Managing quality during change

Successful transformation will require organisations to effectively and systematically manage quality during change. We know that large scale change often poses risks to quality. Even transformation efforts that consciously seek to make quality better and provide benefits in the longer term may encounter challenges through the process of change.

To deliver change while rigorously maintaining and improving quality will require a shift in the way many organisations operate day to day. A Quality Management System offers a structured approach to planning change, risk assessment, controlled implementation and ongoing monitoring and evaluation – all of which can help address that challenge.

Across the UK and Ireland, there are calls to transform care in a range of positive ways – more care in people’s community, digitisation, a focus on prevention, increased productivity and tackling longstanding inequalities. 

Change of this scale can inadvertently undermine care quality if not well managed. Staff turnover, stress, under-resourcing and poor communication are common during periods of change and can contribute to a decline in quality. 

In turn, if staff and patients feel some dimensions of quality are prioritised over others, or that quality of care is not being effectively managed through periods of change, they can feel alienated. Staff might even leave their roles – further fuelling risk to quality. 

Fears about declines in quality also have implications for how the services are being stopped. When  new services and processes are being developed and adopted, it is also necessary to stop or de-implement others in a way that doesn’t compromise quality. 

Successful transformation will require organisations to proactively and systematically manage quality during change. Tools like quality impact assessments are designed to assess and mitigate the impact of service changes in quality and can be useful.

But more fundamentally, organisations need a way to truly embed the management of quality into the fabric of change itself. 

This is where a Quality Management System (QMS) approach can really help. 

QMS have typically been associated with managing relatively stable processes and operations. But the approaches and guiding principles for QMS, together with lessons we at Q have learned from those embedding QMS, provide valuable insights into how quality can be effectively managed during periods of change.

A QMS can provide an operating system for quality – a framework to monitor and manage risks to quality during change. It can help those leading change ensure quality across different domains so that care is safe, effective, caring, person-centred, responsive, well led, sustainable and equitable. 

The four QMS components of planning, control, improvement and assurance can be applied to your organisation’s change process in the following ways:

• Quality planning involves identifying and understanding patient and users’ needs and planning the services, resources and processes necessary to support them. During change and transformation, quality planning might include effectively balancing different drivers of change, setting clear transformation milestones, identifying quality risks and embracing flexibility.
• Quality improvement involves systematic and coordinated approaches to solving problems using specific improvement methods and tools, to achieve measurable gains. During change and transformation, improvement will be even more critical – especially using rapid cycles and prototyping to test changes safely and learn during transition.
• Quality control involves monitoring and evaluating whether quality is being delivered against agreed goals, and acting on any gaps. During change and transformation, control can help maintain consistency, compliance and safety during uncertainty and support rapid refinements by those delivering work.
• Quality assurance involves regularly checking whether a service is meeting needs based on agreed, often external, requirements. During change and transformation, quality assurance may require actively engaging with regulators or commissioners, helping you stay on track and providing transparency to staff and patients.

Crucially, these four components of QMS do not exist independently. They need to be interconnected as much as possible.

Transformation is complex or as The King’s Fund’s report on transformational change describes it: ​‘multi-layered, messy, fluid.’ Frameworks for effective change usually emphasise the importance of data and learning to help find ways through. 

QMS provides a clear framework for systematically thinking through what data is needed, by who and for what purposes. Indeed, many QMS frameworks place learning, feedback and data at their heart. 

Data and learning are both critical within each component and for rigorously connecting the components. Taking the shift from hospital to community as an example transformation:

• Within quality planning, organisations will require a wide range of data to really understand what the population needs from neighbourhood care models, or from care in their homes. This will include drawing on existing academic evidence, horizon scanning, staff and patient feedback data and more informal stakeholder engagement. The quality of this data will shape the quality of the services that are designed.
• Within quality improvement, where new community services or collaborations across organisations are being prototyped and piloted, organisations will need rapid cycle testing and measurement to understand what is working and what isn’t. This shows how to further improve and refine to ensure sustainable change in the right direction. This data should be for learning and improvement and, ideally, be shared with others who are leading the shift to community care.
• Within quality control, as new services become business as usual, organisations will require real time data to help monitor whether new processes and practices are being delivered consistently. Those delivering this work should have the information and agency they need to adjust and refine their work day-to-day.
• Within quality assurance, organisations will require slightly longer-term outcome and assurance data to understand whether new services are meeting the needs identified in quality planning. This assurance activity will reassure patients, staff and other stakeholders around the shift to community care and will also help understand any wider implications of the shift, for example, on particular population groups. This analysis is then fed back into the next quality planning cycle.

Crucially, although data is central to a QMS, it doesn’t necessarily call for more data. Indeed, as QMS become more mature it can provide a systematic approach to streamlining measurement – collecting less data but using it more effectively. Indeed, organisations with well-developed QMS place considerable emphasis on building the ​‘human infrastructure’ to understand and act on data.

Healthcare Improvement Scotland’s (HIS) Scottish Approach to Change (SATC) is a practical approach to delivering change at any level. It provides a compelling example of how QMS principles can be applied to change and transformation. 

The Scottish Approach to Change (SATC) integrates HIS’s QMS model into a high-level change framework that brings together service design, engagement, improvement and strategic planning. It is not a new set of tools, but a way to connect existing resources and methods to support high-quality change using simple language. The SATC includes:

Eight steps of change

1. Identify
2. Understand
3. Develop and design,
4. Prototype and test
5. Review for implementation,
6. Define and implement
7. Embed and sustain
8. Review for spread

Five enablers of change

1. Clear vision and purpose
2. Process rigour
3. Leadership and culture
4. People-led
5. Learning system

Launched in 2025 and developed to support NHS renewal, the SATC (see figure above) sets out a consistent, structured approach to change emphasising the importance of having the right enablers in place. The website resources support it uses simple and accessible language and provides a range of resources.

QMS offer a valuable approach to proactively managing quality and enabling high-quality transformation. 

At Q, we are working to make sure that developments in this space are widely accessible for all to learn from. It’s important that people responsible for implementing and directing change are able to draw on emerging best practices. Especially in times of huge change in health and care, we are here to support organisations and systems on your quality management journeys.

• Q’s Quality Management Systems: resources to help you get started
• NHS Wales QMS framework: Developing a Quality Management System: An operating system for a quality-driven learning organisation
• The first international standard specifically focused on health care quality management was developed in 2023: ISO7101:2023 – Healthcare organisation management
• NHS Providers report: Embedding quality: Principles for a national quality management system