Improving Improvement

The challenges facing the health and care system are considerable — with competing pressures from an ageing population, increasing numbers of patients with multiple morbidities, new technologies, and the need for increasing efficiencies. The complexity of the system, along with the multiple pressures it faces, mean that efforts to improve it often achieve only limited benefits and can have unforeseen consequences. Over the past two decades, there have been numerous calls to implement a more holistic systems approach to transform health and care to address the needs of a changing patient population. However, there has been no clear definition of what this might mean in practice.

Engineers routinely use a systems approach to address challenging problems in complex projects. This allows them to work through the implications of each change or decision they make for the project as a whole. They consider the layout of the system, defining all the elements and interconnections, to ensure that the whole system performs as required. One example is the successful delivery of the London 2012 Olympic and Paralympic Games. Physical infrastructure and practical organisation were brought together, with innovative physical engineering, modelling and simulation of people flows, early testing of venues, and extensive risk management. A systems approach, combined with tried and tested engineering methods and tools, delivered real success on a massive scale.

All health and care improvement initiatives involve people, processes, technologies, the physical environment and systems that, in turn, are part of other systems. For example, the care pathway of an elderly frail patient must meet the needs of the patient, their immediate carer and wider family. Care must also coordinate across community support, a GP practice and hospital teams, and manage the patient’s medication, their physical journey to and around healthcare facilities, home care technologies and associated health and care data. Such complexity means that health and care will benefit from using an approach that considers each relevant element of the system and, critically, the nature and performance of the interfaces between them.

The Royal Academy of Engineering report titled “Engineering Better Care¹ — a systems approach to health and care design and continuous improvement”, was co-produced with engineers, clinicians, and healthcare leaders to explore how an engineering approach could be applied in health and social care to develop systems that meet the needs of patients, carers and NHS staff. It presents a new framework to support ongoing work in service design and improvement in health and care that can be applied at all levels of scale, from local improvement to national transformation.

Comparing current health and care improvement processes with engineering systems approaches, the report found that:

• There was the potential for health and care improvement to benefit from the rigour of the engineering approach to systems, particularly with respect to:
  • systems being centred on people — an effective systems approach is centred on people, their needs, their capabilities and ultimately their role in understanding, designing, delivering and maintaining success
  • iteration before implementation — the behaviour of complex systems is not easily understood and improvement is most often the result of successive iterations targeted at maximising the chance of success prior to implementation
  • design as an exploratory process — improvement results from a creative process that seeks not only to explore the real need, but also to evaluate a range of possible solutions in order to select the best option
  • risk management as a proactive process — the identification of possible opportunities for and threats to a system before they arise is more likely to lead to the delivery of robust and adaptable systems.
• While islands of excellence exist in the use of a systems approach in healthcare, the common sense thinking presented in the report is still far from being common in practice.

The findings from this collaborative project were integrated into a framework, that has the potential to support the work of transformation teams and individuals, and tools, that can help facilitate the methodical application of a systems approach to improvement. This approach can be applied to systems across all scales in the healthcare system, from service level improvement, through to organisational, cross-organisational, or cross-sector level change, dealing with complexity and improving performance.

This toolkit develops the approach presented in the Engineering Better Care report, providing practical guidance and resources to facilitate the application of a rigorous systems approach to health and care improvement. It is intended for improvers of all levels of experience and for challenges of all levels of complexity, and has the potential to have a transformative effect on health and care, with benefits for patients, service users and providers.