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Embedding a culture of quality improvement

Quality improvement refers to the use of systematic tools and methods to continuously improve the quality of care and outcomes for patients. A growing number of health care providers in England and abroad have begun efforts to embed quality improvement methodologies in their work. This report explores the factors that have helped organisations to launch a quality improvement strategy, and the key enablers for sustaining a focus on continuous quality improvement.

The report draws on a roundtable event, semi-structured interviews with senior NHS leaders and stakeholders involved in quality improvement initiatives, and a literature review. It identifies relevant learning from organisations that have already adopted quality improvement approaches, and focuses on how senior leaders can create the right conditions for quality improvement to emerge and flourish.

The impact of quality improvement work is often greatest when it forms part of a coherent, organisation-wide approach, as opposed to discrete, time-limited projects (Dixon‑Woods and Martin 2016). We therefore focus on examples where there have been sustained attempts to embed a culture of quality improvement across a whole NHS provider organisation.

This report is part of a broader King’s Fund programme of work on systematic approaches to improve the safety, experience and effectiveness of care. Many of the findings in this report are supported in our earlier reports on quality improvement, including our report on quality improvement in mental health (Ross and Naylor 2017) and on the need for a coherent approach to quality improvement at a national level (Ham et al 2016). The case for quality improvement is also made in our report with The Health Foundation on lessons for NHS boards and leaders (Alderwick et al 2017).

The next section of this report looks briefly at the rationale for embracing quality improvement approaches in health care. The third and fourth sections explore the evidence from participants in our roundtable and interviews and from our literature review about how health services can initiate and sustain a culture of continuous improvement. The fifth section considers the wider challenges for developing such a culture in the NHS. The final section summarises the key lessons from this research.


The overarching purpose of the study was to capture the narratives and practical lessons from leaders of organisations that are already engaged with quality improvement as a routine way of working. Therefore, we interviewed five chief executives from NHS health, mental health and integrated acute and community trusts. These were primarily those engaged with the NHS Improvement and Virginia Mason Institute partnership (see the next section), but also included one
chief executive of a trust that was not part of the programme. In addition, we interviewed two experts in the field of health care quality improvement (from national NHS bodies).

To capture wider views from within the health system, we also convened a half-day roundtable at The King’s Fund in July 2017, which was attended by 13 senior local and national NHS leaders, to understand their roles in driving quality improvement. Through the interviews and the roundtable, we heard the views of the chief executives of all five trusts involved in the Virginia Mason Institute Partnership programme. Finally, we undertook a rapid review of academic and ‘grey’ literature relating to quality improvement, with a particular focus on Lean approaches to quality improvement.