Traditional improvement approaches are difficult to carry out in the current healthcare environment. It’s no secret that services are struggling to manage daily demands and pressures. Many people working in healthcare are experiencing burn-out, stress and fatigue (Kings Fund 2022). Staff are exhausted and do not have the energy, motivation or headspace to think about improvement because they are struggling. How can we improve the environment they work in to support them to feel energized and empowered to continuously improve? Supporting and creating the space for people to recover and recharge is critical in allowing them to carry out improvement work. To do this, we must start with the culture for improvement.

Many healthcare services heavily focus on strategic improvements that are driven from the top and staff are expected to achieve these strategic drivers. Large improvement initiatives which expect busy and burnt-out individuals to wrap themselves around it are hard to sustain. Organisations need to focus on developing cultures that are person centred—not just task focused —by valuing and building on the excellent care and commitment delivered by many staff throughout the NHS (Dixon-Woods, 2014).

Some cultural factors that need addressing to support staff to carry out improvement are:

1. Time: Staff are struggling to have a lunch break or keep up with their workload. It can feel like extra pressure to engage in large collaborative work that expects too much from them
2. Motivation: Feeling burnt-out and demoralized can mean staff lack the passion to engage in improvements when they can barely survive. Staff want services to get better, but first, we need to make sure things are better for them as individuals.
3. Headspace: It can be difficult to generate fresh ideas when mindsets are stuck on the current pressures. Carrying out improvement work requires a shift into the art of possibilities. This can be hard to achieve when there isn’t the space to be able to stop, reflect and shift thinking. Hierarchy, demand and control, judgmental thinking and fixed mindsets all stop creative thinking from happening.
4. Motive: Improvement does not work in a space of crisis management. Sometimes, there are immediate changes enforced due to the level of risk that are dressed up as “improvements” when they are actually performance drivers. Motives behind improvement work need to be clear and less about reactive behaviors to immediate challenges and more about proactive behaviors to explore solutions to problems. It also means developing cultures based on a commitment to improvement and learning rather than compliance with external standards (Ham et al 2016)

Along with this, traditional improvement methodology talks about “organizational readiness” for improvement, but very rarely does it place the emphasis on “people’s readiness” for improvement. How can we expect staff in hectic, busy environments to feel empowered and energized to carry out improvement? When trying to make improvement work successful, culture comes before capability and capacity.

How can we build a culture of improvement and help staff feel “ready” again to engage in it?

Here are 8 points to consider:

1. Mindsets: Improvement requires new ways of thinking and exploring the art of possibilities. Helping staff to be able to open up their thought processes to completely new approaches, requires a culture that encourages radial thinking without constraints or judgement.
2. Empowerment: True empowerment is not about “giving” someone else the power to do something. Empowerment is people having the freedom to do what they want – some of the most powerful improvements come from staff being able to freely explore things without any sense of imposed direction or consent.
3. Space and time: Improvement takes time. It needs to be weaved into the daily work and not seen as a separate entity. Improvement needs to be stitched into normal working patterns and it needs to occupy the regular spaces people work in. Small steps, gentle trickles and a steady flow of improvement work is more manageable for staff who are exhausted. Being flexible, going fast and slow, ensuring every minute of staff time used is adding value can help reduce the sense of burden. Strong leadership with clear time carved out for staff to be able to have the space to work on improvement is needed
4. “Just do it” needs to become “Think before doing it” – Traditional improvement encourages lots of testing of different ideas – just do it, give it a go and fail fast. The reality is staff no longer have the time to keep trying lots of different things. This requires effort, energy, space and capacity – all of which are precious and limited for people. “Think before doing it” is moving into testing ideas with a bit of evidence/learning behind them.  Learning from the past, each other, experiences and research is needed before any rapid test of change cycles happen. The learning does not need to be extensive, but it could help reduce the number of ideas and cycles people need to try out.
5. Smash the hierarchy –Improvement is done in the corners of healthcare by staff who are working to deliver care to patients; they are those who speak to, connect with and guide them. Those who quietly get on with the daily tasks that give patients what they need. They are not done by senior managers overseeing the bigger picture. For improvement to flourish, the culture needs to shift to adding value and authority into the staff providing care.
6. Systems thinking – Harnessing the power of many and working across boundaries to create improvements by using the knowledge, skills and expertise from a range of staff creates the perfect environment to allow ideas to be explored.  We need a culture that allows fruitful conversations across boundaries, to allow people to share experiences and create common shared purpose to drive improvement. Many times, people have shared how they were not aware of improvements and successes taking place in departments on the same corridor  
7. Emotions – Improvement approaches are traditionally based on joy, energy and excitement. The reality is many staff do not feel these emotions at work which can make them detached or cynical of improvement work. We need to acknowledge and support a wider range of emotions in improvement, to understand stress, exhaustion and validate the pressures. Staff want to be felt, heard, and listened to. Motivation needs to start with a sense of healing, listening, comfort and support.   
8. Rethink the “resistors” – Traditionally in improvement, we label people who don’t engage in improvement work as “resistors.” There can be many reasons for people not being able to connect with improvement work and it is important we don’t label and unintentionally exclude them. As more and more people begin to struggle with improvement, we need to understand why and how we can support them to find the right connections with it. Maybe, it is not them who are the “problem” maybe it’s us and our “approach”

The landscape of improvement needs to change in line with the evolving environment across healthcare. In 2010, the NHS was in a very different position as it was seen as a high-performing health system which unfortunately, has since rapidly deteriorated (The rise and decline of the NHS in England 2000–20, Kinds Fund, 2023). The approach to improvement needs to move from a place where the environment was well fertilized in healthcare, to one that now needs a lot more nurturing and attention to allow it to grow.

With all this in mind, the Improvement Culture Club was created.

The Improvement Culture Club is a space for people to come together and understand how the changing landscape impacts our ability to do improvement. We cannot go on trying to do improvement the same way we used to in the past.

The Improvement Culture Club focuses on what it takes to allow improvement to grow. There are 4 pillars that form it:  

1. Creative thinking: To be able to think without limits, explore things that haven’t been done before and stop doing the same things again and again. Creativity is about how we let ourselves see the world and use it to our advantage to create improvement. Helping people to shift mindsets to allow radical thinking and explore the art of possibilities without limitation
2. Kindness: Improvement should not be “top-down” it should not be dictated; it is not a task and it is not a performance tool. Looking at improvement through the art of kindness, encouragement and creating connections to inspire change is needed – especially when there are so many problem-focused messages surrounding us. The pressure to get better in an environment that is struggling requires a sense of unity, supporting each other and appreciating how hard it is in healthcare.
3. Empowerment: How do we overcome the “red-tape”? How do we invest in our people to lead improvement without boundaries? Empowerment is about how we listen to ideas, support the growth, how people have the protected time, skills and tools to flourish. It’s about overcoming hierarchal thinking, job titles, pay-grades and striving to empower everyone to be bold in improvement.
4. Knowledge: Knowledge is power. How do we learn from the past? How do we learn from each other? Our challenges are not unique, and, in many cases, things have been done before to tackle them. How do we take the time to understand problems, seek learning and stop from jumping straight into trying out new ideas?

This is very much the start of a journey to exploring what it takes to help improvement thrive in healthcare.

Through shared experiences, learning from each other and focusing on the factors that influence the success and engagement in improvement; we can start to understand what needs to be done to keep going during periods of great difficulty in healthcare.

Anyone and everyone is welcome to join the Improvement Culture Club, there are no boundaries to it. Improvement is everyone’s business at all levels and in all the corners of healthcare. Improvement is not hierarchical, it’s not exclusive to people with “specialist knowledge” and not just for decision makers. Improvement is most powerful when there is a collective force behind it. Through this community, we hope to be able to explore what is needed to tilt the landscape of improvement to appreciate the culture needed for it to grow  

You can register your interest here to join the group here: https://forms.office.com/r/qKGzkL4DhN

The group is hosted through Q Community here: https://q.health.org.uk/community/groups/improvement-culture-club/

References

Kings Fund (2022) Written evidence submitted by The King’s Fund (WBR0017, 2020) accessed from https://committees.parliament.uk/writtenevidence/10944/pdf

Dixon-Woods M, Baker R, Charles K, et alCulture and behaviour in the English National Health Service: overview of lessons from a large multimethod studyBMJ Quality & Safety 2014;23:106-115.

Ham C, Berwick D, Dixon J (2016) Improving quality in the English NHS A strategy for action by The King’s Fund accessed https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Improving-quality-Kings-Fund-February-2016.pdf