Developing NHS Lothian's Quality Management System

Simon Watson, Chief Quality Officer introduces our approach to developing NHS Lothian’s Quality Management System.


NHS Lothian has chosen to tackle the long-term challenges of rising demand, rising costs and limited resources in healthcare by making quality the focus of how we run our business.  We believe that clinical quality is driven by the ‘front line’ clinicians and clinical teams that provide the service. 

Our ambition is for clinicians and clinical teams to manage continuous improvement in quality of care.  This may be the start of a process in which clinicians routinely manage more of the business of healthcare with clinical, experiential and operational goals becoming indistinguishable. 

Our first objective is to reconfigure the organisational Management System to create the optimal conditions for clinician-lead Continuous Quality Improvement. We have attempted to identify key guiding principles and objectives, drawing upon past and recent experience, published research and lessons from partners.  However our pursuit of perfection is endless so all work is ‘in progress’, subject to continuous consultation, testing and modification by and with key partners.

Some key guiding principles

  1. Identify, value and nurture leaders and participants in clinical teams to drive continuous quality improvement. 
  2. Value and develop both clinical and managerial skills in clinicians and clinical teams.
  3. Accept that most continuous quality improvement is a series of planned experiments within a Learning Healthcare System (LHS), not the result of large plans drawn up in offices
  4. Help clinical teams acquire the skills and resources to experiment on the LHS.
  5. Temper standardisation with an acceptance that there isn’t a ‘perfect system’ for us to copy.   
  6. Make the most of what you’ve got by collaboration - internally and with neighbours. 
  7. Be able to measure the small gains acquired from lots of experiments.
  8. Use information to manage the organisation by fact, not just intuition.
  9. Be bold in bringing cost as a component of efficiency squarely into the remit of ‘quality’.

Early objectives

  1. Develop a shared vision for whole organisational quality, closely aligned to the IHI Triple Aim – best population health, quality of individual care and reduced/controlled cost per capita of healthcare. 
  2. Identify key cross-cutting clinical care pathways representing a ‘Pareto’ of population health need – eg cancer, cardiovascular, diabetes, respiratory, frailty, the socially ‘excluded’ etc.
  3. Wrap support around the clinical teams operating along these key pathways and vital supporting services to facilitate Continuous Quality Improvement:-
    • Information – clinical process, outcome and financial
    • Project Management
    • Team/Leadership development
    • Capability and capacity building in Quality and Improvement Science
  4. Create meaningful and frequent opportunities for Management and Clinicians to work together on really difficult challenges
  5. Create strong clinical engagement mechanisms so all quality management infrastructure is co-developed between management and clinical teams.
  6. Create meaningful partnerships internally and externally to share the labour and rewards of Continuous Quality Improvement.
  7. Put the needs of relieving suffering from patients at the centre of clinical decision making
  8. Create and implement a long-term business strategy based upon quality.
  9. Meaningfully support clinicians and managers in safely testing radical innovations as well as small tests of change.