Overview

Over the past five years, West Suffolk NHS Foundation Trust (WSH) has transformed its approach to continuous quality improvement, evolving from a handful of isolated projects into a trust-wide programme that embeds improvement into everyday practice. Under the leadership of Senior Quality Improvement Manager, Natasha Rivers, and with renewed executive sponsorship, the Trust has focused on building infrastructure, capability and culture to support sustainable improvement at every level of the organisation.

The challenge

When Natasha Rivers joined the Trust in 2020, there were 12 active quality improvement projects underway across the organisation. Frontline teams were already demonstrating a strong desire to improve services and outcomes for patients, with pockets of excellent improvement activity taking place. The opportunity was to build the infrastructure, capability and leadership support needed to help improvement activity grow, spread and become more sustainable across the Trust.

Natasha’s focus was to:

• Build a sustainable culture of continuous improvement.
• Develop improvement capability and capacity at all levels of the organisation, including senior leaders.
• Align improvement activity with the Trust’s strategic priorities.
• Create the conditions for frontline staff to lead and test improvements that matter to patients and colleagues.
• Deliver this transformation through a small specialist improvement team.

The approach

Securing leadership support

Building on the growing momentum for improvement across the Trust, the appointment of a new executive leadership team provided an opportunity to further align continuous quality improvement with the organisation’s strategic ambitions. The continuous quality improvement team worked in partnership with executive and senior leaders to strengthen understanding of improvement methodology at board level and reinforce the important role leaders play in supporting improvement. This included a dedicated board development session and workshops for senior operational and clinical leaders focused on leading and enabling improvement within their services.

Building continuous quality improvement infrastructure

Over the last 18 months, the Trust has effectively relaunched its continuous quality improvement programme by creating a comprehensive improvement infrastructure:

• A four-tier training programme, including introductory, foundation, leadership and coaching pathways.
• A six-month continuous quality improvement Leaders Programme where participants learn improvement methods while delivering real projects.
• A continuous quality improvement coaching programme designed to embed improvement coaches across departments and divisions.
• A centralised prioritisation and triage process for all improvement projects.

Aligning improvement with strategy

Rather than treating continuous quality improvement as a standalone initiative, the Trust embedded improvement principles throughout its organisational strategy. Continuous quality improvement became a strategic priority, with improvement language and methodology embedded within the Trust’s enabling strategies and reflected in the development plans for the new Quality Management System (QMS) for 2026–27. This has helped strengthen the alignment between quality improvement and organisational development, supporting a more consistent approach to improvement across the Trust.

Prioritising resources

Recognising the limitations of a small continuous quality improvement team, West Suffolk introduced a structured prioritisation framework. Quality Improvement projects are assessed and categorised according to their alignment with Trust priorities:

• Tier 1: High-priority projects aligned to Trust, divisional or departmental objectives, with a significant impact on patient safety, patient outcomes or staff outcomes.
• Tier 2: Projects with moderate strategic alignment.
• Tier 3: Projects that support local service priorities and continuous improvement, while contributing to quality, safety, patient or staff outcomes.

This approach ensures all staff can access improvement support, balancing the delivery of strategic objectives with the empowerment of frontline teams to identify, test and implement improvements that matter to their services.

This approach ensures all staff can access improvement support, balancing the delivery of strategic objectives with the empowerment of frontline teams to identify, test and implement improvements that matter to their services.

Results

Growth in improvement activity

The Trust increased from 12 active quality improvement projects in 2020 to a peak of 240 projects. Following a strategic review, the portfolio was refined to approximately 120 projects, with a stronger emphasis on quality, impact and alignment to organisational priorities.

Building capability

The continuous quality improvement programme has achieved significant reach across the organisation:

• More than 1,500 staff trained in quality improvement.
• More than 1,600 staff engaged in continuous quality improvement activities or awareness programmes during the last 12 months alone.
• Participation from clinical and non-clinical staff, including porters, cleaners, warehouse staff, nurses, advanced clinical practitioners, trainee doctors, consultants and allied health professionals.

Culture change

One of the most significant outcomes has been a shift in mindset. Supported by a dedicated communications and engagement campaign, staff increasingly see quality improvement as part of their day-to-day role rather than an additional task. Improvement language is becoming embedded across teams, and staff are proactively seeking opportunities to apply quality improvement methods.

The Trust has also seen growing engagement from senior leaders, clinicians and service leads, with continuous quality improvement champions emerging across a range of specialties and services, including Emergency Medicine, Critical Care, Community Services, Surgery and Midwifery. Their visible leadership and active involvement have been instrumental in building improvement capability, supporting frontline teams and embedding a culture of continuous improvement within their areas.

Improvement in action

Continuous quality improvement methods have been used to support a diverse range of improvement priorities across the Trust, from improving clinical documentation and patient safety processes to enhancing community services, patient pathways and operational performance.

Rather than being confined to individual projects, continuous quality improvement is increasingly being used as a structured approach to addressing challenges across multiple services and disciplines, supporting both strategic objectives and frontline-led improvement.

Looking ahead

The Trust is now focused on the next phase of its continuous quality improvement journey, including:

• Embedding a Trust-wide Quality Management System.
• Strengthening links between continuous quality improvement, patient safety audit and human factors.
• Expanding coaching capacity across divisions.
• Increasing the use of continuous quality improvement in complex operational and strategic programmes.
• Supporting care accreditation and quality assurance initiatives through improvement methodology.

With executive support firmly established and improvement capability growing across the organisation, West Suffolk is positioning continuous quality improvement not as a project or programme, but as the foundation for how improvement happens across the Trust.