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Improving Improvement

A toolkit for Engineering Better Care


Important Topics

A number of important topics typically arise in the context of improving of complex systems, regardless of the improvement model used or system perspective taken.




The following short sections are intended to describe a range of topics that are important in the successful delivery of system improvement. They are intended to bridge the gap between the broad principles embodied in the sections on Improvement Questions and Improvement Process, and the activities and tools described in the section on Improvement Resources, while remaining relevant to other established improvement approaches.

The topics described here are not intended to be an exhaustive set sufficient for all improvement, rather they represent a starting set that cover the topics that the Toolkit authors have particular knowledge of in practice or have seen the Toolkit users struggle with during training sessions. More topics will be added in time as the users of this toolkit identify further areas of interest for the improvement community.

Planning Meetings

Meetings may take many forms, but all draw people together for a purpose. As a result there is always a need to plan meetings carefully to ensure that they fulfil expectations, whether they are for team building, fact finding, designing or reviewing. Typically, one or more activities define the purpose of the meeting, which then has to be carefully choreographed to ensure that there is:

  • Clarity of purpose and a concise, time-stamped agenda,
  • A shared expectation of what can be achieved in the time available,
  • An appropriate list of attendees to match the purpose and expectations,
  • A suitable location to accommodate the activities planned,
  • Clear guidance for the meeting chair and facilitators,
  • Pre-prepared presentations, posters, prompts and other resources,
  • Appropriate communication to participants before the meeting,
  • Adequate time for reflection and analysis after the meeting.

Experience shows that the best meetings are the result of careful preparation and planning with the team facilitating the improvement programme, key stakeholders and the meeting hosts. Similarly, it is important to spend time to reflect on the meeting when it is fresh in mind and later, when further analysis of the material generated has been completed, in order to:

  • Discuss things that went well or could be improved,
  • Identify people who were not present or should be included in the future,
  • Consider how the meeting contributed to the overall improvement programme,
  • Identity needs for further action or immediate follow-up,
  • Discuss preliminary plans for subsequent meetings,
  • Draft a summary communication to the meeting participants.

Again, experience shows that the best overall outcomes are the result of timely reflection by the team facilitating the improvement programme, key stakeholders and the meeting hosts. Above all else, the role and limitations of meetings should be understood in the context of the wider improvement programme and the activities required to deliver sustainable success.

Characterising Stakeholders

An important activity within any improvement programme is the identification of system users and stakeholders. There is particular value in identifying users and stakeholders in the early stages of a programme and ensuring the team continuously update knowledge of their needs. Personas may be developed to capture particularly important characteristics of representative users or stakeholders.

The Stakeholder Map is a living document which may be used in electronic form, as a large poster or an interactive worksheet.

Useful toolkit resources: a Stakeholder Map worksheet, Stakeholder Map poster and Stakeholder cards can be downloaded from the Resources part of this toolkit.

Successful improvement involves and depends on a wide range of stakeholders and system users who, at any point in time, will have different levels of interest in and power to influence such improvement, There is value in characterising stakeholders, in terms of their interest and power, to ensure that they are sufficiently informed, engaged or managed during all stages of an improvement programme.

The Stakeholder Influence map is a living document which may be used in electronic form, as a large poster or an interactive worksheet.

Useful toolkit resources: a Stakeholder Influence worksheet can be downloaded from the Resources part of this toolkit.

Mapping Systems

An effective systems approach to improvement relies on the communication of information to describe and interpret the current system, and any proposed changes to it, from a variety of different perspectives. There are a plethora of formal and informal diagramming and mapping approaches available to assist these activities, where each approach is likely to accentuate some features of the system it used to describe and to ignore many others. It is therefore important to select the diagramming or mapping approach(s) best suited to the information that is to be captured and shared.

Diagrams highlighting the structure of systems can be particularly useful in conveying an understanding of how things are connected, where the nature of the connection may be represented as a simple link or a directional or causal relationship. Similarly diagrams examining the behaviour of a system provide a richer picture of the nature and performance of people, processes and information flows in the system, and may range from static representations to dynamic simulation models.

In all cases, diagrams and mapping are typically limited to representing certain perspectives of a system and seldom capture everything. Multiple maps and diagrams may be required and a mix of formal and informal approaches may also be appropriate. For example, storytelling can provide a rich narrative when formal interview approaches or focus groups would be difficult to convene. In all cases, the process of building the pictures with the right team can provide significant benefit in itself, enabling a consensus view of the system to emerge.

A rich picture of the patient journey can be very helpful in identifying the key steps of such a journey, particularly in terms of their location, the patient’s condition at that point in time, and the people and treatment involved. A Design Wall is a graphical device that can assist in the capture of such a picture and its visualisation by the improvement team. The design wall is readily extensible to suit the length of the journey and can be drafted by an individual or, more usefully, the whole improvement team.

The Design Wall includes reference to the following key elements:

  • Step: describe the particular step in the patient journey
  • Summary: summarise the overall experience of the delivery of care associated with this step
  • Place: describe the location(s) where this step happens
  • Stakeholders: describe the stakeholders involved in this step
  • Diagnosis: describe the primary diagnosis that the patient is likely to have at this step
  • Function: describe the patient’s current level of functioning at this step
  • Symptoms: describe the patient’s symptoms at this step
  • Changes: identify causes of changes to the diagnosis/function/symptoms and if they are reversible
  • Prognosis: describe the quality-adjusted life-years that might be achieved if changes were reversed
  • Wishes: describe how the patient wishes to be cared for at this step
  • Plan: describe the current management plan for the patient’s future care
  • Information: describe where the patient’s information is recorded and/or how it is communicated
  • Resources: describe the NHS and other resources being used at this step
  • Social: describe the extent to which the patient’s social network is able to provide appropriate care

The design wall is a living document which may be used in electronic form or as a worksheet.

Useful toolkit resources: a Design Wall worksheet can be downloaded from the Resources part of this toolkit.

Analysing Requirements

The management of the improvement process also requires careful management of the translation of the aim of the improvement into realisable system requirements. This is often a complex, iterative process in its own right, but one that is critical to success.

Every improvement should have a clear aim. This will not only align with the existing or proposed purpose of the system, but also with the desired improvement in quality to be delivered by the system. The aim may include a number of facets, relating to clinical and cost effectiveness, patient safety and patient experience, that align with the broad definition of quality commonly used in health and care. The aim will also be bound to the expectations of the service commissioner and relevant external targets.

The different stakeholders involved in the system and the improvement programme will inevitably have different needs, aligned with their interests and responsibilities. Any successful system will therefore satisfy some of these potentially conflicting needs more than others. Typically, it is the job of the service manager or improvement programme manager to capture, assess and ultimately rationalise and resolve conflicts, thus prioritising these needs in response to the expectations embodied in the aim.

The prioritised needs can usefully be organised into a number of core themes that represent the essence of the things the systems must do. These provide a practical reminder of what the system should deliver as a result of the improvement programme and how this might be measured. These themes are also likely to form the basis of the case for change, providing more detail on how the aim is to be achieved.

Finally, the themes are translated into individual system requirements that provide detailed, realisable performance targets for the improvement team. These can usefully be expressed as either demands, i.e. things it is imperative to satisfy, or wishes, i.e. things it would be desirable to satisfy.

As with the improvement questions, the principles of the requirements pyramid can be applied to simple systems as well as more complex systems of systems. As the complexity of a system increases it is important to consider the design of the architecture of the system as a whole as well as the detailed design of the corresponding elements or sub-systems. The aim, needs, themes and requirements may then apply at all levels of abstraction of the system and should be consistent with those for the parent system and other adjacent or lower-level sub-systems. Any improvement will then need to satisfy the requirements at all levels.

The system architecture, as part of the whole system requirements, will not only need to describe the system decomposition into key sub-systems and their associated aims, but also carefully specify the nature of the interfaces between these sub-systems. As the sub-systems emerge they will need to be evaluated against their individual requirements, before their integration into a single system and evaluation against the whole system requirements. In practice, interface management remains an essential and critical part of any system development.

The system stakeholders are also likely to vary according to the system or sub-system under consideration. As a result, it is imperative that the decomposition and subsequent integration of the requirements pyramids reflects this map of stakeholders, particularly in the derivation of the system architecture with its associated aim, needs, themes and requirements.

Creating Concepts

While there is always the temptation to take the first thing that is thought of and develop a solution based on that ‘idea’, creativity should be an exploratory process that initially generates a large number of ideas, which are then gradually filtered, refined and coalesced, to deliver the ‘best’ solution. A thorough exploration of the solution space inevitably challenges assumptions regarding the problem to be solved, and this is true of both improvement and new service design challenges. Once the process of exploration and refinement has been completed, it is extremely unlikely that the idea initially thought of as the ‘best’ remains through to completion.

There are many creativity approaches and tools that inspire individuals or teams to come up with ideas. Most of these separate the initial creativity method from the inevitable filtering required to find ideas worth developing, and some focus particularly on avoiding fixation in order to maximise the search space. In all cases, the quality of the ideas created will depend critically on the understanding of the problem and the context within which it is set. This in turn allows the definition of a clear set of requirements and key themes for the improvement and new service design challenge. This is an iterative process that encourages the ongoing exploration of the problem alongside the exploration of the solution1, while accepting that the emphasis inevitably moves from the former to the latter over time.

Creativity may be the preserve of a few individuals or the whole project team. Yet, regardless of the origin of ideas, solutions typically need to satisfy a range of prioritised stakeholder needs articulated through the problem statement and system requirements. Throughout the improvement or design process, evaluation of ideas, concepts and emerging solutions needs to be made against these needs and requirements in order to provide a transparent rationale for the filtering and selection decisions made. The formality of such a process can depend on the scale and complexity of the problem to be solved and the importance of evidencing the development of the solution. A simple meeting note recording key decisions may be sufficient for small, low-risk improvements, where a more formal considered process is required for complex challenges.

The House of Quality2 is a well-known process from product development that provides a framework for relating needs to possible solutions is such a way as to make the rational for selection decisions transparent. It enables the early evaluation of ideas before too much is invested in the development of deliverable solutions.


  1. Eleven lessons managing design in eleven global companies. Design Council, London, UK, 2007.
  2. The House of Quality. Hauser and Clausing, Harvard Business Review, 66(3): 63-73, 1988.

Managing Risk

The management of risk is an important part of any successful improvement programme, where any likely reduction in expected quality may be seen as a risk to the delivery of the improvement itself, in addition to the risk of operational failure of the actual programme. There is a risk that any of a number of programme requirements and stakeholder expectations will not be met, corresponding to deviations in performance related to patient safety, patient experience, clinical and cost effectiveness, or the improvement process.

In this context, risk assessment is a key component of risk management which may be thought of as the process of identifying, assessing and controlling opportunities for and threats against the performance of an organisation, product or service delivery system, where such performance may relate to a range of quality, safety, operational, financial or reputational measures. Such assessment is a component of existing models of healthcare improvement, such as the IHI Model for Improvement, Lean Thinking and Six Sigma, and also has a long history of development in engineering and service delivery. The Royal Academy of Engineering report, Engineering Better Care1 highlighted risk as one of four key perspectives, alongside people, systems and design, necessary to deliver effective care.

Risk assessment, as a process to reduce the impact of threats against a system, involves a number of key elements which are usefully described by ISO/IEC 31010:2019, Risk management — Risk assessment techniques2. This standard describes a framework for risk management and introduces tools typically used in risk assessment.

In practice, risk management is a continuous process that begins at the inception of any improvement programme and can continue long after delivery. It may also be the trigger for improvement following an incident or routine safety review. The key to the success of the process is the availability of a clear and agreed description of the current system, and/or some future system, which can be systematically and rigourously assessed by a method attuned to the nature of that description. Such prospective risk assessment complements the more typical retrospective assessment and forms the heart of the ‘Safety-I’ approach to system safety management1.

The identification and exploitation of opportunities to learn from exceptional performance represents the alternative face of risk management. This view, known as ‘Safety-II’, has gained much traction in recent years as an activity that complements traditional ‘Safety-I’ methods by focusing on the system’s ability to succeed under varying conditions3. In practice, both approaches should be used to encourage an holistic approach to reactive and proactive risk management. This requires a paradigm shift in the traditional priorities of safety management, expanding the focus beyond the need for incident investigations to active investigations into the variations in practice that might be exploited to consistently achieve good practice. The outcome curve for health and care practice needs to shift to the right.

Cultural and organisational change and adoption of knowledge of human factors, the discipline concerned with the understanding of interactions among humans and other elements of a system, are parts of the answer. They will facilitate a shift from a traditional Safety-I to a combined Safety-I and Safety-II approach, which aligns with the Assess and Seek questions described in the Engineering Better Caresection.


  1. Engineering Better Care, a systems approach to health and care design and continuous improvement. Royal Academy of Engineering, London, UK, 2017.
  2. ISO/IEC 31010:2019, Risk management — Risk assessment techniques. International Organization for Standardization, 2019
  3. From Safety-I to Safety-II: A White Paper. Hollnagel, Wears and Braithwaite, The Resilient Health Care Net, 2015.


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