Intended for healthcare professionals


How to move beyond quality improvement projects

BMJ 2020; 370 doi: (Published 27 July 2020) Cite this as: BMJ 2020;370:m2319
  1. Amar Shah, chief quality officer, East London NHS Foundation Trust; national improvement lead for the Mental Health Safety Improvement Programme, NHS Improvement and RCPsych; quality improvement lead and chair of QI faculty, Royal College of Psychiatrists
  1. East London NHS Foundation Trust, London, E1 8DE, UK
  1. amarshah{at}, Twitter: @DrAmarShah

What you need to know

  • Quality improvement, by itself, does not represent a holistic approach to managing quality

  • Quality improvement needs to be used alongside quality planning, quality assurance, and quality control to create a single, consistent management system

  • Knowing when and how to use each of these four approaches, and creating an appropriate balance across all four, is the gold standard

In recent years we have seen a proliferation in the interest and use of quality improvement in health and healthcare. This represents a promising shift in our mental models about how to solve some of our most complex quality issues. Alongside the increasing use of the word “improvement” in our everyday language within healthcare, there are differences in understanding of what exactly we mean by the term “quality improvement.” This article explores the difference between quality improvement and a quality management system, by defining quality improvement and describing how to best use quality improvement alongside control, assurance, and planning as part of a more holistic management system focused on quality.

Is quality improvement the same as improving quality?

Quality improvement should be seen as part of an overall system of quality management. Quality improvement is a systematic and applied approach to solving a complex issue, through testing and learning, measuring as you go, and deeply involving those closest to the issue in the improvement process.1 Anyone who has undertaken quality improvement work will testify that it is not easy—you are generally tackling a problem to which we do not know the solution, and where part of the answer is about behaviours, and hearts and minds. Quality improvement can be used to reduce unwarranted variation, reliably implement interventions that have been shown to improve outcomes, or discover new solutions through a process of innovation. As we are looking to learn whether a particular service or issue has improved, the process also involves reviewing data to see whether something has changed over time.2 A range of different methods can be used, from the Institute for Healthcare Improvement’s Model for Improvement to the Toyota Production System and Six Sigma. The evidence suggests that there is no significant difference in efficacy among these different methods, the key seems to be fidelity to a given method for a long period of time to embed changes into the organisational culture.3

Just as all care is delivered in teams, quality improvement is best done as a team, of staff and patients working together on what matters most. We ought to reserve our limited capacity to undertake quality improvement for where it will have the greatest return—to solve complex adaptive problems. Factors related to the success of quality improvement efforts include aspects related to the quality improvement project team (diversity, involvement of key stakeholders, experience of quality improvement), the microsystem (leadership, culture, capability and motivation to change) and the wider environment (organisational culture, leadership, external motivators).4

What else is needed for quality management?

If we’re using quality improvement to solve complex adaptive problems, then we need other approaches for different types of problem. Quality improvement works well as part of a quality management system that incorporates several approaches to ensure that we are meeting, and exceeding, the needs of those we serve.5

Planning or redesign

Planning or redesign involves understanding the needs of the population, customer, or service user, and looking at the evidence and best practice across the industry in order to ascertain what structures and processes we need to put in place to optimise outcomes.6 This is something we might do once a year as part of our annual planning or commissioning process. The quality planning process helps us set goals, through understanding the needs and desires of the end user. We can then design what we need to put in place within our operational structures and processes to achieve this, using the available lived experience and knowledge, as well as the evidence base and innovation literature.7


One of the main mechanisms used traditionally in healthcare to improve quality has been quality assurance. Assurance involves occasionally checking that we are meeting a particular standard or threshold. This is usually about achieving standards and obtaining a simple binary response—OK or not OK. Audit, accreditation, and inspection are common mechanisms of assurance in healthcare.8 While assurance is helpful in ensuring we are meeting set standards and identifying gaps that need addressing, it isn’t a mechanism to help us to achieve new levels of performance. Innovation and creativity are needed to discover new practice, and many issues require behavioural change. The occasional checking process is not conducive to exploration, deeper insight, and ownership of change.

Quality control

Quality control is probably the least developed part of quality management in healthcare. This incorporates good operational management, monitoring performance in real time within the team, taking action when needed to bring the system back into control, and escalating rapidly when we can’t solve a problem.9 Quality control ought to be owned and managed by the team or service rather than be supported from outside the team (as assurance often is). Features of a robust quality control system include visual management that allows a transparent display of the key metrics for the service; regular huddles around the data to discuss and take action; and rapid escalation when problems can’t be solved within the team.

How can these four approaches be combined within the service?

Together, improvement, assurance, planning and control form the quality management system (fig 1).

Fig 1
Fig 1

The four aspects of a quality management system: planning, control, assurance, and improvement

This draws on the work of Joseph Juran, who developed the quality trilogy of planning, control and improvement.4 While manufacturing has largely managed to eradicate assurance due to the high level of reliability and advanced quality control systems, in healthcare there is still a significant portion of activity devoted to assurance – both within organisations, and from outside organisations. A key challenge in healthcare is to balance energy and activity across these four domains: planning ought to be an annual activity; improvement should be used in short bursts to achieve new levels of performance; assurance ought to be used occasionally to check whether standards are maintained; and control should be the way daily work is managed in a team.

Different tools and approaches to use in the four aspects of quality management

Figure 2 shows some of the improvement tools that might be used within each type of quality function.

Fig 2
Fig 2

Examples of tools that might be used within each of the four aspects of a quality management system

One of the main responsibilities leaders have within teams and organisations is to ensure the four different aspects of quality management are balanced and that the appropriate approach for a particular type of opportunity is deployed. In order to support our teams and people in managing quality, it will be important to understand how different members of the team can contribute to each of the four aspects of quality management. Everyone in the team, including patients, should play an active part in a robust quality management system (table 1).

Table 1

Roles of different team members within each aspect of the quality management system?

View this table:

Best practice use of quality management in a service

The activities in the management system should not be considered as isolated entities, but as being interconnected and sequential. Once a year, we go through a deep quality planning or redesign process, involving a range of stakeholders and data to understand the needs of the system and to develop structures and processes to achieve the desired outcomes. Once we have completed the planning or redesign phase, we move into quality control. This enables us to monitor ongoing performance and respond in real time to any changes outside the parameters that we would expect to see. A visual management board and regular huddles with clear escalation protocols form a robust quality control system. This allows us to build into our service occasional assurance activities in order to check that standards are maintained. These checks could be through tools such as audit or accreditation. Where a gap between actual performance and desired performance is identified, a small diverse team would be brought together to use quality improvement for a brief burst of rapid-cycle testing of new ideas designed to achieve a new level of performance. Once this is achieved and sustained, we move back into quality control to hold onto these gains. The system has, of course, undergone a number of changes through the quality improvement process, so these must be fed back into the next quality planning process. And so the cycle repeats.

The highest performing teams reduce assurance activity, create an intentional annual planning or redesign process, build a real-time quality control system (as this rarely exists in healthcare at the moment), and use quality improvement for the right type of problems in short bursts of rapid-cycle testing and learning.

In summary, in order to improve health and healthcare for those we serve, the quality management system represents a holistic approach to achieve this. All four types of activity will be needed, and the real challenge is to know which of the four management approaches is appropriate for the opportunity, and to balance our energy appropriately across all four.

Education into practice

  • Can you describe what you currently do in your service within each of the quality management functions: planning, control, assurance, and improvement?

  • How are you currently balancing your energy and time across these four domains, and what do you think the current balance should be?

  • Can you describe your role in the team’s quality management system?

How patients were involved in the creation of this article

Service users are deeply involved in the quality management system at East London NHS Foundation Trust, including quality improvement projects, planning and redesign, and quality assurance programmes. Shared learning over many years has contributed to our understanding of how to manage quality, what a quality management system should incorporate, and how to best involve and partner with service users within each of the quality management functions.

Sources and selection criteria

This article is based on my experience of supporting our approach to quality at East London NHS Foundation Trust, which is seen as one of the world leaders in healthcare quality improvement. Our approach to quality, and my role as chief quality officer, encompasses planning, control, assurance, and improvement as discrete but linked functions. This article is based on our practical experience and learning of building quality management systems, at team, department, and organisational levels.


  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; externally peer reviewed.


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