What Influences Quality Improvement Processes in Health Care?


Nov 10, 2020

Patient communicates with her doctor via a laptop for advice, photo by Henfaes/Getty Images

Photo by Henfaes/Getty Images

The COVID-19 pandemic has forced health care services and systems to make substantial, rapid changes to the ways in which they operate. It is likely that many of these changes will be retained in the post-COVID-19 era. Using digital technologies to access non-urgent health care services, for example, is unlikely to be fully relinquished in favour of a return to in-person appointments, although some patient–health care provider interactions will inevitably continue to require face-to-face consultations.

Doing things differently opens up opportunities for doing things more effectively and efficiently, provided that the risks associated with new models of care are identified and successfully managed. For example, effective transition to remote patient consultations and monitoring at scale requires the training of frontline staff to ensure that high quality is maintained. This includes training to avoid the risks that remote consultations and monitoring can give rise to, such as missing cues from patients that may be picked up more readily in face-to-face interactions. It also means evaluating these new ways of doing things, to ensure that they work as well as intended for all the groups involved.

This evolution in service delivery offers important opportunities for improving care quality and patient experience in many areas—remote maternity care or the remote monitoring of patients with diabetes being just two examples. Making the most of these opportunities, it will be important to ensure that the evidence base on how quality improvement happens and what influences its success is incorporated into decisionmaking.

Recent RAND Europe research considers six key influences on improvement processes that need to be in place to support quality improvement in health care organisations. The insights from this research may be particularly pertinent to engage with at the present time, as health care services try to respond to the pressures of the COVID-19 pandemic and move to new service delivery models while sustaining some traditional ways of operating.

Doing things differently opens up opportunities for doing things more effectively and efficiently, provided that the risks associated with new models of care are identified and successfully managed.

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The six influences are: leadership; relationships and interactions that support an improvement culture; skills and competencies; patient and public involvement, engagement, and participation; using data for improvement purposes; and working as an interconnected system of individuals and organisations, influenced by internal and external contexts. We discuss what each of these mean in practice. They represent key aspects of the social and organisational context for quality improvement in health care service provider organisations.


Effective leadership in the context of supporting health care quality improvement is characterised by sustained and continuous engagement from different types of leaders and improvement champions representing diverse health care specialities, multiple levels within organisational hierarchies, and clinical, managerial, and executive dimensions of health care leadership. The literature suggests that leaders should develop and disseminate a compelling narrative for the long-term strategy and value of any planned improvement activity, with clearly articulated roles and responsibilities for both themselves and those they seek to lead. This is central to cultivating staff trust in the values, vision, and expertise of its leadership. Importantly, different types of leadership are needed for different contexts and phases of improvement, and it is important to find a balance between leadership styles. Overly hierarchical leadership risks disrupting the community ethos that can help drive improvement activity. On the other hand, over-reliance on voluntary social linkages alone can put quality improvement communities at risk of disintegration.

Relationships and Interactions That Support an Improvement Culture

A culture of improvement can be developed and sustained by fostering supportive relationships and regular interactions between all individuals and groups involved in improvement activity. These relationships are most effective when characterised by open discussion, transparency, sustained collaboration, and feedback to support continual learning. In addition, improvement processes can be influenced by exchanging learning between organisations, by creating a shared understanding of the benefits that can accrue from improvement activity among staff in an organisation, as well as a shared understanding of the challenges that can be experienced along the way and how these might be addressed. Intra- and inter-organisational interactions can be supported by developing a clear strategy that considers what to communicate, to whom, how, and when.

Skills and Competencies

Improvement processes rely on appropriately resourced staff who are trained in the requisite technical and social skills.

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Improvement processes rely on appropriately resourced staff who are trained in the requisite technical and social skills—both are important to make improvement work in a real-world context. This is vital for staff at all levels, from those at the coalface of improvement to leadership and senior executives, because improvement is a collective and socially constructed phenomenon. Educational components relevant for health care staff can be integrated into the design of an improvement initiative in many ways, for example in the form of simulations, scenarios, lectures, workshops, role-play, and/or experiential learning with feedback. Such training can have a more positive influence on improvement processes if it is provided regularly, for example as part of continuous professional development.

Using Data for Improvement Purposes

Data can help to identify improvement needs, inform the design of improvement interventions and implementation strategies, and support monitoring, evaluation, and learning. Good evaluation is central to improvement, but it is not possible without access to accurate and relevant data on the quality of care. Organisational culture and staff attitudes towards data and evidence influence the extent to which they are used in improvement. This includes whether staff see data as relevant and meaningful, and therefore helpful in supporting their individual roles and collective goals, and whether they trust data quality, accuracy, and the credibility of its source. The effectiveness of data in guiding improvement activity is also influenced by when it is provided, to whom, and how. Feedback must be timely to have traction, and data needs to be communicated in user-friendly ways tailored to each purpose and audience.

Patient and Public Involvement, Engagement, and Participation

Patients, carers, and the public can contribute to improvement in diverse ways, for example: in patient and public involvement roles (actively advising on the design, implementation, or evaluation of improvement initiatives); in patient engagement roles (receiving and engaging with information and knowledge about improvement efforts); and as participants in the delivery of an improvement study or improvement initiative. Achieving meaningful contributions from patients and the public requires a clearly communicated strategy about when and how their contributions can add value to improvement efforts, clear roles and responsibilities, feedback, and recognition of patient and public contributions.

Working as an Interconnected System of Individuals and Organisations, Influenced by Internal and External Contexts

Taking account of local history and context when planning improvement activities can help to ensure more effective intervention design and implementation. An organisation's internal management and governance approach as well as the external context (e.g. policy mandates, payment regimes, reporting structures in the health system) can all influence how committed clinicians are to quality improvement. Furthermore, regular interaction between different parts of the health care system (primary, acute, community, and social care) can aid improvement efforts when there is a high degree of interdependence and need for coordination between activities happening in different parts of the system.

Taking account of local history and context when planning improvement activities can help to ensure more effective intervention design and implementation.

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Quality improvement requires attention to all the interdependent influences discussed above. This can be a significant ask for organisational leadership that is pressed for time and resources—all the more so during a pandemic. However, nurturing the various interrelated aspects of the social, cultural, and organisational environment needed to support quality improvement in a cohesive and coordinated way matters if improvement efforts are to lead to tangible and sustained results. It is also conducive to building lasting organisational capabilities for improvement.

For example, embedding remote consultations and remote monitoring into ongoing clinical practice during and after the COVID-19 pandemic is both a service transformation challenge and an improvement challenge. This is because of the scale of transition required across the health and care system in relation to the past.

Staff training, for instance on how to manage risks associated with remote patient consultations and monitoring, is likely to be important to ensure that it is done safely and well. Improvement in this space also requires the implementation of a secure data and ICT infrastructure that can effectively support safe and high-quality remote care—for example to upload patient photographs for clinical diagnosis.

Patient and public engagement is necessary to understand what is acceptable, what works, where risks lie, and for whom remote interactions do not work and risk exclusion—such as for people with limited access to or experience of video conferencing. And working as an interconnected system is required to ensure that activities remain coordinated between primary, acute, and social care. All of this relies on an effective and diverse group of leaders and staff committed to a culture of improvement and to delivering high quality care.

Periods of rapid change offer both opportunities and challenges for health care quality improvement. Understanding the building blocks that need to be in place to support improvement processes may help those seeking to embed improvement capabilities and capacity into their organisations, both as we emerge from the COVID-19 pandemic and beyond.

Gemma-Claire Ali and Emily Ryen Gloinson are analysts working in the area of innovation, health, and science at RAND Europe. Sonja Marjanovic is RAND Europe's Healthcare Innovation, Industry, and Policy director.