The very kind people who funded my PhD from the healthcare charity, the Health Foundation published a new report this week: ‘The Improvement Journey’. The report helpfully distils and summarises the improvement landscape in the UK (although much of the document appears to be more about England, than the UK). The report collates together some of the context and journeys that NHS organisations and improvement teams have faced over the last decade or so, to share learning about how we might continue to improve health and care going forward. The report is a substantial document and I am rather proud to discover that improvement work I have led or contributed to feature in this, including the Bolton Improving Care System (BICS), and a paper from my thesis connected to improvement capability is cited.
The report makes a distinction between locally run, microsystem based, projectised improvement activity and more substantive, meso or macro-system based, organisational or system wide improvement activity. To my mind, the report argues that more organisational and system wide improvement and associated capability is needed going forwards and uses examples (mostly from across England) to illustrate the point.
In general, I agree with the need to move towards more strategic ‘organisational’ improvement and find this report quite fascinating. This report clearly builds on other calls for improvement at scale, or as Dixon-Woods and Martin (2016) indicated healthcare needs to ‘act like a sector’ and ‘reduce projectness’. This is this music to my ears. We cannot continue to put as much substantial effort in to as many small projects as we currently do. Such projects that, for example say, often involve stickers in notes, to remind people to do things or just involve a minor change to a process (yes, I am stereotyping, but hopefully you get my point rather than get offended). Or sometimes, these projects are really only being completed to meet an educational requirement, such as a dissertation project (not all, but a good few). These small improvements do feel terribly big to new improvers and I commend them for their efforts. It is important work. But on their own, these types of mostly disconnected stand-alone projects are unlikely to move any of the big dials for patients or stakeholders, any time soon. Furthermore, in my experience anyway, much of this type of intervention seems to be short lived, perhaps a Hawthorne effect, with little sustainability for a number of reasons, including the reasonably high turnover of the people who led the projects.
I also feel it is important to really consider where to focus improvement expertise. Over the last few years, many quality improvement academies and training courses have launched, and these do lead to excellent learning and improvement projects – some big, more likely small. Some delegates go on to lead to great improvements in time. However, I’m not clear if the ratio of ‘new improvers coaching’ is in balance with the need for more experienced coaching for improvers on their third or fourth or fifth, hopefully much more complex projects. I wonder if the big focus and concerted effort directed into enthusing, teaching and coaching newbies, and students etc., means there seems to be less focus on ‘the leaky bucket’ after beginner ‘certification’ or after a job move or rotation. More emphasis on ‘intermediate’ improvers (what other phrase could I use?) to retain and utilise that knowledge and experience, and learning to help us go deeper, learning to help us work on the more complex challenges faced in patient care.
Finally, I think it is important to acknowledge the difference between an organisation or system deliberately or otherwise ‘letting a thousand flowers bloom’ which may or may not accumulate into something bigger; and an organisation or system having many, many improvers doing projects collectively leading to many marginal gains that add up into a clear strategic direction. Ensuring goal alignment, prioritisation of resources and the leadership commitment and visibility that comes from such longer term goals and which can only be achieved by trying to improve together within an organisation or system. In lean, this is facilitated through the concept of True North goals – a never ending constant direction of travel.
I find it important, and unsurprising, that the evidence and the organisation examples, in the learning report, have constancy of purpose from goals and leadership direction and commitment. The need to ensure engagement and ideas from staff and patients, and the need to scale. The combination of bottom up and top down improvement work. This reminded me of the work from Prof. John Bessant and colleagues, some 20 years ago, on developing strategic improvement capability. Their paper described this next step as moving from ‘structured improvement’ to ‘strategic improvement’. I feel a general sense in this report, that it is still mostly rare to observe organisational (or system) improvement in health care (in English healthcare at least) and moving towards more strategic improvement capability in organisations, building on the learning to date would be helpful.
To proceed, it may be useful for us to consider why many organisations find the jump to strategic improvement difficult and fail to sustain the leap; and what is substantially ‘different and extra’ or even superfluous within organisational improvement rather than micro-improvement? What additional support is required, what support may need to be removed? What does it mean for system-wide organisations and stakeholders, such as regulatory agencies? What does it mean for topic focussed national programmes? What does it mean for talent management and leadership continuity? And what does it mean for how we train and educate staff to develop organisational improvement capability?
On this last point, my PhD research findings suggest that organisational improvement capability is much more than individual skills and knowledge, incorporating other important dimensions, including leadership and culture. Perhaps then, there is an avenue to explore in bringing the fields and departments of Quality Improvement, leadership and Organisational Development much more closely together, as there is much duplication anyway. This could increase a team based focus for improvement rather than predominantly individual development. More importantly, this joint working may also help organisations and systems to move those ever important stakeholders dials and improve the patient experience, helping us to achieve our shared purpose for patients.
A collective act like this, could help us to not just develop talented individuals to lead (micro) improvements; but also to develop and support talented organisational teams with embedded improvement capability. It may also help us ensure that when individuals leading improvement activity move on, the ongoing improvement journey towards sustainable organisational improvement for patients can continue.