Achallenge facing the NHS is how to transfer innovations and improvements from one organisation to another and thereby reduce variations in service delivery (Horton et al, 2018). Sometimes, this merely reflects the slow spread of successful innovations, but at others, factors such as culture, staff skills and established habits affect their successful replication in another setting (Horton et al, 2018). It is not simply the innovation and its implementation but also the context and interaction between these elements that influence success.
Context is a set of factors that affect improvement efforts and may not be easily modifiable. Bate (2014) argued that it has four measurable dimensions—strategic, cultural, technical and structural—and inadequacy in any one affects prolonged significant improvements and sustained learning. Robert and Fulop (2014) identified multiple levels of context (micro, meso and macro) and examined how they combine to affect the sustained success of quality improvement. Following up, Ovretveit (2014) identified critical conditions for an improvement to be successful; these vary depending upon the innovation, and different elements of the context affect different types of innovations. Horton et al (2018) suggested that the ‘replicability problem’ can be solved if teams adapt and implement innovations to work in their own settings. Thus, new technologies, practices and models of care must be sympathetically adapted to the specific context with the engagement of all those affected if they are to be successfully implemented and sustained. Perhaps it would be helpful if there were ‘spread programmes’ to enable the successful cascade of innovations.
‘It is not simply the innovation and its implementation but also the context and interaction between these elements which influence success.’
Much can be learned from reported quality improvement initiatives even though their successful adoption requires careful thought. Goulder and Kar (2013) described how an integrated, multidisciplinary, community-based approach to diabetes care focussing on knowledge and self-management of diabetes enabled the discharge of over 600 patients from secondary care. Pringle et al (2014) reported significant improvements in information sharing for palliative care patients since the implementation of electronic palliative care summaries, so people receive care reflecting their wishes and inappropriate hospital admissions are avoided. Sanders and Fitzpatrick (2017) described their self-management strategy for clients of a rapid response team using the Plan-Do-Study-Act model and reported its impact on staff knowledge and confidence to support clients. Quality improvement may also involve student healthcare professionals; Brown et al. (2018) reported the success of an interprofessional education model for risk assessment and prevention of geriatric falls, with high satisfaction rates among the students involved.
Finally, Lucas and Nacer (2015) suggested that an ‘improver’ regularly displays 15 habits falling under five categories—learning, influencing, resilience, creativity and systems thinking. They contend that certain approaches to teaching and learning are better at developing capability in understanding and implementing improvements. As most district nurses know, engagement and co-production are central to improved service delivery.