Quality improvement and measurement: what non-executive directors need to know

Overview of what quality improvement and measurement is and how NHS non-executive directors can ensure that this approach is used by health boards.


Why do we need to improve quality?

Everyone has two jobs – to do the job they were appointed to do (either paid or as a volunteer) and to improve that job. This is the essence of quality improvement ( QI).

Why not settle for the status quo? Why should we accept a need to improve?

In a society where shifting demographics means a higher proportion of older people, we know there will be an increased demand on services in the future. Equally, our culture is changing. This is reflected in new and changing demands from those receiving care. Costs are increasing. There are new medicines and technologies to be assessed and considered. In this complex environment and where there is increased pressure on finances, retaining the status quo is not an option. We may have to improve just in order to keep abreast of current pressures.

Continuing with sub optimal care can result in unnecessary costs. Improvements can bring about, for example, better use of resources through reduction of time spent in hospital due to infections, or stop unnecessary movements of people or materials. QI can make a contribution to the cost efficiency of a service; there is a business case for QI (Health Foundation, 2009). It can also support the 'skill and spirit' of the workforce through addressing and improving everyday problems.

It is the Board's responsibility to oversee the work of the NHS Board and also to oversee the improvement of that work.

This booklet is designed to help NHS Non-Executive Directors to understand their obligations in QI.

What is Quality Improvement?

'Quality Improvement is defined as the application of a systematic approach that uses specific techniques to improve quality. Though there is a range of different approaches that fit under this umbrella they all have the following in common:

  • The concept of a cycle of improvement which involves data collection, problem definition and diagnosis, generation, testing, iteration and selection of potential changes and the implementation and evaluation of those changes.
  • A set of tools and techniques that support individuals to implement the cycle of improvement.
  • A recognition of the central importance of engaging those who receive and deliver a service in the improvement of that service.
  • A recognition of the importance of organisational context and the need for senior clinical and management leadership.'

'The combination of a ''change" (improvement) combined with a "method" (an approach or specific tools) to attain a superior outcome.'

Health Foundation

'The combined and unceasing efforts of everyone – healthcare professionals, patients and their families, researchers, payers, planners, administrators, educators – to make changes that will lead to better patient outcomes, better system performance, and better professional development.'

Batalden PB, Davidoff F; Qual. Saf. Health Care; 2007

There is no single definition of QI. Many approaches and definitions, however, share a number of underlying principles, including a focus on:

  • understanding the problem, with a particular emphasis on what the data, both quantitative and qualitative, tells us;
  • engaging with staff, those receiving care, and individual stakeholders to ensure that the will for change is built, and that this will translates to action;
  • understanding the processes and systems within the organisation – particularly the journey and experience of those receiving care;
  • examining the demand, capacity and how people move through a service;
  • identifying from evidence and developing ideas for changes we believe will be improvements;
  • selecting the most appropriate tools to generate a change;
  • reliably delivering that change over time; and
  • evaluating and measuring the impact of a change.

To improve services effectively we need to set clear aims, establish measures, test changes and reliably implement, sustain and spread these changes. There is a variety of well-tested tools and methods which can successfully support improvement in services to make sure that the NHS in Scotland provides maximum benefit to patients in an effective and safe way. The whole process from considering a potential improvement through to identifying what to do and testing the improvement is called the QI Journey.

Here are a couple of examples that illustrate what we mean by QI.

'Think, Check, Act', NHS Greater Glasgow and Clyde

In NHS Greater Glasgow and Clyde, hospital staff have been supported through a QI initiative, 'Think, Check, Act' to be more alert to the possibility of a patient in their care having diabetes. A diabetic patient risks an episode of hypoglycaemia, which has unpleasant symptoms, is potentially life threatening and is associated with an increase of hospital stay and one year mortality after discharge. Following the intervention, involving a short formal teaching intervention and the introduction of a 'hypobox' in one ward, the resolution of hypoglycaemia within 15 minutes rose from 28% to 88%, with a 20% reduction in the incidence of hypoglycaemia.


The 'Highland Quality Approach' – NHS Highland

NHS Highland has an approach to QI referred to as the 'Highland Quality Approach'. The following links provide general information about the HQA and also an example of a paper where the impact of this methodology is presented to the board.


Other Boards in Scotland are taking organisational approaches to quality improvement. The QI for Board Members pages on the ihub contain some information about these experiences.


Email: Sarah.Hildersley@gov.scot

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