Why managing quality in healthcare requires a steady hand

Improving service quality
31st March 2015

Managing quality in healthcare seems like a rather sedate affair in the academic literature. In my experience it’s more like trying to control a herd of wild horses!

I know….sounds a bit dramatic.

But this is how I see it when I reflect back on my service management days. It’s important to keep control of all the key elements of quality to achieve genuine service improvement. The challenge for all leaders in healthcare is to maintain a steady hand.

The wild horses I’m referring to are the Six Dimensions of Quality —



person centred,




It’s a framework widely used in the NHS. While the Six Dimensions framework has its origins in the USA health sector, the versatility of the framework makes it applicable to most service sectors. Personally I find the framework a useful way of making sense of quality, particularly in situations of high complexity.

Focusing on one dimension risks losing control of the others

In Scotland the Scottish Government sets the strategic direction for improving quality in the NHS. A few years ago the spotlight was on improving waiting times for treatment in cancer services and for surgical operations such as in hip and knee replacements (the timely and equity dimensions). Things improved and these waiting times became shorter. The focus then moved to ensuring services were safe, effective and efficient and person centred.

I can understand why different dimensions are selected for closer attention at a strategic level. Prioritisation allows additional resources to be targeted at areas needing improvement. However the closer you get to the people you serve, the more unpredictable the management of quality becomes. Rather than being selective, there’s a need to keep a watchful eye on all six dimensions simultaneously.

That’s why it can feel like trying to control a herd of skittish horses. Each one straining at the reigns ready to race off at the slightest hint of a loosening of the grip. It’s a constant balancing act to minimise the unintended consequences of addressing one dimension at any one time over another. Introducing a new practice based on best evidence (effectiveness) may increase costs (efficiency) and this may lead to less people being seen within a given period (timeliness). It may also have implications for staff skill (safety, effectiveness) and on it goes.…

The importance of the Six Dimensions Framework

Viewing quality through the lens of the Six Dimensions Framework enables you to be more proactive and mindful about quality management. It also gives a degree of comfort once you accept that the quest for an acceptable level of quality is never ending. At least as a leader you know where you stand and sometimes it will be just about holding steady as changes to improve services bed down.

The criticisms about a lack of compassion in the NHS suggests that person centredness has been side-lined in the race to address the other more volatile dimensions. It is now reasserting itself and holding its own among the quality pack. Rather than being seen as a separate dimension, person centred practice must be at the very heart of the quest for quality. Like patient safety, it must be the measure against which the other dimensions are judged.

Improving the quality of healthcare needs determined leadership and a steady hand on the reigns. In the right environment the wild horses will settle but managers and clinical leaders must play their part, working together.
















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