From framework to action: supporting Improvement across systems

Transformation and enabling large scale change in health and care is complex work. It’s hard to navigate, especially as single organisations and teams. To have impact at this level requires system-level thinking. This means intentionally working across multiple organisations, sectors and geographies to create the conditions and change required to improve health outcomes for the population. 

When applying this to improvement and transformation work, it can be challenging to consistently and collectively identify, visualise and describe the activity needed when working across multiple organisations. 

Over the past few years, along with our partners and members, we have been exploring how we can do this, which resulted in the first iteration of our Cross-System Improvement Framework. Using this prototype in our programmes, we looked to learn with members, work out how they could use the framework in action, and what resources would be useful to support people taking whole system approaches. 

We have now re-designed the framework following feedback, and have designed an accompanying toolkit to support conversations about cross-system improvement. 

The Cross-System Improvement Framework aims to raise awareness of all the activities involved in system improvement. It draws out distinct activity that supports creating the conditions for improvement to succeed, and how improvement is delivered across large scale systems. 

It builds on evidence from team and organisational approaches to improvement to identify what’s distinctive when working across multiple organisations to deliver large scale change.

This new design of the Cross-System Improvement Framework has taken into consideration conversations, feedback and input from Q members, senior leaders from across the UK and Ireland, and experts in large-scale change to help people use in practice. 

We used the framework to support people in our Learning and Improving Across Systems programme and teams in our Provider Collaboratives Improving Equitably programme. We’ve also started to use it in work with Integrated Care Boards (ICBs) on specific cross-system challenges. Looking at improvement on this scale is relatively new, so use cases and feedback from people working at this level have been crucial to help us understand how to support others navigating this type of work.

Building on this experience, we designed a toolkit for people who want to create awareness of what is involved in system improvement in their teams and organisations. The framework is designed to surface where activity is currently taking place, to inform decisions and strategy that will support transformation in health and care.

Taking a whole system approach means holding all the types of work together, and this can be visually overwhelming. But we felt it was important that people take a holistic approach. The framework is split into two halves. It is also structured across three levels, to help teams understand and organise their improvement work: domains, modes and activities. 

There are the six core areas of work we have labelled ​‘domains’ that support system improvement. Together, they describe the types of work needed to create the conditions for effective change and deliver transformation. 

• Collective vision and leadership
• Aligned operating model
• Capability, connections and culture
• System and pathway redesign
• Continuous Quality Improvement
• Targeted Innovation

The session plans in the toolkit reflect the challenges of finding the time and space to do this type of work together. Through the exercises we’ve shown ways people can move through the different domains. We suggest how you can pick up and come back to conversations to build a coherent picture that shows how interconnected this work is, and what’s happening in isolation. 

Through feedback we were asked to think about identifying a starting point. Whether for partners coming together to solve a particular problem or individuals working on complex problems. Our starting point for both, is to think about how individuals can bring in others working on different parts of the system together, and supporting them to create system-wide awareness. 

Change is neither linear nor sequential. We’ve heard from people using the framework that there is a need to move dynamically through the different domains and activities. One Q member described a process of moving back and forth between the two halves of the framework. They initially focused on activity that creates the conditions, then tested changes by moving into delivering transformation, and found themselves moving between the two halves. They recognised that improvement at this level is a balance across the domains. If teams put all their effort in one domain while not dictating what that balance might be for different systems, it creates a negative feedback loop. 

We have designed the toolkit and updated framework for people who are leading improvement and transformation and are interested in exploring the framework with their teams. 

Operating at this level, means holding a system, organisational, team and a personal view. 

Moving between these different viewpoints of the system is challenging. There is a need for leaders to know when they need to zoom in and zoom out to create a comprehensive understanding of how a system is currently operating. We recommend that people using this toolkit with their teams have advanced collaboration skills to hold different views together and help people make sense of and uncover patterns, and opportunities to be able to create the narrative for change. 

We encourage you to share your experiences of using the toolkit with us, so we can continue to build the evidence base about change across large systems.

If you’re looking for more bespoke support for your system, or support in using the framework with your teams, we can help you. Our System Improvement Support is a high-impact, tailored service that equips you to drive large-scale, sustainable change quickly and collaboratively.