Leading Quality
Welcome to Leading Quality, the show that dives into the real-world stories and strategies of healthcare quality improvement leaders at all levels, from Frontline Champions to C-Suite Executives. Each episode uncovers how these dedicated professionals tackle complex topics in real healthcare environments. Discussion range from QI fundamentals, to leadership, technology, AI, and beyond. If you’re passionate about elevating patient care and want practical insights that go beyond the buzzwords, this podcast is for you. Tune in for inspirational conversations, innovative frameworks, and the behind-the-scenes details you won’t hear anywhere else, and discover how you, too, can lead quality improvement from wherever you stand in healthcare.
Leading Quality
The Architecture of Belief: Amar Shah on Improvement at NHS Scale
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Why This Episode Matters
Healthcare organizations often treat improvement as a set of projects, tools, or training programs. Amar Shah’s work at East London NHS Foundation Trust (ELFT) and NHS England points to something larger: the long-term work of building belief, capability, infrastructure, and leadership routines so improvement becomes part of how a health system thinks and operates. This conversation explores what it takes to move from local improvement activity to organization-wide and national-scale improvement strategy.
Key Ideas Explored
- Building belief as a core design challenge in improvement
- Moving from centralized QI support to distributed improvement capability
- Why storytelling is essential improvement infrastructure
- Co-design as both an ethical commitment and a driver of better results
- Scaling improvement from ELFT to NHS England’s national improvement work
Takeaways for Quality Leaders
- Treat belief in improvement as something you must deliberately build, not something you can mandate.
- Invest in stories that make improvement visible, credible, and emotionally meaningful.
- Build distributed coaching capability so improvement support lives closer to the work.
- Help boards learn improvement through better questions, better data, and better routines.
- Use co-design early and seriously, especially when tackling complex system problems.
Continue the Conversation with Dr. Amar Shah
Resources & Frameworks Referenced
- NHS IMPACT
- NHS Frailty improvement collaborative
- Kostal & Shah, Putting improvement in everyone’s hands
- IHI/ELFT, Fostering an Improvement Culture
- Shah, Applying improvement to the co-creation of quality
- Shah, How to move beyond quality improvement projects
Leading Quality is a podcast for healthcare leaders committed to improving systems, culture, and outcomes.
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New episodes published every other Thursday at 7AM Eastern Time.
Credits:
Host, Writer, and Executive Producer
Jason Meadows, MD
Produced by
Thrive Healthcare Improvement
Edited by
Milan Milosavljevic
Tools Versus Mindset
People can use all the tools in the book and still not be true improvers because their way of thinking about the world around them hasn't really changed. There's a technical element to quality improvement. There's a method, there's tools, there's disciplined ways of working through challenges and problems, but there's also a mindset. And I don't think it's sufficient to just apply the technical side. Welcome to Leading Quality, the podcast spotlighting the people moving healthcare forward from the front lines to the C suite. I'm your host, Jason Meadows. Professor Amar Shaw is the National Clinical Director for Improvement at NHS England, and previously spent 15 years at East London NHS Foundation Trust, or ELFT, where he helped lead one of the most important organizational improvement journeys in the NHS. He's a physician, a psychiatrist by background, and became England's first executive chief quality officer, bringing improvement expertise directly to the boardroom alongside clinical, operational, financial, and nursing leadership. He has also worked nationally through the Royal College of Psychiatrists, applying improvement at scale across complex mental health priorities. This episode focuses on what it actually takes to make continuous improvement part of how a healthcare organization works. We discuss quality as a management system, a mindset, and a way of solving the problems that matter most to patients, staff, and communities. A deeper question we explore is how belief in improvement is created and sustained. How do you move from a few motivated people in the center of the organization to hundreds of improvement coaches distributed across it? How do boards learn to ask different questions? How do stories, relationships, data, co-design, and rigor work together to change what people think is possible? What I enjoyed most in speaking with Amar was exploring the lessons learned at different levels of scale, from frontline teams and organizational transformation at Elft to national improvement strategy through NHS Impact. He understands both the technical discipline of improvement and the human work required to make it real. Professor
ELFT’s Burning Platform for Safety
Amar Shaw, welcome to the show. Lovely to be here. Thanks, Jason. Amar, you spent 15 years at East London NHS Foundation Trust, or ELFT, during a period when it became widely recognized as an exceptional example of continuous improvement in healthcare. Can you take us back to the beginning of that journey? What was the organization facing and how did the improvement work begin? So I it was 15 years in total, and I arrived at a time when the organization was really hit by a number of serious safety events and was really thinking about how it wanted to operate in the future. So there was a burning platform when I arrived to look at safety and quality and think about the best possible way to equip the organization to deliver care that people could really be proud of and met the standards that people would expect in our local communities. And we had the benefit of some independence, some autonomy to be able to take the organization in a slightly unusual direction. The application of quality improvement was still relatively new in England, in the NHS, and certainly new in the field of mental health, primary care, community health, which was where most of our work was. And actually, it took a bit of a leap uh to really get the organization committed to that. It took a couple of years of um preparatory work, uh trying to help the board really think about what it would mean to become an organization that was committed to continuous quality improvement and also to engage and excite our workforce, which was about three and a half thousand people at that time. And then once we began the journey, uh we recognized very quickly that we wouldn't be able to do that by ourselves. We had very limited skill or expertise in quality improvement. So we partnered with the Institute for Healthcare Improvement, which was again an amazing opportunity and really brought world-leading thinkers and advisors to help us on this journey. And to be honest, you know, we've taken it step by step. I don't think we had a perfect plan at the beginning. We knew that there was energy and willingness to try to apply continuous improvement and learn our way into it. We had some help and support from trusted partners at the IHI. And we very gradually worked our way into it and started to learn as we went. And it's been a it was a fascinating learning experience for me and for lots of people, I guess. And we were really privileged to be able to have the opportunity to lead and to influence the way the organization was being run and managed. And over time we were, you know, we went from small scale work to being able to apply improvement at much greater scale to tackle the big priorities of the organization and build a more holistic management system within which improvement was just a part. Obviously, 15 years is you know quite some time to invest in one organization. Um, but the hope is that we've created belief, we've created enough capability, we've created an infrastructure that will enable it to sustain that journey beyond one person. So we always knew at the beginning that it would take a while. It would take, we, we, we had the sort of milestone of 10 years in our minds, me, me and the chief medical officer at the time, Dr. Kevin Cleary. The two of us knew it would take about 10 years to really embed something like this into the fabric of the organization and the way that people just approach problem solving at work. Um, and you know, we've given it more than 10 years, and and I hope that the organization sustains and continues to learn and progress in the field. Yeah, I mean, what a what a journey it must have been. And sounds like it was a really important choice then to partner with the IHI. I'm
From Central Team to 200 Coaches
curious as you've gone on. I understood you started with kind of a more centralized improvement model, and then it became more distributed. I wonder if you can tell me about what that looked like at the beginning, how it evolved and why. Well, at the beginning, we had no infrastructure or expertise at all. Uh, and we began with a temporary structure of two people in a central role who were there sort of in a second, so for a limited period of time, just to test this out. And we grew that from two people to five people in year two. Um, and as the momentum and energy and the willingness to apply quality improvement took hold, uh, we realized very rapidly that the demand and the growth of activity could never really be supported meaningfully from a team in the center of the organization. So we in year two talked with the IHI and started to build a more distributed model of capability. And we started to, we created the improvement coaching program at that stage, which is now delivered by the IHI around the world. But the very first one was co-designed with the IHI in in East London. And that's the birth of you know, skilling up clinicians, managers, administrative staff with uh deep skills needed to support other teams to apply quality improvement in a robust way. And from that first cohort in 2016, we now have you know over 200 improvement coaches. They have full-time jobs that they they're released for a couple of hours a week to take on this role alongside their substantive role. Um, but it is it is an important infrastructure now because each part of the organization, which operate as sort of autonomous business units, they recruit their own pipeline of improvement coaches. When their projects are approved to proceed, they support through allocating an improvement coach. So it's sort of a self-sustaining cycle of demand being met by that capacity of improvement coaching. Um and most projects are now supported by an improvement coaching. That central team still exists, but it hasn't really grown in the last six or seven years. But that central team has built its expertise to be able to design large-scale programs which are sort of meeting strategic goals for the organization, to deliver capability building across the organization, to provide sort of strategic advice and coaching for our clinical and operational leaders across the organization. That's their primary function in the central team. And so if I'm understanding it, first of all, I can imagine these, you know, two people, and then in second year there was five people. It seems like a really daunting task to have to figure out improvement at any scale with, I think you said 3,000 or so employees within the trust. Does the does the central team's role then shift to uh essentially train the trainers or or you know, minting new coaches when when there's a need to increase the number of coaches? I mean, you're right. It was daunting in a way, but also very exciting. Uh and we we had to work very closely with the executive team. One of the absolute joys was the trust that the executive team placed in us to be able to lead and guide the journey with them. Um and, you know, we made a lot of mistakes along the way, but we also were able to see the benefits of equipping our clinical teams with this set of skills and letting them loose to solve things that they really cared about with their patients and service users. And those stories of impact were what kept us going, and I think what gave us the growing belief that this was absolutely the right decision to make, and we needed to keep going and actually strengthen our approach to it. Over time, obviously, that central team um, you know, we started to build a sort of more sort of clear structure within that central team of people who were deeply skilled improvers, but we needed more than that. We needed data analysis, we needed project management, we needed events and communications expertise. So we started to grow a range of different skills in that central function, reporting all the way through to the board. And actually, you know, my role on the board came about through really starting to demonstrate the benefit of this at strategic level and recognizing that for us to really um harness improvement in a strategic way, we needed that expertise at the board too. So, my role of chief quality officer was the first such role in England. So it's it's a little bit different to the CQR role in other parts of the world, in that it was an executive role at peer level with the chief medical officer, chief finance officer, chief nurse, etc. And I think that was an important step again in 2016 for the organization to make that they recognize the value that this different set of skills would bring in the executive and board around sort of organizational learning, around applying systematic approaches to change. Um and again, it was another step in towards deepening the organization's commitment to this improvement journey. Uh,
Why Improvement Belongs in the Boardroom
since you mentioned that, I'm curious what some of the, you know, if you can go a little deeper with with that, why was it so important to be at that executive level? Um, because I know that this is, I think this varies uh within North America where a CQO lies in the org chart. And it sounds like that was uh really important, maybe symbolically, but also in in some really practical ways. I'm I'm curious what um what that was like. It's a tricky question to answer because I, you know, I wasn't privy to all of the conversations about you know the need for this role. Obviously, I was able to apply for it once the organization had chosen to create this role. But I think it it stemmed from uh a belief that this was going to become core to the way the organization functioned. And a growing um awareness and knowledge within the board that clinical skills were really important, but there's a another set of skills around how to tackle complex problems, how to learn effectively, you know, applying systems thinking, using data in really intelligent ways. Those sets of skills, which is what improvement brings, are not necessarily inherent in your most senior clinicians. And actually, there was a uh a realization that it would really advance the thinking and the work of the board to have that set of skills within the board itself. And I think that's um I think that comes from starting to practice uh what you preach as a board, you know, starting to look at data in a different way, starting to ask questions differently, starting to change the board agendas so that quality features more prominently and you're actually bringing real examples of where complex problems are being solved to the board directly. I think that starts to help the board see that there is a new set of competencies required to function really effectively as a continuously improving organization that isn't necessarily going to be filled by the existing sort of standard set of executive roles you might have. So I think it's for for Elft, it was um again a I think a recognition of the belief that had been sort of built over many years through the work of lots of people to demonstrate that this really made a difference. And then a commitment to this at the most senior levels from the the chief executive and the chair of the board, that it was so critical that it merited a voice and would actually help um shape the conversation and the direction of the organization through having a role that specifically brought that set of skills at the executive and board. Yeah, I mean, thinking about it, you know, looking back what 10 or 15 years might have looked like for any of us working in healthcare, that sounds prescient that that they would have that kind of foresight and that kind of motivation. It's really that's exciting. It must have been a great time to do this work. I'm curious, as you went through that that 15-year period as the the chief quality officer, what was some of the work that you're most proud of? I think the most proud moments have been when I've been able to witness or experience people really starting to recognize and appreciate a new way of looking at the world around them. That for me uh brings a joy that's very difficult to dull over time. Um, when you start to see even seasoned, experienced clinicians and leaders, um, as they come into the organization, they start to see the way this organization works and the way people think and the way they interact. And it really does feel different, I think, uh coming into an organization that's committed to continuous improvement. And then they give it a go. They they have the sort of humility to try it, to learn it, and to apply it in their work, and then people start to realize the opportunities that opens up, the creativity, um, the way in which just addressing the power imbalance and giving people autonomy to make changes, the way that that can actually help and actually uh allow us to see solutions that we wouldn't have seen before. That um insight, that sort of uh new sort of opportunities is what I think has been some of the most proud moments that I've seen. There's a there's countless stories of complex challenges that uh we've been able to make headway on, which we would have really struggled on before, from waiting times to patient experience to safety issues like inpatient physical violence, you know, really big complex topics that, you know, with the best will in the world, the executive team wouldn't have been able to solve. Um, you know, but devolving, involving people, being creative, allowing people permission to try new things. So that's given us um a way through uh really deeply understanding those systemic issues and starting to address them in uh creative, innovative ways that have really reaped dividends. So I think that's that's been um you know wonderful to see the the results and the impact of this for people, you know, making care safer, reducing weights for people who really need care. Um and you know, being able to see you know the impact on the people that I personally have mentored in in coming into the improvement function over 15 years. It it's it was a bit of a um a leap of faith at the beginning that there was this new thing and you know who might want to be part of it uh to becoming a much more established career pathway for people. Uh, again, not necessarily a pathway that existed professionally in England to a great extent. Uh, but I do think that the work at Elft has influenced many other organizations uh in England and hopefully beyond to start to standardize um improvement as a professionalism, that people can actually start to deepen their skills and experience and progress through roles uh all the way up to the executive and board level, which I'm not sure I recognize as an option for me when I first began dabbling in improvement 15 years ago, trying to learn my way into it. So lots of things to be proud of, um, but mostly related to people. Uh, this work is all about people and uh relationships and working together, and those would be the moments that I'm most proud of.
Invite: Share What You’re Seeing
I wanted to pause for a moment to invite you into something I'm starting with this podcast. If something from this episode connected with your own experience, where you've seen it work or not work, I'd love to hear about it. There's a short link in the show notes where you can share what you're seeing in your own work. It takes about a minute. I read every response, and over time I'll be sharing what we're learning together in future episodes and in other ways, and giving shout-outs during future episodes to people in the community who share ideas that really move the conversation forward. If you're up for it, I'd really value your perspective. Thanks.
Designing Belief Through Stories
One of the most interesting ideas I encountered while preparing for this conversation is that belief itself seems to become a design target. Not just persuading people to improve, but designing a system that either builds or erodes belief in improvement. Does that align with how you think about it? Well, belief is a word we use quite a lot in the world of quality improvement. When we when we're coming up with a hunch or a theory or an idea we want to test and we try it out in the real world, uh, you know, we we are really trying to build our degree of belief that it works in this given setting and we're able to predict the effect it might have. Um and I think when we are trying to create a culture where people are able to apply more systematic ways of tackling complex problems through the work of quality improvement, I think belief is critical. I for me, this is there's a technical element to quality improvement, there's a method, there's tools, there's disciplined ways of working through challenges and problems, but there's also a mindset, and and I don't think it's sufficient to just apply the technical side. People can use all the tools in the book and still not be true improvers in because their way of thinking about the world around them hasn't really uh changed. Um and so to really adopt um a mindset and to make it part of your way of being requires belief. Uh and obviously that is not something that's easy to measure, it's it's much more subjective. So whilst we we can talk about trying to create belief and will, um you know, Tom Nolan described that original triad of will, ideas, and execution. I think my use of the word belief is not dissimilar to what he would have described as the will to change. But belief, I think, gets to something that's uh more than just a willingness, it's it's it's about uh a recognition that uh and a commitment and a courage that this is the right thing to do, and it's uh it's a more appropriate way to see the world and to grapple with it than the state than the previous ways of of uh tackling change. We have to look at variation, you know, when we're when we're thinking about an organization's maturity around continuous improvement, there's always going to be variation, um, and we need to find ways to have some more objective ways of assessing belief. And that's not an easy thing to do, but it comes through conversation and observation. Uh, you know, how how much do I uh lean on this approach when I'm when a challenge hits me? Do I is my default gonna be to sort of think in more systemic ways? Am I gonna naturally revert to involving a range of people so I get diverse perspectives on the problem? Um, am I am I able to hold attention and not jump into solutions, but actually really try to understand the problem first and build theories? You know, though those are those are, I think, hallmarks of belief in this way of thinking. Um and you know, that. To really be able to assess that, you have to have strong open trusting relationships with people, which is why you know part of my role over 10 or 15 years in Elft and now in a national role has to be to build those open trusting relationships with key stakeholders so that we can have open dialogue where people feel it's safe enough to say I'm not completely convinced, or maybe this isn't the right time to do this, or maybe I don't really feel quite confident enough to apply this approach, you know, as well as being able to coach and guide someone when they are ready, when they're committed and they want to apply this approach. And that's what that sort of central team of improvers, deeply skilled improvers, needs to do with an organization is build those relationships across the whole organization with the sort of senior stakeholders, the clinical leaders, the operational leaders, to be able to coach, advise, guide, and really help them think about their way of applying this to the things that are most pressing on their minds. Now, obviously, taking a quality improvement approach is not always the right thing to do. It's a particular approach that has real merit for particular kinds of challenges. But you know, any leader will tell you they face a hundred challenges at any time, and we can't apply quality improvement to every single one of them, but we can apply some of these principles of the of thinking uh to the world around us. And I think, you know, in the complex world that is healthcare, I think it's it's um you once you start learning about these ways of seeing the world around you and making sense of problems, it's it's hard to challenge that this isn't a helpful way to understand complexity. Uh, it feels very natural to apply these sort of disciplines to complexity of the systems that we all work in every day. You mentioned building the trusting relationships, having trusting conversations as part of the way to build belief in the system and in our capacity to improve. In the time that you were chief quality officer, what did you and your team, what what else did you and your team learn that genuinely changes people's belief in improvement? What are some concrete things that genuinely change people's belief? I think one thing we learned pretty quickly was you can't tell people to do this. Uh you have to create the conditions and the environment in which people feel compelled to move towards this because it's attractive. And um, so uh my role, our role as improvers isn't necessarily as you go around trying to convince everybody about quality improvement. Actually, we need to spend probably more of our time capturing and harnessing the learning that's coming from actual improvement work, being able to curate it, being able to package it, and being able to help people tell those stories. I think the single most powerful vehicle to build belief is stories and storytelling. And actually, you know, we spent maybe a quarter of our time in the central team focused on storytelling. And that might seem like a lot of time. You know, surely you're better off putting that time into actual supporting actual improvement work and getting results. But the results are dependent on people wanting to do the work and having the will and belief to adopt this way of thinking and working. And we are missing a lot of learning if we're not capturing it and sharing it. So actually, capturing and telling stories is absolutely integral to the work of improvement. And you know, we you can do that in lots and lots of different ways. Uh, you know, we could we we've found very creative ways to do this uh and to sort of help people see that quality improvement might at first approach seem like something very technical, very data heavy, and maybe some people might feel scared by that. But actually, we what we worked really hard to make it look and feel different and exciting and interesting and creative from things like you know, creating murals on the wall about to help dispel some myths about what quality improvement is and to make it just part of the environment that people worked in, to actually, you know, almost you know, creating a rap. We we worked with our patients and our staff to actually try to embody what quality improvement meant to them through the form of music and rap, and actually created a rap. And actually, you know, those slightly different ways of describing quality improvement, I think helps us attract and engage a wide audience of people who have different strengths and assets. Um, and I think that's fundamental uh to creating belief. So I think you know, finding ways to keep the language simple and not overly technify the language and use jargon, but really keep it simple. And I think you have to be pretty skilled, I think, in improvement to be able to explain it simply. Uh I think that the more skilled and experienced you are, the easier it is, I think, to make the principles much more prominent and take away some of the language and jargon that sometimes makes it difficult and inaccessible for people. So we try and teach it in simple ways. We try to attract people to it through using really creative forms of engagement and helping people understand what we mean by quality improvement, tell stories in a range of ways from social media posts to videos to stories and presentations, but we also try to make sure it feels valid and credible. It's not no good to share work that people feel is inauthentic. We want to make sure that the results and impact stand up to scrutiny. So having the discipline around the way we present data, you know, being able to uh put work through the peer review process for publication, uh, so that you know we can demonstrate that it meets academic standards of quality in terms of what we're doing. All of those things I think matter. And obviously, people are influenced by different aspects of this work. But I think you know, if we're really going to build belief, we've got to think about a range of ways to connect with what really matters to people about um the work that they come to do every day and why this might offer them something worth pursuing, trying out and experimenting with. Yeah, a quarter of your time spent figuring out how to tell the story. Honestly, it sounds like time really well spent, but not where my intuition would have led me. And that's really that's really great. I um, you know, I'm also glad that you were kind of touching on the idea of rigor there, right? Making something publication ready, submitting it to peer review, because I it highlights kind of a uh something that occurred to me as a tension in this work. Um,
Making PDSA Work in Real Life
on the one hand, you have, you know, this important focus on rigor. And at the same time, we want to make the improvement work feasible for people in a busy healthcare system. How do you think about balancing that rigor with making it possible for people in their busy days to meaningfully engage in this work? That's a really interesting question, Jason. I I guess my um experience has been that quality improvement is not technically that difficult. Applying the discipline and the rigor is not difficult for people who are used to pretty complex environments, um, who are often extremely skilled professionals and are able to do far more complex things in their clinical work, their administrative work. Um I I think it it's just about being disciplined, I think, um, about the way in which we approach change at work. And I I think part of this comes through you know, really making sure that people have a great experience of learning the method and applying it in practice with close skilled support, just an arm's length away, uh, really helping guide them step by step. I think if people have a really good experience, the first time they come into contact with quality improvement, learning what it means, that it's presented to them in simple language, that it's applied and it's not theoretical, but it's really always applied because this is an applied science, and that they have the opportunity to practice, uh, they take it to something they care about, work as a team on something they really want to get better at, and they have really close skilled support. I think those are the core ingredients that mean that people then don't find it so tricky to, you know, when they hit upon a problem, think, well, you know, let's form a team, let's understand this first, let's make get diverse perspectives, let's bring in the odd tool like a cause and effect diagram or a you know a Pareto chart or you know, something or flow chart that helps us understand the system first. Now we're ready to sort of set an aim and build our theory. Let's let's get a piece of paper or a whiteboard and draw a driver diagram. I think the most difficult bits are sticking to the rigor of PDSA cycles. I think around the world, people describe PDSA cycles, but the core tenets of it are still, I think, less frequently described by people than I would love to see. And again, it's not difficult. It's it's stuff that we practiced and learned when we were 11 or 12 years old in chemistry class. You know, there's a very simple approach of, well, let's start with a hypothesis and then let's plan an experiment to test that hypothesis and then let's stop and pause and see what happened using data to just match whether our prediction how true. That's it. The discipline is no more difficult than that. And yet, sort of really sticking to that in our busy clinical environment is tough. It's much easier to just do stuff, think we know the answer, and just put it in place and then hope it works. Um, but that the the the rigor of um quality improvement really is about the rigor of stopping and pausing and reflecting, and taking that little bit of time to think before you introduce a change. You know, what's our theory, what's our prediction, who's going to do what and when and how, and when are we gonna stop and reflect on how it went, and then actually running it and then pausing again. That's the rigor, the the little pauses of reflection that allow you to plan properly and then reflect on how it went. And I think having improvement coaching, having leaders who are actively sponsoring this effort and encourage you to take those reflective pauses and the irregularity with which the improvement coach comes in just helps you create those sort of routines. And those improvement routines, I think, are critical to make the discipline and the rigor come to fruition. Now it's still difficult. Uh, I'm not saying this is easy to do in a busy environment where often we're working shift patterns and it's hard to have the same people meeting two times in a row about the same improvement endeavor. But creating rituals around this, building it into your daily or weekly routines, that for me has to be the way in which we can make sure the rigor and the discipline of improvement as a method allows us to learn as rapidly as we need to. And you've also talked about rigor and teaching improvement methods, uh, creating improvement literacy at the board level.
Helping Boards Learn Without “Teaching”
Um how important is this? And do you think there's a lot of healthcare systems that are that are missing this piece? Well, the board the board needs some uh uh understanding of this. Um would I ever suppose that the board needs to be taught this? No, I don't think so. I think the best approach is to do it by stealth. Uh if the board thinks it's going to be taught something, it's almost inevitably gonna uh come into the room um in a in with an attitude that is not gonna be constructive. But I think if you work closely with the chair of the board and the and the chief executive, you can find ways to help the board learn their way into this new way of being. I mean, if the organization is gonna apply this to the way it works, then data is gonna come to the board in a different way. Now, for me, every time we had a new non-executive on our board, I would meet with them one-on-one. I would show them our performance report that I brought to the board each time, and I would show them the data and we would talk about it. Now, they may never have seen control charts before, but do they need to be taught control charts? No, they're not. These are highly intelligent people. They can read a control chart if I'm presenting it well, if it's visually presented well, it's got annotation and it's got some commentary. A lay person should be able to make sense of it and know where to pay attention and where not to pay attention. But making sure everybody feels when they join the board that they have an opportunity to sort of ask some questions, you know, that and I've had some wonderful questions asked by our non-executives. You know, why is it you use those dotted lines as control limits? You know, do you decide those? Or does the calculator decide those? And how do you set them? And you know, why are certain dots different colours? And when do you choose to change the average line? And I think those are what that tells me people are curious, they're they're wanting to understand why data is presented the way it is so that they can respond and react and ask better questions and give better assurance to the organization as a board. So I think teaching, no, but there's definitely important roles to play in sort of helping board members understand you know their particular role in this, because they do have a really important role in the boardroom when it comes to you know seeding improvement efforts, asking good questions, uh, interpreting the data well, those are sort of core skills. But actually, more importantly, is the sort of work outside the boardroom, you know, really considering how do we role model the behaviors that are going to reinforce this as really important for the future of the organization. And that means simple things like, you know, when we go on leadership walk-rounds, making sure that we ask about improvement. You know, what are you working as an as a team to improve? Tell us about it. I'm curious, I'd like to learn. Um, you know, what what are the things that are getting in the way for you? What are those little pebbles in the shoe that you know you really would wish us to help you unblock? Those those small nudges over a long period of time help reinforce to people that this is valued, this is important, this is an approach that uh we really care about. And the board needs to learn its way into that. And obviously, the turnover on boards means that you know you it's never static. There's always new people with different experience from different industries, um, coming with their own well-tried and tested approaches to leadership. And it takes time and you're never going to have the perfect set of circumstances. You're gonna have to work with what you have. And part of having a role in the board that is seen as expert in this is that you know, you have the opportunity to build those relationships and help people uh see the benefit of this way of leading. Now it's not the only way of leading, but um, it I think has been shown to have merit. And we want to help people recognize that when they want to come and work in an organization like this, even if it's at board level, that the organization has committed to this. This is the way the organization functions, and we all need to learn um how to how to lead in this in this way.
Scaling Improvement Across NHS England
And so we've gotten to this point in the conversation, and I haven't yet mentioned that uh in the last few years now, I think, uh two to two to three years, I think you you've become the national uh clinical director for improvement for NHS England. So a large step up in scale from the work at ELFT. And I'm curious how that transition has been in terms of the things, the lessons that you learned from ELFT, what translated well, and what new learning had to happen uh when you stepped into that role. Well, I think the first thing to say, Jason, is that uh every job I've done in the last 15 years has not existed before. So it's been an interesting journey of sort of creating opportunities or systems recognizing that they needed something and then stepping into it and learning about how to do that role effectively when there was no historical uh no performance to judge myself against. And then so that's both an interesting opportunity, but means that you have to sort of learn quite quickly and adapt and think about how to be most effective in that role. Now, obviously, I had the ELFT role for many, many years, but actually for the last seven or eight years, I was working nationally through the Royal College of Psychiatrists in a national role in the field of mental health, sort of applying improvement at a larger scale to complex topics in mental health. And that gave me an opportunity to sort of start to understand and learn how to work across a much bigger scale on you know, running big improvement collaboratives on topics like workforce well-being, mental health equity. Now, you know, the last three years has been on, I think, one of the biggest improvement programs in the world with 58 organizations, 200 wards, all working together on improving culture of care on inpatient mental health settings. So that I think led to me sort of considering going for this national clinical director role for improvement in in England, which is an interesting role because most national clinical directors have a particular specialism, whether it's orthopedics or cardiology or you know, elderly care, whereas this is a specialism which cuts across everything. And so it could very easily become awe-consuming. And actually, what what we really had to do was think very carefully about a small number of things that we think would have greatest impact to support the the largest publicly funded health system in the world, the England's NHS, to be able to strengthen its approach to continuous improvement. And I know I had the benefit of coming into this role at the same time as you know the NHS Impact framework had been co-designed. So there'd been a period of work before that to sort of create the foundations, recognize that there was a real appetite and opportunity to take improvement to the next level, and that the NHS Impact Framework had been co-designed. And then I was able to sort of step into this role to lead that work over the last three years. And what we've been able to do is work at multiple levels of the system. You know, we have maybe 350 different single organizations like ELFT. ELFT was one, but there are 350 others, all of whom are on this journey somewhere. So how do we really help and enable single organizations to keep maturing and strengthening their continuous improvement approach? Plus, now we we have an architecture in in England which is based around systems, multiple organizations all working together in a particular geographical area. How do we equip systems to tackle systemic issues, bringing multiple organizations together and applying improvement to it through what are our integrated care boards? And now a level up from that is regions, seven, the seven regions of England, which cover big geographies. How do we now equip regions to be able to convene and coordinate improvement work at a regional level? And then a small number of things that we can actually do nationally. Like we have a frailty improvement collaborative right now where we're starting to test and discover new ways to prevent inpatient care for our most frail population in the community. So I think, you know, adopting some of the same things and building improvement capability. We've got two big capability building offers at the moment, uh, one around clinical and operational leaders, helping them learn improvement, how to lead thriving teams and how to manage operational pathways, aiming to reach 20,000 people over 18 months with that um offer, and a board development offer, recognizing that board belief and executive level belief is the most important factor for long-term sustainability. So that program, that three year program, is just about to start its co-design phase. So we've got two really big capability building offers. We've got we've started to feel focused quite a lot of time on networks, really making sure that across England we are learning from each other as effectively as possible. Um there is amazing work happening everywhere. We're just often not aware of it. So a lot of our time has been spent on building and strengthening networks so people can connect with each other, learn from each other, and see examples of great work. And then some results oriented work, both in regions. Um, every region now hosts three learning and improvement networks on our three biggest issues in the NHS so urgent and emergency care, elective outpatient care, and mental health pathway, and starting to do a small number of things nationally as sort of large scale improvement programs. So So it's been a journey of sort of trying to influence, build commitment and engagement, and create a movement with a very limited amount of resource, Jason. I mean, I probably had more resource in Elft than I do in the national role. That seems crazy, but actually it does force you to think about what we can do with very limited resource that's going to enable us to learn better and to increase the rigor and belief of improvement across the country. Two and a half years in this role is a is just a drop in the ocean. This is a long-term journey. There'll be many people before me who've contributed and strengthened the work, and there'll be people long after I'm gone who are still continuing this work. But I think it is a great signal that England has at least committed in the way it has to continuous quality improvement and has really made efforts to try and strengthen its approach to this over the last few years. Yeah, and the the the scale and the effort behind that is, I think it certainly gets noticed. It's it's a big, you know, your presentations are always, you know, very popular at at the IGI conference and elsewhere. And I think um, you know, I from a lot of colleagues uh over in England, I hear a lot of really good things about kind of how you're deeply embracing improvement work uh at the national level. So that's that's really exciting. I'm curious just for our listeners. Yeah, I hope that's partly because of the content, but also because they're fun sessions to be in. They're pretty fun. I I yeah I'm just taking you know a step back, making sure that we're uh uh sharing adequately and defining adequately for the audience. You
What the NHS Impact Framework Is
mentioned NHS impact. I'm curious if you can kind of just walk us through what exactly that is. It's um a co-designed universal approach to improvement. It's it's not designed to replace or to propose a particular method, but it is um designed to help organizations understand the five core components required to really adopt and strengthen an organizational approach to continuous improvement. Um and uh the co-design approach was really important to this. Several hundred people contributed to sort of thinking about what should be part of England's improvement approach. And actually, NHS Impact I think has had more uh positive reaction from people because it doesn't try to force people down a particular route, but it's quite broad. And it's also not just about um quality improvement, the technical side of the improvement method, it's it focuses on you know making sure organizations have very clear purpose and shared vision. You know, really thinking about how we develop people and culture in our organizations, thinking about how we build improvement capability, uh thinking about you know how improvement sits within management systems and not just in isolation. And I think the elements of NHS Impact are designed to be pretty self-explanatory, easy to understand, easy to think about in relation to your own organization. And actually what what I've really try to encourage is that organizations need to take their own path. There is no one path, that's my belief, anyway. Everyone has their own uh slightly winding road to take uh that's going to be particularly suited to their context, uh, their culture, the people in the organization, the environment they're working in, the patients they're serving. You know, we each need to decide how we want to go about improvement. But there are some core elements that all organizations need to consider. And I think the NHS Impact framework is quite a nice way to articulate those. And you know, we began with a self-assessment asking every organization in the country to just think about their own strengths and maturity in relation to those five components of NHS Impact. And then we've tried to make sure that people use it if they find it helpful, but if they don't find it helpful, I'm equally happy for them to adopt improvement in the way that they see fit. The bottom line is you know, there is a growing and uh evidence base that applying quality improvement in rigorous, disciplined ways, not just at the point of care, but at whole organization level, helps improve performance and improves the bottom line. And uh, you know, we need to learn how to do that in um in a in a way that sustains over time. And that's what I'm hoping um people will take away from NHS Impact and apply in their own setting in a way that they think suits the organization of people best. Yeah, and I I heard also in there you talk about the co-design, the importance of that, and how how that influenced buy-in.
Co-Design Evidence That Shifts Results
It sounds like that's another lever or another tool in your toolkit for enhancing belief. Is that right? I think co-design uh is integral to good improvement. Um the the only empirical evidence that I know of in that in this field comes from our work at ELFT. Correct me if I'm I'm missing something, but you know, I don't know of any other evidence that demonstrates this uh yet. But when we looked at our first 500 pieces of improvement work and analyzed them to see, you know, what difference did it make when improvement work was co-designed versus had some occasional involvement of patients or had no involvement, the results were startling for us. You know, co-designed improvement was 2.8 times more likely to achieve its same odds ratio of 2.8. If you had some involvement or true co-design, you were almost four times more likely to um see results than if you had no involvement at all. Um and I think the same goes for organizational approaches or programs that you run. It's not just about projects. I mean, that evidence is about project activity, but I think in any kind of improvement endeavor, you know, one of the principles is that you can't understand a complex system without truly involving a diverse set of perspectives. And so how could we possibly design an organizational approach without involving a range of diverse views? How could we design a large-scale improvement program without involving a diverse set of views? I mean, co-design, uh, true co-design, where you share power and have a range of people involved from outset through to the end, including people with lived experience, uh, is shown to be more effective. It's not just the right thing to do, but it's been shown to help the effectiveness of this work. And I think the stories I've personally seen of people who've been involved, uh, people with lived experience who've been involved in improvement, are truly um truly life-changing. You know, people have been able to build a set of skills, create some confidence, uh, take on part-time roles, get back into recovery and back into society. And uh, you know, it's the right thing to do because we want to involve their perspective and make sure their voices are heard. But actually, it makes such a difference for our work and for the people who are involved. So, yeah, I'm a big advocate, Jason, of co-designers. Still, I still I think it's still an unexplored area uh in lots of improvement work around the world. And I perhaps think I might be biased here, but I think the world of mental health, of behavioral health psychiatry, perhaps is further ahead in terms of really learning how to co-design meaningfully with patients and service users and other parts of the healthcare system. Yeah, that's great. And if you can actually send me the um the uh the publication you cited there with the uh the 2.8 and and I think 4x odds ratio, um happy to link to that in the show notes as well. Um, because I think that's that's a big part of what moves the needle, right? It's great to say that we include co-design. It's great to have leaders talking about the importance felt in doing co-design, but it's um, you know, there's a lot of value in those numbers too. So thanks for sharing that. Speaking
How AI Speeds Up Quality Improvement
of entertaining sessions you've given at the IHI, I know that that uh one of the topics of late for everyone, yourself included, has been what impact AI is going to have on our lives, and and in particular for this conversation on our healthcare lives. It's not central necessarily to our our conversation today. Um, but I know that that it's it's important and it's it's on, you know, I'm sure your landscape. I'm I'm curious kind of what in this this newer national role, how do you see the impact of AI in the next couple of years in in the NHS in England? I mean, AI is impacting on every part of our lives, isn't it? And it's only natural that it's gonna influence the world of work. I think perhaps as we've seen with other kinds of technology, it's probably gonna impact work slower than it impacts on our personal lives. It's there's probably some particular use cases in the clinical world where AI and the use of generative AI in particular is further ahead. Thinking about the use of technology to pick up changes on scans, for example, or ambient voice technology. I think there are particular use cases where we're likely to see greater adoption. I think it's going to have an impact on the world of quality as well. It'll probably be slower because I'm not sure there's a stronger business case for vendors and suppliers to build really good tools for us to use. But even with the basic tools at our disposal, uh they it ought to be influencing the way all of us approach quality improvement. Now, we need to, as individual practitioners, we need to learn and get better at using this tool. I now use it almost every day, and I probably didn't use it every day a year ago. Uh so each of us needs to start learning and experimenting and figure out how we can best use it. But these days, you know, it takes very little time for anybody to use a generative AI engine to sort of search the evidence base on a topic that they want to work on. You know, maybe in the past we had to go uh through literature searches uh to uh an online library and have skill in literature searching to be able to really harness the evidence base. I think these days generative II has put that into the pocket of everybody. Um, you know, creating a measurement plan for a project, you know, people struggle with measurement plans. If you just ask GPT to create a measurement plan um and gave it your aim statement, it would do a pretty good job for you. So I think there are particular things where in the world of quality improvement, generative AI can just speed things up, can give you a head start. It's never going to give you the perfect answer, but it'll give you a pretty good theory about how to solve a problem. It'll give you a pretty good measurement plan. It'll even now start to create some visuals for you. It can create some charts, it can, if you give it some data, it'll do a lot of that technical stuff, which often we struggle with. So I think um it'll it'll speed up, if anything, those bits of QI work where either we don't have the time or the effort or the skill to do it really well, like really harnessing the research literature at the start of a piece of work, or those technical things in Excel where we don't know how to make a Pareto chart or we're not quite sure how to make an SPC chart. I think it'll speed up those elements and just give us more time to actually focus on changing the system, which I think will be a great thing. And you know, there's eventually we'll be able to harness, you know, the large amount of information we have in our organizations in much better ways. Uh, if we put an AI engine onto our data warehouse, we'll be able to start querying and asking questions in a better way. If we look at our incident repository, uh, we'll be able to learn much better than we currently do. Um, those things are coming. I don't know many places in the world that either have the purchasing power or the coding capability to do that themselves yet, but I think those things will come in the next few years. Yeah, absolutely. And you can see, as you're kind of alluding to there, the the pathway for your average frontline clinician to adequate levels of rigor in in quality improvement being being a little easier if you can kind of supplement your you know your weaker areas with with a nudge, you know, uh a little bit up in in uh you know, whether it's statistical process control or creating a measurement plan or something like that. Yeah, certainly interesting times. There's there's far too much to you know to cover adequately in one conversation. I always find I I bite off a little more than than I can chew. But uh I'm really you know I'm excited about it. I'll happily come back for an episode two at some point in the future, Jason. Yeah. Well, I mean, i inevitably that's that's that's where it leads. If you're if you're willing to come back, I'd love to have you.
A Five-Year Vision for System Change
Um and you know, you've described this as a marathon uh of sorts, you know, five years, ten years, uh, and longer. But I am wondering, you know, at least on the foreseeable time horizon, on a let's say a five-year time horizon, what how does NHS England look different if the work you're doing now reaches its highest aspirations? There are so many prerequisites that are going to influence the answer to that, Jason. Um, the NHS is highly political with a small P and with a big P, I guess it's the number one voter concern when it comes to general elections. Um and that means makes it very difficult, I think, to um create long-term effort and ambition around a singular focus like this in the way that organizations have much more autonomy to do. The NHS is a sector, an industry sector rather than an organization. Actually, moving an entire industry sector in this direction is is difficult. But nevertheless, in five years, what I would expect to see is um more examples of single organizations truly adopting quality as its central and organizing focus with much more advanced and rigorous use of improvement methods to deliver results for its local population. I think we have wonderful examples of that across the country at the moment, but in five years, I'd expect to see two or three times that number. Um, I think what what I'd also hope to see is a much better application of improvement across organizational boundaries. For us, that's the next frontier. It's uh relatively straightforward to know what to do in a single organization. It's much less clear how to do this when you are solving a problem that involves health, social care, education, housing, charities, and the voluntary sector all working together and applying an improvement method. That is exponentially more complex. And I think then in five years' time, what I'd really hope to see is rigorous application of improvement, getting results on really challenging systemic issues that can only be solved by partners like that group working together using improvement. And I think in five years we can probably get to a place where we have excellent examples of that happening in parts of England. Yeah, I mean it's an inspirational vision. Uh, I'm I'm so excited to have you uh at the helmet of this work and also joining me today.
Where to Follow Amar and Closing
You know, I just want to thank you so much for this conversation today. For listeners who'd like to follow your work um or connect with you, what's the the best place for them to do that? You're always welcome to connect with me on LinkedIn. I try to post um stuff that I'm up to and things that have caught my eye on LinkedIn. Yeah, just like you, Jason, I've I've tried experimenting with podcasting. So I've had two goes at different series. One chronicling uh the first 10 years of our learning at East London Foundation Trust, and the second series really focused on the world of health and care improvement. So, you know, feel free to look out for those two podcast series if you want to hear more from me about this topic. Beautiful. Thanks so much for the invitation to join, Jason. Really appreciate it. Yeah, of course. And I'll uh I'll link to those in the show notes as well and any other resources that we've mentioned uh during this conversation. Amar, again, fascinating conversation. Uh, I appreciate you bringing me through this important work. Thanks so much. You've certainly increased my belief in this uh, you know, in what's possible here and uh look forward to our next conversation. Thanks so much, Jason. It's been an absolute pleasure. Thank you. Thanks so much for listening to today's episode of Leading Quality. If you enjoyed the show, please take a moment to like, subscribe, and share it with someone who might find it useful. You can find all our episodes at leadingquality.buzzsprout.com or in your favorite podcast app. The show is written and hosted by me, Jason Meadows, edited by Milan Milostavievich, and produced by Thrive Healthcare Improvement. See you next time.
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