Beyond scented candles and quick fixes

Source: NHE Jan/Feb 18

Joni Jabbal, researcher at The King’s Fund, asks why quality improvements and innovations are failing to be adopted by the NHS.

There is now good evidence that embedding a quality improvement approach – where you systematically empower frontline staff to continually test iterative change – has considerable benefits for organisations. If this approach is so effective, why is it not happening widely in the NHS?

The first problem is that quality improvement has an image problem. It is all too often seen as being about “unicorns and scented candles” rather than being a genuine vehicle for performance improvement which, unsurprisingly, can be off-putting for leaders who are focused on results.

The second problem is that, contrary to its image, implementing quality improvement is hard to do, and requires tough choices and leaders who are prepared to hold their nerve. It also represents a fundamental challenge to many people’s concept of what being a leader is, both within organisations and at national level.

This is because embedding quality improvement into the fabric of the NHS requires a fundamental shift in the role of leadership at all levels. At organisational level, this means leaders moving from being ‘problem-solvers,’ a role they often feel comfortable with, to enablers of change. Rather than imposing improvement programmes from the top of the organisation, leaders need to learn to empower staff to develop solutions that they are able to own and feel proud of.

Giving staff the freedom to test solutions

It means giving permission, space, skills, and trust to staff. It requires a mutual exchange of ‘gives and gets’ (roles and responsibilities of staff and the organisation), which amount to a formal ‘compact’ between an organisation and its staff. This includes giving staff and teams the permission to try and test solutions to problems, having a clear and agreed vision for the organisation to achieve high-quality care, and ensuring staff have adequate time to dedicate to quality and safety activities.

The personal energy and effort leaders need to put into building capacity and capabilities for quality improvement should not be underestimated. If you are not used to leading in this way, then change can be personally tough.

A new compact is just as important at national level. Too often, external performance management creates a culture of compliance and risk aversion in NHS organisations and, at its worst, this disempowers those working in organisations and creates an overreliance on central guidance. This is the opposite of what is needed for quality improvement.

Instead, providers need to be adequately supported by the national bodies to focus on their improvement journey. Again, this means agreeing mutual roles and responsibilities, including a shared realism about what quality improvement approaches can deliver in the face of funding pressures and workforce shortages.

Above all, it means a joint commitment to a 10- to 15-year journey and the determination not to be blown off course by the next month’s performance numbers. As one NHS trust CEO we spoke to put it, the role of national bodies “may be to remove barriers to improvement, not to be the organisation that comes in with top-down solutions and tells you how to deliver care.”

If all this sounds very difficult, then that’s because it is. So you can understand why for every chief executive put off by the ‘unicorns and scented candles’ image, there is another who can see the benefit of quality improvement but puts it in the ‘too difficult’ box.

But while quality improvement is not an easy option or a quick fix, it is the right thing to do. Organisations that provide the training, time and support to allow those at the frontline to flourish will, in turn, see their long-term organisational performance flourish as a result. Above all, introducing and sustaining a quality improvement approach can unlock more efficient and high-quality services, but this requires both bravery and commitment from senior leaders at organisation and national levels.


Top image © Peopleimages



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