Quality improvement

This section introduces the quality improvement theme. Resources to support this theme are:

Quality agendas across the UK

All health care systems strive to provide safe and good quality health care; improve patient experience, tackle effectiveness and update practice in the light of evidence from research. The four UK countries have described what quality in health and social care means for them. They are building on the learning from previous quality improvement initiatives in order to deliver sustainable and continuous quality improvement of health and social care systems.

Quality is a “complex notion” (Health Foundation 2013, para1). In a report published in 2001 the Institute of Medicine in America proposed six specific aims for the improvement of the health care system in America that addressed key quality dimensions. The report said that health care should be: safe; effective; patient-centred; timely; efficient; equitable (Institute of Medicine 2001). These are often referred to as the six dimensions of quality and have continued to be influential, as is evident in the national health improvement strategies across the UK.


The continuous improvement of the quality of services and, more specifically the effectiveness and safety of services, and the quality of the experience undergone by patients are principles enshrined in the Health and Social Care Act 2012, and in the NHS Constitution (DH 2013).

In England the focus of activity as underlined by the Department of Health’s first mandate to the NHS Commissioning Board (now NHS England) is on improving health and care outcomes (Department of Health 2012a). The Mandate covers the period 2013 to 2015 and is supported by three outcomes frameworks for the NHS, public health and adult social care. These have been updated and brought into greater alignment to support joint working and integrated care. The frameworks set out high level areas for improvement, alongside supporting indicators which enable progress to be tracked and comparisons to be made. They provide a focus for quality improvement across health and social care (Department of Health 2012b).

NHS Improving Quality (NHS IQ) aligns with the five domains of the NHS Outcomes Framework (NHS Improving Quality 2013a). NHS IQ aims to build on the strengths and learning of the previous successful improvement programmes, including the NHS Institute for Innovation and Improvement to “create an improvement resource for the health and care system that is world class and sustainable in the long term” (NHS Improving Quality 2013, p.3). This includes developing a new improvement system for safety across the NHS.

The quality standards developed by the National Institute for Health and Care Excellence (NICE) describe high priority areas for quality improvement relating to treatment and prevention of different diseases and conditions, or services and interventions to support social care needs (NICE 2013a). They are intended to be central to supporting the delivery of the best possible outcomes in health and social care (NICE 2013b).

Northern Ireland

Northern Ireland has a ten year strategy, and accompanying implementation plan, prioritising the protection and improvement of quality within health and social care and identifying five strategic goals to achieve this. With reference to the six dimension of quality the strategy defines quality under three main headings: safety; effectiveness (the degree to which each patient and client receives the right care) and patient and client focus (Department of Health, Social Services and Public Safety 2011).

The implementation plan recognises the importance of building on the multitude of quality improvement initiatives already undertaken by health and social care bodies and which support the strategy. The plan highlights the promotion of a set of improvement methods and techniques and provision of training and resources to use them, and during the first two years the five work-streams are to include improvement methods, quality training and quality measures. The plan recognises the interdependencies with other key initiatives such as the Transforming Your Care initiative (Department of Health Social Services and Public Safety 2012).


The six dimensions of quality are central to the Quality strategy for NHS Scotland (NHS Education for Scotland n.d.). The strategy has three quality ambitions around person-centred, safe and effective care (Scottish Government 2010). Key elements in the strategy are the formation of a Quality Improvement Hub by a partnership of national improvement agencies in Scotland, and the Scottish Patient Safety Programme.

The aims of the Quality Improvement Hub include: alignment of the quality improvement agendas of the collaborating organisations; building on and maximising resources and expertise; provision of support, education, training and technical expertise in improvement science (NHSScotland 2013a).

Healthcare Improvement Scotland is one of the collaborating agencies and provides evidence based advice, guidance and standards as part of its support for improvement. It also takes a lead role in co-ordinating the work of the Scottish Patient Safety Programme (SPSP) which aims to ‘steadily improve the safety of hospital care right across the country’ (Healthcare Improvement Scotland 2013a).


Standard 6 of the Standard for health services in Wales is about the requirement to participate in quality improvement activities using recognised methodologies and reliable recording and measuring systems. The accompanying guidance expands upon this and links to useful organisations and resources. These include the National Clinical Audit and Outcomes Reviews, a section on clinical effectiveness in the Governance e-Manual, and in particular the patient safety programme and the methodologies for improvement and multidisciplinary audit developed by 1000 Lives Plus (NHS Wales 2013).

1000 Lives Plus forms the national improvement programme for Wales “supporting organisations and individuals to deliver the highest quality and safest healthcare for the people of Wales”. It encompasses all health boards and trusts in Wales and engages with all health care staff and with a network of students and academics. It focuses on building capacity and sustaining and spreading improvements. This includes programmes covering different areas and support for collaborative working to test new methods and protocols. The 1000 Lives Plus Faculty is a small group of senior clinical or managerial leaders who provide leadership and clinical expertise to support the programmes.

Quality improvement in practice

The Health Foundation, in a guide on quality improvement written for health and trust board members, expresses their belief that “there is a compelling case for applying organisational and industrial quality improvement approaches to health care” (Health Foundation 2010, p.4). The guide suggests that although evidence for the reduction of costs resulting from the use of these approaches is ‘patchy’, the overriding factor is the safety of health care. Moreover, an online resource from the Royal College of Nursing (RCN) makes the point that – “patient safety is both a characteristic of a health care system and a way of improving the quality of care” (RCN 2012, para 1).

Good examples of what has been achieved through patient safety initiatives are the Scotland Patient Safety Programme first established in 2008 and which, in addition to its work in the acute sector and paediatric patient safety, is developing programmes in maternity care, mental health and primary care (Healthcare Improvement Scotland 2013b). The activities and outputs of the Patient Safety First Campaign which launched for NHS England in 2008 have continued to impact and, although the campaign closed in 2010, the website has evolved as a ‘hub’ for a number of improvement programmes and resources (Patient Safety First 2013). The 1000 Lives Plus quality improvement programme in Wales developed from the 1000 Lives Campaign which achieved its aim of saving 1000 lives and preventing 50,000 episodes of harm in Wales (1000 Lives Plus 2012). For related and further developments in patient safety improvement see the RCN online resource Patient safety and human factors.

An independent analysis of evaluations of the Health Foundation’s quality improvement programmes makes the point that, “perhaps the overriding message is that there is no magic bullet in improvement” (Health Foundation 2012, p.26). The report highlights many aspects of the way quality improvement is approached and managed which can influence success, and it provides a tabulation of practical lessons in overcoming challenges to improvement. It underlines the complexity of interconnections that can occur between these factors, for example multiple approaches may be required that may seem contradictory. Also solving one difficulty might raise another. But the report also makes the point that there is much that can be learned from these experiences, and also that much has been achieved in the way of successful projects.

In the end “in every improvement movement there comes a point where you have to engage people in a practical way that makes sense and can be shown to work” (1000 Lives Plus 2011a, p.4). The quality improvement guide produced by 1000 Lives Plus in Wales aims to create a shared understanding and language for improvement and describes a set of techniques that can be applied in different settings and can involve multiple stakeholders. A nursing edition of the guide has also been produced. It contains examples of improvements made which have also been mapped to the RCN Principles of Nursing Practice (1000 Lives Plus 2011b). The eight Principles can themselves offer a framework for quality improvement as they describe what everyone, staff, patients and carers, can expect from nursing practice (RCN 2010).

Similar to the 1000 Lives Plus website in Wales, the Quality Improvement Hub in Scotland provides a focus for support providing information, learning and guidance. The Knowledge Centre section is designed to bring together key resources to inform improvement activities - topics, case studies, tools and current awareness (Quality Improvement Hub 2013b).

For further tools see the section in this clinical governance resource on Quality improvement guidance and tools.


All of the items in this reference list are available online. They were last accessed on 8 May 2013. Some of them are in PDF format – see how to access PDF files.

1000 Lives Plus (2011a) The quality improvement guide, Cardiff: 1000 Lives Plus.

1000 Lives Plus (2011b) The quality improvement guide: nursing edition, Cardiff: 1000 Lives Plus.

1000 Lives Plus (2012) About us, 1000 Lives Plus website.

1000 Lives Plus (2013) 1000 Lives Plus website.

Department of Health (2012a) The Mandate: a mandate from the government to the NHS Commissioning Board: April 2013 to March 2015, London: DH.

Department of Health (2012b) Improving health and care: the role of the outcomes frameworks, London: DH.

Department of Health (2013) The NHS Constitution for England, London: DH.

Department of Health, Social Services and Public Safety (2011) Quality 2020: a ten-year strategy to protect and improve quality in health and social care in Northern Ireland, Belfast: DHSSPS.

Department of Health, Social Services and Public Safety (2012) Transforming Your Care, DHSSPS website.

Healthcare Improvement Scotland (2013a) Improvement and implementation support, Healthcare Improvement Scotland website.

Healthcare Improvement Scotland (2013b) Scottish Patient Safety Programme, Healthcare Improvement Scotland website.

Health and Social Care Act 2012

Health Foundation (2010) Quality improvement made simple: what every board should know about healthcare quality improvement, London: Health Foundation.

Health Foundation (2012) Overcoming challenges to improving quality – lessons from the Health Foundations improvement programme evaluations and relevant literature (PDF 1.4MB), London: Health Foundation. 

Health Foundation (2013) What is quality, Health Foundation website.

Institute of Medicine (2001) Improving the 21st-century health care system in Crossing the quality chasm: a new health system for the 21st.century, Washington: National Academic Press. Chapter 2.

NHS Education for Scotland (n.d.) Quality Strategy for NHSScotland, The Knowledge Network: Evidence into Practice website.

NHS England (2013a) NHS Improving Quality, NHS England website.

NHS Improving Quality (2013b) Our strategic intent (PDF 827.1KB), Redditch: NHS IQ.

NHSScotland (2013a) Quality Improvement Hub, Hub website.

NHSScotland (2013b) Quality Improvement Hub: Knowledge Centre, Hub website.

NHS Wales (2010) Doing well, doing better: standards for health services in wales (PDF 675KB), Governance e-Manual.

NHS Wales (2013) Doing well, doing better: standards for health services in Wales supporting guidance. Standard 6: Participating in quality improvement activities, Governance e-Manual.

NICE (2013a) NICE quality standards, NICE website.

NICE (2013b) More information about NICE quality standards, NICE website.

Patient Safety First.

RCN (2010) Principles of Nursing Practice, RCN website.

RCN (2012) Patient safety and human factors: definitions and aims, RCN website.

Scottish Government (2010) The healthcare quality strategy for NHSScotland, Edinburgh: Scottish Government.