Improving safety in healthcare—is quality improvement the answer? A blog by Claire Cox

Summary

The healthcare landscape is evolving rapidly, with increasing complexity in patient needs, technological advancements and regulatory requirements. As this complexity grows, ensuring patient safety remains a top priority. One of the most widely adopted strategies for enhancing safety is quality improvement (QI), but is QI the right tool for navigating and improving safety in an increasingly complex health system asks Patient Safety Learning’s Associate Director Claire Cox, in this blog for the hub.

Content

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.
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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.
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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.