Developing a culture of quality within the
United Kingdom healthcare system
Henry Stahr
Director, Centre for Excellence Development, University of Salford, Salford, UK
Introduction
The UK National Health Service (NHS) is one
of the largest organisations in the world. It
employs nearly one million people and on a
typical day almost a million people visit their
doctor, 130,000 their dentist, 33,000 receive
treatment in Accident and Emergency, 8,000
people are transported in NHS ambulances,
1.5 million prescriptions are dispensed, 2,000
babies delivered, 25,000 operations carried
out, 30,000 people receive a free eye test and
100,000 people receive a visit from a district
nurse (DoH, 1999). It has a total budget of over
£48 billion and provides a comprehensive and
relatively high quality service.
The demands and expectations of the NHS
continue to increase and from the patients'
perspective long waiting times for non-
emergency treatment are particularly
problematic. Many healthcare professionals
feel that the NHS is under-funded while
governments feel that the service's problems
will not be solved simply by increased
expenditure.
Over the past ten years the UK healthcare
system has been bombarded with a plethora
of quality initiatives including Resource
Management, Clinical Audit, Evidence Based
Medicine, Patient Focused Care, Investors in
People, ISO 9000, Clinical Governance,
Controls Assurance and more recently the
NHS Plan and Working Lives. However,
although sometimes difficult to see, these
initiatives do have a relationship with each
other, which is clarified by Joss et al.'s (1994)
view of quality.
Quality, culture and the EFQM
Excellence Model
Joss et al. (1994) identified three levels of
quality: technical, generic and systemic.
``Technical'' initiatives are mostly
concerned with the employment of specialist
knowledge and expertise to solve a problem.
``Generic'' initiatives are concerned with
meeting and following generally agreed or
imposed standards, while ``systemic''
initiatives are concerned with making sure
that the whole organisation works as an
integrated whole in order to ensure long
term success.
Many quality initiatives are of the
technical and generic kind and they have
dominated quality management in the
health service. Carr and Littman (1993)
describe this as the ``spotty quality
approach'', which has led to a mixed
reaction from healthcare professionals.
However, a common theme can be identified
in that quality initiatives are a set of
unrelated and temporarily fashionable ideas
with little lasting value. There is a strong
sense therefore that just as people start to
understand and use one fashionable idea
another is introduced.
In order for quality approaches to make a
significant impact they need to affect the
culture of an organisation and in order to do
this they need to be of the ``systemic'' type.
The ``systemic'' level of quality is
characterised by full integration of all
aspects of the organisation's activities into
focused action on continuous improvement
and consumer needs. Systemic approaches
are more likely than generic and technical
approaches to be successful because they
impact on everything that managers and
clinicians do. They become the culture of the
organisation.
However, systemic approaches need to
have a system in which to operate and
systems need a framework on which to put
the flesh of quality activities. A powerful
model increasingly being adopted within the
UK healthcare system is the European
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[ 174 ]
International Journal of Health
Care Quality Assurance
14/4 [
2001
] 174±180
# MCB University Press
[
ISSN 0952-6862
]
Keywords
Quality, Model, European
Foundation for Quality
Management, Implementation,
Kaizen
Abstract
It is established that there are
three levels of quality, technical,
generic and systemic with
systemic being the preferred goal
for Salford Royal Hospitals NHS
Trust (SRHT). In an effort to
achieve their goal SRHT embarked
on using the EFQM Excellence
Model to provide one overarching
framework for all their quality
initiatives. The article explains
SRHT's approach to
implementation and integration in
addition to providing a flavour of
the outcomes observed from the
journey so far. In essence, many
benefits were realised, some
aspired to, some unexpected and
all worthwhile and welcomed.
However, even after seven years
the organisation still does not
have full deployment, which
confirms that efforts to assure
excellence need to be relentless if
there is to be a sustainable culture
change that puts quality at the
heart of day-to-day decision
making.