sites, employs almost 6,000 permanent staff and has an annual income of £400m. The trust’s QI programme began in 2014 and was given an outstanding rating by the CQC in September 2016, which it retained after its 2018 inspection. Key features of the trust’s approach to QI include:

  • a strategic, long-term, board-level commitment to QI, board-level leadership of quality, and investment in partnership with the Institute for Healthcare Improvement
  • a single, integrated system that incorporates quality planning, quality control, quality assurance and QI
  • a central QI team to coordinate QI work and support teams, and a ‘people participation’ team
  • a focus on the involvement of service users and carers as full partners in QI work
  • the development of the ‘ELFT QI method’ to enable multidisciplinary teams, service users and carers to tackle quality issues that matter most to them
  • clear, organisation-wide priority areas for improvement that bring together multiple teams across the organisation (eg enjoying work, violence reduction, improving access and reshaping community services), while also allowing teams to work on what matters to them and their service users
  • a programme to build improvement capability that has trained over 3,500 people in 4 years at multiple levels of the organisation, from executives and board through to service users and carers
  • a re-design of information systems to give staff better access to the data they need to understand quality and performance and to support their QI projects.

The trust has also recently decided to expand its mission to improve the quality of life of all the people it serves, with a new emphasis on population health. This approach, which focuses on the determinants of health as well as inequalities, will involve more partnership working and collaboration with neighbouring bodies in the local health system. The trust has already begun using QI to achieve the triple aim – of improving population health outcomes, experience/quality of care and value for money – for specific populations.

Key quotes from East London’s 2018 CQC inspection report

‘Quality improvement remained central to the work of the trust. The trust has made further progress in the use of a quality improvement methodology. The numbers of staff training and using the methodology had continued to grow. We saw that this methodology gave genuine opportunities for staff and patients in wards and teams to identify areas for improvement and make changes. The use of quality improvement was widespread throughout the trust.’

‘The trust had retained an overwhelmingly positive culture. Staff were largely very happy and said how much they enjoyed working for the trust. They valued the open culture and felt that when concerns were raised they were taken seriously and where possible addressed. They also felt supported by the trust’s ‘no blame culture’ and willingness to learn when things went wrong. This was reflected in the results of the staff survey where the trust overall staff engagement score was 3.90. It was better than the national average of 3.79 for trusts of a similar type. The trust recognised that not all teams were as positive as others, and was using the QI methodology to enable those teams to make changes where needed.’

Further information

  • East London NHS Foundation Trust QI microsite (
  • East London NHS Foundation Trust Annual Report and Accounts 2017–2018
  • East London NHS Foundation Trust Inspection Report 2018

Northumbria Healthcare NHS Foundation Trust

Northumbria Healthcare NHS Foundation Trust employs more than 10,000 staff and provides care from 11 main sites, as well as from community sites and in people’s homes across North Tyneside and Northumberland. These sites include an emergency care hospital, general and community hospitals, an outpatient and diagnostic centre, an elderly care unit and an integrated health and social care facility, as well as the management of six GP practices. It has an annual income of over £530m and was given an outstanding rating by the CQC in May 2016. The trust has:

  • a named executive lead for QI, who is supported by clinicians and managers with formal QI training as well as ‘flow coaches’ and Q members
  • a quality strategy that aims to balance compliance with national guidelines with prioritising local quality issues which are important to patients and staff. It also seeks to ensure that any plans align directly with the trust’s strategic vision, lead to measurable improvements in quality and encourage continuous improvement. Each year, it focuses on a small number of core quality priorities, which in 2018/19 are sepsis, frailty, patient flow, falls, and patient and staff experience. The trust has one of the most comprehensive patient and staff experience programmes in the NHS, using real-time data to enable improvements in quality
  • set up a 'quality lab': a forum attended by a wide range of executive representatives, senior clinicians, transformation managers and service leads to monitor its QI programme and address improvement barriers within the organisation. They have developed the trust’s ‘formula for improvement’, which incorporates five steps:
    • engage and involve
    • fully understand the current situation
    • generate ideas
    • start small – make a change and look at the impact
    • share, sustain and celebrate
  • developed a ‘leading for improvement’ training programme, run over 3 days, that incorporates the trust’s formula for improvement. This is being rolled out across the organisation for all levels of staff, clinical and non-clinical. ‘Pocket QI’ 1-day training is also available to participants in apprenticeship and development programmes
  • set up a Flow Coaching Academy to provide training for improving flow at care pathway level. Eleven care-pathway teams have been coached to date, including frailty, emergency department and 'discharge to assess'
  • established RUBIS.Qi, the external-facing QI delivery arm of the trust. RUBIS.Qi is the official support provider for the latest rounds of the Health Foundation’s Scaling Up and Innovating for Improvement programmes, coaching more than 40 teams across the NHS. In partnership with the King’s Fund, it is also delivering NHS Improvement’s Leadership for Improvement board development programme, which is supporting 20 boards to embed QI in their organisations.

Key quotes from Northumbria’s 2016 CQC inspection report

‘When we spoke with managers and staff throughout the trust, the “Northumbria Way”, which incorporates the trust’s values, behaviours and culture was evident[…] There was a "can do" culture that is evident across the organisation with staff encouraged at all levels to make changes to services that would improve the quality of care to patients.’

Further information

  • Northumbria Healthcare NHS Foundation Trust Operational Plan 2018/19
  • Quality Account 2017/18
  • Northumbria Healthcare NHS Foundation Trust Quality Report

Western Sussex Hospitals NHS Foundation Trust

Western Sussex Hospitals NHS Foundation Trust operates three hospitals and a range of community services, including GP surgeries. It employs 7,000 staff and has an annual income of £435m. It was given an outstanding rating by the CQC in December 2015. In 2016, the trust’s chairman, chief executive and executive directors also took on the leadership of neighbouring Brighton and Sussex University Hospitals Trust, whose CQC rating has since risen from inadequate to good. The trust has:

  • implemented a trust-wide transformation programme, Patient First, to make continuous improvement part of staff’s day-to-day role and to empower and enable them to drive change. It is based on the lean approach used successfully by providers such as Thedacare in the US
  • established a ‘Kaizen Office’ with a dedicated team to establish a consistent, sustainable, trust-wide approach to improvement over the long term
  • used a patient-first concept to align its QI approach with its workforce strategy and its efforts to ensure that the trust is financially sustainable
  • developed a capability-building programme to equip staff with the skills to deliver continuous improvement, with training available for every staff member, beginning at induction and going all the way through to ‘lean practitioner’ level
  • asked managers to empower their teams to identify and make improvements in their areas of work and introduced improvement huddles to give all staff a voice in identifying opportunities for change.

Key quote from Western Sussex’s 2016 CQC inspection report

‘The executive team provided an exemplar of good team working and leadership. They had a real grasp of how their hospital was performing and knew their strengths and areas for improvement. They were able to motivate and enthuse staff to ‘buy in’ to their vision and strategy for service development. Middle managers adopted the senior manager’s example in creating a culture of respect and enthusiasm for continuous improvement. Innovation was encouraged and supported. We saw examples that, when raised directly with the Chief Executive and her team, had been allowed to flourish and spread across the services. We saw respectful and warm relationships internally amongst staff teams, the wider hospital team and outwards to external stakeholders and the local community.’

Further information

  • Western Sussex Hospitals NHS Foundation Trust’s ‘patient first’ webpage (
  • The Patient First: Western Sussex Hospitals NHS Foundation Trust Annual Review 2017–18
  • Western Sussex Hospitals NHS Foundation Trust Quality Report

* According to Professor Ted Baker, the Chief Inspector of Hospitals, ‘QI has been shown to deliver better patient outcomes, and improved operational, organisational and financial performance when led effectively, embedded through an organisation and supported by systems and training. When QI is used well, it gives us confidence about the long-term sustainability of the quality of care. More informally, when we visit trusts that have an established QI culture, they feel different. Staff are engaged, they are focused on the quality of patient care, and they are confident in their ability to improve. This is also reflected in surveys of staff and patient satisfaction.’

The CQC draws a distinction between efforts focused on ‘improving quality’, which it argues all NHS trusts will be undertaking (eg through their quality assurance and control processes) and ‘quality improvement’, which involves ‘the use of a systematic method to involve those closest to the quality issue in discovering solutions to a complex problem’.

An approach pioneered by Sheffield Teaching Hospitals NHS Foundation Trust and supported by the Health Foundation.

§ Q is a Health Foundation initiative that connects people with improvement expertise across the UK. The community includes people at the front line of health and social care, patient leaders, managers, researchers, commissioners, policymakers and others.

‘Kaizen’ is a core concept of the Toyota Production System, which, loosely translated from the Japanese, means continuous improvement. It aims to ensure maximum quality, the elimination of waste, and improvements in efficiency.

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