Challenge 1: Convincing people that there is a problem

One fundamental, but often poorly met, challenge for improvement efforts is that of convincing healthcare workers that there is a real problem to be addressed. Clinicians and others may argue that the problem being targeted by an improvement intervention is not really a problem; that it is not a problem ‘around here’; or that there are far more important problems to be addressed before this one.6 ,15 Trying to convince clinical teams who think they are already doing well to change is likely to be futile unless they can be shown that action is really needed.

Those designing and planning interventions should be careful to target problems that are likely to be accepted as real. Possible strategies for establishing the problem as a problem include hard data to demonstrate its existence, patient stories to secure emotional engagement,24 engage the clinicians in defining what they would like to improve in their service and show that there is a ‘relative advantage’ in implementing the intervention.25

Challenge 2: Convincing people that the solution chosen is the right one

Improvement interventions are often ‘essentially contested’: everyone may agree on the need for good quality but not on what defines good quality or how it should be achieved. Clinicians and others may resist change on grounds that interventions lack sufficient evidence or are incongruent with preferred ways of practising that already appear to deliver good results.8 ,26 Ensuring that there is good quality scientific evidence to support interventions, and that implementers are well briefed and capable of handling challenge, is therefore critical.6 ,27 One strategy for ensuring acceptability of interventions involves using well-facilitated forums to discuss and debate the evidence and expose it to challenge, rather than hoping that the evidence will ‘speak for itself’.28 ,29 It may also help if improvement efforts are underpinned by a clear and explicit ‘programme theory’8 —an account of the activities to be undertaken, and the causal links between these activities and the outcomes sought.30 Among other things, a programme theory makes explicit why an intervention is likely to work, and helps clarify focus and strategic direction. Considerable effort needs to be invested in the initial programme theory, but it should not be regarded as fixed and immutable; it may develop over time as those engaged in the programme learn from their experiences of implementation.24

Challenge 3: Getting data collection and monitoring systems right

Data collection and feedback are indispensible to improving quality. Data help in demonstrating the scale of a quality problem and show what is happening in response to an intervention. But data collection, monitoring and feedback systems are remarkably hard to get right: they are often poorly understood, poorly designed and poorly implemented.15 Local teams may lack expertise and experience in collecting and interpreting data or they may struggle with systems that are designed for collecting administrative and clinical data but not for monitoring quality.8 Measures that are excessively burdensome, or not seen as credible by the target community, risk alienating, rather than engaging, clinicians and producing confusion about how far changes are real.6 ,9 Poorly chosen measures can also provoke gaming where participants are incentivised to produce the desired numbers without the intended changes in practice.31 Measurement systems need to be explicitly designed into improvement activities from the start, and they need to be adequately resourced.32 ,33 Systems need to be fit for purpose and avoid imposing excessive burdens or other unintended consequences, and staff need training on how to collect and interpret data.

Challenge 4: Excess ambitions and ‘projectness’

Enthusiasm for improving quality is very natural but it can easily overwhelm the available resources. Ambitious ‘stretch goals‘ and talk of ‘transformation‘ may risk alienating people early on and later lead to disillusionment if aims are not realised. The scale of resource required to support improvements is often underestimated,6 ,11 but without adequate financial support, infrastructure, managerial skills and dedicated time, efforts to improve quality can quickly run into difficulties.34 Difficulties can be compounded when new initiatives are not given a diagnosis phase or enough time to ‘bed in’.25 Activities such as team- and relationship-building are time-consuming, especially when they start from a low base, and it may be hard to sustain enthusiasm and effort over long periods and maintain focus when interests and priorities move elsewhere.15 The scale and demands of improvement interventions therefore need careful assessment at the outset and the implications of involvement need to be explained.17

Improvement efforts are also prone to acquiring a ‘project’ status that can bring opportunities but also threats. Though projects can be key tools for introducing novel work practices,35 they offer benefits, including a distinctive focus, identity and drive, excitement and interest. If projects lack ongoing senior managerial support, they may be undertaken at the margins of mainstream activities, and it can be difficult to make the transition from project to institutionalisation as part of wider organisational policies, procedures and norms. Perhaps most corrosively, activities seen as time-limited risk simply being tolerated or ignored until they go away by coming to an end. This points to a need to find a compromise between harnessing the distinctiveness of projects as a tool for change and ensuring that such projects are also aligned with the wider ‘direction of travel’ of organisations.

Challenge 5: Organisational cultures, capacities and contexts

Trying to secure improvement in situations where organisational capacity is inadequate, and culture is adverse, can result in emotional exhaustion and evaporation of support.36 Differences in morale, leadership and management in organisational settings may lead to variation in outcomes.15 ,37 ,38 Organisational cultures supportive of personal and professional development, and committed to improvement as an organisational priority,39 are, unsurprisingly, more likely to provide an environment where improvement efforts can flourish.12 However, some clinical staff may be actively hostile towards improvement efforts, or simply put little effort into their support.40 Some managers can be too busy to take an interest in improvement projects or may even feel threatened.12 Attempts to secure resources, such as budgets and release of time to support improvement, may sometimes be seen by managers as illegitimate or as political acts by clinical staff, and handled accordingly.36 The complexity of many interventions can also pose significant challenges for organisations. Lack of adequate structures to support improvement activities often means creating new systems and processes from scratch.6 ,9 Team instability—arising, for example, from lack of succession planning, rotating staff, shift patterns and use of agency staff—can result in stalled progress or make it difficult to sustain collective knowledge and enthusiasm.6 Outer contexts, including shifting policy agendas and regulatory requirements, can be a major barrier,11 ,12 because of their effects of organisational turbulence and staff distraction and instability of structures and teams. Problems can occur when improvement efforts run counter to centrally driven national pushes and pressures or are introduced into environments already suffering organisational stress from mandated requirements. At senior management level, interventions that fit with strategic goals and organisational aspirations are more likely to be met with active enthusiasm.41 Involving service users in organisational change may increase its legitimacy and its chances of success, ensure that improvements are focused on patients' priorities, and assist in dissemination activities.15 However, evidence that user involvement improves quality and outcomes remains limited42 ,43 and many challenges still remain.44 External support from professional societies or consultants may also be important in overcoming limitations of local expertise and capability. However, the extent to which external support can compensate for major structural and resource deficits or adverse organisational cultures is unclear.

Challenge 6: Tribalism and lack of staff engagement

Engaging staff and overcoming a perceived lack of ownership are among the biggest challenges in improvement efforts.45 Boundaries between professional, disciplinary and managerial groups present important obstacles to change, and consensus within one profession is not always shared by others.15 Middle managers and frontline staff can be especially difficult to engage in improvement, because they already face numerous, complex, competing clinical and organisational demands, often with inadequate staffing, limited resources and equipment shortages.6 Resistance to improvement efforts can also result from attempts to guard professional autonomy and suspicion about externally led change.46 Yet professional norms, values and networks can also offer an important resource in seeking to improve care7; professions can often secure conformity of their members to norms and standards more effectively than managerially led efforts.47 ,48 Avoiding a situation where improvement is seen simply as a managerial intrusion into professional concerns is thus important.25 ,49 However, there is a danger that being too deferential to existing norms, values and behaviours may result in failure to challenge poor quality practices. Norm-disrupting tactics may be needed to confront institutionalised complacencies.24 Tapping into profession-specific networks, norms and values can help mobilise commitment and enthusiasm more effectively than coercive tactics.25 ,50 ,51 For example, peer-led audit can achieve high participation and trusted results.15 Peer support, though resource-intensive, can also produce highly valued interaction and help to sustain momentum, build confidence and provide a source of encouragement and motivation through sharing common problems.11 ,14 ,15 However, groups may require expert help in teamwork and relationship management to realise their potential.11

Challenge 7: Leadership

Leading improvement efforts well is challenging and delicate, requiring a combination of technical skills, facilitation skills and personal qualities.12 It needs to happen at multiple levels and needs to ensure alignment with staff priorities, and active work among staff to foster collaboration and engagement with improvement aims.25 ,39 ,46 ,52 Respected individuals can play a vital role in encouraging colleagues across different professions.15 Key to success may be ‘quieter’ leadership, less about bombastic declarations and more about working to facilitate collaboration.53

Challenge 8: Incentivising participation and ‘hard edges’

Busy clinicians may need incentives if they are to prioritise improvement activities. Many improvement efforts seek to draw on the intrinsic motivation of healthcare professionals to maximise the quality and effectiveness of the care they provide for patients. Visible improvements and unequivocal evidence of potential patient benefit through credible feedback6 can encourage greater clinician involvement in what may otherwise be seen as relatively low-status activity with poor rewards.16 ,18 However, ‘softer’ modes of persuasion are sometimes enough to stimulate changes to practice. A combination of soft persuasive tools and ‘harder edges’ that involve a firmer approach to leading change may be needed—for example, using peer review and audit as a means of both supporting change, and reminding participating sites that they are being held to account, or including involvement in quality activity as a criterion for engagement in continuing professional development and revalidation.15

Challenge 9: Securing sustainability

Besides their potential to meet resistance at their inception (see challenge 4 above), ‘projects’ may be especially vulnerable to challenges of sustainability. Clinicians' and managers' interest may dwindle when, at a project's end, they are faced with new, competing priorities.15 Most initiatives have to be resource neutral, or use existing resources more efficiently, if they are to continue.15 Sustainability is threatened when there is over-reliance on certain individuals and by assumptions that interventions will simply diffuse on their own or readily transplant from one context to another.15

The available evidence suggests the need for explicit attention to ‘spreading learning and sustaining change’ from the outset.8 ,12 Demonstrating clinical effectiveness, efficiency and mainstream relevance is important to this,8 as is ‘locking in’ changes by adapting performance management policies, organisational infrastructure and institutional processes.34

Challenge 10: Risk of unintended consequences

Though it is often assumed that quality improvement programmes are harm-free, there is some evidence that they can produce unintended and unwanted consequences54—including, ironically, that of souring clinicians against quality improvement.6 Attention is needed to alert on the possibility that improvement efforts may produce iatrogenic effects. In a few projects, for example, there were unexpected opportunity costs, which were felt by some to outweigh any benefits.