Part II: Building an organisational approach to improvement

The improvement journey

Building the capability, infrastructure and culture needed to deliver sustained organisation-wide improvement is a journey that can take several years.

In most cases, there is no single driver for the development of an organisational improvement programme. It can be the result of many different factors: a major patient safety incident that reveals systemic failings and highlights an urgent need to do things differently; the arrival of a group of senior leaders or clinicians with a shared interest in improvement; or the realisation, from a peer learning visit to an influential provider elsewhere, that the organisation is not performing as well as it imagined. Evidence of unwarranted variations in patient outcomes, staff experience and use of resources both within the trust and when compared with other trusts can also help to galvanise change. External drivers, such as a critical inspection, can also have a major effect.

There are six steps an organisation should take to plan, deliver and sustain an organisational improvement programme.

1. Assessing readiness

While organisation-wide approaches to improvement vary in their gestation and development, a useful starting point for organisations is to understand their ‘readiness for change’., This is the extent to which the organisation is both psychologically prepared for change (shown by the maturity of its learning climate), and has the right infrastructure, governance arrangements and leadership in place. There are numerous tools available to guide organisations through this process such as the ORCA tool, the ORIC measure, Chamberlain’s QI building blocks framework, AQuA’s QI maturity matrix and the Health Foundation’s own high-level organisational-improvement checklist. Few organisations will be able to meet all the key change criteria at the start of their improvement journey, but they need to be clear about where their capability gaps are, and have a good plan to address them.

2. Securing board support

In most organisations, an essential early step is securing the support and confidence of the board. Without their commitment to a long-term programme of improvement, and their willingness to finance the skills and infrastructure development needed to implement it, little can be achieved. A strong clinical voice at board level can often be useful in persuading the board to make QI a priority.,

Much depends on the board’s level of confidence and authority. A stable board with an established identity, and which is highly regarded externally, is well placed to embrace the challenges associated with a long-term, whole-organisation improvement programme. Moreover, it has the confidence to filter the offers of support and recommendations that come from national and regional bodies appropriately, giving priority to those that fit their improvement vision or way of working. By contrast, a newly appointed chair or chief executive in a trust with a history of performance challenges that is under heavy regulatory, political and media scrutiny, may not have the confidence or capital to embark on an ambitious programme of long-term improvement.,

3. Securing wider organisational buy-in and creating a vision

Having secured board-level support, the challenge is to persuade others across the organisation of the case for improvement and create a compelling improvement vision. To do this, improvement leaders need to understand and tap into the intrinsic professional motivations of staff at each level of the organisation, and ensure that any initiative does not become caricatured as a top-down programme, or driven by cost-cutting. One way to guard against this is by building in stages, perhaps by working first with a few improvement enthusiasts, and then convincing others to follow their lead once they have demonstrated a positive impact on care quality and staff experience.

Embedding a culture of distributed leadership across the organisation, with the aim of giving staff at all levels the opportunity, permission, and the confidence to identify and test new ideas, is key. Time spent by trust leaders trying to unlock the expertise that lies in every part of the trust, and encouraging and supporting staff to use this knowledge to help drive improvement, can be invaluable. As well as chipping away at the perception that there isn’t time to improve, a concerted push by senior leaders to champion improvement that is driven and owned by teams on the front line will help to address the anxiety that some staff may feel about taking on the responsibility for doing things differently. In what is still a very hierarchical service, in which seniority matters and some professions are perceived as more likely to provide leadership than others, these barriers should not be underestimated.

As well as working to ensure that there is broad clinical support for improvement, senior leaders need to invest time in bringing junior and middle managers and other corporate staff on board. Having engaged and supportive ward managers, for example, who want to be involved in improvement and will tackle the obstacles that will inevitably emerge is essential. What’s more, it is vital there is no dissonance between the senior leaders’ message about fostering and embedding distributed leadership and the language and behaviours of managers throughout the organisation.

4. Developing improvement skills and infrastructure

At the same time, organisations need to begin to build their improvement infrastructure. A key consideration is how to ensure teams at each level of the organisation have the general and specialist improvement skills needed. To deliver sustained, organisation-wide improvement, a systematic approach to building improvement capability across the trust is required. Many capability-building frameworks and instruments have been developed to support this process. Some of these focus on the type of skills and behaviours required and some consider the ‘dose’ of skills needed at each level of an organisation., This investment in improvement skills needs to be accompanied by the development of measurement systems able to collect, analyse and feed back data on the effects of improvement activity, and the capability and capacity to make full use of these systems. The development of standard operating models to ensure the standardisation of core processes and activities across the trust, and, where appropriate, with other providers in the local system, should also be considered. Alongside national initiatives such as Getting It Right First Time and NHS RightCare, such standard operating models can help trusts to address unwarranted variation in service delivery.

5. Aligning and coordinating activity

As the improvement programme grows and matures, the task of aligning the different strands of improvement activity becomes ever more important and challenging. This coordinating role, which would normally be undertaken by senior figures with oversight of all trust activity, is necessary to ensure that individual initiatives are consistent with the trust’s overall strategy and mission, and that improvement teams and other organisational development activities are not pulling in different directions. It is also crucial in identifying and unlocking operational barriers to improvement and ensuring that resources are allocated intelligently.

6. Sustaining an organisation-wide approach

It can take time for an improvement programme to become really embedded in an organisation. Maintaining momentum over that time, and ensuring that staff, patients and external stakeholders remain engaged and supportive of the programme, arguably requires as much effort and skill as it takes to get it underway. Having generated some early wins by focusing on the services most amenable to improvement, or those where there is the greatest appetite or capability for change, the challenge is then to maintain that success, while also engaging services and teams that are less ready for improvement. The reality is that the pace of improvement is uneven, and performance can sometimes fluctuate as new ideas are tried, adapted and improved.

All this can be challenging, both for the QI leaders within an organisation and for the board, which may have invested significant political capital and money in the programme. Yet board-level support for the programme at this point is critical. The long-term success of the programme can hinge on the board’s willingness and ability to manage the delivery expectations of external stakeholders, to give front-line teams the ‘air cover’ they need to experiment and refine their interventions, and to maintain a constancy of purpose in the face of external pressures.,

What helps is a growing awareness that developing a successful organisational improvement programme is a long journey. The well-publicised improvement journeys of leading US providers such as Intermountain and Virginia Mason, which began several decades ago, coupled with more local examples, such as Salford Royal NHS Foundation Trust, are useful in dispelling the notion that an organisation-wide approach to improvement can somehow be created overnight.

Different approaches to building improvement capability and expertise

Most trusts that have developed an organisational approach to improvement have, at some point, looked for external support. The extent of the support varies. Some have sought informal advice and assistance from peers at the start of their improvement journey, but have focused on building improvement capability from within by strengthening the improvement coaching and leadership skills of their existing staff. Others have entered into more formal partnerships with external organisations in the commercial or not-for-profit sectors, or with other organisations within the NHS.

Building from within

Some trusts have focused primarily on building the improvement capability of existing staff through in-house programmes. The impetus and initial leadership of such programmes often comes from staff who have attended external training programmes and fellowships and have used this expertise to develop the first wave of improvement coaches and mentors within the trust.

For example, Sheffield Teaching Hospitals NHS Foundation Trust has developed a Microsystems Coaching Academy, training 273 improvement coaches to help teams improve care. Building on this approach, the Health Foundation is now partnering with Sheffield to develop a network of Flow Coaching Academies. As of 2019, there are seven local Flow Coaching Academies across the UK, each helping clinicians and managers develop capability in applying team-coaching skills and improvement science at care-pathway level.

Support from commercial and not-for-profit organisations

NHS trusts can turn to commercial and not-for-profit organisations for strategic advice and practical support in developing their improvement capability. For example, the US-based Institute for Healthcare Improvement offers a range of ‘customised services’, from an on-site diagnostics service aimed at identifying ‘high-value improvements’, through to support for large-scale improvement initiatives and ‘multi-year, multi-touch’ strategic partnerships such as its arrangement with East London NHS Foundation Trust. Providers can also access support from established commercial consultancies or NHS bodies such as NHS Interim Management and Support.

At a regional level, Academic Health Science Networks play a role in creating the right environment for change within and between organisations, by identifying and spreading innovations, creating opportunities for organisations to connect and share ideas, and leading regional-level change programmes. Meanwhile, regional improvement academies and centres, such as the Yorkshire and Humber Academy, West of England Academy, Cumbria Learning and Improvement Collaborative, and Advancing Quality Alliance, are sources of improvement skills training, along with learning events and bespoke consultancy support. This allows smaller providers with limited in-house training capacity to contract out some of their needs related to building improvement capability. These organisations also publish resources for providers on how to build and deploy improvement capability: the Advancing Quality Alliance’s recent paper on building a culture and system for continuous improvement is a good example.

Support from peer organisations

NHS trusts aiming to improve the quality of their services have often looked for inspiration, advice and support from exemplar organisations in the UK and beyond. Historically, this learning has tended to take place through informal peer-to-peer engagement, learning visits or secondments. However, the publication in 2014 of the NHS’s Five year forward view and the Dalton review, which recommended that ‘ambitious organisations with a proven track record should be encouraged to expand their reach and have greater impact’, has prompted a number of trusts to expand and formalise their offer to their peers. For example, Northumbria Healthcare offers a range of clinical and corporate services and consultancy support through the Northumbria Foundation Group, one of the Acute Care Collaboration vanguards within the New Care Models programme. With The NHS long term plan calling for a greater emphasis on ‘mutual aid’ and collaboration between providers within local health systems, both informal and formal peer-support activity looks set to increase.

Another emerging trend is for trusts to enter into a formal partnership, either on a mandatory or voluntary basis. Such partnerships can help improve performance and tackle unwarranted variation in service delivery between trusts by giving participants the opportunity to learn from the best-performing trusts and to standardise practice. In 2016, for example, Salford Royal, one of the first trusts in the country to receive an outstanding CQC rating, agreed to provide leadership and improvement support at the neighbouring Pennine Acute Hospitals NHS Trust. The partnership, which led to Salford’s chair and chief executive taking on the equivalent responsibilities at Pennine Acute Hospitals, followed a CQC inspection that gave Pennine Acute Hospitals an inadequate rating. In 2017, the partnership was cemented through the creation of the Northern Care Alliance, consisting of four locality-based ‘care organisations’. Meanwhile, Western Sussex Hospitals NHS Foundation Trust, which has an outstanding CQC rating, took on the leadership of neighbouring Brighton and Sussex University Hospitals NHS Trust in 2017. In 2019, Brighton’s rating rose from inadequate to good.


The resources required

Finding the resources to get an organisation-wide programme up and running can be a significant challenge. It is possible to build capability and support improvement teams using existing staff and resources, but that will require organisations to release staff from their normal duties to teach or plan improvement. Without spare resources to back-fill posts and set up support processes, among other things, this can prove very difficult. The reality is that significant upfront investment is usually necessary. For example, Berkshire Healthcare NHS Foundation Trust, a community and mental health care provider with a turnover of £245m in 2016/17, has invested £1.4m over 2 years in bringing in an external partner to support its bid to develop QI capability across the whole of the trust. It has also a recruited a central ‘QI office’ of six staff, launched a quality management and improvement system to train and support staff and developed a ‘true north’ improvement vision.

Even after this initial investment, there will still be annual running costs of an improvement programme once it is underway (eg to finance a central improvement team). Estimates of how much money is needed are hard to find. One estimate from the US suggests that providers allocate up to 1% of their annual turnover to their improvement programmes and infrastructure. It is uncertain, however, how applicable this figure is to a UK context, given that this agenda is considerably more developed in the USA than here. Trusts would benefit from new guidance on this topic to help them plan their programmes.

The return on investment

Quantifying the return on QI investment is notoriously difficult. Health care provider organisations are complex entities, and it can be hard to disentangle the effects of specific QI interventions from those of other activities. The task is harder still when it comes to organisation-wide improvement programmes composed of a diverse range of workforce and infrastructure-related investments. Evidence about return on QI investment tends to come from case examples, such as a 2013 study of the Mayo Clinic in the USA.

One organisation that has tried to identify and understand the return on investment from its trust-wide improvement programme is East London NHS Foundation Trust (Box 2).The trust has developed a framework for evaluating its return on investment, comprising six domains. The framework distinguishes between the benefits of specific improvement initiatives, which are more amenable to economic analysis, and the wider cultural benefits of organisational improvement (eg improved staff experience and retention and fewer absences), which are harder to quantify or attribute to the programme, but are still significant. East London argues that it is only by looking at its return on investment through these multiple lenses that the true value of its trust-wide programme becomes visible.

Box 2: The East London NHS Foundation Trust framework for evaluating return on investment from QI

  • Patient outcomes and experience – improving practices, pathways and services to improve treatment and care.
  • Staff experience – improving staff engagement has an impact on recruitment and retention.
  • Productivity and efficiency – removing non-value-adding steps in processes results in improvements in productivity and efficiency.
  • Cost avoidance – improving services and the work environment may allow an organisation to avoid significant costs, such as reductions in staff sickness (decreasing use of agency staff).
  • Cost reduction – improving services may also create opportunities for removing costs entirely from the system, such as reducing the number of beds and wards needed by improving length of stay.
  • Revenue generation – building a reputation for quality and improvement can help to generate new business and reduce the risk of being decommissioned or losing business.

At a time when many trusts are struggling to find and keep staff, and are investing significant resources in recruiting and training new staff, or in covering vacant posts through agency staff, the potential workforce benefits of investing in improvement, highlighted by East London’s framework, are significant. Moreover, there is increasing evidence that a positive organisational culture is associated with improved patient safety and quality outcomes.,

Nevertheless, it can take some time before it is possible to start generating a return on investment. Furthermore, the experience of the Jönköping QI programme in Sweden suggests there is an ‘investment threshold’ that must be crossed before organisation-wide performance improvements start to be realised.

What are the enablers of organisational improvement?

Translating a desire for change into an organisation-wide programme capable of delivering sustained improvements in safety, quality and experience presents a set of challenges. Through analysis of the peer-reviewed improvement literature and Health Foundation improvement programmes and publications, we have identified enabling factors that contribute to the success of an organisational approach to improvement. They fall into four broad categories:

  • leadership and governance
  • infrastructure and resources
  • skills and workforce
  • culture and environment.

Leadership and governance

For any organisation-wide programme to flourish, there needs to be visible, focused leadership for improvement at board level, right from the start., A clear endorsement of the programme signals that it is central to the trust’s strategy for the long term, and can be vital for getting the support and momentum the programme needs. However, the board also needs to show its sensitivity to previous improvement efforts across the trust and highlight the importance of building on that work and the improvement expertise of existing staff.,,, This will help to engage staff who may be experiencing a degree of ‘improvement burnout’ and may be sceptical of new improvement visions. A willingness by the board to seek out staff and patient views and use them to shape the improvement vision will also help it resonate across the organisation.,

The board also has to maintain constancy of purpose, understanding that changing complex systems is difficult, unpredictable and time consuming. Improvement teams need time and space to plan, prototype, evaluate and refine interventions.,, It can help if there is stability at board level, in terms of both its membership and its culture.

Good strategic and political skills are important. The ability to reconcile the tension between short-term performance demands and long-term strategic improvement objectives (‘organisational ambidexterity’) allows the board to give improvement teams at the front line the ‘air cover’ they need to deliver change.,,,, Also valuable is a strong internal locus of control and the ability to prioritise the external demands and offers that complement the organisation’s goals.,

The improvement culture of the organisation is influenced by the behaviours and attitudes of the board. A governance climate geared towards ‘problem sensing’ rather than ‘comfort seeking’, is important in shaping a reflective, learning culture within the organisation. Looking outwards to identify and embrace knowledge, expertise and ideas developed in other organisations is also important.

Embedding a culture of distributed leadership at each level of the organisation is essential for teams at the front line to feel they have the autonomy and permission to lead improvement.,,, In addition, patients and service users should be encouraged to co-create and contribute to improvement work, as well as to inform organisational improvement strategy.,,

Boards and senior leaders need effective governance and management processes so that they can ensure that all improvement activities are aligned with the organisation’s strategy and that they fit with existing workflows and systems.,,,,,,, For leaders to effectively monitor and evaluate the delivery of improvement interventions, they need access to reliable, timely and relevant data about organisational performance, as well as the skills to analyse and act on them appropriately.,,,

Infrastructure and resources

A management system and infrastructure capable of generating timely, relevant and accessible data on the delivery of key improvement indicators is an essential feature of any organisation-wide improvement programme.,,, As well as the means to build and maintain such an infrastructure, improvement teams need the skills to collect and interpret relevant information and to ‘measure for improvement’,,,,, along with access to skilled analysts.

Delivering and sustaining improvement can require significant resource. In addition to securing sufficient money, time and physical space to drive improvement, organisations need effective mechanisms for deciding between competing requests for resources.,,, They also need to consider how to encourage and reward improvement across the organisation.,,,

Skills and workforce

To ensure that an organisation has the necessary capability to drive improvement, all staff should have at least a basic grasp of improvement approaches and tools,, and be given the opportunity and guidance to put their skills into practice., Efforts to promote awareness of the ‘habits of improvers’ and steps to strengthen them across the organisation are also necessary. For clinical teams and communities, this needs to be combined with ongoing training about methods to standardise and improve care.,,

Meanwhile, operational managers and clinical improvement leaders should have the skills and motivation to implement microsystem-level improvement., There also needs to be sufficient capability and capacity to analyse data to continually monitor quality and performance.

As well as having staff with the right skills, organisations need effective social and professional networks in place for improvement interventions to get embedded as widely as possible.,, The presence of a stable and cohesive ‘social architecture’ – how people cluster, connect and coordinate to deliver a coherent and integrated service – is another core enabler of organisation-wide change.,

Finally, it is also important to ensure that every part of the organisation – clinical and corporate – can plan and deliver improvement. Aligning workforce-related strategies (recruitment, retention, pay and benefits, education and training) and functions (HR, payroll, occupational therapy) with improvement strategies can create opportunities for productive joint working between corporate and clinical staff.

Culture and environment

The presence of a supportive, collaborative and inclusive workplace culture has a significant bearing on an organisation’s ability to deliver improvement. A positive organisational culture has been consistently associated with a range of improved patient safety and quality outcomes.

Organisations also need to focus on developing a learning climate in which:

  • leaders express their own fallibility and the need for team members' input
  • individuals feel that they are essential, valued, respected and knowledgeable partners in the change process,
  • individuals feel psychologically safe to question existing practice, report errors and try new methods,,
  • teamwork and multidisciplinary collaboration is promoted and supported,,,,
  • there is sufficient time, space and opportunity for reflective thinking, learning and evaluation.,,

These factors help maximise an organisation's absorptive capacity for learning, problem solving and adopting new ideas and innovations. Box 3 summarises the skills and behaviours that staff at each level of an organisation need to design, implement and embed an organisation-wide approach to improvement.

Box 3: The skills and behaviours needed at each organisational level

Boards and executive teams need to:

  • provide visible and focused leadership for improvement
  • drive the development of a compelling mission, purpose and way of working
  • reconcile short-term external demands with long-term organisational improvement objectives
  • show constancy of purpose and give front-line teams time, space and permission to plan, develop and refine improvement interventions
  • make available sufficient resources to identify, plan and deliver improvement
  • promote a culture of distributed leadership throughout the organisation
  • have access to reliable, timely and relevant data about organisational performance and the ability to analyse the data and act appropriately
  • ensure that the views of staff and patients help shape organisational strategy and improvement priorities
  • build on previous improvement work and ensure that existing improvement expertise in the organisation is valued and maximised
  • seek out relevant knowledge, expertise and innovation from outside bodies and use it to inform improvement strategy and practice
  • create a governance climate geared to ‘problem sensing’ within the organisation, rather than ‘comfort seeking’
  • ensure alignment between improvement activities, workforce functions and organisational strategy.

Operational managers and clinical improvement leaders need to:

  • have the skills and motivation to implement microsystem-level improvement.

Staff at all levels need to:

  • be empowered to identify and implement improvement
  • have a basic grasp of improvement approaches and have developed the ‘habits of improvers’.

Patients, service users, families and carers need:

  • the opportunity and support to co-create improvement and inform organisational improvement strategy.

Everyone needs to be supported with:

  • measurement, monitoring and feedback mechanisms capable of the timely collection and analysis of multiple types of data
  • a cohesive, supportive, collaborative and inclusive workplace culture
  • a learning climate that promotes teamwork and multidisciplinary collaboration and in which people feel psychologically safe to question existing practice and try out new ideas and approaches
  • sufficient resources and time to identify, plan and deliver improvement.

What are the barriers to organisational improvement?

The challenges involved in implementing and sustaining an organisation-wide improvement programme are many and varied. Organisations that have succeeded in overcoming them are the exception rather than the rule.

Almost all NHS trusts in England have some experience of using QI methods, but usually at the level of individual improvement initiatives. For example, a study looking at the implementation of lean-based improvement approaches in English NHS trusts found that in 2010, 78% of trusts had some experience of lean, but very few had implemented a coherent, managed programme of lean-based activity. Even fewer had put in place a lean-inspired system of working that ‘was championed at an executive level as a whole-hospital approach’. (The Bolton Improving Care System and the North East Transformation System were among the small handful of those identified who had done so.) A US study of hospital-based improvement programmes produced similar results: of the 1,200 hospitals surveyed, 69% had adopted a systematic improvement approach such as lean or six sigma, but only 12% had reached a ‘mature, hospital-wide stage of implementation’.

The size and complexity of NHS trusts is one challenge. Most NHS trusts are complex, multi-site systems providing a wide range of care services to large and often dispersed populations (often as a result of successive mergers over several decades). For example, Northumbria Healthcare NHS Foundation Trust – which employs 10,000 staff, provides care from 11 sites across the county and manages six GP practices – is a major integrated care system. Even many smaller trusts, such as those based around traditional district general hospitals in small towns and suburban areas, now typically incorporate a number of acute and community-based facilities.

Current workforce and financial pressures are also significant challenges.,, At a time when trusts are dealing with rising demand for care at the same time as resource constraints and staffing shortages, the challenge of planning and delivering a programme of trust-wide improvement can seem overwhelming. Given that the full benefits of such investment may only be realised several years later, it is understandable why some trusts focus on meeting nationally defined access and financial targets. Furthermore, trusts that are under severe pressure, and trapped in cycles of crisis followed by short-term fixes, are often also psychologically ill-prepared for systemic, long-term change. Facing a series of existential threats, they might adopt a highly bureaucratised form of management that leads to defensive, reactive behaviour and superficial displays of compliance rather than genuine efforts at improvement.

The Health Foundation’s 2015 evidence scan on the barriers to improvement in the NHS provides a useful overview of the main organisation-level obstacles to change (Box 4). Some reflect the absence of the enablers described above, or dynamics antagonistic to them. Others are independent factors that can also be detrimental to organisational improvement.

Box 4: Key organisational barriers to improvement

(From What's getting in the way? Barriers to improvement)


  • Lack of culture of improvement
  • Perceived culture of blame
  • Lack of priority placed on improvement
  • Risk-averse culture and prioritisation of defensive practices
  • Behaviours and ‘rituals’ that undermine improvement


  • Lack of strong leadership and a shared vision for improvement, including at board level
  • Hierarchical leadership structure rather than transformational or engaging leadership
  • Not ensuring leadership and autonomy for improvement at multiple organisational levels
  • Lack of accountability for improvement


  • Limited focus on person-centred care
  • Attempting to localise everything, rather than drawing on regional or national expertise


  • Lack of management time or organisational capability
  • Staff shortages and high use of agency staff
  • Lack of dedicated funding
  • Systems not set up to support integration of improvement into existing processes


  • Lack of information sharing within organisations and teams
  • Insufficient use of the data available
  • Insufficient information and analysis systems
  • Lack of, or inflexible, feedback structures in place


  • Wanting to see ‘quick wins’ rather than allowing improvement time to embed
  • Not allowing dedicated staff time for training or implementation


  • Insufficient engagement of professionals and patients

A systematic review of qualitative studies exploring the characteristics of struggling health care organisations identified similar issues. Low-performing organisations often had a poor organisational culture and dysfunctional external relations and lacked a cohesive mission and adequate infrastructure. In some cases, their difficulties were aggravated by a ‘system shock’, such as a change in leadership, organisational restructuring, or the implementation of a major IT system.

** See and for more information.

†† provides details of consultancy firms operating in the UK in healthcare (

‡‡ From a presentation by T Ferris at the Health Foundation Annual Conference, 2017.

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