NHS workforces are intelligent and well qualified. Absorbing the technical requirements of change programmes and methodologies is not hard for them. Our AHS experts tell us that more often it is culture and behaviour that needs the most attention. Here, Anna Burhouse, one of our Principal Advisers, talks about generating a culture of improvement.


An interesting recent study by Warwick Business School (2022) reported on the national evaluation of the NHS-Virginia Mason Institute (VMI) partnership which supported 5 NHS Trusts to adopt the lean quality improvement methodology that sits at the heart of the VMI QI approach. See: Reports (warwick.ac.uk).

The study utilised highly visual social network graphs to show the difference between the 5 trusts in relation to how staff connected across the organisation, had conversations, shared improvement ideas and learnt from each other. They found that the best performing trusts had the strongest social networks and that this culture had helped them to better apply technical quality improvement tools and methods.

They concluded that “Continuous improvement approaches such as Lean are socio-technical. This means we should pay as much attention to the social side of change (for example, relationships and social structures that foster collaboration, engagement, psychological safety and employee wellbeing), as to the technical side (the infrastructure, training, methods and tools employed to drive change). Our findings suggest high levels of technical capability are a necessary but insufficient condition to foster a sustainable culture of continuous improvement” (2022, p4).

This work chimes with the work of Professor Amy Edmondson at Harvard on how to create better psychological safety in healthcare organisations and why it is essential for high quality service user outcomes that staff feel able to engage authentically in psychologically safe organisational cultures, where everybody’s voice counts and learning from experience is embraced.

In the UK, the work of Professor Michael West is leading the way on how to support compassionate, collective leadership in order to support a culture for improvement. His work demonstrates that clinicians who work in what he calls ‘real teams’, with clear goals and supportive team leadership are much less stressed (West et al 2015; West et al 2022) and that this impacts on better care and improved clinical and corporate outcomes including ‘hard metrics’ such as mortality and improved financial performance (West and Dawson 2012West et al 2011). His work encourages us to think about how patient/service user experience and staff experience are two sides of the same coin and highlights that if you get the conditions right for staff wellbeing you are simultaneously sowing the seeds for better patient or service user care, as the two domains are intrinsically interrelated.


How might you use this thinking in your organisation?

If we acknowledge the importance of the link between patient/service user and staff experience, then doesn’t it makes sense to focus quality improvement approaches on how to build better improvement cultures?

Whilst many organisations have knowledge of this evidence and are supportive of this approach in theory, examples of NHS trusts that currently triangulate patient/service user and staff experience data at scale - for the purposes of improvement and organisational development - are thin on the ground. But those trusts that are engaged in this way are leading the way in how to use this type of data for organisational development and proving it can help at times of acute organisational stress, such as at the height of the pandemic: 'Scared, but not alone': caring for staff during covid-19 | Comment | Health Service Journal (hsj.co.uk).

A bedrock of any improvement approach is how to measure progress, so the greatest challenge in taking this approach is how to establish a reliable, statistically robust, evidence based and confidential way of measuring how staff feel and then to triangulate this data with patient/service user experience. The data produced helps organisations identify positive deviance by highlighting those teams that are thriving and offering consistently higher patient/service user/staff experience and outcomes. Taking an asset-based approach like this can enable organisations to discover the successful behaviours and strategies, and highlight areas of best practice that can be shared across teams. It also helps organisations to better identify those teams most in need and to initiate quick win targeted support and improvement packages, measuring the improvement these types of interventions bring.


Final thoughts

Taking this approach requires senior leaders to understand the importance of adopting a cultural approach to improvement and of prioritising the measurement of what matters. Staff and patient/service user experience are a strong proxy measure for the quality of health care and can help leaders navigate where and how to apply their effort to have impact.

Starting to take this approach does not have to be ‘big bang’, in fact an iterative approach has many benefits to enable learning about what works in your organisation as you go. Starting with one team or one ward, measuring what matters, paying attention to what people say and acting quickly to make improvements creates a momentum of its own. If you do this, you’ll also find that you uncover many ‘micro stories’ of best practice, and moments of compassionate care between people that often go unnoticed and unacknowledged in a single day in the NHS. Finding these stories to go alongside the statistical measures helps to appeal to the head and the heart and build an improvement narrative that sits well with most people’s intrinsic motivation about why they work in healthcare, because despite the pressures that are out there at the moment, most NHS staff I speak to on a daily basis care deeply and want to keep continuously improving. This kind of data motivates change, recognises people’s effort and helps to create a psychologically safe process where learning from experience is the cultural norm.


About the author

Anna Burhouse is Director of Quality Development at Northumbria Healthcare NHS Foundation Trust. She supports NHS teams across the UK to lead complex quality improvement work and to scale and spread innovations. Anna provides improvement coaching, training, board and executive development and leadership of improvement programmes, working with organisations such as the Health Foundation, NHS Improvement and the Royal College of Physicians. She has practised quality improvement in healthcare settings for over 15 years, using improvement methods that embrace co-production and patient experience measures.