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If at First You Don’t Succeed: Meeting the Ongoing Challenge of Continuous Improvement

By Mark Hamilton | Friday, January 11, 2019

How do you reinvigorate improvement work in a large hospital when previous efforts didn’t last? For St. George’s University Hospitals NHS Foundation Trust in London, it began in 2016 with a discussion between colleagues.

“In a way, things started with a conversation in a corridor between three friends about how, as an organization, we could do things better,” says Dr. Mark Hamilton, a consultant in critical care and anesthesia at the Trust. According to Hamilton, he and his colleagues wanted to shift their organizational culture and embed QI into the way they worked. With his appointment as the Trust’s Associate Medical Director in Quality Improvement (QI) and Clinical Transformation, there was an opportunity to make this happen.

Experience, however, made them cautious. “None of the improvement efforts before had stuck,” Hamilton notes, “so we asked each other what would need to be different this time.” The stakes were especially high because St. George’s was in double special measures (a designation given in the UK to a public service organization in need of improvement) for both finance and quality. “We needed to find a way out,” he recalls.

To bring about effective and lasting improvement, the colleagues decided they needed a systematic way to change the culture of how people worked together. According to Hamilton, “We sketched out a center for QI that would help to shift the culture.” Their goal was to empower staff by building QI capacity and capability. Their plan was to provide training on QI methods and opportunities to put what was learned into practice. “I’ve reflected a lot on what quality looks like,” Hamilton remarks. “I think it would be an empowered multidisciplinary workforce that brings the best of improvement to all that we do.”

Hamilton visited organizations that focus on building QI capacity and capability to get their advice. He realized St. George’s needed external support to help them through their journey. In 2017, Hamilton was selected for GenerationQ, the Health Foundation leadership development and quality improvement program. This evolved into getting formal QI and strategic support from the Institute for Healthcare Improvement (IHI) and the launch of St. George’s Quality Improvement Academy (QIA). The QIA helped St. George’s identify both their strengths and their opportunities for improvement. With this information, the Trust was then able to prioritize and sequence where to put their energy and resources.

Lessons Learned

After training small groups of people in QI methods and providing coaching and support, the Trust saw some success, but still struggled to make the large-scale difference they needed. “It was then that we realized that promoting QI as a set of tools wasn’t wrong,” Hamilton remembers, “but it wasn’t the whole story.” Here are a couple of the lessons St. George’s has learned so far on its improvement journey:

  • Learn how to make your case — “We had been through multiple executive leadership changes and that meant people were wary of more change,” Hamilton says. “Getting crucial buy-in from senior leaders for what we wanted to do was difficult. It felt as if we went round the same story again and again before we eventually got some traction.”
  • Culture matters more than tools — “I have come to believe that improvement is 20 percent the tools and 80 percent culture and people,” asserts Hamilton. After spending time working with the IHI and Safe & Reliable Healthcare Safe, Reliable, and Effective Care framework, it became clear St. George’s needed to tackle the cultural underpinnings of QI with even more clarity and passion. “The Framework has given us a great conversational centerpiece to build around,” Hamilton remarks. “It helps us to understand the pieces we are missing and allows us to target our organizational development and culture change program effectively."

The Importance of Collaborative Learning

“To be an authentic learning organization,” Hamilton says, “we have to learn from others and ourselves.” This led St. George’s to join IHI’s Healthcare Improvement Alliance Europe (HIAE).

“The HIAE has so many varied, committed and passionate people that are doing great work in improvement,” Hamilton says. He describes being a member as “the perfect learning environment for anybody working in improvement. The knowledge and seniority of the group is an invaluable sounding board.”

Hamilton attended his first HIAE meeting in London in October 2018 with two of his team members. The HIAE instantly made them feel at home. “The ability to remain non-judgmental and curious is a vital ingredient for improvement,” Hamilton asserts, “and the Alliance encourages and demonstrate those qualities in abundance.”

What’s Next?

The Trust’s Quality Improvement Academy continues to grow. “For an organization of 9,000 staff,” Hamilton notes, “[building capacity and capability] will take time, but we continue to learn from ourselves and others.”

Data will have an increasingly important role to play as St. George’s strives toward continuous improvement. Hamilton says, “We are slowly changing the way we look at and use data by looking at activity over time and changing the conversations to match that.”

Another important aspect of their efforts will be focusing on joy in work. “Our work is not only centered around the patient, but also the development and welfare of staff,” Hamilton remarks. “If we treat our staff and ourselves well, we can do a much better job for patients.”

You may also be interested in:

A Framework for Safe, Reliable, and Effective Care white paper

IHI Health Improvement Alliance Europe

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