Start with this introduction to root cause analysis. (16-minute video) (6-page PDF). A short intro to the toolkit. (3-minute video) Getting started Root Cause Analysis is comprised of the seven steps identified below. When you select a step you will be presented with a table of resources related to this step.

Quality Assessment and Performance Improvement (QAPI) Tools. Plan-Do-Study-Act (PDSA) Worksheet. PLAN: Based on the Goal/Aim Statement, a plan for change is developed and the measure is determined. • Goal/Aim Statement: • Plan: • Measure(s). DO: Describe what happened when the changes. PDSA, or Plan-Do-Study-Act, is an iterative, four-stage problem-solving model used for improving a process or carrying out change. Img When using the PDSA cycle, it's important to include internal and external customers; they can provide feedback about what works and what doesn't. The customer defines quality, so it.

There are tools that will assist you in doing the step and an example of how to perform that step. There is one scenario that is used throughout all the steps to demonstrate a beginning to end effort.

Click on the steps to advance through the process. Select team Root cause analysis is always conducted by a team. This team identifies the root cause(s) of a single event and identifies, implements, and evaluate corrective actions to prevent the event from happening again. This step involves selecting a facilitator and team members. # Tool Use Purpose Audience 1 Describes considerations for selecting a team facilitator and team members.

(2-page PDF) Instructions Sponsor and Facilitator 2 A non-punitive culture vs. A blame culture. (2-page PDF) Instructions Team 3 Key concepts of Just Culture and why it is important to create an environment of free and open reporting. (53-minute webinar) Reference Team. Identify all factors The situations, circumstances, or conditions that increased the likelihood of the event are identified, and analyzed. # Tool Use Purpose Audience 1 Describes how to create a flowchart: A flowchart is a tool that allows you to break any process down into individual events or activities and shows the logical relationships between them. (2-page PDF) Instructions Team 2 Examples of flowchart; current state and future state based on case study.

(2-page PDF) Example Team 3 Describes the fishbone diagram process and provides a worksheet for your use. (3-page PDF) Instructions Team 4 Example of fishbone diagram based on case study. (1-page PDF) Example Team 5 Describes the five whys method for analyzing an event and provide a worksheet for your use. (2-page PDF) Instructions Team 6 Example of five whys based on case study. (1-page PDF) Example Team 7 Describes techniques for identifying and ranking contributing factors.

(3-page PDF) Instructions Team. Change & measure Creating change is the implementation step to make changes to processes and systems within the organization. The team develops a goal, measures, and implementation steps. The implementation steps are trailed using the Plan, Do, Study, Act (PDSA) cycle.

These same steps are used for any quality improvement initiative. # Tool Use Purpose Audience 1 Describes how to set goals and provides a worksheet for your use.

(2-page PDF) Instructions Team 2 Example of how to complete the Goal Setting Worksheet. (2-page PDF) Example Team 3 Describes how to develop measures and provides a worksheet for your use. (3-page PDF) Instructions Team 4 Example of how to complete the Measure Development Worksheet.

(3-page PDF) Example Team 5 Describes how to complete the Corrective Action Plan and provides a worksheet for your use. (3-page PDF) Instructions Team 6 Example of how to complete the Corrective Action Plan Worksheet.

(1-page PDF) Example Team 7 Describes the fundamentals of the Model for Improvement and key concepts about testing changes on a small scale using Plan-Do-Study-Act (PDSA) cycles. (51-minute webinar) Reference Team 8 Describes how to conduct a PDSA cycle and provides a worksheet for your use.

(4-page PDF) Instructions Team 9 Example of how to complete the PDSA Cycle Worksheet. (5-page PDF) Example Team 10 Defines measures that will support and demonstrate outcomes. (30-page PDF) Instructions Team. Communicate & sustain In step 7 the team defines ways to assure the changes they have implemented are communicated and shared with residents, families, and staff. Measures for ongoing monitoring can be developed through use of a dashboard.

Other tolls assist with communication and sustainability. # Tool Use Purpose Audience 1 Use this tool to guide the process of developing a dashboard. The step are intended to help the team members understand the value of a dashboard and the process for creating a dashboard. (4-page PDF) Instructions Team 2 Use this template to tell the story of a change your nursing home made that led to a demonstrable improvement. (3-page PDF) Instructions Team 3 Use this worksheet to plan communications about performance improvement projects. (3-page PDF) Instructions Team 4 This is a resource to help leaders or teams determine if the interventions and changes they are making are sustainable. (2-page PDF) Instructions Team.

This report by The King's Fund has been co-authored with. Key messages • The NHS is facing significant financial and operational pressures, with services struggling to maintain standards of care. Now, more than ever, local and national NHS leaders need to focus on improving quality and delivering better-value care. All NHS organisations should be focused on continually improving quality of care for people using their services.

This includes improving the safety, effectiveness and experience of care. • Quality improvement – the use of methods and tools to continuously improve quality of care and outcomes for patients – should be at the heart of local plans for redesigning NHS services. NHS leaders have a vital role to play in making this happen – leadership and management practices have a significant impact on quality.

Studies have shown that board commitment to quality improvement is linked to higher-quality care, underlining the leadership role of boards in this area. • Improving quality and reducing costs are sometimes seen as conflicting aims when they are in fact often two sides of the same coin. There are many opportunities in the NHS to deliver better outcomes at lower cost (improving value), for example by reducing unwarranted variations in care and addressing overuse, misuse and underuse of treatment. There are many examples across the NHS showing that even relatively small-scale quality improvement initiatives can lead to significant benefits for patients and staff, while also delivering better value. • The potential benefit is even greater if quality improvement techniques are applied consistently and systematically across organisations and systems.

However, this is not currently the case. To deliver the changes that are needed to sustain and improve care, the NHS needs to move from pockets of innovation and isolated examples of good practice to system-wide improvement. In this briefing, we outline 10 lessons for NHS leaders. These provide a starting point for leaders seeking to embed quality improvement in their work.

10 lessons for NHS leaders • Make quality improvement a leadership priority for boards. • Share responsibility for quality improvement with leaders at all levels. • Don’t look for magic bullets or quick fixes.

• Develop the skills and capabilities for improvement. • Have a consistent and coherent approach to quality improvement. • Use data effectively.

• Focus on relationships and culture. • Enable and support frontline staff to engage in quality improvement. • Involve patients, service users and carers. • Work as a system. The NHS faces the challenge of improving quality of care while coping with the biggest funding squeeze in its history. This challenge is significant and, in some parts of the NHS, quality is deteriorating rather than improving: waiting times are increasing (), the numbers of people waiting to leave hospital are at record levels () and services in the community are struggling to meet demand for care in the face of budget cuts and staff shortages (; ).

Improving quality and reducing costs are sometimes seen as conflicting aims. However, as we will demonstrate in this briefing, there are numerous examples showing that this does not necessarily need to be the case. The current pressures on the NHS mean that, now more than ever, there needs to be a strong focus on delivering better-value care and putting quality and safety at the heart of the health policy agenda (). Plans for what should change The NHS five year forward view (Forward View) is the national plan for improving services in the NHS in England ().

It set out a vision for how NHS services need to change to meet the needs of the population, and argued that the NHS needs to make improvements in three main areas: • improving quality of care • improving the broader health and wellbeing of the population • improving financial efficiency. Since then, sustainability and transformation plans have been developed across England to provide more detail on the local changes needed to make this vision a reality (; ). These plans are intended to be the ‘delivery plans’ for the Forward View. The plans are broad in scope, proposing changes in all parts of the NHS by 2021 (). They also call for major improvements in NHS efficiency – typically at well above the rate of improvement achieved in the recent past. A national framework to guide action on improvement capability building and leadership development in NHS services in England has also been launched (). Plans for how change will happen The challenge now lies in delivering the plans and making tangible improvements in NHS care as a result.

This is easier said than done. The plans themselves lack detail on how their ambitious goals for improving care will be implemented (). And NHS leaders involved in developing the plans are concerned about their ability to make change happen in practice (). This challenge is made harder still by the lack of a single, coherent national strategy for how to improve quality of NHS services ().

A recent review of approaches to improving quality in the NHS found that, while improving quality remains a stated priority, implementation is weak (). Gaps in leadership, complex organisational arrangements, inconsistent approaches to measurement and accountability, and insufficient attention to the skills needed to make change happen have held back progress. So too have changes in government policy on the approach to NHS improvement and reform ().

Purpose of the briefing This briefing makes the case for quality improvement to be at the heart of local plans for redesigning NHS services. By quality improvement, we mean the use of methods and tools to try to continuously improve quality of care and outcomes for patients. The idea of making the case for quality improvement is not new, but there is an urgent need for more systematic approaches to improving quality to be adopted across the NHS in England if the ambitious goals described in the Forward View and sustainability and transformation plans are to be delivered. The briefing does this by drawing on existing literature and examples from within the NHS of where quality has been improved and describing how this was done. It describes the potential benefits from investing in quality improvement – including for patients, staff and the financial sustainability of the system.

The primary audience for this briefing is senior leaders in the NHS, given the need for new approaches within organisations and across local systems to improve quality of care. Leadership and management practices are strongly related to performance on quality, and there is a well-established relationship between board commitment to quality improvement and quality of care within their organisations (;; ). What do we mean by quality improvement? All NHS organisations in England are required to improve the quality of the care they deliver. The NHS next stage review () defined quality based on three criteria: • safety: doing no harm to patients • experience of care: this should be characterised by compassion, dignity and respect • effectiveness of care: including preventing people from dying prematurely, enhancing quality of life and helping people to recover following episodes of ill health. This definition has been adopted throughout the NHS in England and was used as the basis of the NHS Outcomes Framework and incorporated into the regulatory framework developed by the Care Quality Commission (CQC) in 2013 ().

A framework from the Institute of Medicine defines six domains of health care quality (). • Safe: avoiding harm to patients. • Effective: providing evidence-based care and refraining from providing services that are unlikely to be of benefit. • Patient-centred: ensuring that care is responsive to individual patient preferences, needs and values.

• Timely: reducing waiting times for care and avoiding harmful delays. • Efficient: avoiding waste. • Equitable: ensuring that care is of the same quality regardless of personal characteristics such as gender, ethnicity, location or socio-economic status. The term ‘quality improvement’ refers to the systematic use of methods and tools to try to continuously improve quality of care and outcomes for patients. There are a range of different methods and tools, such as Lean, Six Sigma and the Institute for Healthcare Improvement’s Model for Improvement. There is no clear evidence that one approach is superior to others.

Rather, it is the process of having a systematic approach to quality improvement and applying this consistently that is important (). While there are many different approaches to quality improvement, there are some key principles that are common to all. These include: • training staff in the nature of systems • using data to understand variation • giving all staff the opportunity to contribute and act on ideas for improvement • using many small-scale trials and tests as a way to learn and improve • ensuring a continuous focus on the needs and experiences of the people served by the system (). Many NHS organisations have started to use quality improvement techniques in discrete projects.

A smaller but growing number have developed more systematic, organisation-wide programmes to ensure that continuous improvement happens at scale (). Opportunities to improve value Quality and finance are closely related through the many opportunities that exist to deliver better outcomes at lower cost (improving value). The NHS, like all other health care systems across the world, sometimes fails to deliver high-quality care. This can lead to poor outcomes for patients and wasted resources for the NHS.

Evidence tells us that there are a range of opportunities to improve value in the NHS (). There are wide variations in how care is delivered across the NHS. Including in primary care practices, diagnostic tests, rates of hospital referrals and procedures, and access to services (). These variations are too wide to be explained by differences in people’s health needs and patients’ preferences.

In other words, they are both unwarranted and avoidable, and represent inappropriate care being delivered to patients. The Getting It Right First Time (GIRFT) programme aims to bring about higher-quality care in hospitals, at lower cost, by reducing unwanted variations in services and practices. It uses national data to identify variation, shares that data with the local staff involved in running and delivering the services (including clinicians, clinical and medical directors, managers and chief executives) and monitors the changes that are implemented. The programme began with orthopaedics and is now being rolled out to 32 different surgical and medical specialisms across the NHS in England. Early evidence suggests that the programme is identifying significant opportunities to improve value, through changes to procurement practices, productivity and quality. In January 2016, 71 of the 142 orthopaedic units in England identified combined savings of between £20 million and £30 million after an initial GIRFT visit, with an additional £15 million to £20 million forecast for the next 12 months (). There are examples of overuse, where care is delivered even though the potential for harm outweighs the benefits. Download Android Studio.

Overuse is bad for people receiving care because they get services that might cause them harm, or at least waste their time or cause unnecessary stress and anxiety. It also creates an opportunity cost for the NHS, as resources are diverted from more effective care. Examples of overuse can be found across the NHS – including the overuse of some acute hospital services, overdiagnosis and overuse of diagnostic tests, and overprescribing of drugs. One example is the overprescribing of antibiotics for people with coughs, colds and sore throats. Estimates suggest that around £3.7 million could be saved each year through more appropriate antibiotic prescribing (). There are examples of underuse, where effective care is not delivered when it is needed. Underuse can lead to people needing more complex care as their condition gets worse – for example if they end up in hospital because their condition isn’t managed properly.

One example of underuse is care for people with diabetes. Around 22,000 people in England die from potentially avoidable diabetes-related causes every year (). Data for 2015/16 shows that around 63.5 per cent of people with type 1 diabetes and 46.3 per cent of people with type 2 diabetes did not receive all nine care processes that could reduce complications related to their condition (). There are examples of misuse, where care is poorly delivered, resulting in preventable harm to patients.

The overall scale of harm in the NHS is not clear, but evidence suggests that preventable harm happens both inside and outside of hospitals in the NHS (). It is important to recognise, however, that most errors happen as a result of the systems people work in, not the people who work in them.

In other words, it is not a ‘bad apple problem’ (). One example is medication errors. Estimates suggest that there are around 50 million prescribing errors in the community, 45,000 prescribing errors in an average acute hospital () and 2,500 potentially preventable deaths in hospitals in England related to medication each year (; Hogan et al 2012). There are examples of waste, delay and duplication in organisational and clinical processes.

Identifying and removing steps that do not add value for the patient, or delay their access to care on return home, can help to improve patient outcomes and experience while freeing up clinical time (; ). Examples include delays in admitting or discharging patients needing acute care due to a failure to enable timely access to clinical decision-makers, diagnostic tests or medicines.

It has been estimated that productivity gains of between £1.1 billion and £2.3 billion could be achieved across England by improving or redesigning acute processes (). Will improving quality save money? These and other examples highlight the types of opportunities available in the NHS to improve quality of care and make better use of resources. This briefing focuses on the range of benefits that can be achieved from investing in quality improvement – including better care for patients, benefits for staff and improvements in productivity and efficiency. Conventional management wisdom also often says that improving quality can save money. While this is sometimes the case, as demonstrated by the significant savings being identified through the GIRFT programme, the relationship between quality and cost in health care is complex and poorly understood (Hussey et al 2013; Smith et al 2013; James and Savitz 2011). Both quality and cost can be measured in different ways, and the impact of the relationship between the two is often spread widely across a health system and over time.

One improvement in quality may take years to save money, while others may never save money at all. Another improvement may save money for one NHS organisation but shift costs elsewhere, while others may expose a new cost that was previously being met outside the health system. This ‘displacement of rewards’ means that providers investing in service improvements may see their return on investment fall to another part of the system, or their income fall if they have reduced activity that they were previously paid for (). This underlines the benefit of taking a ‘whole-system’ approach to improving quality and delivering better value. The evidence on whether quality improvements save money for health care providers was reviewed for The Health Foundation ().

The review confirmed that there are significant opportunities to improve quality and reduce costs in health care – mainly because of the high cost of poor-quality care to patients and the health system. But evidence showing that providers have been able to act on these opportunities is much harder to come. While some interventions (often on a small scale) resulted in quality improvements and reduced costs for providers, others (particularly on a large scale) failed to do so. The literature is also hampered by a lack of high-quality evaluations. It is also worth recognising that many quality improvements will generate productivity gains – for example by removing waste and speeding up processes – rather than cashable financial savings. These improvements will nonetheless have a major impact on NHS finances – for example by allowing more patients to be treated without spending more money. Reductions in length of stay in NHS hospitals between 1998/9 and 2013/14, for example, avoided the need to provide an extra 10,000 hospital beds ().

Increases in day surgery rates over the same period avoided the need to spend £2 billion and enabled 1.3 million more elective patients to be treated. The Institute for Healthcare Improvement has suggested that organisations aiming to improve value should distinguish between the ‘light green dollars’ (potential savings) and ‘dark green dollars’ (actual savings) that result from a quality improvement project, and understand how the former can be converted to the latter (Institute for Healthcare Improvement undated). Finally, it is important to remember that the primary goal of quality improvement is – to state the obvious – to improve quality of care, not to save money. While driving better value is important, quality improvement has a fundamental role in improving all aspects of quality – including the safety, effectiveness and experience of care. All health and care systems should be seeking to improve these aspects of care for people using their services, on a continuous basis.

This section uses five examples to illustrate how quality improvement approaches are being used by teams and organisations in different parts of the NHS in England to improve care and value for money. For each example, we summarise the problem being addressed, the methods used to improve quality and some of the benefits that are being delivered (using data reported from the sites). We also provide links to further resources and information about the work. All of the examples have received some funding or support from The Health Foundation. The five examples given above represent pockets of innovation in particular areas.

They demonstrate that even relatively small-scale quality improvement initiatives can lead to significant benefits for patients, staff and health system costs. The potential benefit is even greater if quality improvement techniques are applied consistently and systematically across organisations and systems. As we have argued previously, ‘only by moving from pockets of innovation to system-wide improvement will the NHS deliver the changes that are needed to sustain and improve care at a time of unprecedented financial and service pressures’ (). However, making this happen is not simple, and many quality improvement initiatives fail to deliver positive results.

In this section, we draw on relevant evidence and experience from the literature, and the examples given, to highlight 10 key lessons for NHS leaders seeking to embed quality improvement within their local systems. Make quality improvement a leadership priority for boards Senior leaders, and boards in particular, play a vital role in setting the strategic direction of NHS organisations and creating a supportive culture and environment for quality improvement. Numerous studies have found an association between board commitment to quality improvement and quality of care within their organisations (;; Jha and Epstein 2010; Jiang et al 2009, 2008). Features of boards that are successful in driving quality improvement include: • having clear goals for improving quality (and making them a top priority) • regularly reviewing quality performance in meetings • having a dedicated quality committee • having board members with experience and training in quality improvement. Boards with higher levels of maturity in governing for quality improvement are also skilled in balancing short-term external priorities with the needs of their own long-term improvement initiatives. Drawing on these studies and other evidence, researchers have created a framework that can be used to assess organisational maturity in governing for quality improvement (). Share responsibility for quality improvement with leaders at all levels While the role of boards is key, responsibility for leading quality improvement also extends well beyond the most senior leaders in the NHS.

Leadership for improvement must be distributed within organisations. A clear, unifying vision for improving quality should be enacted at multiple levels, with co-ordination and alignment between teams, departments and individuals (; Dixon-Woods et al 2014). The examples given above illustrate how leadership for improvement comes from all parts of an organisation (or multiple organisations), as well as from patients and service users. But the support of senior leaders in the organisations involved is important in getting a project off the ground and creating time for staff to design and test new ways of working, as shown in on dementia care in Sussex. Don’t look for magic bullets or quick fixes Improving quality of care is complex and takes time to achieve. Analysis of major improvements in NHS productivity over the past 30 years shows that progress is typically made through a series of small steps rather than giant leaps forward ().

Individual quality improvement initiatives often take considerable time to demonstrate impact, and even the most successful efforts will face obstacles and setbacks along the way. The drivers of health service improvement are also multiple and overlapping; there is rarely (if ever) a single, magic bullet for improving quality. Local context is crucial in understanding the success of different quality improvement programmes (;; Kaplan et al 2010). Interventions that ‘worked’ in one place are rarely easy to replicate in others. The Practical Obstetric Multi-Professional Training (PROMPT) programme () is a good example of this. The programme’s success in helping Southmead Hospital in Bristol to improve its perinatal outcomes and to reduce its litigation costs has encouraged other maternity units across the UK and around the world to implement it. Yet many have found it challenging to match Southmead’s impact.

Embedding the type of attitudes and behaviours that have underpinned PROMPT’s success takes time and is not straightforward. This means that NHS leaders must make a long-term, overarching commitment to improving quality within their own organisation, and set realistic goals for improvement. Rather than searching for magic-bullet solutions, leaders should focus on developing the processes, systems and cultures to support the delivery of high-quality care on a continuous basis (Dixon-Woods and Martin 2016).

Develop the skills and capabilities for improvement Frontline staff engaged in quality improvement need to be given the skills required to identify quality problems, carry out tests of change, measure their impact and act on the results. Boards and executive teams also need to have a good understanding of how change happens in complex systems (see the subsection ‘’ above). These things do not happen by accident. NHS leaders need to invest time and resources in building the capabilities required for quality improvement within their organisation. A case in point is the PROMPT training programme (). A recent review () identified eight broad dimensions of quality improvement capability – including the effective use of data and analysis (see the subsection ‘’ below), systematic use of improvement methods and processes, and a core focus on meeting the needs of service users.

Some NHS organisations that have adopted a systematic approach to quality improvement and invested in developing the skills and capabilities of frontline staff have demonstrated increases in staff satisfaction and retention rates and lower sickness and absence rates (; ). Have a consistent and coherent approach to quality improvement There are various methods that NHS organisations can adopt to improve quality of care – such as Lean, Six Sigma and Plan-Do-Study-Act (PDSA) cycles. Despite differences in terminology, all of these methods draw on a similar set of tools and principles (such as rapid cycles of testing). The evidence suggests that no single quality improvement method works better than others; what matters more is having a consistent approach – in other words, choosing a model and applying it rigorously in practice (Leis and Shojania 2017; Kaplan et al 2012;; ). To avoid quality improvement efforts becoming a disjointed (or worse, conflicting) set of initiatives, organisations also need to put in place systems to co-ordinate different improvement projects and ensure that learning is shared between them (; Dixon-Woods and Pronovost 2016). Use data effectively Intelligent use of data is central to any efforts to improve quality.

Data should be used to identify quality problems, define indicators for improvement and track the impact of different interventions on quality of care. But doing this is not simple; the approach to measurement must be designed carefully if it is to be useful to clinicians and avoid unintended consequences.

Clinical teams wanting to improve quality will require disaggregated data on processes and outcomes of care, as well as time trends to allow analysis such as statistical process control (time series analysis used to identify variation beyond predictable limits). This is likely to be different from data collected for overall performance assessment and management (. Measures that are too burdensome or lack credibility are likely to alienate clinicians and lead to confusion about the impact of interventions (Dixon-Woods et al 2012). And if measurement systems are poorly designed, they can create perverse incentives such as ‘gaming’, where targets are achieved but the intended changes in practice are not (Bevan and Hood 2006). The importance of having access to robust, real-time data is highlighted in, which focuses on the surveillance system developed by the Heart of England NHS Foundation Trust to help renal teams identify people at risk of end-stage kidney disease.

Focus on relationships and culture Effective quality improvement requires much more than just the technical use of tools and models such as those listed in the subsection ‘’. Relationships and behaviours are just as important, if not more so.

Sustained change is more likely to happen in an environment where staff across an organisation can reflect on how things are done now and think about how they could be done better in the future. Equally important, particularly from a senior leadership perspective, is a willingness to give teams working at the front line the time, resources and, crucially, the ‘permission’ to engage in quality improvement activities.

Given the pressures facing NHS staff today, this licence to improve is vital. This, again, highlights the key role of senior leaders and boards, described in the subsections ‘’ and ‘’. Health care organisations must create a culture and environment that supports the delivery of high-quality, continually improving care. In practice, this means having: • a compelling vision for the future, shared at all levels within the organisation • clear, aligned objectives for all teams, departments and individual staff • supportive and enabling people management and high levels of staff engagement • learning, innovation and quality improvement embedded in the practice of all staff • effective teamworking (West et al 2014).

Leadership is a major determinant of organisational culture (West et al 2015). Cost Accounting Pdf Philippines on this page. NHS leaders must therefore work to model and build these cultural elements. For those leading specific improvement projects, it will be necessary to spend time building relationships and engaging with relevant stakeholders involved in the change – for example to gain buy-in and surface any challenges or unintended consequences. Enable and support frontline staff to engage in quality improvement Many of the most successful quality improvement initiatives in the NHS have been identified, designed and implemented by teams working at the front line.

In some cases, they have done so without the explicit support or encouragement of senior leaders within their organisation, or without any meaningful resources (). A shared determination to make a difference, together with an ability to carve out time to focus on improvement work, have been critical to their success. However, it can be difficult for clinicians to engage in quality improvement (). They face several barriers – including a lack of time and resources and a lack of knowledge and skills for quality improvement. There is no simple solution to overcoming these barriers. Providing dedicated resources and project management capacity, having committed leaders capable of sparking enthusiasm, with skills in monitoring and evaluation to clearly demonstrate results, and ensuring alignment with other clinical priorities and health system changes, are all likely to help ().

Finding ways to free up staff time to take part in improvement work or training is another necessary step. It is also important to understand what is likely to motivate clinicians to change their practices – critically, their intrinsic motivation to improve quality of care for their patients (rather than improving efficiency or cutting costs). Rather than being seen as the business of managers, it is important for there to be an understanding that quality improvement approaches can help frontline teams to deliver better and more effective services for their patients. It is also possible to encourage participation by using more formal measures – for example by including involvement in quality improvement as part of required professional development activities, or by visibly reporting data on performance between peers (Dixon-Woods et al 2012, 2011). However, it is important to prepare the ground carefully. Mandating participation in quality improvement training, without first making the case for it, runs the risk that it will be perceived as simply ‘another thing to do’ or a further ‘box to tick’ ().

Equally, any effort to highlight variation needs to go hand in hand with practical support to help teams and organisations to close the gap with their peers. One important lesson from organisations that have successfully built improvement capability at scale is to avoid doing too much, too quickly. Delivering and sustaining change in a few key areas, and working first with a small cohort of volunteers, can help to generate momentum and provide a platform for the roll-out of an organisation-wide programme (). Involve patients, service users and their carers There is generally widespread support and enthusiasm for involving patients, service users and their carers in quality improvement efforts and ensuring that change is ‘co-produced’. This is no surprise: patients have a unique role to play in identifying quality problems (such as duplication and waste), coming up with solutions to address them and ensuring that any change genuinely delivers the outcomes that matter to them (; ). But it can be difficult to know how this should be done in practice.

There are a range of opportunities for NHS organisations to improve quality of care and value for money. Examples can be found across the NHS where teams and organisations are already acting on these opportunities and demonstrating positive results for their patients, as the examples given in this briefing show. But the systematic use of quality improvement approaches within the NHS is still patchy, and many improvement efforts fail to deliver the results expected. NHS leaders – and boards in particular – have a vital role to play in creating a supportive environment for quality improvement within their organisation – for example by providing a clear vision and objectives for improving quality and putting in place the capabilities and support needed for staff to improve services.

Leaders must also work between organisations to develop new care models and co-ordinate improvements. The 10 key lessons outlined provide a starting point for NHS leaders seeking to more firmly embed quality improvement within their local plans for improving services.