Explaining organisational responses to a board-level quality improvement intervention: findings from an evaluation in six providers in the English National Health Service

Background Healthcare systems worldwide are concerned with strengthening board-level governance of quality. We applied Lozeau, Langley and Denis’ typology (transformation, customisation, loose coupling and corruption) to describe and explain the organisational response to an improvement intervention in six hospital boards in England. Methods We conducted fieldwork over a 30-month period as part of an evaluation in six healthcare provider organisations in England. Our data comprised board member interviews (n=54), board meeting observations (24 hours) and relevant documents. Results Two organisations transformed their processes in a way that was consistent with the objectives of the intervention, and one customised the intervention with positive effects. In two further organisations, the intervention was only loosely coupled with organisational processes, and participation in the intervention stopped when it competed with other initiatives. In the final case, the intervention was corrupted to reinforce existing organisational processes (a focus on external regulatory requirements). The organisational response was contingent on the availability of ‘slack’—expressed by participants as the ‘space to think’ and ‘someone to do the doing’—and the presence of a functioning board. Conclusions Underperforming organisations, under pressure to improve, have little time or resources to devote to organisation-wide quality improvement initiatives. Our research highlights the need for policy-makers and regulators to extend their focus beyond the choice of intervention, to consider how the chosen intervention will be implemented in public sector hospitals, how this will vary between contexts and with what effects. We provide useful information on the necessary conditions for a board-level quality improvement intervention to have positive effects.


Supplementary material The iQUASER intervention
The intervention involved the following stages: 1. Individual organisational self-assessment using the QUASER Guide. Foresight Partnership (FP) created an on-line self-assessment survey based on the guide. This survey took approximately 30 minutes to complete. FP recommended that this was completed by the following individuals: All executive directors, including the chief executive, chair, nonexecutive director with lead for quality, all other non-executive directors who wanted to take part, and, at the discretion of the board, divisional directors (clinical leaders) and/or those with a senior QI lead role not on the board. From the results of the self-completed assessment tool FP generated a report for each organisation to discuss and build a shared view of where the key quality improvement challenges are for each organisation. On the basis of the results of the self-assessment questionnaire each organisation was asked to: i.
Identify the areas of quality improvement that they feel need particular attention in their organisation ii. Select one whole-organisation quality improvement intervention to pursue over the year of this programme iii. Nominate three organisational leaders to participate in an initial workshop and 'action learning set' 1 , and two follow-up action learning sets at 4 and 8 months. It was recommended that this included one executive director and one clinical leader. It was also suggested that participants may also include the non-executive director who chairs the organisation's quality-focused subcommittee.

QUASER Workshop and Action Learning
Set. This was a one-day workshop attended by senior leaders from all the participating organisations. The focus for the morning session was on the research that underpins the QUASER guide 2,3 and on developing a collective understanding of the QUASER guide as a framework for developing elements of an organisation's quality improvement strategy. The afternoon session was the first of three action learning sets. Two executive members of each participating organisation were allocated to small groups. The intention was that membership of these groups would remain constant throughout the programme.
The aim of the first action learning set was to create a supportive environment and for participating organisations to draw on the collective experience and wisdom of all the participants so as to: i. Further develop an understanding of what approaches will be most effective to build an organisation-wide quality improvement strategy, based on each organisation's current stage of development, and addressing the areas of quality improvement that may need most attention from their self-assessment. ii.
To explore and develop approaches to implementing an organisation-wide quality improvement intervention.
By the end of the day it was anticipated that all participants would have arrived at specific goals or commitments to take their quality improvement strategies and interventions forward.

Follow Up Action Learning Sets.
Two follow-up facilitated action learning sets (at 3 and 6 months) explored implementation challenges, and ways to overcome them, as well as following up on progress. In addition the final learning set asked participants to reflect on the value of the guide in facilitating QI, as well as the value of facilitated support for implementation.
Attendance at the learning events is given in table S1.  Greater regulatory burden due to status as a non-foundation trust.
During the course of the study the organisation received a poor performance rating from the healthcare regulator and subject to additional scrutiny and assurance activities.
A large number of QI initiatives.

Stable leadership
The board had already spent some time reflecting on QI.
Shared recognition of the need to take a systematic approach.
Currently focused on quality assurance but recognition of the need to focus more on strategy.
During the period of the study there was a change in CEO and medical director. Seen as separate to other QI initiatives and attended to in a superficial way.
Nothing new or different as a result of the intervention.