Response to DH on New Quality Policy

High Quality Care for All – Measuring for Quality Improvement: the approach is a document that sets out the Department of Health's view about what needs to happen to make quality improvement the organising principle of everything that the NHS does. It invites comments. Here are mine.

1. Timeliness, efficiency and equity have all historically been seen as significant features of NHS quality systems. The traditional focus on these 3 issues must not be overlooked when designing a new system. The NHS needs to learn how to judiciously 'blend' these historic features into a new approach that rightly has a much sharper focus on safety, effectiveness and the patient experience.

2. Transparency is a new and important dimension that is missing from the proposals. Transparency needs also to be present in a refocused Quality system. Inviting, or even welcoming, public and patient scrutiny is probably potentially the single most powerful dynamic that can be harnessed for creating a culture that priorities quality improvement.

3. It is absolutely vital that local leaders, especially Chief Executives and Medical Directors of Trusts, feel capable and personally able to devote sufficient attention to this agenda. Partly this requires a conscious effort on their part to appreciate the 'science' of quality improvement, to prioritise quality related work, to signal this clearly to the rest of the organisation, including the Board and to communicate other Trust activities within a broader Quality 'mindset'. To find a broader 'quality narrative' if you like.

4. Ultimately leadership of successful and sustained quality improvement is not something that can be delegated to 'quality technicians'. Most clinicians, understandably, will only be persuaded that we are serious about quality when they see Chief Executives and other local leaders being obsessed with the pursuit of quality, over a sustained period of time. Leaders really do have to have to 'be the change they wish to bring about'.

5. Most organisational cultures will not become more receptive to sustained and effective quality improvement without a clear and visible shift in the leadership behaviour of leaders. The requisite shift in culture also requires the judicious use of positive incentives to reward desirable attitudes and behaviour deep within the clinical and managerial domains. Commissioners in particular can play a key role in co-designing and reinforcing such positive incentive systems. Financially penalising relatively poor performers is not the route to quality improvement.

6. The new, ambitious vision of “making quality improvement the organising principle of everything we do in the NHS” may of course mean that, over time, the 'goalposts' move in terms of what makes a successful Chief Executive, Medical Director and ultimately a successful Trust. Some local leaders will find this transition easier to achieve than others. It is vital therefore that local leaders make the time to create their own effective lateral peer support mechanisms to accelerate their personal learning about what being successful now means in a re-focused NHS. Existing leadership programmes need to be refocused to reflect this need.

7. Less is better when it comes to agreeing and using a national system of metrics. When building a national set of quality metrics the NHS should start small and build incrementally, developing and agreed a more sophisticated set of metrics (with clinicians) as people learn how to measure, interpret and act. One feature therefore of a successful national Quality System will be its' ability to balance the need for a small set of consistent comparative data at the regional and national level with the dynamic of continual adjustment of meaningful metrics at more local levels.

8. All data will be interpreted. Most data can be interpreted in multiple ways. Clinicians, managers, non-executive board members, politicians, patients and members of the public will all be interpreting quality-related data. The NHS needs to ensure that, as far as is possible, useful and timely training in data interpretation is offered.

9. Data is always interpreted in context. For example, relevant patient stories, sitting alongside 'raw' data will have a significant impact on how that 'raw' data is interpreted. Some stories might 'help' the reader see the data as more positive than might be the case. Other stories could easily help create the opposite effect. Much more research needs to happen, urgently, about the psychology of data presentation, especially in relation to sharing data with the public.

nhsquality improvement