The Health Foundation describes Quality Improvement as ‘giving the people closest to issues affecting care quality the time, permission, skills and resources they need to solve them. It involves a systematic and coordinated approach to solving a problem using specific methods and tools with the aim of bringing about a measurable improvement.’ Indeed, the vast array of Quality Improvement methods, tools and approaches can seem overwhelming, but fundamentally they all share the same objective – to improve the safety, efficacy, and/or efficiency of healthcare services.
If Quality Improvement is about improving healthcare services, how does it feed into NHS Service Improvement? Are the two concepts reciprocal? In this article we will explore these questions and look at examples of the impact of Quality and Service Improvement initiatives in different clinical settings.
What is Service Improvement in healthcare?
If we define the healthcare service offering as a range of products, interventions and solutions offered to the general public, then Service Improvement is arguably a much broader concept than Quality Improvement. That’s because making improvements to services can generate cost savings, streamline pathways, reduce clinical errors – and such changes benefit hospitals and patients alike.
However, it’s not always easy to measure such improvements. Thorough research and robust data collection is necessary at every stage of the process in order to quantify improvements made. Service Improvement projects within the NHS are also challenging to implement due to budgetary constraints, cultural issues e.g. resistance to change, and the shifting sands of national healthcare policy.
How Quality Improvement enables Service Improvement
There is no single way to approach Quality Improvement. The NHS England website lists a wide range of resources available to help teams embark on projects within their areas. Efforts can be either formal or informal; and as well as the healthcare workforce, improvement initiatives can encompass the wider healthcare community, including patients themselves, their families and professionals who work outside of the healthcare system but whose roles intersect with it.
Three key areas where Quality Improvement can effect measurable change are patient care, rate of error and department costs. As each of these areas is improved through the implementation of Quality Improvement methodology, Service Improvement occurs as a result.
1. Patient Care
There are various indicators which can show that patient care is suboptimal within an organisation. These may include an increase in clinical incident reports, including near misses, and higher numbers of patient complaints and claims, along with negative press coverage. External reports such as those undertaken by the CQC also often highlight quality concerns.
NHS providers will usually be aware of their quality hotspots within the organisation, but listening to service users and other stakeholders and empowering staff to speak up over quality concerns are critical elements of building an improvement culture.
An excellent example of a whole system approach to improving patient care can be seen in the Dementia Golden Ticket project, run by the NHS High Weald Lewes Havens Clinical Commissioning Group. The project team worked with the whole health and care system surrounding dementia patients and their families to redesign the care model, which resulted in a number of measurable improvements. These included an improvement in the emotional and physical wellbeing and quality of life of people with dementia and their carers, an increased ability for patients to live independently and a reduction in GP consultations, acute care attendances and admissions.
2. Rate of Error
Sadly, avoidable harm is acknowledged to be a major issue in the NHS. A study published online in the BMJ Quality & Safety journal found that more than 237 million medication errors are made every year in England alone. The avoidable consequences of these errors are estimated to cost more than 1700 lives per year, at a financial cost of £98 million. These error rates are similar to those reported in the USA and EU countries, showing that this is truly a global problem.
So how can Quality Improvement techniques reduce these rates of error? A team at Heriot-Watt University used Lean Six Sigma methodology and its associated tools and techniques to address medication errors. The research team experienced some barriers in terms of senior management buy-in and noted that the variation in data collection approaches used by different pharmacies also posed some problems. Overall, however, they found that Six Sigma tools could reduce mean errors and that the use of Lean tools to enhance the workplace environment could reduce staff workload and therefore incorrect dosage calculations and miscommunication between colleagues.
It naturally follows that any organisation that can achieve a reduction in error rates, whether that be in medication errors or any other process, will also see an improvement in the service they provide to patients. Reducing avoidable harm goes hand in hand with offering a better experience to patients and service users.
3. Department Costs
A piece of analysis carried out by the NHS Confederation in July 2022 showed that the health service is facing a real-terms cut in funding of between £4 billion and £9.4 billion, depending on which measure of inflation is used. This has resulted in the requirement for the NHS to make efficiency savings of 2.2 per cent this year, while also seeing unprecedented increases in demand in the wake of the COVID-19 pandemic.
No one would deny that this is a challenging situation for providers to be in. There is good evidence, though, that the application of Quality Improvement methodologies can reduce waste and duplication, thus contributing to the savings needed across the system.
The Getting It Right First Time programme is a national initiative which aims to improve care in the NHS by reducing variation. Through detailed pathway mapping and data collection, the programme has tackled variation in the way services are delivered across the NHS and shared best practice between organisations. The first 12-month pilot in orthopaedics delivered an estimated £30m-£50m in savings, primarily through reducing average length of stay and streamlining procurement processes.
Clinical engagement has been critical to the success of this programme, and this is a great example of how improving quality of care by reducing variance can deliver savings as well as improving the experience of patients and service users along the way. It is also important to note that staff morale will undoubtedly be impacted positively, if the service staff are engaged in providing is efficient, effective and produces good outcomes.
Further examples of NHS Service Improvement Initiatives
ImproveWell has worked with many organisations to help foster cultures of continuous improvement in healthcare settings. Cultures where the improvement initiatives result directly from feedback from staff, gathered in real-time from the frontline of service provision. The resulting improvement initiatives have a positive impact on patient care, make services more cost effective and also improve staff engagement and experience.
1. The Royal Cornwall Hospital NHS Trust
Royal Cornwall Hospitals NHS Trust worked with ImproveWell following a period of intense scrutiny and critical external reports from the Care Quality Commission. Using the ImproveWell solution to collect feedback from frontline staff, the programme contributed to improvements in service quality and patient experience, and resulted in improved staff metrics such as sickness and absence rates, staff survey results and staff morale.
A variety of easy-to-implement changes were put in place to improve the maternity service. For example, by changing the way emergency grab boxes were labelled, 22 hours per week of staff time was saved by reducing the need for duplicate checks. The introduction of digital clocks on wards and delivery rooms has helped to ensure record-keeping is more accurate, which improves patient care and also reduces the potential for litigation. And finally, the introduction of “amnesty” boxes in staff rooms has resulted in savings of approximately £4,000 per year by giving staff an easy way to return resources placed in pockets during shifts.
All these changes were staff-led and improved the service provided to patients as well as saving money. Giving staff a voice to make suggestions and then acting on them swiftly and effectively will always have a positive impact on staff morale.
2. The Royal College of Psychiatrists
In 2021, ImproveWell embarked on a 12-month project in partnership with the Royal College of Psychiatrists which provided opportunities for 38 healthcare teams across 16 UK healthcare organisations to understand and test ideas on the factors contributing to joy in work and wellbeing.
The improvement collaborative was a development of the work already undertaken by East London NHS Foundation Trust on their ‘Enjoying Work’ programme, which applied Quality Improvement tools to improve staff experience and joy in the workplace. Both programmes used the ImproveWell platform to enable teams to collect and view data and to share and exchange ideas.
The results saw an impressive 50% improvement in the percentage of people who enjoyed being at work frequently, a 41% improvement in the percentage of people who experienced no symptoms of burnout and a 38% improvement in the percentage of people who were extremely likely to recommend their team as a place to work.
This programme, the first of its kind nationally, shows how improvement tools can be used systematically to improve staff experience in the workplace, even in the challenging environment that is the NHS post-pandemic.
Using ImproveWell to support Service Improvement
ImproveWell is a digital solution that helps teams and organisations gather actionable real-time feedback, 24/7. Using features including idea management, sentiment tracking and pulse surveys, ImproveWell provides a continuous touchpoint with the frontline to fuel improvements in service delivery, staff experience and patient care.
To learn more about the platform and how it can support service improvement in your team or organisation, request a call with one of our advisors.