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We found that boards with higher levels of maturity in relation to governing for QI had the following characteristics: These characteristics appeared to be particularly enabled and facilitated by board-level clinical leaders. This study contributes to a deeper understanding of how boards govern for QI. The identified characteristics of organisations with mature QI governance seemed to be enabled by active clinical leadership.

Future research should explore the biographies, identities and work practices of board-level clinical leaders and their role in organisation-wide QI. There is growing international attention on the role of boards in supporting high-quality care. Boards of NHS providers in England have tended to follow the unitary board model of the private sector.

They typically have between 10 and 15 members comprising executive and non-executive functions.


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Overall leadership of the board resides with the chair. Executives and non-executives are expected to work collaboratively to develop strategy. However, this form of local accountability is perceived as generally weak, 15 and it has been argued that financial deficits and an increase in central planning guidance have narrowed the differences, in accountability processes, between foundation and non-foundation trusts.

Associated Data

Previous research has found an association between certain board practices and the quality of care. Other characteristics found to be associated with high-quality care were board chairs who were familiar with current performance, and board members with expertise in QI, and who had received formal training in QI. Since the report of the public inquiry into failings in care at Mid Staffordshire NHS Foundation Trust, the importance of involving staff and patients in formulating strategy is increasingly recognised in guidance to hospital boards.

We used findings from this previous empirical research and guidance to construct a framework to explore how governance in relation to QI is enacted by boards. We applied this measure to the 15 organisations in our study to identify the processes adopted by boards with higher levels of maturity in their approach to governing for QI. Our study differs from previous research on hospital boards that has employed board competency frameworks. We used previous research and guidance to construct a framework to explore how hospital boards in England enact governance of QI.

The framework approach was designed for studies with a defined research question of policy or practical relevance. Data were collected between March and November We also collected publicly available board meeting papers from the meetings we observed 30 sets minutes from an additional board meeting for each organisation 15 and Quality Accounts a mandatory report on the quality of services provided by an organisation and published annually.

We asked organisations to nominate five members, both executive and non-executive, including the non-executive director responsible for quality. Interviews were semistructured on the topic of governance of QI and covered the topics in our framework. Notes were handwritten at the time of board observations and then written up afterwards and stored electronically. Interviews were recorded and transcribed. All textual data, including board observations, interview transcripts and documents, were imported into NVIVO software for analysis.

Our analysis followed a number of stages. This was an iterative process that involved successive rounds of analysis, team discussion, testing the emerging measure against the data and refinement. It includes mechanisms such as quality monitoring and reporting, national standards, guidelines and targets. Once the measure was agreed it was used to classify all 15 organisations in our study. Organisations were rated against each item by LP.

The same process was then used to calculate, for each organisation, an overall classification of QI maturity. Our analysis thus involved a combination of deductive and inductive forms of inference. We also used an inductive approach to identify additional themes in the data, returning to the literature to further explain our findings. Informed consent for interviews was obtained from all participants. Board meetings are held in public, although we informed organisations prior to our attendance of our presence and our study. We found a range of board-level activities related to governance of QI.

Boards varied in the extent to which, and the way in which, specific activities were undertaken. Table 3 shows the QI maturity rating for each organisation. The following characteristics emerged as particularly important in understanding variation between organisations: QI as a board priority; balancing a short-term external focus with a long-term internal focus on QI; using data for improvement; patient and staff engagement; and clinical leadership.

Additional data relating to each theme are shown in online s upplementary table S4. Boards with higher levels of QI maturity prioritised QI in their discussions. The priority afforded to QI cannot, however, be inferred simply from the amount of time spent discussing QI as boards with high levels of QI maturity relied on their quality subcommittee to provide detailed scrutiny.

This was in contrast to an apparent lack of confidence in the board subcommittee structures within other organisations where the quality committee report was discussed in full at the board meeting.

The report from the quality committee was given by the Nursing Director. The committee has been inquorate for 3 meetings. Not much reported at this point. Board observation, Organisation 5. All boards faced multiple external accountability requirements. Boards with high QI maturity addressed these requirements but also had agreed plans to improve quality within the organisation in the long term. In these organisations the Quality Accounts contained clear priorities that were well defined and internally driven.

In contrast, in organisations with low QI maturity, Quality Accounts had a large number of priorities that were driven more by external demands, such as national targets for infection control and waiting times for treatment. A focus on values was seen by participants to have benefits in terms of the quality of care provided to patients, as well as in encouraging staff to adopt QI processes. Importantly, it was also felt to lead to more effective functioning of the board by enabling trust between board members and managers:.

Because trust is an essential ingredient, when clearly the board cannot go through every little detail about whether this patient, or that patient has received the right treatment, the right care, the right behaviours from the staff. Interview, chair, Organisation 2. Organisations with high QI maturity received reports where the data were clear, readable, and where different sources of data were discussed together eg, data on staffing levels considered alongside data on staff well-being and patient experience.

Importantly, organisations with a high QI maturity used data for QI, not just assurance. For example, data were linked to actions and these actions were monitored. In contrast, reports to boards with low QI maturity were characterised by a large volume of data, often not clearly presented, reviewed in silos and not linked to improvement actions. Boards with high QI maturity used a range of types of data. In one example from our study the chair used unannounced visits to wards to detect potential problems.

In this organisation the Chief Executive also personally read all complaint letters. It was also considered to be a valuable source of insight into the nature of problems that could then be used as a guide for action. In contrast, organisations with a low QI maturity were less likely to compare themselves with others, and where benchmarking data were used these were considered in isolation from other metrics and used mainly for external reporting requirements.

Boards with a high QI maturity made systematic efforts to collect the views and experiences of staff and patients and involve staff and patients in the development of strategy. In this organisation board members also attended meetings with patient groups and, importantly, translated the issues that were raised in discussion into actions:. Interview, Director of Nursing, Organisation 2. Organisations with high QI maturity were characterised by constant questioning and self-examination. A key feature of organisations with high QI maturity was a culture that supported learning and improvement.

These organisations used external networks for learning, proactively discussing particular issues with staff from regulatory agencies, researching how other hospitals had responded to similar problems and visiting high-performing organisations. In contrast, organisations with low QI maturity appeared more complacent than those with higher levels of QI maturity. At times there was also insufficient challenge from non-executive directors. During one board observation this practice was picked up by a newly appointed chair, as can be seen in the following reprimand from the chair to an executive:.

I think what comes back to the board is our best realistic thinking not an element of wishful thinking. Board Observation, Organisation 7. It was notable that the boards of organisations with high QI maturity had a higher number of clinicians on the board three or more than other organisations. They were also observed to provide the board with helpful analysis of quality and safety concerns, for example, by explaining trends, both positive and negative, and why issues had arisen.

In contrast, the clinical leaders on the boards of organisations with low QI maturity made very little overall contribution to the meeting, speaking only to a small number of items related to their clinical remit. We also recorded instances of there being no medical director in post and no interim provision Organisation 6 , of unhelpful responses from the medical director to questions from the chair Organisation 10 , and clinical leaders who spoke so quietly that the chair, or members of the public, had to request that they speak louder Organisation 5, Organisation 7.

We also observed an instance where clinical leadership was enacted in what we considered to be a largely rhetorical, rather than a substantive, way. For example, one director of nursing spoke at length about her familiarity with front-line patient care, and her concern for quality, but in such a way as to discourage further challenge from non-executive members, potentially inhibiting the effectiveness of the board Organisation There is an indication—from interviews and board observations—that clinical leaders in organisations with high levels of quality governance maturity had also built relationships with external partners, such as commissioners and regional NHS managers, and brought to the board knowledge of the external policy environment.

However, there was also the suggestion that medical directors, in particular, attended numerous external planning meetings, potentially impacting on their role within the organisation, which requires further research. This is alluded to in the following admonishment from a chair to the board:.

The top corridor is empty quite a lot of the time. I take it because you are all in these meetings in [name of locality], which I find annoying. We used a framework developed from previous research and existing guidance to analyse the activities of hospital boards in England to develop a measure of a maturity in relation to governance of QI QI maturity. We applied this measure to the organisations in our study and then explored the characteristics of boards with differing levels of QI maturity.

We found that organisations with higher levels of QI maturity prioritised QI, balanced attention to short-term external priorities with a long-term internal investment in QI, used data for QI, not just QA, engaged staff and patients in QI and had a culture of continuous improvement.

These characteristics often appeared to be enabled and facilitated by clinical leaders. We contribute to the literature on board governance of quality by describing how these characteristics were enacted. However, little is known about how clinicians on the board improve quality. We found that in organisations with a high QI maturity clinical leaders brought in-depth knowledge and understanding of quality issues and provided the board with meaningful analyses of data. Collaborative Learning and Partnerships. Patient and Public Engagement and Involvement.

Mental and Physical Wellbeing. Public Health and Information Intelligence. Improvement Science and Quality Improvement. Research Driven Improvement Projects. Past Events - Now. The eight modules are: Her postgraduate education work included developing "one year in one place" rotations for junior doctors, setting up London's Specialty Schools and devising the first Darzi Fellowship Programme. Fiona was awarded a CBE for services to Medicine in She has been awarded a prestigious Health Foundation Improvement Science Fellowship and led the development of a systematic and scientific approach to delivering improvements in care.

As part of her fellowship Julie conducted comparative research in the UK, Australia and America to explore the use of quality improvement methods in different settings. NHS leaders must therefore work to model and build these cultural elements. For those leading specific improvement projects, it will be necessary to spend time building relationships and engaging with relevant stakeholders involved in the change — for example to gain buy-in and surface any challenges or unintended consequences.

Many of the most successful quality improvement initiatives in the NHS have been identified, designed and implemented by teams working at the front line. In some cases, they have done so without the explicit support or encouragement of senior leaders within their organisation, or without any meaningful resources Bohmer A shared determination to make a difference, together with an ability to carve out time to focus on improvement work, have been critical to their success.

However, it can be difficult for clinicians to engage in quality improvement Wilkinson et al They face several barriers — including a lack of time and resources and a lack of knowledge and skills for quality improvement. There is no simple solution to overcoming these barriers.

Providing dedicated resources and project management capacity, having committed leaders capable of sparking enthusiasm, with skills in monitoring and evaluation to clearly demonstrate results, and ensuring alignment with other clinical priorities and health system changes, are all likely to help Ling et al Finding ways to free up staff time to take part in improvement work or training is another necessary step.

It is also important to understand what is likely to motivate clinicians to change their practices — critically, their intrinsic motivation to improve quality of care for their patients rather than improving efficiency or cutting costs. Rather than being seen as the business of managers, it is important for there to be an understanding that quality improvement approaches can help frontline teams to deliver better and more effective services for their patients.

It is also possible to encourage participation by using more formal measures — for example by including involvement in quality improvement as part of required professional development activities, or by visibly reporting data on performance between peers Dixon-Woods et al , However, it is important to prepare the ground carefully.

Equally, any effort to highlight variation needs to go hand in hand with practical support to help teams and organisations to close the gap with their peers. One important lesson from organisations that have successfully built improvement capability at scale is to avoid doing too much, too quickly.

Delivering and sustaining change in a few key areas, and working first with a small cohort of volunteers, can help to generate momentum and provide a platform for the roll-out of an organisation-wide programme Jones and Woodhead This is no surprise: But it can be difficult to know how this should be done in practice. Armstrong et al identify a number of tips for successful patient involvement in improvement projects, including but not limited to:. A range of tools and approaches can also be used to help achieve these aims, such as the Patient and family-centred care toolkit.

Examples of how patients and professionals have worked together to embed change can also be found in the examples above. Meanwhile, people with dementia and their carers helped to co-design the core elements of the Dementia Golden Ticket model of care example 5. Improving quality will often require organisations to work together and pool resources across local systems of care Ham and Alderwick Developing new care models for people with multiple long-term conditions, for example, may depend on collaboration between primary and community services, acute hospitals, mental health and social services, as well as services outside the health and care system such as housing and employment services.

The approach taken in Sussex to improve dementia services example 5 is a good illustration of this, involving collaboration between primary care, acute and community services, and patients and their carers, to improve the quality and experience of care. STPs have an important role to play in co-ordinating local improvement efforts and developing new approaches across organisational boundaries. Working as a system can also be key to spreading improvements in quality. There are a range of opportunities for NHS organisations to improve quality of care and value for money.

Examples can be found across the NHS where teams and organisations are already acting on these opportunities and demonstrating positive results for their patients, as the examples given in this briefing show. But the systematic use of quality improvement approaches within the NHS is still patchy, and many improvement efforts fail to deliver the results expected.

NHS leaders — and boards in particular — have a vital role to play in creating a supportive environment for quality improvement within their organisation — for example by providing a clear vision and objectives for improving quality and putting in place the capabilities and support needed for staff to improve services.

Leaders must also work between organisations to develop new care models and co-ordinate improvements. The 10 key lessons outlined provide a starting point for NHS leaders seeking to more firmly embed quality improvement within their local plans for improving services. Academy of Medical Royal Colleges Quality improvement — training for better outcomes [online]. Sustainability and transformation plans in the NHS: Alderwick H, Ham C British Medical Journal , vol , j Better value in the NHS: Health Expectations , vol 16, no 3, pp e36—e Azad N, Lemay G Journal of Geriatric Cardiology , vol 11, no 4, pp — Bevan G, Hood C British Medical Journal , vol , pp — New England Journal of Medicine , vol , pp — British Heart Foundation An integrated approach to managing heart failure in the community [online].

British Heart Foundation website. Department of Health High quality care for all: NHS next stage review final report. Milbank Quarterly , vol 89, no 2, pp — Future Hospital Journal , vol 3, no 3, pp —4. Dixon-Woods M, Pronovost P T he challenge and potential of whole system flow. Fulop N, Robert G Context for successful quality improvement.

Making the case for quality improvement | The King's Fund

International Journal for Quality in Health Care , pp 1—8. Reforming the NHS from within: Ham C, Alderwick H Place-based systems of care: Delivering sustainability and transformation plans: Improving quality in the English NHS: Annals of Internal Medicine , vol , no 1, pp 27— Institute for Healthcare Improvement undated. Institute for Healthcare Improvement website. Institute of Medicine Crossing the quality chasm: T o err is human: James C, Savitz LA Health Affairs , vol 30, no 6, pp — Jha A, Epstein A Health Affairs , vol 29, no 1, pp —7.

Journal of Healthcare Management , vol 53, no 2, pp — Journal of Healthcare Management , vol 54, no 1, pp 15— Jones B, Woodhead T Building the foundations for improvement. Milbank Quarterly , vol 88, no 4, pp — Nephrology Dialysis Transplantation , vol 27, suppl 3, pp iii73— Kidney Care UK Chronic kidney disease [online].

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Kidney Care UK website. Health Affairs , vol 22, no 2, pp 17— Leis J, Shojania K How do you get clinicians involved in quality improvement?

Understanding quality in district nursing services: A clear road ahead: Closing the NHS funding gap: National Audit Office The management of adult diabetes services in the NHS: National Audit Office website. National heart failure audit April —March [online]. Healthcare Quality Improvement Partnership website. National diabetes audit, Enhanced health in care homes: Sutton Clinical Commissioning Group website.

Medication safety in the NHS [online]. NHS five year forward view [online]. Developing people — improving care: NHS Right Care