The Scottish Improvement Journey: a nationwide approach to improvement

1. Introduction

Public services face many challenges ranging from increasing demands for services and funding cuts, to inefficient or at times even ineffective processes. Quality improvement can be considered as part of a solution to such challenges, as the approach focuses on doing things better at the system level rather than just having people working more or working even harder. Building on a long history of quality services, driven by staff and professional bodies, Scotland’s present ambition is to make the country the best place to live in. To achieve this goal, the Scottish Government recognises the need for quality improvement in public services and is, therefore, putting great effort into building an integrated landscape of quality improvement in public services.

This paper shares the story of the Scottish Improvement Journey, starting with its innovative beginnings, encompassing 50 years of clinical audit and various improvement programmes, then focusing on the introduction of the world’s first national patient safety programme, and exploring the spread of quality improvement into new social policy areas such as children’s services, education, and justice. Based on experiences of improvement experts, senior leaders and various stakeholders in Scotland together with those involved in improvement works, we demonstrate how a systematic application of a quality improvement methodology can lead to dramatic changes and significant improvement within public services on a national scale. This paper aims to provide an understanding of improvement efforts in Scotland over this period, and share the key factors that led them to success as well as challenges faced along the way.

While improvement has many definitions with little agreement found in the literature (Rowe and Chapman, 2015), the NHS Scotland QI Hub defines quality improvement as the ‘application of a systematic approach that uses specific techniques to improve quality. Though there is a range of different approaches that fit under this umbrella they all have the following in common:

• The concept of a cycle of improvement which involves data collection, problem definition and diagnosis, generation, testing, measurement iteration and selection of potential changes and the implementation and evaluation of those changes.
• A set of tools and techniques that support individuals to implement the cycle of improvement.
• A recognition of the central importance of engaging those who receive and deliver a service in the improvement of that service.
• A recognition of the importance of organisational context and the need for senior clinical and management leadership.’ (Scottish Government, 2016)

Our understanding and use of the term ‘improvement’ throughout this paper, and particularly when discussing early improvement efforts in Scotland, takes on this broad definition encompassing innovation, creativity, design, implementation, or system change, all while focusing on measurement and using whichever improvement methodology or tool that is the most appropriate for the context. This paper focuses on large scale change, particularly the Breakthrough Series Collaborative method developed by the Institute for Healthcare Improvement ( IHI, 2003) and thereafter used within many of the programmes discussed. Recognising there is no such thing as recipe book improvement, our goal is to learn from successful improvement works in one context and transfer the knowledge gained into other contexts.