The Scottish Improvement Journey: a nationwide approach to improvement

This paper shares the story of the Scottish Improvement Journey encompassing 50 years of clinical audit and improvement programmes.

7. Lessons learned and discussion

As can be seen across the numerous programmes and initiatives, Scotland has followed a nationwide approach to quality improvement, learning every step of the way. The existing system was perfectly designed to get the results it was getting and in order to change that, the system needed to be changed. Starting with Scottish Patient Safety Programme, the country learned about implementing strong evidence-based interventions to reduce avoidable harm in healthcare settings. Taking that knowledge forward, there was a move to spreading into other areas of health and public services that needed to build their own evidence base first. With this, a set of more person-centred approaches emerged – co-design of changes and interventions with service users and front-line staff, increased empowerment of front-line staff to drive improvement forward, or the use of patient and service user stories creating powerful motivational messages.

It has been a challenging journey but a successful one. Based on the interviews conducted with the key players along this journey, we present here a summary of these successes and challenges. This is not to say that replicating Scotland’s journey elsewhere is possible; it takes time, resource and key leaders to build, but these factors may point to some of the critical issues for consideration.

7.1 Summary of key success factors and challenges




Confidence in a proven method which delivers measurable results.

The method and behaviours resonated with people, fitted with their values - non-punitive, ‘All teach, all learn’ approach, empowerment gives energy and motivation.

Simple to learn and teach, people do not need to become experts before starting to use the method.

Consistency of method across programmes.

Flexibility – local flexibility, also applied to programme design itself.

Initial difficulties with competing methodologies - programmes worked in silos due to a lack of understanding and trust in one another.

Balancing leadership mandate with allowing people the freedom to design their own interventions.

Ensuring good understanding of methodology before people apply it.

Political buy-in & leadership

Power of continuous ministerial and governmental support giving prominence and priority to QI work.

National direction and guidance with consistency of purpose.

Political will can push programme teams to start before they may be ready and to work on more programmes than they have the capacity to be working on.

Senior leadership

Real commitment to quality improvement across SG leaders as demonstrated in the Quality Strategy. Key leaders remaining constant.

Government approach to moving expertise around to work on new projects may be difficult for the projects left behind and a lack of consistent leadership.

Leadership at board level

Engagement of chief executives, chief nurses, chief medical officers at learning sessions.

Mixture of subject matter experts and improvement experts at board level.

Challenging to keep chief executives and some directors engaged.

Need to understand better how to engage middle management.

Attempts to build board level QI skills – ‘Boards on Board’ initiative.

Competing priorities for focus of activity (e.g. targets).

Front-line staff

Strong will and motivation to work towards aims –visionary aims of working together for the greater good by making care safer or improving the lives of children resonated with everyone.

Empowerment to create and drive forward improvement owned locally while knowing it is aligned to the big picture ( EYC, RAfA, PACE).

Need for understanding why the reason for the programmes, and what the impact of the teams’ work is, or disengagement may result.

Convincing subject matter experts that there is a better way of putting evidence into practice – or even that traditional methods don’t work.

A lack of skill or will or capacity to reliably record the iterative steps of testing changes which are needed to articulate key interventions for national spread.

Capacity building

Various capacity and capability building programmes equipping people with the skills they need.

SPS Fellowship helped with clinical engagement.

Pace of producing enough improvement advisors and leaders required to provide access to support to all who need it.

Fast growth of programmes places strains on resources.

Underutilised resource of trained Improvement Advisors – not all in roles where their skills, knowledge and talents can be harnessed.

Will building

Relationship building with all stakeholders: up-front engagement with all organisations touched by the work but also continuous support provided.

Empowerment of front-life staff leads to high engagement.

Sensitivity to the dynamics of other organisations and respect to existing work at the introduction of a new programme.

Managing will and enthusiasm the success creates - balancing the intentionality to not waste will & controlling the growth into new areas


Partnership with IHI fundamental to success.

Acceptance of involvement of a US-based company

Supporting the process to transition well from a dependency relationship through to co-design and co-delivery and ultimately through to expert advice when needed.

Data & measurement

Positivity around using data and measures differently than for performance management and judgement.

Importance of data to demonstrate the existence of a problem, to create will for change, and to demonstrate improvement.

Emergence of stories to accompany quantitative data charts – helps explain why certain things happened and creates powerful motivational messages.

Trust that data will be used only for improvement, not for judgement and creating league tables.

Lack of data or rigor of data reporting, particularly beyond acute care settings. In non-acute settings, data skills sometimes lacking.

Lack of standardised platform for collecting data, automatised extraction and reporting, reflecting and reporting on it, for extrapolation of a national message. Duplication of data recording and reporting due to lack of an IT infrastructure. This was the case even with the IHI extranet as the boards were inputting the data into this separately to the local systems.

Completeness of data coverage (e.g. 11 of 15 hospitals reliably report)

Multiple stakeholder groups

Opportunities for co-production of improvement and in some cases co-design of interventions.

Bringing people together in a multiagency context.

Different understandings of improvement and conflicting language with the same words often used to mean different things

Achieving results

Public celebration of achievements locally, nationally, and internationally.

Managing expectations across all levels of leadership.

Success can lead to over-ambition and confusion over priorities.


Small scale country with short and connected infrastructure – the system is an enabler rather than barrier.

Variety of rural and urban settings across the socioeconomic spectrum.


Taking time to prepare for the work, and to build will, infrastructure, and capacity – yet balancing that with not waiting for perfect conditions.

Recognising it takes time to prepare, plan, and to get the results, especially with community change where it may take a generation to see the change.


Branding, belonging to a big national programme that has impact is very powerful for building will across all levels.

Publicity is worthwhile and very powerful.

Reflecting the improvement methodology itself, the Scottish improvement journey is marked with learning and sharing of the learning. All the points highlighted above come from the experience of the those who led on the various high-profile improvement programmes across Scotland. The collaboration across staff groups, agencies, and sectors is a remarkable outcome of the journey. A final message of recommendation from these experts would be to be clear about the ambition, to be ambitious but real about expectations, to start before being ready and to stick to it. Spreading of this success does not work by simply transplanting a solution, the usual steps of building will, acknowledging the problem, testing change, and implementing reliable interventions need to be repeated every time.


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