You'll discover how to:

•  Understand why improvement programmes lose momentum.
• Capture frontline improvement opportunities before they are lost.
• Build continuous improvement rather than continuous projects.
• Turn frontline insight into organisational intelligence.
• Prioritise and implement improvement opportunities consistently.
• Measure improvement beyond completed projects.
• Demonstrate improvement to executives, Boards and regulators.
• Create a culture where improvement becomes everyone's responsibility.

The guide introduces a practical continuous improvement cycle:

Observe → Capture → Review → Prioritise → Implement → Measure → Share → Repeat

Helping organisations ensure improvement opportunities become meaningful organisational change rather than remaining isolated ideas.

Alongside the guide, there is a a free 30-minute webinar. See more.

Embedding Martha's Rule into practice: Lessons from our pilot

Over the past year, our focus has been on embedding the components of Martha's Rule (MR) into everyday clinical practice—ensuring that staff across all levels understand their role in the process and feel equipped to respond effectively to concerns raised by patients and families.

Tailored education for diverse staff groups

One of our earliest challenges was designing education that resonated with different staff roles. We recognised that ward nurses, medics and other clinical teams needed training that reflected their specific responsibilities within the MR pathway. Initially, we concentrated on face-to-face sessions supported by PowerPoint presentations. These laid the groundwork for understanding MR, but we knew we needed something more scalable. That’s why we developed an e-learning package, which is now live on our hospital's e-learning hub and is included in staff mandatory training. The e-learning package is structured to provide appropriate awareness within individual staff groups, ensuring consistent understanding of deterioration across the board. 

Using data to drive safety and insight

From a data perspective, we explored how to assess the safety of our current system and identify what information we needed to monitor effectiveness. We examined numerical indicators such as:

• deterioration rates
• cardiac arrest calls
• admissions to paediatric critical care.

In addition, we collected qualitative data around complaints and incidents—especially those involving parental concerns.

We triangulated these data sources to build a clearer picture of where improvements were needed. Although much of this analysis has been internal, we’ve begun integrating elements into the HIVE system (our electronic patient record system), to create dashboard-style visibility. We’ve also developed a dedicated database to track MR calls, allowing us to identify themes and trends by team, location, age, ethnicity and, potentially, deprivation.

Listening to families: A crucial voice

Although patient groups weren’t directly involved in shaping the e-learning package, we did engage with families during the early stages of the MR pilot. Their feedback was invaluable. Many expressed frustrations about unanswered queries and feeling left in limbo and feeling disempowered by a lack of cohesive response. These insights helped us reinforce key messages in the training, particularly around how concerns are acknowledged and escalated.

Looking back, we recognise that capturing family feedback earlier would have strengthened the process. We’re now addressing ongoing challenges, especially for families whose first language isn’t English. While many preferred phone communication, we’ve taken steps to improve accessibility.

Expanding access and inclusion

We’ve created a multilingual space on the MR site, allowing users to select their preferred language. To bridge the gap between ward posters and digital resources, we have added QR codes that link directly to the site. This will include contact details for the MR team and background information about the initiative. It’s a tangible outcome of the pilot and a testament to how much we’ve learned along the way.

What happens after a call?

Encouragingly, families have reported that their concerns are being responded to once MR calls are made. We’re also mindful not to interpret low call volumes as a sign that everything is fine. That’s why we continue to monitor all sources of information, ensuring we’re not missing signs of deterioration.

From pilot wards, we haven’t seen incidents or complaints that suggest missed cases, nor admissions to critical care that raise red flags. But vigilance remains key.

What’s next?

The e-learning package will be rolled out beyond pilot wards, ready for a hospital-wide rollout in mid-October 2025, ensuring widespread access and training before full expansion. MR principles are now embedded in induction for new nursing staff and resident doctors, reinforcing our commitment to making MR a core part of our culture.

What has your experience been in implementing Martha's Rule?

We'd welcome more experiences of implementing Martha's Rule we can share on the hub. What were the challenges? What worked well?

You can share your with us by commenting below (sign up here for free first), or submitting a blog, or by emailing us at content@pslhub.org.

Background

About 10 years ago, I listened to a friend’s experience navigating cancer and puzzled over the challenges encountered. These made me question my prior assumption of 'patient-centricity' across healthcare.

In 2015, the Organisation for Economic Co-operation and Development (OECD) released a report highlighting the complexities of the Australian healthcare system. This led me to realise that while we do have patient-centred care, it is often provider dependent, not system-wide, and relies on the patient (or carer) to navigate the system; a time when individuals are at their most vulnerable.

Given 'the standard you accept is the standard you walk past”, I decided to do 'my bit' to address this.  I enrolled in a Master of Public Health, researching healthcare navigation in Australia. I found there was a fragmented approach to try and address an already fragmented problem. This led me to embark on a PhD as well as develop a policy and advocacy platform: #NavigatingHealth.

Setting up a national network and community of practice

My focus has always been on a practical approach that solves problems for individuals but also seeks to understand how to scale these at a systems level to sustain change in the long-term.

If this was a known problem, why was nothing being done to address it? Surely this was something government were addressing... or there must be an app? I spoke to lots of people—patients, carers, speakers at conferences, those who had written books of their healthcare experience and, yes, those developing apps. Everyone agreed it was a problem, but nothing was addressing the totality of the problem.

The problem was not just in navigating healthcare, but also the challenges navigating related systems, such as those for people with disabilities, or for aged care, as well as social services and education.

#NavigatingHealth started life as two, 60-minute webinars held in mid and late September 2021, supported by the Australian Disease Management Association. The inaugural webinar speakers provided vignettes across a life journey—from childhood through to getting older—based on their own lived-experiences as patients, carers or professionals (not-for-profit, health services and government). 

The positive reception of the webinars led to setting up a bimonthly national network and community of practice in Australia that ran until the end of 2024. The meetings were deliberately not recorded to build a safe space for people to share ideas, build tacit (word of mouth) knowledge and a like-minded solutions focused community. Summaries of all the events and speakers are available on the #NavigatingHealth project page.

In health, information and projects evolve. Building an online community was low-cost and accessible to everyone.

The success of the Australian approach led to a series of global webinars using the same format of expertise provision from individuals in research, policy, and advocacy and health services. The first global webinar was held in 2022 attracting over 20 countries.

Connecting and collaborating

The 'glocal' community continues to grow. Projects are constantly evolving, elevating and expanding as well as exiting often impacted by funding constraints.

In the spirit of a complex adaptive learning health system, core to our success is the community knowledge built through relationships, trust, like-values and non-linear interactions. Taking an approach that is resourceful versus one requiring constant resourcing (we use accessible tools such as LinkedIn and more recently Bluesky) to provide an effective, free platform to keep individuals in touch with one another.

Our dedicated #NavigatingHealth project page on the Nossal Institute for Global Health website at the University of Melbourne acts as a central hub for events and resources. The genesis during the pandemic and expansion virtually through Teams and Zoom, as well as in-person post-pandemic, has enabled different ways to expand the national community, the global network and we welcome all-comers. The project is voluntary and our success is based on linking people, developing relationships, sharing expertise, maintaining momentum and the opportunity we all have to impact into #NavigatingHealth.

The annual forums, 2024 #NavigatingHealth Simplifying Complexity and 2025 #NavigatingHealth Enabling Patients, System-Wide, focused on bringing together colleagues nationally in Australia. The  in-person workshops created the opportunity to build community, share ideas, leverage learnings and also provide educational content.

These collaborations have allowed development of materials for curriculum and teaching, and an evolving conversation about the importance of systems-thinking.

We developed a short global project collecting stories from individuals who are happy to be involved. Our video, NavigatingHealth - why this matters, provides a glimpse of our approach.

Looking forward

The Future of Health Report published in 2018 highlights that our health systems, locally and globally, will change from 'one size fits all' to one that is personalised. The challenge is how?

Future of Health Report, CSIRO 2018.

The 'secret sauce' is that by working collaboratively we can all be part of evolving and effecting systems change. The work is underpinned by equity and a focus on enabling early access to care, addressing barriers, such as financial or cultural constraints, and helping to make visible information asymmetries and power imbalances to ensure effective collaboration and co-production. 

Building on the success of our past forums, planning for 2026 is underway. Block out 1 April 2026 in your calendar for the inaugural #NavigatingHealth Day!

Our collective expertise is our power—let’s do this!   

Want to know more? Please get in touch with Siân at navigating-health@unimelb.edu.au or via LinkedIn.

Further reading on the hub:

• The challenges of navigating the healthcare system
• How the Patients Association helpline can help you navigate your care
• Lost in the system? NHS referrals

Understanding QI in healthcare

Quality Improvement (QI) refers to systematic efforts to enhance healthcare processes and outcomes through data-driven interventions. QI frameworks, such as the Plan-Do-Study-Act (PDSA) cycle, Lean and Six Sigma, focus on continuous monitoring, identifying inefficiencies and implementing evidence-based solutions.[1]

By targeting system vulnerabilities, inefficiencies and variations in care, QI initiatives aim to foster a culture of patient safety and deliver consistent safe and effective care. However, as healthcare systems become more complex, can QI alone address the multifaceted challenges of ensuring patient safety?

The role of QI in enhancing safety within the NHS

QI plays a crucial role in enhancing patient safety by adopting systematic, data-driven methodologies to improve healthcare delivery. Within the NHS, numerous organisations have established QI initiatives, teams and trained personnel to improve the safety and efficiency of care. The recently introduced NHS Impact framework aims to equip all NHS organisations, systems and providers with the skills and techniques required to embed continuous improvement into everyday practice.[2]

Strengths of QI in enhancing safety

Data-driven decision making

QI frameworks rely on real-time data to identify trends, measure performance and implement solutions. This evidence-based approach helps in proactively addressing safety risks and reducing adverse events.[3] By leveraging robust data analysis, NHS organisations can identify systemic weaknesses and implement targeted interventions to enhance patient outcomes.

Systematic and scalable interventions

QI methods, such as Lean and Six Sigma, focus on standardising processes to minimise variability in care. This is particularly beneficial in high-risk environments, such as surgical units, emergency departments and intensive care units.[4] The NHS’s systematic approach ensures that successful QI initiatives can be scaled across multiple settings, fostering consistency and reliability in care provision.

Continuous improvement culture

A core strength of QI is its emphasis on continuous learning and adaptation. By actively engaging frontline healthcare professionals in problem-solving, QI fosters a safety-oriented culture that promotes innovation and accountability.[5] Within the NHS, the NHS Impact framework underscores the importance of building a shared purpose and vision, investing in people and culture, developing leadership behaviours, building improvement capability and capacity, and embedding improvement into management systems and processes.[2]

Reducing costs while enhancing safety

Preventing medical errors and reducing inefficiencies not only enhances patient safety but also lowers healthcare costs. Many hospitals have demonstrated significant financial savings by implementing QI-driven safety initiatives.[6] By reducing avoidable harm and improving workflow efficiencies, the NHS can achieve cost savings while maintaining high standards of care.

Governance, patient safety and the quality dilemma

Governance in healthcare, often referred to as clinical governance, is defined as “a system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish”.[7] This involves monitoring systems and processes to provide assurance of patient safety and quality of care across the organisation.

A key challenge in QI implementation is navigating the quality and patient safety dichotomy. While quality improvement aims to enhance efficiency and effectiveness, it must not compromise safety. Balancing these aspects requires a structured approach, integrating QI methodologies with robust governance mechanisms to ensure that safety remains paramount.

Limitations of QI in complex health systems

1. Resistance to change

Implementing QI initiatives requires cultural and behavioural shifts, which can face resistance from healthcare professionals. Without strong leadership and engagement, efforts to improve safety may fall short.[8]

2. Fragmented healthcare systems

Modern healthcare systems involve multiple stakeholders, including hospitals, primary care providers, insurers and policymakers. QI initiatives often struggle with alignment across these diverse entities, limiting their effectiveness in ensuring comprehensive patient safety.[9]

3. The need for holistic safety strategies

Although QI is a powerful tool, it may not be sufficient on its own. Addressing safety in complex systems requires integration with other approaches, such as human factors engineering, regulatory frameworks and digital health innovations.[10][11]

4. Data overload and implementation challenges

Although data is essential for QI, excessive reliance on metrics can lead to ’analysis paralysis’. Additionally, implementing QI interventions at scale can be resource-intensive, requiring time, training and financial investment.[12] In my experience, teams often seek more data, sometimes requesting information that we don’t have access to or that isn’t always reliable. There are times when data merely describes a potential problem rather than addressing it directly—but because gathering data is easier than implementing solutions, it can become the default focus, slowing progress.

The use of emerging safety science tools for reviewing ‘work as done’ has yielded valuable insights into the discrepancies between ‘work as imagined’ and ‘work as actually performed’. These insights highlight the complexities and adaptive nature of real-world work practices, often revealing gaps between prescribed procedures and practical execution. However, while these insights provide a nuanced understanding of workplace dynamics, they do not always translate into tangible, quantifiable data that directly supports QI methodologies.

QI relies heavily on measurable data to assess performance, identify inefficiencies and implement evidence-based interventions.[13] Traditional QI approaches, such as PDSA cycles, Lean and Six Sigma, are data-driven, emphasising statistical analysis and process metrics.[14] In contrast, the insights derived from safety science tools often emphasise qualitative aspects, such as human factors, resilience engineering and system complexity.[15] While these insights enrich our understanding of organisational performance, they may not always align with the structured, empirical requirements of QI methodologies.

Bridging this gap requires integrating qualitative insights with quantitative data collection methods. Techniques, such as ethnographic observations, safety culture assessments and frontline worker narratives, can complement QI initiatives by providing context to numerical performance indicators.[16]

The way forward: Integrating QI with broader safety strategies

To maximise its impact, QI should be integrated with other safety-enhancing approaches:

• Human factors engineering: Designing systems that account for human limitations can reduce errors and enhance safety.[17]
• Regulatory and policy support: Strong governance structures and safety regulations can reinforce QI efforts.[18]
• Digital health solutions: Leveraging artificial intelligence, electronic health records and predictive analytics can complement QI initiatives for improved safety outcomes.[19]
• Interdisciplinary collaboration: Engaging multiple stakeholders—patients, families, carers, clinicians, administrators and policymakers from differing healthcare sectors across the system—can ensure a holistic approach to safety improvement.[20]

Conclusion

QI is a vital component in enhancing patient safety within the NHS, providing a data-driven, systematic approach to continuous improvement and cost reduction. The NHS Impact framework ensures that governance and patient safety remain central to healthcare delivery.[21] However, in an increasingly complex system, QI should not be viewed as a standalone solution. Instead, it must be integrated with broader strategies, including human-centred design, technology, policy support and cross-sector collaboration.[22]

A safety management systems approach, as highlighted in Healthcare Safety Investigation Branch (HSSIB) reports, is essential to embedding a proactive, system-wide perspective on patient safety.[23] Additionally, aligning QI efforts with patient safety standards and Patient Safety Learning standards ensures a structured, evidence-based approach to mitigating risks and driving sustainable improvements.[24] Furthermore, regulatory frameworks, such as the National Patient Safety Strategy and the NHS Patient Safety Incident Response Framework (PSIRF). provide additional guidance for fostering a learning culture and improving incident response.

In conclusion, while emerging safety science tools offer profound insights into the realities of work as done versus work as imagined, these insights must be systematically incorporated into data-driven QI frameworks. By integrating qualitative and quantitative approaches, organisations can achieve a more comprehensive and effective strategy for continuous improvement and enhanced safety performance. The key challenge for healthcare leaders is not whether QI is essential, but how to optimally combine it with these frameworks and strategies to build a resilient, high-quality healthcare system that continuously evolves to meet patient safety needs.

References

1. Institute for Healthcare Improvement. The Model for Improvement, 2020.
2. NHS England. About NHS Impact, 2024. [Accessed 21 February 2025].
3. Berwick DM. The science of improvement. JAMA, 2008; 299(10): 1182-4.
4. Graban M. Lean hospitals: Improving quality, patient safety, and employee engagement. Taylor & Francis Group, 2016.
5. Batalden PB., Davidoff F. What is "quality improvement" and how can it transform healthcare? Quality & Safety in Health Care, 2007; 16(1): 2-3.
6. Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ, 2016; 353, i2139.
7. NHS England. Governance, patient safety, and quality, 2024.
8. Greenhalgh T., et al. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Quarterly, 2004; 82(4), 581-629.
9. Shortell SM., et al.  Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress. Milbank Quarterly, 1998; 76(4), 593-624.
10. Carayon P, et al. (Human factors systems approach to healthcare quality and patient safety. Applied Ergonomics, 2014; 45(1), 14-25.
11. Carayon P, Schoofs Hundt A., Karsh, B-T, et al. Work system design for patient safety: The SEIPS model. Quality and Safety in Health Care, 2014; 15(Suppl 1), i50–8.
12. Pronovost P.J, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 2006; 355(26): 2725-32.
13. Institute for Healthcare Improvement. Quality improvement essentials toolkit, 2021.
14. Deming WE. Out of the crisis. MIT Press, 1986.
15. Hollnagel E, Woods DD, Leveson N. Resilience engineering: Concepts and precepts. CRC Press, 2006.
16. Vincent C. Patient safety. John Wiley & Sons, 2010.
17. Reason J. Human error. Cambridge University Press, 1990.
18. Leape LL, et al. Transforming healthcare: a safety imperative. BMJ Quality & Safety 2009; 18(6), 424-8.
19. Wachter RM. The digital doctor: Hope, hype, and harm at the dawn of medicine’s computer age. McGraw-Hill Education, 2015.
20. Grol R., et al. Improving patient care: The implementation of change in health care. John Wiley & Sons, 2020.
21. NHS England. The NHS Impact Framework: Embedding Continuous Improvement. 2023.
22. Dixon-Woods M, Martin G. Does quality improvement improve quality? Future Hospital Journal, 2016; 3(3): 191–4.
23. Healthcare Safety Investigation Branch. Safety management systems: an introduction for healthcare. 2023.
24. Patient Safety Learning. The Patient Safety Standards. 2020.

• A learning health system (LHS) is a way of describing a systematic approach to iterative, data-driven improvement. Learning health systems are able to learn from the routine care they deliver, and improve it as a result – as part of ‘business as usual’.
• This research suggests there is a large gap between the promise and practice of LHSs. This is partly due to the lack of a clear definition, vision and evidence base around LHSs, meaning it can be difficult to know where to start or how to make progress.
• This report, part of Health Data Research UK’s (HDR UK’s) Better Care programme, was informed by a literature review, interviews, a survey of more than 100 expert stakeholders and a series of practical case studies, offering real-world examples of LHS approaches already being taken.
• It explores four important areas especially relevant to LHSs: learning from data, harnessing technology, nurturing learning communities and implementing improvements to services. In these areas, targeted action by policymakers and organisational leaders could lead to tangible progress in developing LHSs.
• Amid all the pressures the health and care services are facing, we should be wary about seeing LHSs as a ‘nice to have’. A step change in the health service’s learning and improvement capability is needed if it is to find a sustainable route to recovery and effectively reshape care to meet future health needs.

One of the standout successes of the initiative has been the rise in Patient-Initiated Follow-Up (PIFU) rates. More than 50% of CAD attendees opted for this approach, a significant increase compared to the 12% seen in other services. Although national evidence on PIFU’s effectiveness is still emerging, these figures suggest that CADs are making a real difference in promoting long-term self-management.

This publication reflects on ELFT's 10-year improvement journey and learning thus far on the following areas of focus:

• Origins of Quality Improvement at ELFT
• Develop an improvement-focused Board
• Foster an improvement culture: Senior leadership
• Establish an infrastructure for improvement
• Build improvement capability
• Design and deliver large-scale improvement
• Meaningfully engage people in QI
• Use data for learning and improvement
• Engage external partners in QI
• Develop a Quality Management System

The learning is informed by interviews with nearly 30 people, in a range of roles, who have been part of the improvement journey. ELFT's experience is shared in the hope that it may provide inspiration and ideas for other health systems around the globe who are on a similar pursuit of continuous improvement.

• review the care provided in the Emergency Department (ED), so that patients are seen promptly, offered pain relief, and admitted to an appropriate specialist ward within four hours.
• use the NHFD website to see why surgery is delayed, and work together so that this happens by the day after patients present with a hip fracture.
• use the NHFD website to see what more can be done to avoid patients becoming confused in hospital and to ensure that they are well enough to get out of bed on the day after their operation.