1 August 2019

QI Essentials: Quality, Cost and Value

For the first time in our improvement journey, this year we are directly targeting value as a primary goal in our portfolio of improvement efforts. We are starting to move from one approach to quality and another to cost, to an integrated approach to quality, cost and value. Have a read of Amar’s latest QI Essentials Blog…



When we embarked upon our quality improvement journey at ELFT back in 2013, we thought quite hard about how we could frame this new direction for the organisation in a way that would resonate with people and inspire, but without undermining our previous approaches and efforts to improve quality. We didn’t get it right, in many ways, and we’ve been continually adapting and improving our approach to improvement over the last six years.

One aspect of our QI approach that we all seemed to agree on was that it had to be purely focused on quality. We believed that a focus on quality would lead to better cost management, but supportive literature from the mental health and community health setting was non-existent. We were concerned that if we even mentioned cost when we explained why we were embarking on a quality improvement journey, we might ignite anxieties that this was really all about cuts and cost savings wrapped up in new jargon. In England, this is a heightened anxiety in the context of recent QIPP (quality, innovation, productivity and prevention) programmes which were largely focused on cost, and CQUIN (commissioning for quality and innovation) which is again largely perceived as the threat of losing income if we don’t achieve certain targets. So, we framed our first organisational mission, back in 2013, around quality – providing the highest quality mental health and community care in England by 2020. And we supported and encouraged all our quality improvement projects to focus purely and simply on quality of care.

Our early QI work was aimed at reducing harm from community acquired pressure ulcers and reducing inpatient physical violence, as well as improving access to community-based services. As people started to see that we could discover solutions to some of our most complex quality issues by involving those closest to the issue in a deep process of discovery, innovation and iteration, we have slowly but surely built belief across the organisation in the systematic and inclusive approach of quality improvement.

Two years into the work, having achieved step changes in many of our big organisational quality goals, we began to ask the question about whether we could measure the cost impact of the work. If we reduced inpatient physical violence, this meant that we were avoiding the costs of extra staffing, extra medication, extra days in an inpatient bed, the costs of repairs to the ward, the cost of days lost due to staff sickness, and on and on… We brought our entire finance team together with an expert in economic evaluation to learn the approach of predictive cost modelling. Our finance team began to work alongside our clinical teams to understand the cost of harm, and to predict the costs avoided by preventing harm. We’ve now been able to publish much of this work, for others to use.[i],[ii]

Although we only partially realised this at the time, our quality improvement approach as an organisation was impacting on far more than just the quality of care we were providing. We have since developed a framework to describe the return on investment that we have seen through quality improvement,[iii] as shown in the image below:



We’ve recognized that, first and foremost, the return from quality improvement is about improvements in patient, service user, carer and family experience and outcomes. This might seem obvious, but it’s directly related to the core purpose of the organisation so is absolutely critical to the business case for QI. There is increasing literature supporting the case that adopting quality improvement, genuinely ceding power to those closest to care to be able to improve the system they work in, and providing them with the skills and support to do so, leads to a better experience at work. Makes intuitive sense, and is increasingly borne out in the evidence.

We’ve also seen large numbers of teams demonstrate that they can improve productivity through quality improvement, even if their quality improvement work was driven by a quality goal rather than by efficiency needs. For example, our community based psychology teams who are now able to see more patients more rapidly, with fewer non-attendances, with no extra resource. Our teams working on harm reduction have been able to quantify the costs avoided by preventing harm, such as physical violence or through improving the disciplinary process so that fewer staff are suspended.[iv] And a small number of teams have been able to demonstrate recurrent cost savings through removing cost from the system entirely, such as our older adult mental health wards which have redesigned the way they work to support people to stay in their homes for longer, instead of coming into a hospital bed, enabling us to close a ward and realise about £1m recurrent savings.

The key to all these other types of return from quality improvement are that they were first and foremost about tackling an aspect of quality that really mattered to those who use the service and those who work in the service. They weren’t driven by the need to avoid cost, remove cost or improve efficiency. They were by-products, but what an incredible effect when aggregated across an organization.

As we’ve been able to quantify these additional aspects of value, and tell the story back to our teams, there is increasing belief that quality improvement impacts on value beyond just quality. This has given us the courage to let go of our old language of cash releasing efficiency savings, and start adopting the language of improvement more consistently – talking about waste, variation and value instead, and recognising the opportunity of engaging our entire organization in this conversation and search for improved value, rather than allowing the burden of finding our 4% of annual efficiency savings to sit heavily on the shoulders of a small proportion of our most senior staff.

For the first time in our improvement journey, this year we are directly targeting value as a primary goal in our portfolio of improvement efforts. And every one of our QI projects will be supported to predict and measure the impact of their work on other aspects of value, beyond their primary quality goal – this might be impact on staff, or productivity, or costs avoided. We are starting to move from one approach to quality and another to cost, to an integrated approach to quality, cost and value.

Two weeks ago, I visited a ward in our forensic service and met with a team of staff and service users who talked passionately about their plans for the next ward QI project. The idea was sparked by our conversations about waste and value in the organisation, and has inspired service users and staff on the ward to identify areas of ward spend that they believe are waste and could be better utilised. Some of this is driven by a desire to be more environmentally friendly, and some is driven by a desire to refocus our limited resource on activities that really help improve quality of life for those we serve. It was genuinely humbling to see the energy and passion amongst service users and staff to ensure that we, and they, get maximum value for every pound of public money. This, in a single story, epitomises how far we’ve come and what we are aspiring to…

[i] Brown, J., Fawzi, W., McCarthy, C., Stevenson, C., Kwesi, S., Joyce, M., Dusoye, J., Mohamudbucus, Y. & Shah, A. Safer Wards: reducing violence on older people’s mental health wards. BMJ Qual Improv Report 2015;4: doi:10.1136/bmjquality.u207447.w2977

[ii] Taylor-Watt, J., Cruickshank, A., Innes, J., Brome, B. & Shah, A. Reducing physical violence and developing a safety culture across wards in East London. British Journal of Mental Health Nursing 2017;6(1):35-43

[iii] Shah, A. & Course, S. (2018) Building the business case for quality improvement: a framework for evaluating return on investment. Future Healthcare Journal 2018;5(2):132-7

[iv] Shah A., Aurelio, M. & Fitzgerald, M. (2017) Quality improvement for non-clinical teams. NEJM Catalyst


You can read all past QI Essentials posts here.

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