Building a quality improvement (QI) system across a whole organisation


Dr Amar Shah, Associate Medical Director & Consultant forensic psychiatrist for East London NHS Foundation Trust, talks about his experience of building a QI system at his trust and shares his advice for other providers who are looking to do the same.

Dr Amar Shah, Associate Medical Director & Consultant forensic psychiatrist for East London NHS Foundation Trust

What does it take to build a QI system across a whole organisation?

Over the last few years, we've gradually and intentionally worked towards embedding a culture of continuous improvement at East London NHS Foundation Trust, a mental health and community services provider with 5000 staff spread across over 150 clinical sites, serving a population of approximately 1.5million. Whilst we are still a long way from this goal, we bear the pride and scars from lots of learning along the journey.

What would it take to nurture a culture of continuous improvement within every trust in England?

Stable, credible leaders who truly understand quality improvement

Every high performing healthcare system has one common element – consistency at the top. Having stability and credibility within the executive team is an absolute pre-requisite if you’re considering a major shift in the way you run your organisation. 

Second, but just as important, is a coalition of executives who truly believe in their hearts that there is a better way to lead. Culture stems from the behaviour of those who lead, and so the executive team will need to shift the way they respond to issues, talk (and listen) to others, and how they spend their time. In the NHS we have a major deficit in knowledge among those who lead our organisations about improvement. This needs to be urgently addressed if we’re serious about the application of quality improvement methods in England. 

Third, is strong clinical leadership. This is the group who will need to lead the actual work of quality improvement, helping teams identify their big quality issue, bring alignment with strategic priorities and both engage and build capacity for QI work across all staff levels and professional disciplines. This is probably the hardest of all roles in embedding QI culture, as they will need to balance attention and demands from the current system, whilst supporting the transition to the new way of operating.

People to lead a new movement

It’s a difficult place to be, leading work that challenges the status quo.

Each organisation will need to find people who can take on this role – being highly skilled at communicating and engaging across all areas within and outside the organisation, able to run a fast-moving agile operation, applying both strategic and tactical thinking to adjust and pace the work to the opportunities and challenges that are faced, and having the ability to work most effectively through influence and networks rather than formal authority. Their job will be to build a movement from the edge of the organisation, redesign almost all corporate systems to support the work, and align improvement activity from the executive team to the clinical team.

Once you find these people, the first task will be to develop them into internal quality improvement experts, with the skills and confidence to guide and coach others.

Room to manoeuvre

The work of supporting QI needs leadership attention – it can’t be delegated. So the senior leaders will need to have breathing space to do this, away from any heat from the quality or financial regulators. You’ll also need to convince people that this new approach is going to stick, and that they really truly do have license to innovate – both of which will be hard to do when the organisation feels pressured from outside, and when leadership attention is obviously focused on tackling today’s difficulties through command-and-control methods.

So, where does that leave us? Well, probably with the pragmatic view that not all trusts are going to be ready to do this work at the same time. However, we should see ourselves as all being on a journey, with different methods needed at different points along this trajectory.

The goal is clear though – a better way of working that unleashes the huge creativity and passion of those who use our services and those who deliver our services, to continually reflect, test, learn and improve health and healthcare for the population.

You can find out more about the other great work that Amar's trust is doing by visiting our improvement directory

If you're interested in finding out more about implementing QI into your organisation, email You can also follow Amar on twitter @DrAmarShah

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