Findings

Summary of findings

In our conversations with trust leaders, it was clear that greater support from national bodies is essential to help trusts transition from reactive to proactive quality management.

This includes embedding clear quality goals and standards in national planning tools such as the annual planning guidance, a shared national focus on both productivity and quality, and a regulatory approach that enables and supports proactive quality management.

The importance of a system-wide shared language around quality was also repeatedly raised.

Trust leaders highlighted that, to navigate the increasing complexity of healthcare, national bodies must foster more sophisticated conversations about risk – ones that move beyond linear models of cause and effect, embrace uncertainty and support adaptive, creative responses to emerging patterns in care quality.

It's important that tools such as QMSs are designed around adaptability, learning and continuous improvement, rather than command-and-control models.

Trusts were broadly supportive of the idea of a national QMS framework for each organisation to adapt to its own context. They pointed to the benefits and risks, along with the enablers and barriers, of implementing organisation-wide QMSs.

We explore some of the key design principles trusts suggested would be important in the development of a national framework:

• designed for diverse and complex settings
• establishes a common language for quality management
• grounded in operational reality
• focuses on systemisation rather than reinvention
• promotes QMS as a coordinating infrastructure
• aligned with regulatory and oversight requirements.

Designed for diverse and complex service settings

Finding: a national QMS framework must be flexible and context-sensitive, allowing for variation and risk predictability, and able to be differentiated by service type and organisational maturity.

Finding: the framework must focus on outcomes and learning, rather than compliance and control.

Finding: before the framework is developed, it would be useful for the Department of Health and Social Care (DHSC) and NHS England (NHSE) to understand which processes in each service pathway could be standardised.

In each interview it was clear that, within the health service, there are two key types of variation that may affect care: variation between organisations and variation within organisations. Several interviewees acknowledged that trusts operate across a wide range of operational and clinical contexts, which differ in terms of risk, regulatory oversight and process or outcome predictability. A national framework should therefore consider both types of variation.

Healthcare has been described as ‘20 different industries under one banner’, making a national framework for an organisation-wide QMS a challenging ambition. Indeed, there are areas of highly standardised care such as pharmacy, radiotherapy, nuclear medicine and much of the process of blood transfusion. These are so-called ‘islands of reliability within the wider, more chaotic hospital environment’.

Then there are sections of the trust such as emergency departments and maternity services, which have unpredictable workflows, patients and risk levels. A QMS will need to support quality management across these multiple settings. A careful and thorough analysis of each service pathway is therefore needed to understand the extent to which each process can feasibly be codified.

There was particular concern that a rigid or overly prescriptive QMS could inhibit innovation and fail to accommodate variability across different service pathways. One participant noted that QMSs could easily become ‘anti-quality improvement’ if flexibility and responsiveness were hindered by excessive reliance on standard operating procedures.

An overreliance on systems such as QMSs can inadvertently create cultures where staff are discouraged from thinking critically or adapting processes in response to emerging challenges. Any new framework must therefore carefully balance standardisation with flexibility.

It is worth noting that, within the recently published evaluation of NHS IMPACT, one of the key learnings is ‘don’t rush to prescribe and specify’. Several participants advocated for a QMS framework that allows for differentiation based on service type, organisational maturity and local context, with a tiered or developmental framework that recognises progress or variation, perhaps aligned with the improvement approach taken by NHS IMPACT.

This approach would enable trusts to tailor QMS implementation to the specific needs and risks of each pathway whilst still aligning with the organisational approach to quality management and national principles.  

Promotes a national and organisational shared language on quality management

Finding: a clear national vision and definition for QMSs is needed, including a clear picture of what success looks like and how they interact with existing tools such as the Patient Safety Incident Response Framework (PSIRF), the National Quality Board’s (NQB) Seven Steps and audit cycles.

Finding: national bodies should clearly set out how QMSs and safety management systems interact.

Interviews highlighted a lack of shared understanding of what constitutes a QMS within trusts. While many organisations report having QMS-related components such as dashboards, audit mechanisms and improvement cycles, these are often implemented in isolation and interpreted differently.

This reflects the lack of a clear definition at national level of what a QMS is – and what it isn’t. To further complicate the picture, it is also unclear at national level whether trusts should be implementing a QMS and/or a safety management system. There is no coherent description of how the two interact.

Trust leaders also cautioned against conflating QMSs in other industries with those in healthcare. Unlike industrial settings, healthcare operates in a high-variability, relational environment where outcomes are complex, multidimensional and often difficult to standardise. Healthcare requires adaptive approaches that account for human factors, clinical judgement and diverse patient needs.

Many trusts confirmed that they have elements of a QMS in place, but there is significant variation across the sector both in interpretation and application.

A QMS can be conflated with dashboards, audit cycles, improvement methodologies or tools such as PSIRF, leading to inconsistent implementation. One participant noted that ‘QMS has become a trendy word in the health service, which means it is potentially being misunderstood’.

Trust leaders discussed the potential to create a shared organisational language on quality through organisational-wide QMSs. Several said it can be difficult to find a shared way of talking about quality between clinical, operational and financial teams.

A national framework could helpfully provide a mechanism to support these conversations, and to demonstrate how different teams can work together, challenging the narrative that cost and quality are opposing forces.

Finally, given leadership turnover, one participant suggested that a QMS could be helpful in ensuring organisational consistency in how quality is led and managed.

Grounded in operational reality 

Finding: trusts are operating under significant and varied pressures, many of which are unpredictable. A national QMS framework must provide a stabilising force from board to ward by recognising these realities and enabling structure, clarity and a shared language for decision-making.

Finding: QMSs should provide a template to help trusts formally and thoroughly understand what quality looks like for their local population, so systems can be properly designed around this.

Participants reiterated that any national framework must be practical and grounded in operational reality. There is a danger in promoting an overly theoretical framework based on ‘work as imagined’, which could become a bureaucratic exercise.

The framework must recognise constraints such as workforce shortages, digital gaps and demand pressures. A purely theoretical model risks being dismissed or implemented poorly.

A QMS can helpfully act as a support tool and a stabilising force for boards and leaders during acute operational pressures, such as during winter, strikes or other system shocks, by providing structure, clarity and a shared language for decision making.

This is reiterated by healthcare safety researchers Charles Vincent and Rene Almaberti, who outline that ‘continual anticipation and adjustment of the system are essential if risk is to be managed effectively’. A QMS can provide a helpful framework for this continual anticipation and adjustment cycle to be implemented.  

A QMS should provide:

• a structured framework for decision-making based on pre-agreed quality principles and thresholds (for example, organisational red lines – one trust noted that corridor care was their red line)
• mechanisms for escalating concerns from board to ward and triggering agreed responses when red lines or thresholds are breached
• a shared language and common reference points for clinical, operational and executive teams so that decisions align with organisational values, patient and staff needs, and financial priorities
• a mechanism to maintain teamwork and clarity during periods of pressure
• a mechanism to support structured reflection and improvement after a period of pressure by capturing what worked and what didn’t, embedding a learning culture.

Trust leaders also suggested that a QMS framework could support organisational processes for documenting and understanding local population needs, so the QMS is designed to deliver on them.

Systemisation rather than reinvention

“For me, there is something about getting clarity on what the basics are and then looking at how you work through those different maturity levels. This means you’re making progress within your maturity rating, and there is something much more cogent about that because you can see what you need to do to get to the next level” – director of quality governance (acute trust)

Finding: ensure the national QMS framework includes clear, practical guidance on how trusts can connect and systemise existing quality components, rather than requiring new systems.

Participants consistently emphasised the importance of building on existing quality components and processes, rather than introducing new ones. Many trusts already have QMS components in place but lack a coherent structure to connect them. A national framework could demonstrate how these pre-existing components can be brought together and systemised, rather than suggesting that new ones are created.

QMS as a coordinating infrastructure 

Finding: National bodies should ensure the national QMS framework actively aligns with existing standards and planning structures, enabling trusts to deliver against them.

As Dr Penny Dash noted in her recent review of the patient safety landscape: "Provider organisations typically must address multiple priorities, targets, standards, requirements, guidance, directions, programmes, incentives and measures that are set externally, and are answerable to the many different bodies outlined in this review with overlapping and potentially conflicting requirements".

Participants noted the potential value of a national QMS framework in aligning existing standards and planning structures. One trust leader described how their trust had analysed over 55 regulatory standards to create a single set of cohesive standards on which to base their QMS.

A national framework could replicate this on a larger scale, reducing duplication, streamlining compliance and supporting coherence across operational, clinical and strategic domains.

The framework could also set out quality priorities that align with annual planning guidance, helping trusts to integrate quality goals with operational and financial targets.

Several participants suggested embedding benchmarking to allow performance comparisons between trusts and service lines. This would support improvement and sharing of best practice, but should not be used punitively.