Creating a culture of continuous improvement: a system level QI network

Traditional organisation-centric improvement approaches are insufficient to address system-level challenges such as unwarranted variation, fragmented pathways, and population health inequalities. 

Recognising these challenges, the Hertfordshire and West Essex Integrated Care Board (HWE ICB) quality improvement (QI) team established a system-wide Quality Improvement Network to enable shared learning, build capability, and foster a social movement for improvement across the system.

Prior to the project, QI activity existed within local provider organisations but lacked a consistent and coordinated system-level infrastructure, shared language or mechanism for cross-sector collaboration and shared learning.

The aims of the HWE ICS QI and learning network were to: 

• Create conditions for system-level improvement, connecting individuals and organisations (including non-NHS partners) working on shared system health outcomes.
• Build QI capability at scale through a suite of training, open to all partners.
• Support shared learning through access to a wealth of QI resources and evidence base. 

The project applied IHI’s Whole systems quality approach and Q’s Cross-system improvement framework. The project was supported by Q as part of our Supporting Q Connections programme. 

The Network evolved through two overlapping phases: 

The HWE QI network was initially launched and established by the senior sponsor in 2023. 

From September 2024 onwards, the new QI System Lead further built on these foundations. This included delivering a series of virtual and face-to-face focus groups, engaging more than 200 staff across the system. Feedback informed responses to the NHS IMPACT self-assessment tool, where 16 of the 22 indicators suggested that HWE ICS was at the start of its improvement journey. 

A refresh and relaunch of the HWE QI Network including: 

• Co-producing an improvement values and behaviors charter as well as network goals. The charter underpinned all activity and the values were critical in building trust, psychological safety and sustained commitment across all partners including voluntary sector.
• Developing and delivering a robust communications and engagement plan to promote improvement offers, and to build the agency and will for system level improvement.
• Delivery of a suite of improvement support which partners across the system could flexibly access:
  • Bi-monthly webinars showcasing QI projects and stories.
  • QI training – offering both in-person and virtually improved reach and ease of access.
  • Streamlined routes for sharing QI resources – content was shared on the NHS Futures platform and was coupled with ​‘Weekly Wednesday’ QI bulletins and a Microsoft Teams channel.
  • Weekly coaching clinics to support local teams undertaking improvement work.
  • Communities of practice, bringing professionals together to use improvement methodology to deliver on shared outcomes.
• QI was embedded within the ICB, integrating quality as part of daily business strategy. Examples included: shared data access between clinicians and inclusion of QI in wider ICB leadership development programmes such as graduate management. 

System-level improvement is complex because organisations operate with different priorities, cultures and capabilities. Building alignment across NHS, local authority and voluntary sector partners required sustained efforts based on relationship-building and trust. 

Variation in data quality, availability and interpretation across organisations made it difficult to establish shared baselines and consistently measure impact. Earlier access to better population/​patient health data between system partners is pre-requisite to strengthening joined-up improvement work. 

Keeping people engaged while balancing operational pressures was challenging. Competing priorities often limited capacity for improvement work. We addressed this issue by offering a consistent, easily accessible suite of flexible learning opportunities to sustain engagement.

As the network grew, balancing broad reach with meaningful engagement became more difficult. Maintaining quality while expanding access required careful coordination. 

Executive sponsorship was also key as this enabled improvement efforts to be aligned to strategic priorities. Focusing on few rather than many has made practical delivery of QI possible. 

A pragmatic evaluation approach was adopted, combining process measures (membership numbers, attendance, training delivery sessions) and outcome measures (such as qualitative participant feedback). 

Member impact stories were mapped to immediate, applied, realised and potential value of using QI to deliver on priorities. 

• Network membership tripled within first 6 months and continued to grow.
• Cross-sector membership increased by 20%, including local authority and VCFSE partners.
• Nine webinars were delivered in 2025 (exceeding the target of six).

• Introduction to QI training delivered to over 10% of ICB staff and system partners in Year 1.
• 93 QI system coaching clinics took place.
• Participants reported increased confidence in using improvement tools, collaborative skills and ability to lead and support QI work. 88% of staff reported the HWEICB QI training offer as ​‘highly recommended’.

Gathering member impact stories demonstrated how the network was adding value in different parts of the system. Examples include:

• Immediate value: learning and development, being part of a network with supportive and encouraging colleagues.
• Applied value: informing trust QI training and QMS infrastructure; including QI and training as part of corporate induction; application of QI tools in daily work; better use of data to inform QI work.
• Realised value: ICB QI presentation and facilitation at trust workshop; network members championing the QI resources with other colleagues.

Dementia System Pathway improvement workshops: 

• The ICB QI team supported several system QI planning workshops with acute dementia services, community services and VCFSE partners. Applying QI tools such as process mapping and driver diagrams, these workshops enabled partners to understand and scope out ways to improve experience of care, and improve outcomes for people with dementia through joint ways of working.

High Intensity Users (HIU) Mental Health Collaborative: 

• Launched in July 2025, this partnership across NHS providers, local authority and VCFSE aimed to improve outcomes, value, and equity for people with complex mental health needs, high intensity users. 

Several themes emerged as critical enablers of system-level improvement: 

• Invest early in relationships and focus on aligning improvement efforts around shared purpose and priorities across system partners.
• Leadership needs to be authentic, distributed, comfortable with ambiguity and convey shared outcomes in a pragmatic way. A distributed shared leadership was integral to HWE QI network’s success:
  • An orchestrated and collaborative effort from specialist improvement coaches, advisors, and senior QI leaders, to enable the delivery of improvement. 
  • Executive sponsorship was also key and improvement efforts were aligned to system strategic priorities.
• Expert facilitation skills and a persuasive communication strategy are essential to creating conditions for change and building the will. Providing accessible, blended learning opportunities that cater to varied QI capabilities can improve reach and engagement with QI. A shared MS teams’ channel and NHS futures page for all NHS and VCFSE partners ensured easy access and consistent use. 
• Improvement is iterative and practical; system level improvement is ambiguous and complex. Applying the cross-system framework required movement back and forth between the domains of creating conditions and delivering improvement. Understanding the big picture whilst starting small and building momentum supports a social movement for change and requires high degrees of agility.
• Collaborations built on psychological safety generate a multitude of ideas, however the design and execution of improvement efforts require rigor and patience. 
• Celebrating learning and impact is key to holding the early wins and sustaining momentum for long-term improvement.
• Quality control at system level has been hardest to define. It relies on trust, and real time local feedback loops. A whole system approach to quality requires integration of various activities at the same time with built in learning.
• Improvement needs to be integrated within daily business activity. Develop an ecosystem with improvement leaders, capability building as well as shared improvement language, behaviours and ways of working. Improvement work should be sustained through normal governance process and across all business functions. 

As HWE transitions into a new Central East ICB configuration, the Network will: 

• Link into national and regional improvement and learning networks to share learning. 
• Further embed QI from board to front line through a broader quality management systems approach 
• Explore the use of digital tools and AI as an enabler to support improvement at scale.