How does service improvement feature in healthcare education?

Given the relatively recent introduction of service improvement methodology in the NHS, it is not surprising that it has not been part of the taught curriculum for healthcare students until recent years (NHSI, 2008). In his 2008 review of the NHS, Lord Darzi recognised the important role of the next generation of healthcare professionals in the design and delivery of healthcare services. He directed a new challenge for healthcare education to produce a workforce capable of achieving the significant challenges facing modern health care. More specifically, Darzi’s ‘A high quality workforce: NHS next stage review’ (Darzi, 2008) defines how the NHS, higher education and industry should work together to improve the skills and competencies of the work force with the ultimate aim of improving the quality of services offered in the NHS.

In 2006, the NHSI, working in conjunction with Warwick University, began developing a programme of service improvement training that it believed could be relatively easily embedded into the curriculum for all healthcare students (Lister, Larner and Lynch, 2011). It embarked upon a widespread programme of education for Higher Education Institutes (HEIs) across the country and invited any HEI that was delivering education to healthcare professionals of any discipline, to join the programme. By 2010 there were over 50 universities involved and the teaching had been rolled-out to an estimated 10 000 students across the United Kingdom (Lister, Larner and Lynch, 2011). At the University of East Anglia we have been an active partner in this process and have developed our own model of service improvement teaching that incorporates all of the key elements recommended by the NHSI (Larner, 2012a, Larner and Collier, 2012).

Our experience of setting students a real service improvement task to undertake during practice placements has been extremely positive. Not only have we found that students are able to use a process mapping tool to analyse an aspect of a clinical service, but that they are consistently able to identify and suggest improvement ideas that could be implemented in practice. The feedback received on these tasks from the practice educators who supervise the students has been overwhelmingly positive. The ultimate value of this service improvement teaching will be measured in the future, by identifying whether graduates have been able to use their newly developed knowledge and skills to implement meaningful and sustainable service improvements in practice. However, there are numerous immediate benefits of this teaching that have become evident to us as we have developed our service improvement teaching (Larner, 2012b). These relate to the very nature of service improvement and the behaviours and attitudes that underpin the methodology. It encourages you as a student to develop your creative thinking, to take an innovative and entrepreneurial approach, and to challenge many of the assumptions that underpin our everyday working. Students value the opportunity to communicate effectively with the whole multidisciplinary team and, ultimately, to work within teams to bring fresh perspectives to the workplace. If we look at employment more broadly for a moment, there is a strong correlation between these types of activity and what employers want from you as a graduate. For example, the Confederation of British Industry (CBI) states that graduates need to be able to demonstrate a positive attitude, a ‘can-do’ approach, a readiness to take part and contribute, openness to ideas and a drive to make things happen (Lowden et al., 2011).

The literature indicates that employers want graduates who can adapt to the workplace culture, use their abilities and skills to evolve the organisation and participate in innovative teamwork. Employers also value critical thinking and reflection, as these skills are required for innovation and anticipating and leading change (Harvey et al., 1997; Little, 2001, in Lees 2002). Each of these things can be ably demonstrated through engagement with service improvement. We have found that the majority of our students are able to use any experience, however small, to demonstrate how they would transfer these valuable skills to any potential new working environment. By doing this they are also able to show that they are innovative, creative and team-focused.


Service improvement as an ‘employability skill’
Hillage and Pollard (1998) described employability as the knowledge, skills, attitudes and behaviours required by individuals to seek, obtain and sustain employability at all levels in the labour market. Some fairly comprehensive employability skills-mapping exercises have been carried out in the field of health care over recent years, in order to help both employers and staff to understand the requirements of different job roles at different levels. Two examples are particularly worthy of mention, as between them they cover a very wide range of generic employment roles and responsibilities across the whole health sector.

The Knowledge and Skills Framework KSF for Health (DoH, 2004; NHS Employers, 2010)
A broad, generic framework designed to be widely used across the UK NHS. It identifies the core knowledge and skills that individuals need to be able to demonstrate when applying for employment, using a consistent language and common classification. The KSF was simplified and relaunched in 2010 after independent review by the NHS Staff Council.

The Employability Skills Matrix ESM for the Health Sector (Skills for Health, 2014)

A practical tool developed by Skills for Health, the Sector Skills Council for all health employers, NHS, independent and third sector organisations. It identifies the typical personal skills, qualities, values, attributes and behaviours required for working in health care. Like the KSF, it is intended to support staff in their career development; but it is also a useful resource that assists employers and commissioners in defining the employability skills required by staff working at different career levels and in different roles across the wider healthcare sector.

Both of these mapping tools are useful to look at when you are preparing for a job interview because they put service improvement into context with the overall package of employability skills you will be expected to demonstrate in your new job role. Therefore, they will help you to put what you have learnt from your experience into words that relate to these expectations. Irrespective of where you work, both tools can be considered helpful for conceptualising how you have developed valuable transferrable skills in the language that employers understand and appreciate, which will enhance your chances of securing the job you want.

What level of service improvement experience will be expected?

The relative importance placed on having some experience of service improvement is clearly demonstrated within the Knowledge and Skills Framework by the fact that it is one of the six core dimensions identified. Four levels of experience are identified within the KSF, which should give you some idea about where your personal knowledge and skills fit.

Level 1

The most basic KSF level expects that employees are able to ‘make changes to their own practice and offer suggestions for improving services’. It is worth noting that it is an expectation that any member of staff, whatever their role or responsibility, is able to do this. Therefore, an employer will expect you to be able to talk about it. You should start by asking yourself if you can recall times when you have made suggestions for improving a service and how you did this. What evidence do you have that your ideas were listened to and whether they were helpful and constructive? This highlights the value of keeping a track of all of the improvement ideas you have had, what has provoked them and what tools you may have used during the analysis of the problem. Here an employer is most likely going to be looking for enthusiasm and passion for improvement, with the emphasis being on ideas and suggestions rather than actual improvement projects. Some creative thinking, some basic awareness of service improvement tools and a willingness to get involved are, therefore, an advantage.

Level 2

This level expects that employees are able to ‘contribute to the improvement of services’. Showing an awareness of how and why engagement is required at this level is essential for healthcare graduates. Although most students will have been taught some theory of service improvement somewhere in their educational programme, an employer will be looking for more here. Whilst all of the things highlighted in level one are still likely to be valuable, it is most likely that a lack of structure and logical thinking will find many people out at this level. Therefore, this is where you need to be able to call upon some real examples of service improvement activities that you have been involved with. They do not all have to be fantastic winning ideas that saved lots of money, although that would be nice! My advice here would be for you to identify some good examples of small improvement projects you have been involved with and analyse them carefully in advance. In case you are unclear of what types of experiences count as service improvement, some real life examples of student projects are given at the end of the chapter in the case studies section.

Time for reflection

What was the problem and how did you go about analysing it?

Who was involved and who did you talk to?

What tools did you use?

What was your improvement idea?

What were the benefits of what you did?

What were the barriers to change?

How would you measure the impact of your idea in the future?

How will you make sure your change is sustainable in the future?

It is highly unlikely as a new graduate that you will have had the opportunity to take an idea right through from the problem to the solution. Therefore, you almost certainly will not have been able to follow the cycle further down the line to assess the impact. However, if you have been involved with two or three good ideas as a student, and you can understand the theory and reflect on the learning outcomes of your project, then you will be able to talk with some authority on how you can contribute to the improvement of services.

Level 3

At this level an individual is expected to ‘appraise, interpret and apply suggestions, recommendations and directives to improve services’. Not all new healthcare graduates will be able to demonstrate actual engagement at this level, but some will. Here lies a clear opportunity for individuals to set themselves apart from the crowd by showing how they have engaged at this level by really applying theory to practice. Graduates who have undertaken practical service improvement tasks whilst on practice placement will have a distinct advantage here and evidence of implementing even basic improvements is likely to be received well by employers. Nevertheless, if you have not had the opportunity to do this during your training you do not need to panic. Graduates who can show that they appreciate how service improvement might be applied in practice should still be able to perform well at interview.

Level 4
This level expects employees to ‘work in partnership with others to develop, take forward and evaluate direction, policies and strategies’. Normally this would not be an expectation of new healthcare graduates, being more the remit of experienced leaders and managers. Nevertheless, an awareness of these higher level expectations of service improvement would show leadership aspirations. There is a balance to be found here between confidence and arrogance when it comes to articulating one’s own skills and knowledge, particularly when experience is limited. However, if well evidenced a discussion of this nature would be recognised by most employers as leadership potential.