Earlier this year, I took part in the virtual webinar on improvement and systems, alongside peers at The Foundation Group, hosted by NHS Providers as part of the trust-wide improvement board development programme. The session posed the question; how can improvement across place be delivered? As a board member, clinician and improver, this was a timely conversation. At East London NHS Foundation Trust, we're part of two different integrated care systems (ICSs) and are seeking to apply the principles and method of systematic quality improvement across these two health and care systems.
Like all of us, I don't have the answer; this is something we're going to have to discover together. As we navigate our way through what is a new challenge for us all, I hope these reflections help.
The value QI brings to a system
As a first step, at board level, we need to be more proactive about articulating what value quality improvement (QI) brings to system working. QI is a systematic approach to solving complex problems. This is valuable in the context of place and system based approaches to care delivery, where complexity is only going to increase. QI also depends on having an appreciation for systems thinking which, again, is going to be critical to improving outcomes for our local populations.
Good QI work involves a range of stakeholders. Anyone involved in QI will have experience in engaging a range of people. Often this will involve people outside of their usual team, for example other clinical or corporate teams, or patients and service users. This is all useful experience in working across and seeking to address power balances. So QI already brings experience of bringing people together across boundaries and around a shared purpose, which we can leverage when we think about applying the same approach within a place based care system or integrated care system.
Quality improvement should not sit in isolation; any organisation that successfully embedded a QI approach has realised it isn't a discrete programme but part of a holistic management system that integrates with planning, control and assurance. These are core components of any management system that is focused on quality – a framework that is inherently transferable to system design at the level of place or ICS.
Three areas of impact
I'd argue that at system level we should focus our efforts in three areas, to realise the opportunities in how we start to systematically build and apply our improvement capability outside the boundaries of a single provider:
- QI isn't just a method or set of tools, it's a mindset as well as a method for problem solving. We know that without leadership, improvement struggles to flourish and survive. The leadership behaviours that nurture improvement are different to those in a command and control structure; far more about curiosity, getting close to where the work is, playing an active sponsorship role – coaching and enabling behaviours, rather than directing behaviours. Perhaps our first opportunity is to try to create consensus amongst system leaders about our approach to problem-solving. Without congruence around our mindset, it will be hard for behaviours and assumptions to be aligned.
- Common language and capability. Every organisation that has adopted quality improvement can see the power of different teams, from different clinical areas, who have been trained differently, having a single language of improvement to be able to communicate and learn together when tackling common challenges. Now we need to build this common language across a system. It may be that as healthcare providers we already have some fluency that we can bring to bear when we work together, but large parts of our health and care system don't.
We need to be mindful of this, and develop a plan to encourage a common understanding and skill in improvement across all parts of our system, including citizens, service users, local authorities and the voluntary sector. Alongside this, we need to keep things simple – the actual method and approach of quality improvement are simple to grasp and apply. We have a tendency to over-complicate and use too much jargon that simply prevents engagement.
- We all know that we can't simply add quality improvement onto the shoulders of our people and teams. We need to make space for this by taking away work of lower value. We also know that tackling complex issues relies on leadership support and skilled improvement expertise amongst staff delivering care. We will need to find the capacity to create this infrastructure for improvement at place and ICS level, as many have already built at the provider level.
One false assumption to make is that providers already have improvement capability and capacity, and we can simply apply this to working at place and ICS level. This would be a false economy, and would impact on the continuous improvement activity within providers. We need to build new capacity and capability, or perhaps – as the commissioning and provider landscape integrates – repurpose the existing capacity that has until now been directed towards more transactional activities in the commissioning world.
As I look back over the last decade, we have seen a widespread adoption of quality improvement within the provider landscape in England, albeit with the variation in belief and results that you might expect. We have an opportunity to bring our learning from this so that quality, and our best practice approaches to managing quality, are central to the design of our integrated care systems.