Stop the world, I want to improve: governing for quality improvement when there’s no ‘off switch’

Author Daniel Camero
Posted 2018.01.03

Blog by Will Warburton, Director of Improvement at The Health Foundation

I often feel like I struggle to stop to think these days. An ambitious work programme, the visibility of my Outlook calendar to colleagues, an efficient executive assistant and a frustratingly unshakeable people-pleaser tendency to say ‘yes’, mean each working day rapidly fills with the paraphernalia of organisational life: meetings, document reviews, interviews, signoffs, and events.

At the same time, my smartphone, underground wi-fi and social media platforms conspire to keep a steady flow of messages from work, home and the outside world streaming in each day.

But for all that, working at a senior level in a charitable foundation, I’m in the fortunate position to be in control of how I allocate my time. I can protect an hour each day in my diary. I work with a coach, talk to my boss, and allocate time each month to undertake uninterrupted reading and writing. In a rare triumph of man over machine, I’ve even learned to turn off ‘push’ notifications on my phone.


Not so easy


Perhaps being ‘always on’ is now a standard feature of senior management roles in any industry. But at a joint Health Services Research UK and Health Foundation event last week, I was reminded how much harder that is for those working in NHS boards, who also carry multiple layers of responsibility to patients, staff, and communities, under the scrutiny of regulators, press and politicians. In organisations that keep the lights on to serve patients 24 hours a day, seven days a week, creating conditions that allow people to escape the daily pressure, reflect and improve is not so easy.

This event, the first in a series, brought together leading health services researchers with policymakers, regulators, and executive and non-executive provider board members. Professor Naomi Chambers presented research looking at how boards in acute hospital trusts in England have responded to the 2013 Francis Inquiry report, and Professor Naomi Fulop presented her team’s work on how hospital boards govern for quality improvement.

Stories of intense external pressure on boards abounded, both from the research and discussion that followed.

Research interviews quoted a provider executive saying ‘there are no weekends in our world any more’. A regulator spoke of trying to explain to colleagues why sending large data requests, without notice, to an operationally challenged trust at 4pm on a Friday afternoon might be counter-productive. Another provider executive, working in a challenged organisation, recounted how a downgrade in regulatory status had led to the loss of valued external expert support. Non-executives told of an overload of requests on limited time.

The pressure of the regulatory environment was perhaps best encapsulated in a finding from Professor Chambers’ research, where provider board members were asked to assess how well they understood what was important to different stakeholders. Remarkably, board members reported that they understood the priorities of regulators better than they understood the priorities of either staff or patients.


Taking back control


In this challenging context, there was rich learning from the research and the experience of participants in the room of what could be done to enable boards to lead quality improvement in their organisations.

Professor Chambers’ research, to be published in 2018, describes how board roles and behaviours contribute to developing organisations that can manage risk, balance competing interests, develop relationships, enable sustainability and improve services. For example, effective boards play roles as:

• ‘Shock absorbers’ – moderating the force of transmission of external pressures

• ‘Coaches’ – supporting a culture of improvement

• ‘Diplomats’ – balancing stakeholder perspectives

• ‘Sensors’ – seeking out problems and providing challenge.


Professor Fulop’s team described the characteristics of boards with a high level of maturity of governing for quality improvement. They found that such boards:

• explicitly prioritise quality improvement

• balance short-term, external priorities with long-term, internal investment.

• use data for improvement, not just assurance 

• engage staff and patients

• encourage a culture of continuous improvement


These characteristics appeared to be particularly enabled and facilitated by engaged and vocal boardlevel clinical leaders. The research is available on the BMJ Quality and Safety website.

So might the learning from this research be applied to support better governance for quality improvement? Certainly, regulators in the room, from CQC and NHS Improvement, seemed every bit as conscious of the importance of designing targeted regulatory approaches that support boards to improve from within. They also seemed willing to explore how the research could inform the development and application of policy frameworks, to strike the balance, again in the words of Professor Chambers, so that appropriate regulatory ‘grip’ doesn’t become ‘throttle’.

At the same time, when even the most experienced and able board leaders seem vulnerable, there was also agreement that provider boards mustn’t give up their agency. It might not be possible for an entire health care organisation to block out a day in the diary, and there might not be an ‘off switch’ for external pressures. However, the stories of successful organisations holds out hope that provider boards retain the power to take control of and deliver on an agenda for improving quality of care.

Will Warburton is Director of Improvement at the Health Foundation, @willwarburtonHF