Mind the improvement gap

NHS England’s CNO, Jane Cummings launched ‘Leading Change, Adding Valuethe framework for reducing variation in the outcomes of care delivery while adding value in what we do as nurses. For effective change and improvement to occur, it needs a set of conditions for it to happen. But what are those conditions that enable improved outcomes to reduce variation in care, and how can they be replicated? In other words, what’s the gap between the best possible care and how do we overcome it to improve care?

With large scale improvement change, we often think of projects, outputs, and deliverables rather than the pre-disposing set of conditions which are almost the ‘welcome mat’ for leaders to consider to affect and drive successful change. I describe it as the “planets being aligned”, and you need to have these elements in place to enable leaders to transform. Many transformational leaders have their own lists of predisposing factors. What I am writing about here are those that I’ve found essential for me in the work I do with clinical teams in the NHS.

I was asked to describe the conditions that allow reducing variation, and these are five conditions that have worked for me.


Hans / Pixabay

First and foremost, there needs to be a vision. I mean a compelling vision which is more than a desire, one in which others can see, buy into and recognise the need of feeling being part of it will make a difference. The vision needs to almost excite yet challenge

The vision needs to be ‘corporate’, so while it is likely to be individually led, the vision needs to have an impact, ideally as part of contributing to the wider strategic goal of the organisation, service or professional agenda. High performing organisations, such as Virginia Mason, align all their deliverables to their organisation’s strategic direction and their vision can be described in everything they do and by everyone doing it. They can explain why it is important at strategic level, and what difference it will make to patient care.

Teams then translate this into local action and have a shared vision of what the organisation is aiming for as well as seeing the impact in what they do.


Unsplash / Pixabay

Unsplash / Pixabay

By urgency I mean a need to make a visible difference in the short to medium term. This is very different for an emergency change or reactive change. As nurses, we can often come to the solution before we truly understand the problem and start to deliver change only to find we have not fully understood the implications of the change or the true underlying issues.

A sense of urgency come from a clear, conscience, vision, which sets the conditions for action. Those involved will want to prioritise this, and create the energy, and promote the need for the desired result, with clear benefits which are realistic, transforming and long-term. Urgency doesn’t necessarily mean immediate action, as some ground work will need to be done and may take some time, but urgency creates an energy to create a consensus, a shared goal and a desire to change. The challenge with urgency is to resist the need for knee jerk, and the combination of clear vision, strong leadership and measurable benefits will get one to that point.


There is a difference in ‘leading’ and ‘doing’. Leading is setting the vision, the case for change, leading from the front. Doing isn’t leading and if you’re ‘doing’ you can’t lead. A lesson we’ve all probably learnt. However, in resource-tight times, there is a need to do elements of delivery as well as leading. The trick is getting the balance right!

Investment in project managers/ delivery leads pays dividends rather than having leaders working through hours of detail when in fact they need to establish rapport, sells the vision and takes the journey of reaching out to those who need to be convinced the commitment can be done.

To lead well means being passionate about what you want to achieve, if you don’t buy into the vision, or have the time to lead, will impact the overall agenda.

Shared Commitment

SCY / Pixabay

SCY / Pixabay

One of the biggest failures in making a sustainable transformation is a lack of shared commitment. By this I mean, an agreed commitment to the desired change. I have learnt that success comes when people make a confirmed agreement to a desired change. I mean (and have seen) organisations make leaders/leads/partners, verbally commit to an action/desired outcome / the ‘whatever’ the vision is.  This ‘commitment’ binds and cements those to either actively participate or ensure their department contributes accordingly.

A shared commitment is one all sign up to, will push when times get tough, support and also means when the benefits are yielded, they can see their commitment to come to fruition. Consider getting teams to verbally commit to a goal/task/vision and see the benefits happen faster.

Beneficial results

AndreaTasselli / Pixabay

AndreaTasselli / Pixabay

Effective change needs to be have improved results that are tracked over time, that is, by having tangible benefits which delivers the vision, rather than an output.  Results should be focussed on improving quality of care over time, and they can also assure, but data for assurance is not the same as improvement data, because it isn’t stretching you to the desired goal or the vision you’ve set.

Using data to track improvement means having clear, agreed elements to measure to provide the improvement information with stretch. Stretch is a what gives long lasting improvement.

Be careful to measure what you need to see as an improvement rather than what you think you is an improvement, start by defining what success looks like and reverse engineer. A small number of well articulated, developed improvement measures are better than lots of data which do not show the improvement, even if that is partially achieved. Remember, no data without a story, and no improvement story without improvement data.



Also published on Medium.

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