Enablers to a QMS

Participants noted that implementing an organisation-wide QMS would be both desirable and challenging. Feasibility was suggested to hinge on several interrelated factors – these are explored below. 

Workforce capacity and adequate resourcing

Many trusts highlighted workforce capacity and resourcing as fundamental barriers to effective QMS implementation. Limited staffing, lack of protected time and competing operational pressures were seen as challenges to embedding QMSs.

Trusts noted a shortage of expertise to design, implement and sustain comprehensive QMSs, particularly in those facing high demand and workforce shortages. Implementation relies on engaged staff, but challenges such as burnout, staffing gaps and inflexible work patterns make this difficult.

To mitigate these barriers, several trusts called for national-level support teams with specialist QMS expertise to work alongside local staff during setup. Without this, there is a risk of creating yet another framework that exists in theory but is not embedded in practice.

Good practice shared by trusts:

• aligning QMS with existing strategic priorities to reduce duplication and integrate quality into business as usual
• closer collaboration between quality and operational teams, ensuring shared ownership (and therefore shared resources) for QMS creation
• cross-provider initiatives such as shared quality improvement (QI) training programmes, seen as cost-effective ways to build capacity and create consistency.

Areas where trusts flagged more national support is needed:

• specialist national teams to support initial QMS implementation
• clearer guidance on shared responsibilities and co-designed models for QMSs
• training and leadership development focused on building cross-functional skills and promoting a shared language between quality and operational staff.

Data and interoperability

Trusts noted that, to have a useful QMS, the ability to integrate disparate data sources would be critical. However, interoperability of systems remains a significant barrier across the NHS. The lack of connected digital infrastructure makes it difficult to triangulate information from multiple quality sources, such as workforce data, patient safety incidents, clinical audits, and patient experience, in a way that drives meaningful insight or action. In some cases, this leads to environments described as “data rich but insight poor”, where performance is tracked closely, but quality is undermeasured or inconsistently defined.  

This disconnect has significant and worrying implications for patient care. Without a coherent and holistic view of the quality of care being delivered by trusts, there is a risk that early warning signs are missed or acted on too late. The current volume and fragmentation of data can also create an administrative burden; diverting clinical and managerial focus away from frontline care. In some cases, this results in duplicated effort, fatigue, and disengagement from teams, which in turn can erode the quality, safety, and personalisation of care that patients ultimately receive.

Good practice shared by trusts:

• cross-functional working groups bridging clinical, digital and quality teams
• local self-assessment tools feeding into real-time dashboards, helping teams see their data in context at team, directorate and trust levels.

Areas where trusts flagged that more national support is needed:  

• Development of a national set of simplified, outcome-based metrics aligned with what matters to patients and staff. Some trusts mentioned it would be helpful to benchmark their performance against national performance. 
• Better national interoperability standards, while maintaining local flexibility to adapt data use to organisational needs.
• National leadership to help align and simplify expectations, including integrating PSIRF, CQC standards, and other frameworks to avoid duplication. 

Culture and staff wellbeing

A recurring theme across trusts was the critical role of organisational culture in enabling or obstructing effective quality management. Research has also long pointed to the important role that organisational culture plays in enabling high quality patient care.  

While a QMS can provide the structures and tools for assurance and improvement, trusts noted that culture plays a key role in determining whether those tools are meaningfully used or simply become another compliance exercise. Some participants described environments where staff felt unable to speak up, where mistakes were met with blame rather than learning, and where the basics, such as staff rest spaces, were overlooked. In these contexts, even well-designed quality systems risked being ineffective or disengaging. 

Therefore, while it is helpful that national attention is given to the development of frameworks to support proactive management of quality, we also need widespread prioritisation of culture across the entire healthcare sector. National leaders, including government, regulators and arm’s length bodies, play a vital role in shaping the values, behaviours and practices of the sector, and it is important there is national system-wide commitment to both promoting positive cultures and to staff wellbeing as well as this work to create quality management system frameworks.  

Good practice shared by trusts:

Many trusts are actively creating the conditions for quality to flourish. Participants shared a range of approaches that are already making a difference:

• Avoiding an “anti-variability” mindset. Local flexibility and adaptive practice are essential for innovation and improvement.
• Creating psychological safety, where staff feel safe to raise concerns, share ideas, and learn from mistakes without fear of blame.
• Genuine staff involvement in setting quality priorities, with co-designed improvement efforts based on what matters most to patients and frontline teams.
• Visible recognition and informal appreciation for staff effort and performance.
• Routine, inclusive conversations about quality, helping to embed a shared understanding and collective ownership across teams.
• The value of board engagement not just in assurance, but in actively shaping and supporting improvement priorities.

Areas where trusts flagged that more national support is needed: 

• National prioritisation and investment into ‘cultural basics’, such as creating spaces for staff breaks and wellbeing, which build trust and engagement over time.
• Developing and promoting compassionate leadership in every layer of the system that models openness, empathy, and accountability.
• Creating and promoting systems that support open conversations, including honest discussion around acceptable levels of risk in pursuit of quality improvement
• Sustained, united commitment to positive culture and quality across all levels of the healthcare system.