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Transformation, Insights

Bottom-up and top-down quality improvement

It can be difficult to get the right balance between bottom-up and top-down change – our Transformation Team discuss their work with healthcare organisations to use a locally-owned, centrally-supported approach to encourage the best of both.

Improving services, improving care for patients and improving the experience of staff. What’s not to like? Quality improvement (QI) is widely recognised as “a good thing” – and all forward-thinking healthcare organisations strive to foster a culture of continuous improvement.

An admirable aspiration – and any reasonable person would be hard-pressed to argue against it. So organisations should encourage their staff to run as many QI project as possible, right? Well – yes and no… 

Bottom-up and top-down quality improvement

See this piece making the case for Quality Improvement by The King’s Fund.  

One of the key principles of QI is that projects should originate on the shopfloor. Staff on the ground are best placed to identify opportunities for improvement and to deliver these improvements. This bottom-up approach is also most likely to drive staff’s enthusiasm and passion – especially important if they’re running a QI project on top of their day job. So far so good.  

However, QI programmes can end up losing their focus. Is “a thousand flowers blooming” really the most effective approach? The implicit rationale is that the very process of running any improvement project is a good thing for the organisation, regardless of impact and even if it’s more closely tied to an individual’s own passions than to corporate objectives. But without aligning to corporate objectives, QI projects can end up becoming peripheral to the fundamental organisational change required, and prone to fizzling out once the individual’s personal interest and motivation to overcome obstacles starts to wane. 

In our experience at The PSC, we’ve learnt the importance of achieving a happy medium and developing a locally-owned, centrally-supported approach. This means combining genuine local ownership with organisation-level prioritisation and oversight. Nice soundbites, but what does that mean in practice? 

We’ve recently been working with Sussex Partnership NHS Foundation Trust (SPFT), to co-develop their Reducing Length of Stay Improvement Programme - read more about that here. The objective is to safely reduce delays that mental health inpatients experience preventing them from returning home, to reduce the Trust’s reliance on out-of-area inpatient beds.

At the pilot stage of the programme, the Trust identified 15 individuals, from a range of disciplines, to act as QI project leads – with the clear expectation that all projects had to be geared towards reducing patients’ length of stay. We worked with these nominated leads to marry their own professional interests and improvement ideas with those initiatives prioritised by senior management and the programme steering group. We then created a framework of supportive accountability by providing training and weekly mentoring for the project leads, whilst also setting a project review date at which point they needed to present their progress and what they’d learned to members of the Trust executive team.  

There’s nothing revolutionary about this approach. In many ways, it’s basic management: give someone a job to do which they feel ownership over, set clear goals together, provide a supportive environment for them to flourish, review progress. See, for example, Ken Blanchard’s The One Minute Manager. The approach is surprisingly powerful, and delivers impressive results:  

  • On one ward, the number of patients for whom the multidisciplinary healthcare team had identified specific tasks increased from 6 to 20 over the course of a month – resulting in more focused planning and care 
  • In one community team, the proportion of relevant ward rounds attended by lead practitioners increased from 25% to 80% over a couple of weeks – resulting in improved communication and discharge planning 

And this tangible impact is on top of the well-documented personal development and positive cultural benefits that come from running QI projects; for example, one project lead commented that “I knew what I wanted to change but didn’t know how. This programme has given me the structure and tools to make that change.” 

We’re hosting a virtual roundtable event on Thursday 29th September, between 16:00 and 17:15, where we’ll be hearing more from SPFT about their improvement programme, as well as from other mental health trusts grappling with how to reduce length of stay in their hospitals. We’d love anyone interested in this issue to join us and contribute to the conversation. Get in touch with Harris Lorie ( if you’d like to attend the roundtable, or if you’d like to discuss how The PSC could help your organisation with transformational improvement.    


Authors: Harris Lorie and Chris Bradley from The PSC's Transformation Team. 

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