BMJ Qual Saf doi:10.1136/bmjqs-2011-000760
  • Narrative review

Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant literature

  1. Graham Martin
  1. Social Science Applied to Healthcare Improvement Research Group, Department of Health Sciences, School of Medicine, University of Leicester, Leicester, UK
  1. Correspondence to Professor Mary Dixon-Woods, Social Science Applied to Healthcare Improvement Research Group, Department of Health Sciences, School of Medicine, University of Leicester, 2nd Floor, Adrian Building, University Road, Leicester LE1 7RH, UK; md11{at}
  1. Contributors MDW and GM designed the study, reviewed the evaluation reports, identified relevant literature and led on writing of the article. SM reviewed the evaluation reports, prepared summaries of the reports, coded the findings of the reports, contributed substantially to writing and redrafting and helped in managing the project.

  • Accepted 20 February 2012
  • Published Online First 28 April 2012


Background Formal evaluations of programmes are an important source of learning about the challenges faced in improving quality in healthcare and how they can be addressed. The authors aimed to integrate lessons from evaluations of the Health Foundation's improvement programmes with relevant literature.

Methods The authors analysed evaluation reports relating to five Health Foundation improvement programmes using a form of ‘best fit’ synthesis, where a pre-existing framework was used for initial coding and then updated in response to the emerging analysis. A rapid narrative review of relevant literature was also undertaken.

Results The authors identified ten key challenges: convincing people that there is a problem that is relevant to them; convincing them that the solution chosen is the right one; getting data collection and monitoring systems right; excess ambitions and ‘projectness’; organisational cultures, capacities and contexts; tribalism and lack of staff engagement; leadership; incentivising participation and ‘hard edges’; securing sustainability; and risk of unintended consequences. The authors identified a range of tactics that may be used to respond to these challenges.

Discussion Securing improvement may be hard and slow and faces many challenges. Formal evaluations assist in recognising the nature of these challenges and help in addressing them.


  • Funding The Health Foundation funded this review.

  • Competing interests None.

  • Patient consent Not applicable.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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