King’s Fund: The DNA of improving healthcare organisations


Maxine Power reveals how can we support NHS leaders to bring about quality improvement.

Professor Maxine Power, Director of Innovation and Science at Salford Royal NHS is speaking today, Wednesday 25 May, at the King’s Fund sixth annual leadership and management summit in London.

Participants followed all the activity live on twitter with #kflead.

Coverage from the event, including video/audio clips and all presentation slides, are now available on the King’s Fund website.


Maxine’s session follows the keynote address ‘Innovations at hospitals around the world resulting in both cost savings and quality improvement’ from Dr. John Toussaint, Chief Executive Officer, ThedaCare Centre for Healthcare Value (United States).

This week I have been out and about talking to colleagues in NHS Improvement, the English national body for regulation and improvement, about what excellence looks like in healthcare organisations. More importantly, they, like many others are trying to ‘crack’ the DNA of the improving organisation. Its fair to say, there is no shortage of materials describing the journeys of those organisations who are thought to be ‘high performing’ . The Health Foundation and the King’s Fund have been resolute in describing these characteristics. My ruminations in this blog aren’t based on questionnaire surveys, one to one interviews or focus groups, they are based on 10 years of having worked in improvement. Here are five characteristics which I believe ‘define’ a high performing, improving organisation:

Leadership and Culture

Improvement is deeply embedded into the culture of the organisation through its values, organisational development and workforce plans. This isn’t simply a plan on a page, it is ‘alive’ – you can see the values in the environment, the behaviours of staff and most importantly in the operating practices. Recruitment, annual appraisal and professional development programmes centre around the need to continuously learn and improve. Perhaps most importantly frontline teams at the sharp end of delivery have the freedom to act and are supported by senior leaders and middle managers. Solutions are actively sought from the frontline and leaders know that their role is to support and unblock, not command and control.

Measurement and intelligence

High performers learn from data, indeed I would go as far as to say they are obsessed with it. When you speak to a leader of a high performing system they are conversant in quality, performance and efficiency metrics. They know what their HSMR has been for the last three years and take pride in telling you how it has come down and how they made that happen. They can also connect improvements in quality with value to the patient and are constantly  listening to the voice of the patient and co-creating value. They have as much respect for qualitative information collated at the individual patient level as they do for aggregated population or service line metrics and they are constantly asking why? So, working on reducing admissions, they will be constantly looking at why people are getting admitted and tailoring their interventions and improvement plans to their learning. For these organisations data is the life blood and they work tirelessly to make it reliable, accessible, actionable and meaningful. In today’s NHS high performers are also committed to enabling learning through more and more sophisticated data systems. They focus not only on installing the right systems (electronic patient record, roster management, acuity, tracking) but on working with teams to make the data collection process part of the workflow, electronic data are trusted and used ‘real time’ for both improvement, standardisation and assurance.

Careful project selection and management

Improving organisations understand that focus is the key to success. They avoid the temptation to think that more is better and systematically seek out a small portfolio of improvement programmes which are high value. Once they have these programmes, leadership take ownership and support frontline teams to deliver but first there is a structured diagnostic phase for each programme. The ‘problem’ is unpacked. Aims are set and a clear plan of action and measurement strategy are developed. There is clarity around the method being used for improvement and why that has been selected. The clinical process of assessment, diagnosis and treatment is replicated at the system level and these organisations are constantly trying to improve their outcomes through learning about ‘what works and why?’. We see this time and again in high performing teams and high performing organisations. Conversely we see ‘priority thickets’ and 1000 small projects in those who are starting on the improvement journey. The challenge here is to be brave enough to stop projects, liberate capacity, redirect it and say ‘this is what we are prioritising this year’, not many have the courage to do this.

Relentless focus on talent and building capability

People, people people this is the focus of the improving organisation. The organisation exists for the people, not the other way round. In improving organisations there is a palpable pride and this pride is infectious. It comes from recognising contributions made and systematically setting up systems of reward. People are proud to work in an improving organisation and they trust their peers to look after their loved ones. But this isn’t enough on its own. Improving organisations have a relentless focus on learning and build capability in the science that underpins improvement. They have a clear plan for how many people need to have which skills and by when and they are relentless in pursuing this above all else. They focus on people as members of teams and recognise that change happens in teams.

Improvement and assurance are seen as two sides of the same coin

The improving organisation understands that quality assurance and quality improvement are both necessary. In the same way as a football team requires a defence AND an attack to win a game. They don’t react to challenge by ‘putting more defenders in goal’ or manage improvement by bringing defenders forward and telling them to ‘attack’. There is careful thought and planning about how the quality team operates corporately and this is replicated throughout the system. There are local assurance systems established which can be used to hardwire improvements into the DNA of the organisation to re-set the system and deliver reliable, high quality care to every patient every time.


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