Time for our ICSs to embrace continuous improvement

Over the past few decades, I’ve been fortunate enough to work on several major improvement projects in hospitals around the country. They can be full on – but hugely rewarding.

There’s now an exciting opportunity to do similar work at an integrated care system level; establishing a culture of continuous improvement across what are incredibly complex health and care systems.

Our ICSs will soon be coming up to their second birthday. They already have their hands full trying to break down historical cross-organisation silos in order to achieve their core objectives around population health, inequalities, cost, quality, and staff morale. Continuous improvement is vital if they are to deliver what is being asked of them.

Through its laudable IMPACT programme, NHS England is gently nudging them towards embedding a systematic approach to continuous improvement. With their organisational structures in place, now is the time for ICS leaders to turn their focus to this. Otherwise, we risk it drifting down the list of priorities, destined to be little more than a “nice-to-have” rather than a “must-do”.

There’s a stumbling block here though. Across much of the sector, the concept of continuous improvement, operational excellence or continuous quality improvement – call it what you will – is still not particularly well understood. For too many people, CQI (let’s go with that for now) is something that clinicians do through small-scale, discrete, tactical projects, delivering minor, highly localised improvements to how they deliver patient care.

That’s no bad thing – but nor is it seen as fundamental to how a CEO runs their health and care system. That’s why this traditional form of CQI rarely delivers sustainable long-term outcomes or further improvements – because it’s not embedded into the fabric of how a system operates. It’s not seen as being able to deliver major financial benefits, solve debilitating workforce issues or provide a response to the latest existential crisis. The reality is that – done properly – CQI can absolutely deliver all those benefits.

Currently, for many ICSs, CQI remains an extrinsic consideration; a set of behaviours, tools and processes and an underlying philosophy that they’re yet to fully embrace

The bedrock of CQI

However, for CQI to be done properly, certain things are non-negotiable. Alignment and focus (emerging from a clear purpose and vision that’s shared across the entire system); investment in people and culture; appropriate leadership behaviours; and effective management systems that embed improvement into everything the health and care system does.

That purpose and vision stems from understanding what citizens, patients and staff want from their ICS. Therefore, the biggest question for any ICS board right now should be whether they’re collectively aligned on the small number of things that matter the most.

Thinking about that, anyone who’s ever spent any time working their way through hospital or ICS board papers knows how enormous they can be. Confronted with a set of priorities or key performance indicators that could be more than 150 lines long, all you see is an impenetrable mass of red and green indicators.

You can’t talk about everything on there, so you resort to scanning the list, looking for red lights. You can’t ever know why every red is a red, so then you risk heading off on a superficial, tangential conversation about it.

As with most things in life, when you try to do everything, you typically end up achieving nothing. You just imperceptibly nudge everything along, only ever reacting to where the biggest issue is.

Stay on target

That’s why focus and alignment are essential if you’re to deliver meaningful change. In turn, that requires strong leadership and a commitment to the cause because it’s guaranteed that, at some point, you’re going to be pulled in different directions or encouraged to change track.

That’s not to say you simply lose sight of those other 150 KPIs. You just don’t want to be talking about them all the time. Therefore, you’re going to need good systems and processes to warn you when something that you’re not looking at all the time does actually become an issue.

I think it’s analogous to how you drive your car. You focus on the essentials; your speed, your fuel, the cars around you and so on. You then think about (and act on) the other things when you’re alerted to there being a problem; low tyre pressures or washer fluid, for example. But if every time you got in your car, you had a discussion about the 150 processes that get that car moving, you’d likely never leave your driveway.

For inspiration on how to make CQI work at a system level, we can look across the Atlantic. Colleagues of mine recently returned from a study visit to the US where they visited three highly successful healthcare organisations, each one every bit as complex as our ICSs. One of those was UMass Memorial Health. UMass have been on their CQI journey for 20 years now. They have incredibly tightly defined standard work processes that determine how the health and care system operates. But their staff are also empowered (and encouraged) to make improvements in their particular area.

There’s a focus on behaviours, rather than simply outcomes. There are management systems that can see an emerging issue escalated from the ward to the board in a matter of hours. And there’s a relentless focus on communicating the UMass way of doing things to everyone across the organisation; something that’s personally led by the CEO.

Make the extrinsic, intrinsic

Currently, for many ICSs, CQI remains an extrinsic consideration; a set of behaviours, tools and processes and an underlying philosophy that they’re yet to fully embrace. Make those intrinsic to a health and care system; make it the way they run their business; embed it at the heart of day-to-day operations and the results will come.

This is how ICSs will address and resolve their biggest challenges – financial, workforce or otherwise. It’s how they’ll cope with emerging crises; by trusting in the process and not reverting to old ways of working. And with all this embedded into the system’s culture, they’ll benefit from a highly sustainable, repeatable, improvement process.

In doing this, there are major quick wins that they can secure. The significant issues they’re facing can also be addressed. Delivering the even bigger rewards will take time, however, as UMass and many more can attest. They’ve already benefitted from 20 years of making mistakes, learning lessons, iterating, improving and refining. It’s time for our ICSs to set out on that same path.