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Analysis Quality Improvement

How organisations contribute to improving the quality of healthcare

BMJ 2019; 365 doi: (Published 02 May 2019) Cite this as: BMJ 2019;365:l1773

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  1. Naomi J Fulop, professor of healthcare organisation and management,
  2. Angus I G Ramsay, NIHR knowledge mobilisation research fellow
  1. UCL Department of Applied Health Research, London, UK
  2. Correspondence to: N J Fulop n.fulop{at}

Naomi Fulop and Angus Ramsay argue that we should focus more on how organisations and organisational leaders can contribute to improving the quality of healthcare

Key messages

  • The contribution of healthcare organisations to improving quality is not fully understood or considered sufficiently

  • Organisations can facilitate improvement by developing and implementing an organisation-wide strategy for improving quality

  • Organisational leaders need to support system-wide staff engagement in improvement activity and, where necessary, challenge professional interests and resistance

  • Leaders need to be outward facing, to learn from others, and to manage external influences. Strong clinical representation and challenge from independent voices are key components of effective leadership for improving quality

  • Regulators can facilitate healthcare organisations’ contribution by minimising regulatory overload and contradictory demands

Improving the quality of healthcare is complex.12 Frontline staff are often seen as the key to improving quality—for instance, by identifying where it can be improved and developing creative solutions.34 However, research and reviews of major healthcare scandals acknowledge the contributions of other stakeholders in improving quality, including regulators, policy makers, service users, and organisations providing healthcare.56

Policies on the role of organisations in improving quality have tended to focus on how they might be better structured or regulated. However, greater consideration is required of how organisations and their leaders can contribute to improving quality: organisations vary in both how they act to support improvement78 and the degree to which they provide high quality healthcare.9

Some earlier studies suggest that high performing organisations share several features reflecting organisational commitment to improving quality. These include creating a supportive culture, building an appropriate infrastructure, and embedding systems for education and training.1011 Subsequent reviews of quality inspections12 and reviews of evidence on factors influencing quality improvement,9 and board contributions13 indicate that organisational leadership is crucial in delivering high quality care.

We discuss how organisational processes such as development of a strategy and use of data can be used to drive improvement, the characteristics of organisations that are good at improvement, and what to consider when thinking about how organisations can help improve quality of healthcare and patient outcomes.

We present evidence on the role of organisations in improvement drawn from acute hospital settings in the UK and other countries. Although contexts may vary—for example, in whether health policy is made at regional or national level, or in the form and function of healthcare organisations—the lessons have potential relevance to all settings.

Placing healthcare organisations in their context

Health systems operate at three inter-related levels: macro, meso, and micro (box 1). Research suggests that an organisation—through its leadership and processes—can bridge these levels to influence the quality of care delivered at the front line.141516

Box 1

Macro, meso, and micro contributions to the quality of healthcare14

Macro (national health systems)

  • Regulatory system

  • Finance

  • National priorities and policies

  • Accreditation

Meso (hospitals)

  • Strategies

  • Systems

  • Processes

  • Cultures

  • Practices

  • Structures

Micro (departments, teams)

  • Relational issues

  • Communication

  • Professional work

  • Competence


A key macro influence on organisations performing their role in improving quality is the way the healthcare system is governed and regulated. Regulation provides accountability to the wider system and therefore has a potentially strong influence on how healthcare organisations approach improvement. For example, multiple regulators in healthcare systems, as is the case in England, can lead to “regulatory overload,”17 making it hard for organisations to focus on quality improvement rather than quality assurance18 because of the need to respond to different (and potentially conflicting) regulatory approaches, priorities, incentives, and sanctions.171920

How can organisations contribute to improving quality?

Organisations can use various levers and processes to translate external inputs (such as policy and regulatory incentives) and internal inputs (such as local assurance systems providing data on performance and capacity) to support quality improvement.71821 Organisations can facilitate improvement by developing and implementing an organisation-wide quality improvement strategy92223 that includes the following actions:

  • Using appropriate data to measure and monitor performance202122

  • Linking incentives (both carrot and stick) with performance on quality1622

  • Recruiting, developing, maintaining, and supporting a quality proficient workforce21

  • Ensuring sufficient technical resources and building a culture that supports improvement.916

Many of the key organisational activities important to improving quality, such as setting strategy and agreeing performance measures, are defined at organisational level by the board.13 Bottom-up, clinician-led improvement is often seen as the answer to the quality challenge, and it is an important part of successful quality improvement.324 However, relying solely on frontline staff to lead improvement is risky because professional self interest can shape or limit the focus of improvement activity.222526 Furthermore, lack of system-wide or organisation-wide agreement on objectives might result in variations at system level, reflecting localised priorities rather than what is likely to provide the best care for patients. As well as empowering staff and supporting system-wide staff engagement in activity around improving quality420 organisational leaders must challenge localised professional interests, tribalism, and resistance to change.1822

The reorganisation of acute stroke services in the UK (fig 1) shows how leadership can play a pivotal role in managing professional and organisational resistance to changes that aim to improve quality of care. Importantly in this case, leaders cited external organisations’ priorities and public consultation responses when holding the line against local resistance to change.25

Fig 1
Fig 1

Leading and implementing system-wide change across organisations: centralising acute stroke services in London and Greater Manchester252728

The culture of organisations is commonly considered important in improving quality, as discussed elsewhere in this series.202930 Although the relation between culture and quality is complex, organisations can use formal and informal managerial processes to influence culture and thus improve quality of care.30

What helps organisations contribute to quality?

As set out in box 1, the relationship between a healthcare organisation and its external environment (especially regulators) is important in that organisation’s contribution to quality.1823 A qualitative study of hospitals and their external environments in five European countries showed how some were better able to align multiple financial and quality demands.7Figure 2 shows contrasting organisational responses to external demands and the features of both the external demands and the organisations that contributed to these different responses.

Fig 2
Fig 2

How hospitals respond to external finance and quality demands7

Organisations can also contribute to improving quality through participation in (or leading) major system change, working beyond their own catchment areas across their local system—for example, integrating health and social care services31 or centralising specialist acute services across multiple hospitals in a given area.3233 Evidence suggests that how such changes are led and implemented influences the impact of the changes, including on patient outcomes (fig 1).

What do organisations that do well in improving quality look like?

Research suggests that organisations that deliver high quality care show high commitment to improving quality, reflected for instance in how organisations are led (eg, senior management involvement) and managed (eg, use of data and standards). As an illustration, fig 3 contrasts the approaches taken by US organisations with high patient mortality from acute myocardial infarction with those that have low mortality.

Fig 3
Fig 3

Contrasting organisational approaches in US healthcare organisations with the top and bottom 5% risk standardised mortality for acute myocardial infarction in 20178

Some recent research has developed the concept of maturity in relation to how boards of organisations govern for quality improvement and what organisational processes accomplish and sustain it.18

More mature boards tend to use data to drive improvements in quality rather than merely for external assurance,1820 and they combine hard quantitative data on performance with soft data on personal experiences to make the case for improvement.22 They also engage with relevant stakeholders (including patients18 and the public), translate this into strategic priorities,91011 and have processes for managing and communicating information with stakeholders.8918 They value learning and development472234—for example, drawing on external examples of good practice to achieve initial improvement then focusing on local, creative problem solving for continued improvement.34 Finally, these organisations are outward facing, engaging with and managing their wider environment, including payers and other provider organisations.7132934

By contrast, organisations with lower levels of such capabilities (such as lack of coherent mission, high turnover of leadership, and poor external relationships) appear to slow or limit improvement.183536 Some interventions have been identified to help organisations struggling to improve quality.35 Furthermore, research on organisational turnaround provides evidence of organisational leaders harnessing crises, such as major safety issues or financial difficulties, to drive radical change and improvement.3637 Key changes to turn round organisations have included refocused accountability systems (eg, making quality a key performance indicator, devolving accountability to clinical teams1138), introducing processes to facilitate improvement (eg, dedicated improvement roles,3638 increased training opportunities, and sharing timely data on quality and cost with clinical teams113638), supporting culture change (eg, increasing collaboration between clinicians and management113638 with clinicians leading on quality and management supporting them), and learning from the experience of other organisations.113638 However, for such interventions to have a chance of success, organisations need both sufficient space to think and the people to make change happen.23

The composition of senior leadership seems to influence how well organisations deliver on quality. Having clinicians on the board has been associated with better organisational performance,2339 through enhanced decision making, increased credibility with local clinicians (facilitating frontline uptake of policy), and making organisations more likely to attract talented clinicians.39 Active discussion of strategy is enhanced by independent challenge by non-executives who are well versed in quality issues; this is likely to enhance focus on quality at board level, ensuring it is at the heart of an organisation’s vision and strategy.13 As noted elsewhere, focus is growing on service users guiding improvement.40 However, it has been challenging to involve service users meaningfully at senior leadership level.41

What can we conclude?

Although organisations are central to improving quality, there is much variation in how they contribute, both locally and at system level. We have described ways in which organisations can contribute to improvement in terms of their processes (such as how they develop strategy and use data to drive improvements in quality), their leadership (such as how leaders engage with and manage both their external context and local professional interests), and underlying features (including coherence of external demands and leadership stability). Box 2 summarises these themes. However, the balance of priorities among these is unclear: organisations will want to analyse how they can maximise their contribution to improving quality taking account of their particular context.

Box 2

What helps organisations contribute to quality?

Organisational process

  • An organisation-wide quality strategy to shift from external assurance to prioritising improvement

  • Combine hard and soft data to drive quality

  • Engage and communicate with stakeholders, including patients and carers, staff, and external partners

  • Build culture of trust, supporting innovation and problem solving

Organisational leadership

  • Support system-wide staff engagement in improving quality

  • Be outward facing, to learn from and manage external context

  • Challenge local professional interests where necessary

  • Feature a strong clinical voice and independent challenge, especially on the board

Underlying features

  • Space to think about improving quality

  • Resources to implement improvements

  • Coherent external requirements: avoid regulatory overload and contradictory demands

  • Stability of leadership


Regulators and policy makers also need to consider how they can better facilitate healthcare organisations’ role in improving quality. Organisations are more likely to deliver quality improvement effectively if externally set objectives are clear and manageable, and there is time and resources with which to meet these. Regulators should seek to avoid generating regulatory overload and contradictory demands; and they should strengthen organisational leadership’s hand by giving them headspace to look beyond compliance and prioritise improving quality.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare that NJF is an NIHR senior investigator and was in part supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Barts Health NHS Trust. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

  • Contributors and sources: Both authors made substantial contributions to the conception and design of the work; to the acquisition, analysis, and interpretation of data; and to drafting the work and revising it critically for important intellectual content. NJF is the guarantor.

  • This article is part of a series commissioned by The BMJ based on ideas generated by a joint editorial group with members from the Health Foundation and The BMJ, including a patient/carer. The BMJ retained full editorial control over external peer review, editing, and publication. Open access fees and The BMJ’s quality improvement editor post are funded by the Health Foundation

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