Cecilia Vindrola-Padros - Department of Applied Health Research, University College London, London, UK
Jean Ledger - Department of Applied Health Research, University College London, London, UK
Melissa Hill - NHS North Thames Genomic Laboratory Hub, Great Ormond Street Hospital, London, UK
Sonila Tomini - Department of Applied Health Research, University College London, London, UK
Jonathan Spencer - Nuffield Trust, London, UK
Naomi J. Fulop - Department of Applied Health Research, University College London, London, UK

Background  There is limited knowledge about interventions used for the improvement of low-performing healthcare organisations and their unintended consequences. Our evaluation sought to understand how healthcare organisations in the National Health Service (NHS) in England responded to a national improvement initiative (the Special Measures for Quality [SMQ] and challenged provider [CP] regimes) and its perceived impact on achieving quality improvements (QIs).Methods  Our evaluation included national-level interviews with key stakeholders involved in the delivery of SMQ (n=۶); documentary analysis (n = ۲۰); and a qualitative study based on interviews (n = ۶۰), observations (n = ۸) and documentary analysis (n = ۲۹۱) in eight NHS case study sites. The analysis was informed by literature on failure, turnaround and QI in organisations in the public sector.Results  At the policy level, SMQ/CP regimes were intended to be “support” programmes, but perceptions of the interventions at hospital level were mixed. The SMQ/CP regimes tended to consider failure at an organisational level and turnaround was visualised as a linear process. There was a negative emotional impact reported by staff, especially in the short-term. Key drivers of change included: engaged senior leadership teams, strong clinical input and supportive external partnerships within local health systems. Trusts focused efforts to improve across multiple domains with particular investment in improving overall staff engagement, developing an open, listening organisational culture and better governance to ensure clinical safety and reporting.Conclusion  Organisational improvement in healthcare requires substantial time to embed and requires investment in staff to drive change and cultivate QI capabilities at different tiers. The time this takes may be underestimated by external ‘turn-around’ interventions and performance regimes designed to improve quality in the short-term and which come at an emotional cost for staff. Shifting an improvement focus to the health system or regional level may promote sustainable improvement across multiple organisations over the long-term.

Low-Performing, High-Performing, Improvement, Interventions, Special Measures for Quality, UK