This research looks at improvement cultures in health and adult social care settings.
We commissioned SQW and the Kings Fund Library Service to carry out this rapid literature review and write the summary and full report.
Background and introduction
The rapid evidence review brought together evidence from two sources:
- A search of literature databases and websites
- A call for evidence issued to key stakeholders identified by CQC.
In total, 40 documents were fully reviewed. The evidence used in this review is recent and broadly relevant for health and adult social care in England. It spans a range of settings. But, there are some limitations to the literature:
- There was less evidence on adult social care than health care settings
- Most of the documentation on health care was not focused on one type of setting. Most evidence spanned multiple setting types.
Findings from the rapid literature review
The role of culture in improvement
Culture is described as a key element, or even a prerequisite, of quality as well as improvement.
Improvement cultures are cyclical in nature. Characteristics of a good improvement culture align with conditions needed for its development.
There are different characteristics of culture that work together to drive improvement.
The development of an improvement culture relies on commitment, consistency and sustainability.
Characteristics of a good improvement culture
The literature identifies consistent characteristics of a good improvement culture. These are:
- Reassurance and safety: an environment where individuals can raise concerns without fear.
- Quality and effective: engagement and empowerment of staff. Teamwork and collaboration. Embedded and continuous measurement of impact.
- Caring and person-centred: commitment to the values of compassion, civility and respect. Person-centred approaches.
- Learning organisations: there is focus on problem solving and learning.
- Leadership: leadership is compassionate, open and honest. There is mutual trust. There is leadership buy-in to improvement.
Development of improvement cultures
A good improvement culture requires a range of conditions to develop. They work in conjunction to create (or inhibit) an environment in which a good improvement culture can flourish. These conditions are categorised into four themes.
Leadership
- Consistent and stable leadership is a key enabler to improvement. But, a change in leadership can also drive improvement.
- There is no consensus on the most effective leadership structure. One study argues for a non-hierarchical approach. Another reports that top-down leadership can facilitate an improvement culture.
- Leadership behaviours influence improvement cultures. This includes visible and proactive leadership. It also includes leadership open to innovation and experimentation.
Engagement
- Staff engagement is a key influencing factor in the development of improvement cultures. This includes involving staff in decision making. It also includes encouraging their contribution to improvement initiatives.
- Involving people who access services and their families can enable improvement cultures. Listening to the voices of people reveals improvement gaps.
- Good internal and external partnerships and relationships can support a culture of innovation.
Capabilities and capacity
- The availability and quality of training for staff enables improvement cultures. Having processes in place to support consistent and meaningful training is key.
- Some literature highlights the influence of quality improvement approaches on improvement cultures. These approaches can provide structure to delivering improvement, but this is not always the case.
- There are ways of measuring change which can help settings to understand their progress. This includes benchmarking key indicators or capturing people’s views.
- Time and space to engage with quality improvement and innovation activity is key. Staffing levels and resourcing influence culture.
Systems, structures and processes
- Access to accurate and timely data is key, as is using and sharing a wide range of data.
- Implementing strong quality assurance structures and processes supports the development of improvement cultures.
- The development of improvement cultures should align with existing processes, infrastructure and policies.
Outcomes of improvement cultures
There is a positive association between ‘good’ culture and ‘good’ outcomes. The literature identifies a range of outcomes associated with good improvement cultures. This includes:
- Improved service performance
- Improved quality of care
- Better experiences of people who access services
- Improved staff skills, knowledge and experiences
- System change.
Conclusions and learning for CQC
The findings from this rapid literature review provide relevant insights for CQC. The key possible areas for consideration by CQC are set out below.
Regulatory functions
- Viewing improvement holistically is important. Various elements of ‘good’ culture need to be in place to achieve and sustain improvement.
- Both espoused and ‘lived’ culture are key. Disconnect between espoused and experienced culture may (but not always) indicate disfunction.
- The evidence highlights the importance of sub-cultures. Exploring cultures at different levels in a setting is likely to prove key.
- CQC may wish to assess and inspect for evidence of an environment where people feel they can speak up and that their voice will be heard.
- It is important to monitor and assess how services capture and use people's voices.
- Training and supporting people to be involved in service improvement activities is an enabler. CQC may have a role to play in sharing examples of good practice. CQC could also inspect and assess for this.
- CQC may wish to consider how their assessment process captures evidence of staff empowerment and influence. CQC could consider sharing examples of good practice.
- Developing an improvement culture takes time. Ensuring realistic expectations, including identifying expected interim outcomes, may prove useful. A logic model or theory of change could support this.
- Wider factors can support or inhibit improvement. Understanding the context can help to understand an organisation’s culture. It also may enable CQC to further support settings.
- Leaders have a key role in enabling improvement. Leaders are not always those in leadership roles. Identifying the extent to which leaders recognise and act on this may prove useful.
Influencing role
- Setting out what CQC defines as an improvement culture within health and adult social care may help to provide clarity and direction to the sector.
- Consider how CQC colleagues can communicate the cultural behaviours sought from settings.
- CQC could explore and promote examples of top-down and bottom-up culture setting
- CQC may wish to consider its own relationships at local and national levels. The literature states that these relationships should be supportive relationships. This reflects those seen within a good improvement culture.
- CQC may wish to consider the role of education providers and supervisors in influencing the culture of the future workforce.
- CQC’s forthcoming role in assessing ICS’s may be worth reflecting on. The literature demonstrates the importance of effective, active collaboration at a local level. CQC may wish to explore how they can encourage this and share good practice.
- We expect others will benefit from the findings of this review. CQC may wish to consider how (and to whom) to share the findings.
- The evidence indicates a need for realism about how far CQC can influence improvement cultures in settings it regulates. Commitment and investment in staff is more likely to achieve reform and improvement. A focus on compliance is less likely to achieve this. This indicates that CQC may wish to consider how it exerts its influence.
Considerations for future research
There are gaps identified through this review. CQC may wish to consider whether (and if so, how) to address the identified evidence gaps. These are as follows:
- Evidence on improvement cultures in adult social care settings. This evidence may exist, but may require a wider call for evidence.
- Evidence of how improvement cultures vary between different healthcare settings. The majority of evidence encompasses multiple settings.
- Evidence around improvement cultures across partnerships and systems. Improvement cultures at this level could influence organisational improvement cultures. They are therefore likely to be strategically important.
There are also gaps in understanding the association between culture and improvement. The evidence base suggests that this understanding is increasing, but, it is still relatively emergent.