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Improving Improvement

A toolkit for Engineering Better Care



This introduction provides a brief description to the application of a systems approach to health and care design and continuous improvement.


The pressures facing the health and social care system are considerable and the complexity of the system makes improvement challenging. In recent years there have been numerous calls for the use of a systems approach in efforts to transform health and care. However, until the publication of the Engineering Better Care report by the Royal Academy of Engineering, there had been a lack of a clear definition of what this might mean in a health and care context.

The Engineering Better Care report aimed to describe the engineering systems approach and explore, in partnership with healthcare leaders, whether such an approach could be applied to health and care. While healthcare professionals know intuitively that there is a need to involve stakeholders in decisions and think across pathways, and many people working to improve health and care are aware of and use systems techniques, lessons could be learned from the different perspectives of the engineering sector and the analysis and rigour applied in engineering systems. The Engineering Better Care report was based on an extended conversation within a unique forum of experts, in collaboration with the Royal College of Physicians and the Academy of Medical Sciences. It brought together systems engineers, health and care professionals, quality improvement experts, and patient representatives to develop a new and integrated systems approach for health and care service design and improvement.

The framework and tools described in the Engineering Better Care report aimed to stimulate conversations with funders, healthcare provider leaders, teams and individuals delivering quality improvement and service design. This toolkit is the direct result of these ongoing conversations and work continues with the Royal Academy of Engineering, the Royal College of Physicians, the Royal College of Anesthetists, the Academy of Medical Sciences and the Health Foundation, led by the University of Cambridge Engineering Design Centre, on its development and application to improvement practice.

Engineering Better Care describes the development of a systems approach to health and care design and continuous improvement, taking inspiration from both the healthcare and engineering sectors. It takes a broad view of systems (or systems of systems) as a set of elements that include people, processes, information, organisations and services, as well as software, hardware and other systems that, when combined, have qualities that are not present in any of the elements themselves. It then proposes that a systems approach is a process that integrates four key and complementary perspectives:

  • People: understanding of interactions among people, at the personal, group and organisational levels, and other elements of a system in order to improve overall system performance
  • Systems: addressing complex and uncertain real world problems, involving highly interconnected technical and social elements that typically produce emergent properties and behaviour
  • Design: focusing on improvement by identifying the right problem to solve, creating a range of possible solutions and refining the best of these to deliver appropriate outcomes
  • Risk: managing risk, based on the timely identification of threats and opportunities in the system, assessment of their associated risks and management of necessary change.

Each of the four perspectives of people, systems, design and risk can be seen as individual components within an overall improvement process. However, while each uniquely contributes to a systems approach, they are inextricably linked and the challenge is to integrate them within a useful, versatile and systematic process that repeatedly delivers results. The Engineering Better Care report presents the improvement process as an ordered set of questions, based on the individual perspectives, that should be asked until the current system is improved to delivered something measurably better into service. That sequence of questions has been extended to introduce questions related to the management of the improvement process. More details are provided in the Engineering Better Care section of this toolkit.

An improvement process may also be characterised by the key activity strands required to transform the current system into something measurably better. These are likely to focus on particular aspects of a successful improvement process:

  • Understand the Context — describes the circumstances or setting that surround a system and all the factors that could influence the system and its improvement.
  • Define the Problem — describes the detail of a particular challenge within a system and all the requirements for change necessary to improve the system.
  • Develop the Solution — describes a way of solving a particular problem within a system and all the elements of change necessary to improve the system.
  • Collect the Evidence — describes the information and all the measures used to evidence the validity of a particular solution(s) to a problem within a system.
  • Make the Case — describes the set of facts or arguments in support of improving a system and delivering a particular solution(s) to a problem within the system.
  • Manage the Plan — describes a detailed proposal for enabling change to a system and delivering a particular solution(s) to a problem within the system.
  • Agree the Scope — describes the context of the improvement envisaged in terms of the extent of the ambition for improvement and the boundary of the system of interest.

These strands will be present throughout the improvement process, but the emphasis given to each one should vary. At different stages of the improvement process there will be different targets for each of the strands, with early focus more likely on the context and problem and later emphasis on the solution and evidence. The strands will be delivered through the selection of specific, individual activities supported, where appropriate, by the use of standard tools. An initial set of activities and tools are included in the toolkit, along with resources to assist with the overall planning of the improvement process and the planning and execution of individual activities.

The Improvement Process section provides more details on the specific activities that might be performed within of these strands.


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