No more leaving it to chance: how to take charge of improvement

After 15 years of leading improvement work I am now working to review the safety and quality of services and encourage improvement through inspection and regulation. It seems an appropriate moment to share my top 10 improvement tips for health and care leaders.

‘Leading improvement work across the NHS is a practical pursuit. It requires a clear, unambiguous goal that will push you to do things differently’

I remember meeting Rodney Partington, who survived a stroke, a few years ago. He told me he was lucky “because I had my stroke in the week. Goodness knows what would have happened if I’d had my stroke at the weekend. Shouldn’t every one of us have the best chance possible, no matter what time or day of the week it is?”

Leading improvement work across the NHS is a practical pursuit. It requires a clear, unambiguous goal that will push you to do things differently. It requires making intricate connections across all parts of the health and social care system, as well as agile working from policy to boards, wards, patient pathways and commissioning.

At the same time, it demands a systematic approach within a framework of improvement science. At a personal level it requires ambition and a determination to make a difference.

In any change you need to answer three simple questions before you can start making improvements:

• Where are we now?
• Where are we going?
• How are we going to get there?

1. Describe and understand the pathway

“I hear and I forget, I do and I understand,” said the Chinese philosopher Confucius.

Improvement is a practical exercise; no improvement is ever achieved sitting at a desk. Improvement leaders need to walk the pathway, hear the patient and carer voice, and learn about their experience of care.

Without understanding the pathway there is little chance leaders will lead change with conviction and passion. No business plan will ever do this. Four-fifths of an improvement leader’s time should be out in the field, living improvement.

2. Be clear about what your ideal looks like

Improvement work requires a vision that is bold, ambitious and clearly articulates what the best should look like. It is extraordinary now to recall that in 1999, waiting times for colorectal and urological cancers were nine months from referral to treatment, involving 6-9 visits from first seeing a GP.

Today the maximum wait is eight weeks. Of course, targets are only a means to an end, but even establishing these means can be contentious. We would never get into a car and just drive, hoping to end up in a better place without knowing where we were going, yet that is what many improvement leaders do.

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3. Focus on the vital few things

Improvement leaders should try to focus on the vital few things that will make the biggest difference. Long lists of improvement programmes are likely to remain long lists of unfulfilled ambitions.

‘Improvement work is built not on technical know-how, but the ability to foster good working relationships’

NHS Improving Quality’s five legacy bodies were originally responsible for more than 130 different programmes of work. When we reviewed this it became clear that although there was a tremendous amount of great work, the picture for the service was confusing.

As an example, we had 22 programmes focusing on inpatient stays, all trying to get patients into and out of a bed quicker, as well as preventing them from coming into hospital in the first place.

While the local application is different, the principles for change were exactly the same across all programmes. Rationalising these programmes and aligning them under a single scheme of work focused on seven day services will have a much greater impact than the previous 22 ever did.

4. Know your methodology 

It really does not matter which improvement methodology you use as long as you stick to it and see it through. All too often this does not happen. It is unlikely any improvement work will show sustainable results in less than a year.

5. Understand the context

We need to do more for less, while ensuring high quality and safe systems. Previous experience tells us at least 30 per cent of costs, in terms of duplication, rework, delays and handovers, can be stripped out of inefficient processes or pathways; these are ripe for reinvestment.

Improvement leaders should seek out the best of practice and help to disseminate this for the benefit of local communities and overall health, not just single services or organisations.

6. Build relationships from the start 

Improvement leaders need to be expert coaches and facilitators of change, with the ability to solve tomorrow’s problems. Around 70-80 per cent of improvement work is built not on technical know-how, but the ability to foster good working relationships.

7. Seek to learn every day

Improvement leaders need to support learning about improvement science to discover what services are like, how they can change and to develop a culture of can do, must do and support to do. Learning and reflection is a vital part of this.

8. Be resilient

During the lows (typically 6-9 months into an improvement project) service performance will dip, confidence in the work will decline, staff engagement will wane and criticism of the work and often of the leader will sharply increase. An effective improvement leader will show their strength by holding their nerve and seeing things through to renewed success.

9. Know when to stop   

Whole system change often takes five years or more. At stages in this process it is easy for improvement leaders to take on an operational rather than improvement role. But they are there to help support and facilitate change, not to run endless meetings, write business plans or commission guidance. 

10. Happy staff make happy improvers 

Staff whose values and beliefs align with the goals of leading improvement work, who are given the tools and development to do an effective job and who are supported at each and every stage will be the ones who keep going when it gets tough.

‘Improvement work is all about taking luck out of the system’

If they are reminded at those moments of people like Rodney Partington, they are likely to be happy staff, whose ambition will surpass any initial expectation. 

In this complex world we tend to resist seeing the system through the eyes of the patient or carer. Instead we see it from myriad organisational structures, preoccupy ourselves with failure and rarely build the improvement capability locally. The key messages from this, although simple, can be easily overlooked. As improvement leaders, our goal should be to:

• stand in the patient’s shoes;
• go and see what is happening;
• search out the best;
• carry out change together;
• focus on the key things;
• involve everyone; and
• keep learning.

Harking back to Rodney’s comments, this is all about taking luck out of the system.

Dr Janet Williamson is deputy chief inspector of general practice and dentistry at the Care Quality Commission and was director of the national improvement programmes at NHS Improving Quality until April

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