How do you know when improvement is spreading?

If you are trying to contribute to a change in culture, or even create a social movement, it is going to be very hard to know when you have achieved it.  It can also sometimes be strange for those of us who are passionate about improvement to be trying to influence something like culture when it is so difficult to measure. Measuring things is what we do!

It is probably sensible, therefore, to accept that we will never be ‘finished’ and it will always be hard to usefully quantify the volume of improvement underway in an organisation – For example, counting the number of QI projects started or the number of people who have completed a QI training course seems a little arbitrary to be calling ‘success’.

Instead we should maybe try to look out for the spread of improvement.

Dandelion with seeds blowing away in the wind across a clear blu

The Quality Improvement Hub created by NHS Scotland team produced a document that describes the 10 key factors underpinning spread and sustainability of quality improvement in healthcare.

It is a really helpful document and has some useful tips on how to create ‘spread’, which the NHS Scotland team describe as ‘when best practice is disseminated consistently and reliably across a whole system and involves the implementation of proven interventions in each applicable care setting’.

Thinking about how we can improve the spread of improvement in our organisation, we came to a couple of lessons we have learned from elsewhere:

1 – Understand that spread is going to take time

Having visited and spoken with colleagues from other NHS organisations who are also on a journey to embed a culture that embraces quality improvement, we have learned a lot and picked up some useful tips.

For example, when we visited the team at Sheffield Teaching Hospitals NHS Foundation Trust last year, we discussed how it was important to foster and support organic improvement activities and to ‘go where the energy is’.

We discussed that it was important to provide teams with a basic understanding of improvement skills and then support people in the next stages of the journey – understanding that the spread of the adoption of these skills and ideas will take time.

2 – Welcome and encourage the innovators and the early-adopters

The ‘Diffusion of Innovation’ model is an established theory which can be used to describe the spread of improvements as well as the adoption of improvement skills.  Some people will be familiar with the diagram below:


Any change or new idea will not spread or be adopted by all people instantly.  Instead, there is a flow between groups of people over time.  Therefore, it makes sense to work initially with the people who want to be involved in improvement (the innovators and early adopters).

The ideas and approach will then spread to those who are naturally more cautious and even to those will resist until there is no alternative to change.

Although this may feel like a natural process, the learning from elsewhere is that this actually takes persistence and hard work.

We can help the process along by carefully thinking about the groups, how to communicate with them and remembering why we resist change.  We can also help the process along by reaching-out and welcoming the innovators and early adopters into a QI community; as well as encouraging them to share and celebrate their successes.

Spread in action

Last Thursday (which had started out as not-a-great-day) was completely turned around by a 15 minute meeting in the afternoon with a clinical colleague who wanted to discuss their idea for a QI project.  The colleague in question had submitted their idea online and was meeting with Katherine from our team for some advice.

In five minutes our clinical colleague described what it was she wanted to improve; how she was going to measure the improvement; and what changes she and her colleagues were proposing to make.

She also described the team she had worked with to design the changes and the senior colleagues she had engaged with for support.  She went on to describe a full PDSA approach – completely unprompted.

We were able to help with a couple of practical issues there-and-then, but there was no other support required from us  It was a simply a great idea for a QI project from someone we had never met before; who was curious about making a change and was following the model for improvement.

As well as being a great idea for an improvement project, it was a real indication to me that the improvement approach is starting to spread in our organisation and a sign that there are an increasing number of innovators and early adopters out there.

Please let us know what you think in the comments section below.  Have you noticed the spread of improvement as well?

Finally, if you have an idea for an improvement you would like support with, or if you would just like to discuss, you can get in touch here.


Mark – @MarkH_Work



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