OP186 Building an evidence base to support challenged NHS organisations to improve quality and patient safety: interview-based qualitative study

Background

NHS organisations vary significantly in the quality and safety of care they provide to patients. Despite a series of public inquiries and investigations highlighting deficits in care, maternity services continue to be characterised by high-profile patient safety failures. Previous research suggests how clinical services respond to improvement programmes is highly variable. Less clear, however, is why this happens and how it might be addressed. We aimed to add to the evidence base for supporting improvement in low-performing healthcare organisations by prospectively identifying distinctive features of these settings and how improvement programmes might be designed to address them.

Methods

We conducted an interview-based qualitative study involving 94 participants to investigate implementation design for a novel safety improvement programme for NHS maternity services, with a focus on implementation problems that might be faced by challenged units (we defined these services as those rated ‘Inadequate or ‘Requires Improvement’ by the Care Quality Commission). We sought to identify both organisational barriers to improvement and the features of challenged services that might undermine improvement processes, with a view to optimising implementation design. Our sample captured a diverse range of stakeholders in NHS maternity care, including clinicians, managers, and system stakeholders at local, regional and national level.

Results

Features of challenged maternity services that might constrain their ability to improve care in response to an improvement programme include: limited organisational capacity; absence of high-quality leadership; variable management practices; resourcing inequalities; and dysfunctional cultures that undermine organisational learning. Features of the regulatory environment of the NHS maternity system, particularly those related to the design of mandated improvement initiatives, may further limit the capacity of services to improve. Enhanced support for these settings may include the provision of additional targeted, intensive implementation support, strengthening clinical governance systems, and customised approaches to programme resourcing.

Conclusion

Challenged maternity services face distinctive internal and institutional barriers that constrain their ability to improve care. The design of safety improvement programmes and other initiatives needs to take account of variation in organisational capacity and quality of leadership and management. Our findings add to the evidence base for supporting improvement in challenged healthcare organisations, and contribute to wider debates around the best means of securing improvement in failing public services.