Quality Improvement

At Southern Health we are constantly working to improve our services. Our aim is for the people who use our services, their families and carers, to have the best possible experience and outcomes.

Healthcare can be very complex, involving many people, so it’s crucial that we work in a proven and collaborative way to make improvements that last, and really make a difference.

To achieve this we have adopted a specific method called Quality Improvement.

Quality Improvement in Southern Health involves:

  • identifying a specific area for improvement
  • taking the time to fully understand the situation from different perspectives, gathering data and feedback
  • using special techniques to find solutions, involving professionals, patients and families so everyone has a voice
  • constantly testing and adapting once changes have been made

The Trust employs Quality Improvement experts who work alongside our clinical services, to use Quality Improvement methods to make any changes, big or small. Our aim is for everyone in the Trust to use Quality Improvement in their teams and services.

Quality Improvement empowers our staff, service users and carers, who are the real experts. Working in this way will help us develop a culture of continuous learning and improvement in Southern Health.

This video features some of the people that have participated in our Quality Improvement projects and how rewarding they found it. Find out how you can get involved here. 

So where did it all begin for the Quality Improvement programme, and introducing new methodologies and ways of working to teams across the Trust?

Southern Health, along with the whole of the NHS, is at a point where significant change is required. With an increasing population and people experiencing more complex conditions than ever before, staff work under increasing pressure. It is widely recognised that existing ways of working will not be sustainable, and will no longer enable us to give the best outcomes for our patients. 

The Trust embarked on a period of substantial transformation in late 2017, beginning with a focus on our approach to quality improvement. We wanted to learn from best practice seen in other NHS Trusts and implement some of these successes locally, as well as build on the excellent work already taking place within our own organisation. We are always striving to improve and the challenge was to make this real and sustainable change - it couldn't be a small project and it couldn't fizzle out. 

This means shifting the culture of decision making, giving our employees the autonomy and confidence to make changes themselves where they know that outcomes for patients can be improved. Initially we worked in close partnership with colleagues from Northumberland, Tyne and Wear NHS Foundation Trust, to learn from their experience in this process of transformation and improvement.

The programme has seen a number of staff take part in intensive quality improvement training, learning practical tools and methodologies that can be applied in all our services. These QI certified leaders are now using their new knowledge and skills to lead transformation projects and also provide support and training to others, so that their expertise can be shared and used to deliver real change.

There is a commitment that we involve our service users and their families in our improvement work. The Trust Board is clear that in order to make the right changes in the right places, a collection of staff, service users, patients and their carers and families must be involved at every stage. Those who deliver and receive our services are the experts in helping to make them more effective, and this is a key driver for the programme.


We have established some key principles to inform our quality improvement method;

  • Pursue value and quality as defined by the end user 
  • Understand through observation – go, look, see, measure 
  • Remove waste – work that adds no value and burdens staff 
  • Create flow 
  • Make it visible so you can see what is happening 
  • Standardise, document and continuously improve operations 
  • Co-production. We involve service users and carers in all of our quality improvement work. Only when we have those that use our services involved can we truly know how to improve. 

We encourage our staff to act on their quality improvement ideas at a local level using the PDSA (Plan, Do, Study, Act) model to help them implement their ideas and actions as effectively as possible.  This tool is easy to use and can help staff solve local problems.


We have developed a range of activities to embed evidence based tools throughout the Trust, including training and coaching.

QI coaches.jpgCoaches 
We have a central team of expert QI Coaches - responsible for coordinating and promoting the quality improvement approach and embedding QI culture.

QI Certified Leaders
We have trained a number of QI Certified Leaders who are able to lead teams to deliver service transformation and small-scale change projects.

QI Practitioners
We offer training courses for all staff in the form of "bitesize" QI methodology to equip staff with the tools to be able to carry out their own smaller scale QI projects within their teams. This can be offered as part of a team development day using our QI Olympics package.

QI Foundation
We want everyone in the Trust to know they are expected to identify and undertake improvements as part of their role. We want to inform them through regular communications and promotion of quality improvement including conferences, website and social media.
We seek to involve service users and carers in all of the Quality Improvement work that we do. Whether that is simply asking for feedback and consultation, or fully involved in the development and delivery of improvement. No matter how small or large, service user and carer involvement is paramount to our Quality Improvement work.

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