Findings

The levels of involvement in the programme varied between the executives; however, all gave accounts of the value that they believed to have brought at all stages of the process. They considered their involvement in the initiative as a significant influence on the potential for programme success/failure. I went away on leave, came back, and it had just all gone downhill because I wasn't there. (Interviewee 8)

The most reported barrier to their involvement was their time constraints to participate within programme efforts, which was often attributed to the demands of managing a large Trust. Facilitators of their engagement included early involvement in the process (from helping at the application stage or/and from attending the first learning session), learning about the programme (such as the QI techniques, the targets set, the support networks available and the motivational impetus delivered by IHI), and having other executives and staff engaged with the programme. it's really important the Board is engaged early on in a real way and that the Board begins to see the data. (Interviewee 3)

Five primary managerial roles within the SPI programme were identified (presented in table 2). These dimensions are described within this section along with example quotations provided in table 3. In terms of weighting, the dimensions ‘commitment and support’ and ‘monitoring progress’ were referred to by almost all CEOs. Most CEOs also discussed ‘embedding programme elements’ and ‘staff motivation and engagement’. Resource provision was mentioned less than the others, but was still referenced by well over more than half of the CEOs. Although not discrete from one another, our findings show some indication of the stages in which CEOs most get involved in these dimensions, most notably resource allocation before the start and (to a lesser extent) at the end of the programme, followed by engagement, motivation, commitment and support for staff and towards the end of the process the CEOs are more likely to engage in decisions and strategies to embed the programme elements in order to sustain it.

Resource provision

Funding to support the SPI programme was deemed important and many CEOs recognised this as one of their primary contributions to the programme. This took two forms: their activities to bid and secure funding from outside the Trust (both at the application stage of SPI and for its continuation) and their authorisation of internal Trust resources (both financial and human resources). Each organisation involved in the programme were provided with an allotted sum of money (approximately £270 000 per hospital) and external resources, such as external monitoring by IHI. After the official 2-year period of implementation, withdrawal of these resources instigated plans to ensure that resources covered by initial funding and support could be continued. The most common resources authorised by CEOs for the SPI programme were: time allowed for SPI work and training; data collection and data support personnel; and an SPI coordinator to oversee the project.

Staff motivation and engagement

The CEOs described activities that empowered, motivated and reinforced staff involvement with the SPI programme. In accounts of motivating staff, the CEOs described ‘creating an appetite’ and ‘free[ing] up peoples thinking’, reporting an aim of changing staff attitudes towards the programme. Their actions to empower staff also included allowing them more power to authorise resources. Leadership walk rounds were considered as a particularly useful tool for shared dialogue and as a listening exercise. The walk round involved speaking with frontline staff across the hospital and was the principal activity of the CEOs position in the ‘leadership workstream’. Constant communication with staff was critical to encourage their engagement with the programme. At times the CEOs were called in to deal with resistance to the programme, whereby they would either discuss the situation with the resisters, attempt to instill a sense of purpose, or in the worst case, threaten disciplinary measures for not adhering to SPI practices. Doctors were singled out as the profession with the most resistors, therefore facilitating doctor engagement was a commonly cited role. CEOs who attended SPI learning sessions to learn about relevant improvement practices reported that their learning helped when engaging staff, as they were more knowledgeable on various aspects of the programme, such as QI techniques and targets set.

Another critical task was encouraging Board buy-in through highlighting the programme strategies and targets. An NHS Board is made up of a chairman, executives, directors and non-executives and, through regular meetings they jointly oversee, offer direction and are responsible for the financial and quality performance of the hospitals within their Trust. Employed by the Trust, the full-time executives/directors (eg, CEO and Medical Director) are responsible for the day-to-day oversight of the hospitals and together with the chair and non-executives (recruited externally to the Trust on a part time basis) are all responsible for overall governance, strategy, achieving performance targets and standards. Therefore, collectively they hold influence over the quality and safety of their organisations.

Commitment and support

All 17 CEOs highlighted the importance of personal commitment and most believed that they acted as a support to staff implementing the programme. Some CEOs described acting as a role model to others and most agreed on the powerful effects that their visible commitment had. Demonstrations of commitment included: attending learning sessions; emphasising the purpose of SPI; attending leadership walk rounds; integrations of safety into the Board agenda such as safety stories at meetings and prioritising it on the agenda; speaking at sessions to explain the programme; and providing approval for SPI-related practices. These were considered demonstrations of commitment to SPI because they required observable effort by the CEOs to prioritise, promote and become involved in the programme. Some made the point that acting as a figurehead is not enough, and that visible acts of commitment need to follow. A few described the potential for loss of momentum if their commitment was absent. Several interviewees recognised their role in creating the right climate and environment for others to undertake the programme work effectively; however, they fell short of offering detailed description of what this actually involved. The interviewees reported to further aid their staff with statements of purpose and direction. This endeavour was also referred to as ‘selling’ the process. This was done through disseminating the programme aims and targets via workshops to staff and presentations to the Board. The CEOs also increased their involvement when SPI work activity was not heading in the right direction.

Monitoring

Monitoring the progress of the initiative was a frequently reported activity. The CEOs monitored progress by reviewing SPI outcome measures, reading reports, checking information and asking for information on particular programme actions and challenges at Board meetings. Outcomes were reviewed on a weekly or quarterly basis depending on the Trust, often in the form of presentations, safety-style dashboards and Run Charts.23 While regularly reviewed, it was not always analysed or actioned; however, many CEOs agreed that it both raised awareness and flagged safety issues, as well as offering the Board an opportunity to prioritise, openly discuss, understand and address trouble areas. Monitoring of progress was not only to explore challenges, but also as a way of ensuring that targets were met. Feedback to senior management at Board/project meetings on whether staff were complying with SPI prescribed activities was thought to be a powerful influence on staff engagement and accountability. This is because staff were influenced by positive or negative responses from senior management. Accountability was generated at these meetings through assessment of targets met and actions delivered. The CEOs primary intention to monitor the process and its key clinical indicators was to become familiar with the programme and to keep track of progress rather than to improve compliance. Timeframes were set by the workstream leads and coordinators but CEOs would query the programme leads if they were falling behind on self-imposed deadlines and targets. Outside of the meetings, the CEOs did not audit the programme's progress or compliance to it; instead they relied on the implementers of the programme to report back on these, especially if there were any problems.

Embedding programme elements

Many CEOs discussed changing system processes and strategies in order to facilitate change necessary for new SPI activity and procedures. Embedding them into existing systems and processes was considered the most efficient way to sustain practices and the most cited approach used. The profile of quality and safety targets and plans were raised through adding SPI objectives high on the agenda and amending strategies to focus on SPI prescribed activity and aims. Examples included adding SPI targets into mission statements and strategic objectives. Integration of programme elements into existing systems involved amendments to processes, such as changes to performance management systems and strengthening lines of accountability associated with targeted outcomes. Putting reporting mechanisms in place and incorporating SPI elements into other existing initiatives, such as Lean (a continual improvement process model), were other frequently quoted methods of integration, as was including practices into staff objectives and individual performance management.

Limitations

It is important to highlight that this research has not been able to assess any association between the CEOs’ roles and successes/failures of the SPI programme. It instead describes the CEOs’ self-reported contribution to the programme. These self-reports may be subject to social desirability bias, especially as the interviewees were involved in the application process to secure implementation and additional programme funding. In a previous research survey of 635 of the SPI participators (including the CEOs), not only did senior management and frontline staff have many divergent views on the programme's strengths, weaknesses and impact, but also the senior managers held overall more positive views than the frontline.22 ,24 Equally, the fact that this sample volunteered for this high-profile initiative brings with it a self-selecting bias that is arguably likely to have led to an overestimation of the involvement that senior managers at this level would typically engage in within most improvement initiatives in their Trusts. However we have tried to lessen this limitation with supplementary analysis with staff views of those involved in SPI.

The SPI programme achievements remain unclear. In a large formal evaluation of hospitals involved in the SPI programme, while gains in quality and safety were found, the gains were no larger than in the control hospitals that were not involved in the programme.36 In particular, there may have been improvements in specific areas in some hospitals which were not detected by the broader evaluation. The evaluators themselves further noted that large-scale effects may take a longer time to surface.36 As the SPI as a programme did not demonstrate overall improvement or elucidate which organisations performed better than others, it is difficult to link CEO self-perceptions with formal outcomes, and the existing data does not show clear enough trends for this analysis. Lastly, the sample size is relatively small yet can be judged respectable when considering that the interviewees included all but one of the CEOs in charge of all of the NHS Trusts that participated within SPI across the UK and when considering the low number of CEOs in the wider UK population compared with other healthcare professionals. Nevertheless, a larger sample that is less homogeneous would have strengthened the study and its findings.