A 10-year partnership between IHI and East London NHS Foundation Trust (ELFT) to embed quality improvement (QI) principles and approaches in all aspects of Trust operations.

Summary

East London NHS Foundation Trust (ELFT) is a provider of community health, mental health, primary care, and specialist services in England to a population of approximately 2 million people across Bedfordshire, Luton, and East London.

In 2013, ELFT partnered with the Institute for Healthcare Improvement (IHI), who provided a program of capability building, expert support for the fledgling quality improvement team, strategic guidance and coaching to the executive team, and board development. In 2015, this work progressed into a strategic partnership.

IHI led numerous waves of the Improvement Science in Action program to equip staff with the skills needed to solve quality issues in their workplace. ELFT and IHI jointly developed ELFT’s first Improvement Coaching program, delivered in 2015–2016. In addition, ELFT has equipped its central team of full-time improvers through IHI’s Improvement Advisor Professional Development Program.

The strategic guidance and coaching to the ELFT executive team were critical in enabling the senior leadership team to adopt leadership behaviors to support the development of a culture of continuous improvement. Guidance to the QI team enabled the development of an improvement infrastructure that could provide close, skilled support to teams across the organization.

Since 2013, quality has become central to the organizational strategy at ELFT, recognized by the UK’s Care Quality Commission (CQC) awarding ELFT with three “Outstanding” ratings in 2014, 2018, and 2021 — the first organization of its type to achieve this.

Over the years, ELFT has tackled its most complex challenges using quality improvement, with results across all domains:

• A 30% reduction in inpatient physical violence (the most commonly reported safety incident at the organization)
• Reductions in waiting times for community-based services (including working though the backlogs and higher demand seen post-pandemic)
• Increased staff satisfaction and engagement, with some of the highest scores across all health care providers in England (per an annual NHS staff survey)
• Improved reliability of inpatient observations for higher risk patients (to 99.6%), accompanied by a reduction in violence (23%), verbal aggression (36%), racial aggression (60%), and sexual aggression (16%) in a large-scale QI program across all 52 inpatient wards
• A 100% increase in organizational revenue over the decade due to an increased reputation for high-quality care

Background

A series of safety events in 2010, including one in which an inpatient killed another inpatient, emphasized the need for fundamental, system-wide change. Fred Inman, ELFT’s COO at the time, noted concurrent challenges of finances, capacity, access, and low morale. The safety incidents, in Inman’s words, created an “imperative to do better and more.”

So, ELFT leaders sought to learn from the highest performing health systems around the world and their use of the methods and tools of quality improvement. What they saw and heard when they visited and spoke with other organizations committed to improvement was an understanding that effectively implementing QI requires changing culture. Professor Jonathan Warren, ELFT Chief Nurse from 2010-2017 noted, “It’s about having a culture that’s receptive to improvement. You need to be brave enough to allow staff to make decisions and be willing to tolerate that things may go wrong…QI is…this process of trying things out, failing, and then trying something else.”

Now with an understanding of the scope of the changes needed, ELFT looked inward and realized they did not have the capacity, capability, or knowledge to create and manage this degree of change by themselves. Thus the organization sought a partner and after a competitive tender process, entered into a relationship with IHI in 2013, which became a strategic partnership in 2015.

Leaders at ELFT laid the foundations for effective and sustainable change by carefully making the business case to their board for the investment in quality improvement, and by engaging with staff at all levels. These conversations and sessions with staff leveraged the existing desire to improve the quality of care delivered to service users. Leaders found QI to be an “easy sell” to the staff because they were the ones who most clearly saw the direct impacts of poor quality. And they were the ones who would be empowered to become active change agents in their own work.

Approach

As with any consulting engagement, IHI tailored its approach to the specific needs and circumstances of the partner. In the case of East London NHS Foundation Trust, IHI found a partner who wanted a complete transformation to become an organization centered around quality. So IHI worked to co-design approaches and solutions that matched this inspiring ambition.

Using Data for Improvement

At the heart of IHI’s approach is the Model for Improvement — the simple method for identifying, testing, and evaluating potential improvements. Effective use of the Model for Improvement relies on using data for improvement (rather than judgment). And to generate actionable data, ELFT developed (in partnership with IHI and their own data and analytics team) a data infrastructure that collected, analyzed, and displayed data according to the principles and methods of quality improvement (e.g., data over time, statistical process control charts). The tools and approach of making data transparently available to clinicians in a way that helps them understand variation led to the Trust winning the Florence Nightingale award from the Royal Statistical Society in 2022, and the Health Service Journal (HSJ) Digital Award in 2023.

Senior Leader Engagement

While many improvement programs use a “bottom-up” approach for specific improvements (to leverage the expertise and experience of those directly involved in care), system-wide transformation also requires development and engagement by the board and senior leadership.

Among the first steps ELFT took were to require QI training (delivered by IHI) for all C-suite leaders. IHI also conducted development sessions with ELFT’s Board, to support the transition from a quality assurance-focused board to an improvement-focused board. This also stimulated a change in the board agendas, and the format of papers and data that the board viewed. Eventually, the Trust was regularly reviewing Whole System Measures displayed in Shewhart (control) charts. Just as important as the quantitative data was the deliberate use of stories to illustrate why improvements were necessary and impactful. ELFT’s Board shifted the structure of their meetings to allow for more time to hear firsthand stories from both patients (service users) and teams conducting improvement work. The result of these changes was a truly improvement-focused board that both supported and modeled the behaviors known to improve quality.

ELFT created the first Chief Quality Officer role in England, in 2017, which was held by Dr. Amar Shah. This role, part of the C-suite and reporting directly to the CEO, was critical in guiding the organization's and board’s improvement journey over many years.

Leadership Programs and the "Dosing" Approach

As C-suite leaders and ELFT’s Board developed their own QI expertise, IHI also delivered improvement trainings for other leaders in the Trust. At the same time, they worked with early QI adopters to develop sustainable, in-house improvement trainings that ELFT could eventually conduct on their own.

All of these QI trainings used what IHI calls the "dosing" approach for QI expertise. IHI has learned over the years that people in different roles need different degrees of training on QI — there isn’t a one-size-fits-all training. ELFT adopted the IHI dosing approach as it developed its ongoing trainings for staff and leaders.

Strategic Guidance and Celebration

Throughout the partnership, IHI supported strategic guidance and coaching sessions with the C-suite every two months. These were opportunities to ask questions, surface challenges, and co-design and redesign programs and initiatives based on the most recent data.

IHI also participated in annual, in-person strategic visits. These visits were opportunities for the IHI team to hear and learn from all parts of the organization and help set and adjust the strategic direction of the partnership for the next year. These visits were also opportunities for ELFT leadership to recognize and celebrate the improvement work across the organization, reflect on progress, and develop the plan for the year ahead. ELFT also conducted their own “QI conferences” as ways to maintain momentum and enthusiasm for change and to foster the culture of continuous improvement.

Decentralized Improvement

As more and more staff and leaders developed their expertise through direct experience in improvement work, the responsibility for quality dispersed throughout the Trust. This enabled the quality leaders to spend more time coaching and supporting the teams. This is, in some ways, the “Holy Grail” of whole system transformation. When everyone in an organization understands quality as their responsibility, QI becomes embedded in every process and system.

What Matters

The first question the Model for Improvement asks is, “What are we trying to accomplish?” This fundamental question points to the essential importance of aims in QI work. Determining what those aims are requires a holistic approach. ELFT developed their improvement aims by listening to both staff and service users about which outcomes mattered the most to them. These conversations directly informed the selection of specific improvement programs. In ELFT’s case, some of the first aims selected were around violence prevention because this was the most commonly reported safety incident, and the issue that staff and service users wanted to tackle. They went on to focus on aims such as reducing incidence of pressure ulcers, improving access and patient flow, improving equity, and making work more enjoyable. Continually engaging with staff and patients on which outcomes are important to them is a crucial strategy for whole system transformation.

Results

It is important to note that the impressive results described below were achieved by the staff and leadership at ELFT. IHI was an enthusiastic and engaged partner, but as with all consulting engagements, the ultimate responsibility (and therefore the ultimate credit) belongs to the people working in the system. As IHI Vice President Pedro Delgado noted, “…partner[ing] with an organization that was keen to embed continuous learning and improvement across their daily work — partnering with staff and service users in service of results for and with those they serve — was extraordinary. Over time, the commitment to co-production and co-design has been sustained, which is uncommon for organizations.”

Among ELFT’s impressive results are the following:

• A 30% reduction in inpatient physical violence (the most commonly reported safety incident at the organization)
• Reductions in waiting times for community-based services (including working though the backlogs and higher demand seen post-pandemic — see Figure 1)
• Increased staff satisfaction and engagement, with some of the highest scores across all health care providers in England (per an annual NHS staff survey)
• Improved reliability of inpatient observations for higher risk patients (to 99.6%), accompanied by a reduction in violence (23%), verbal aggression (36%), racial aggression (60%), and sexual aggression (16%) in a large-scale QI program across all 52 inpatient wards
• A 100% increase in organizational revenue over the decade due to an increased reputation for high-quality care

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Quality improvement has become fully embedded at ELFT, informing all operational and strategic planning. The UK’s Care Quality Commission (CQC) awarded ELFT with three “Outstanding” ratings (2014, 2018, and 2021) making it the only organization of its kind in the UK to attain this standing.

ELFT has also become a national center of learning for quality improvement. ELFT hosts an Open Morning every four months, to allow others to spend time in the organization, and learn firsthand about the approach to quality. Thousands of leaders from across the heath system and beyond have attended these Open Mornings.

ELFT has also developed an integrated management system, which incorporates quality improvement but also connects this with an advanced approach to quality assurance, a systematic approach to strategy development and annual planning, and a more sophisticated daily management system for quality control — with real-time data, visual boards, huddles and escalation processes.

The embrace of quality improvement at East London NHS Foundation Trust can and has inspired others to embark on similar quality journeys. ELFT's generosity of spirit is exemplified by the freely available QI resources on their website.

Related Information

• Fostering an Improvement Culture: Learning from East London NHS Foundation Trust’s Improvement Journey Over 10 Years
• Building a Culture of Improvement at East London NHS Foundation Trust
• East London NHS Foundation Trust QI Resources