Table 2

Success factors of a continual improvement system

A. Success factor I: information
 1. Provide continual and reliable information about best practice
 Best practice (CL*)‘It was good to have a team of senior experts presenting feasible improvements on the topic area in the beginning.’
 2. Provide continual and reliable information about current practice
 Adverse events‘We were invited to sit in the Quality Council because of our improvement efforts.’
 Monitoring performance (CL)‘Important to present numbers continually to maintain motivation.’
 Testing changes (CL)‘It's difficult to run an improvement project without measuring. Must know how the improvement work is going.’
 Statistical process control (CL)‘Inspiring to see that when changes are implemented, it shows in the results. We could not see this in the same way before.’
 Control charts (CL)‘The control charts were easy to communicate to the staff.’
 Balanced measurement‘Other important things are postponed or set aside. Should it be measured? What has lower priority must also be measured.’
 Follow-up measurement‘To establish continuous measurements to follow the process through the project period and into daily operations. It is important to register causes on why we did not reach the aim. Changes can then be started.’
 3. Benchmark systems and outcomes to others
 Benchmarking‘To view our own outpatient clinic in the light of other clinics will confirm our high quality. We have documents and facts to support this discovery.’
B. Success factor II: engagement
 4. Anchor the improvement work to the leadership at all stages
 Top down/bottom up (CL)‘The improvement work was anchored in the top management team and grew up from the bottom. We all agreed there was a need for changes.’
 Support and priority‘Management must support the improvement efforts, and at the same time give clear signals to slow down other activities.’
 Clearing the path‘Key professionals had not established an ownership, even if the management had. This fact inhibited the work and prevented development. Here the management had to show that they were in charge and clear the path.’
 System focus‘Balance between measuring, registering and not controlling. Communication is important to the balance against feeling too controlled. This is a delicate balance.’
 Sustainability‘Too little interest and effort from the top management to sustain the improvements. Must demonstrate special interests.’
 5. Focus on and engage the patient and family in all stages of the improvement work
 Patient-centred targets (CL)‘We based the efforts on patient centred targets, this made it easier to involve the staff.’
 Patient involvement‘The Breakthrough should give the patients’ perspective and patient involvement more space, making a system which would include patients in the improvement team.’
 Mesosystem cooperation‘Important with commitment and contact with cooperating partners in the care track.’
 6. Anchor the changes to the professional environment
 Dialogue‘Inhibited by lack of dialogue with the colleagues before, during and after change.’
 Influence (CL)‘Choosing the focus area ourselves was essential to the ownership, inspiration and improvement process. If the project we worked on had been decided by others, we would have failed and the resistance increased. We were balancing on a knife's edge.’
 Reputation (CL)‘We have earned a good reputation and better response from our cooperating partners in the care track (different treatment levels).’
 7. Engage the staff in all stages of the improvement work
 What’s in it for me? (CL)‘What’s in it for me—an important foundation for making people realise that the improvements are benefiting them, related to the busy daily schedule.’
 Autonomy‘The staff felt a need for improvements; it did not only come from external sources. Department involvement is important.’
 Ownership‘Closeness to the changes, measurements and the daily work is important. Established ownership; see that this is good for the patient and for my situation and the staff—then it is ok’
 Perseverance‘To implement improvements is painful. To reprioritise the use of resources, change ways to do things in daily work; some of this was difficult much of the time. This also varied from clinic to clinic.’
 Pride (CL)‘The focus on improvement and quality makes us proud.’
C. Success factor III: infrastructure
 8. Base the infrastructure on improvement knowledge
 System (CL)‘Knowledge of system and organisation is important.’
 Variation & measurement (CL)‘Knowledge about statistics and SPC (statistical process control)—recruit people with this competence in the future. This requires other professionals in the hospital environments.’
 Psychology (CL)‘Understanding that we are not Our Lord. We cannot rule over others.’
 Theory of knowledge (CL)‘Success was totally dependent on the structure, the continual improvement method.’
 9. Multidisciplinary improvement teams tailored to the topic
 Multidisciplinary (CL)‘The composition of the improvement team is extremely important, personal chemistry, complementary and many competencies.’
 Inclusion of a physician (CL)‘It is an advantage that the project has been connected to The Norwegian Medical Association and important to involve the physicians.’
 Interest in measurement‘One person in the improvement team was good at handling data’ (Measurements).
 Influence‘Helpful if the team has respect and impact on the ward.’
 Credibility‘It is inhibiting if the leader of the improvement team has low credibility in the professional environment.’
 Early adopters‘Enthusiasts are needed.’
 10. Develop a learning system tailored to the different target groups
 Everybody (CL)‘We learnt a method for thinking and working that can be helpful on several areas.’
 Leaders‘If no one pulls it along, no one retains it and the level above isn't interested, it will disappear.’
 Teamwork skills (CL)‘Important to have good cooperation in the team and among the employees at the site to secure the ownership.’
 Training and coaching (CL)‘Contact with an advisor, especially in the beginning. Very important to start in the right way, getting on to the right track immediately.’
 Mutual learning (CL)‘Demanding but useful to present in small groups at the conference. A good possibility to get feedback and discuss our own project.’
 Spread‘Afterwards we are encouraged to present the project on conferences and seminars and internal meetings.’
 11. Develop a system to facilitate the improvement work
 Time‘That there is time during a normal workday to work with improvements.’
 Availability‘Important that the supervision is easily available.’
 Access to software‘Without software for measurement it is difficult to run improvement projects. Following the development of the improvement work is essential.’
 Access to data‘It is a problem if health providers don’t receive the data they have recorded themselves.’
 Reliable data‘The data obtained were not always reliable.’
 12. Develop a follow-up system to secure sustainability
 Sustainability‘Follow-up system should be developed and used until the changes are sustainable.’
 Continual improvement‘Afterwards we were prepared to create another project using the same framework. We missed backing. We could have focused more on how to continue working with this method.’
  • * Comments mainly related to the collaborative learning system of Breakthrough Series Collaboratives are labelled with (CL).

  • The Quality Councils of the Norwegian hospitals are mandated by law to follow-up adverse events.

  • A mesosystem is a ‘collection’ of microsystems that contribute to the care of the patient as the patient ‘travels’ through the healthcare system on their ‘journey.’ The mesosystem may also include microsystems that do not provide care directly but support the direct care (such as radiology testing or nutrition).

  • CL, collaborative learning.