How to self assess

All NHS organisations and systems are being supported to embed an approach to improvement aligned with NHS IMPACT (Improving Patient Care Together).

In April 2023, NHS chief executives asked for a jargon free NHS IMPACT self-assessment to help systems, providers and partners understand where they are on their journey to embed each of the five components of NHS IMPACT.

The NHS IMPACT team has co-designed a self-assessment tool which is a maturity matrix for the five components. This should allow them to identify their strengths and opportunities for development when applying an organisational/system wide approach to improvement and provide a framework to build a development strategy.

The self-assessment is designed to stimulate a discussion and debate. It will provide a starting point and enable an action plan to be developed to embed the five components of NHS IMPACT.

The first NHS IMPACT self-assessment to be made available supported acute and mental health providers. Following a period of co-production and testing the NHS IMPACT self-assessment is now available for any NHS organisation and system to use.

Download the NHS IMPACT self-assessment.

Access the questions for the NHS IMPACT self-assessment.

Taking a learning and improvement approach and actively listening to stakeholder feedback, the National Improvement Board agreed that NHS England would not ask for organisations and systems to submit their self-assessment return to NHS England. The reasons for this are:

  • Requesting the self-assessment to be returned to NHS England would dilute the benefit to the organisation completing it.
  • The purpose of the self-assessment is to allow honest self-reflection for organisation itself.
  • The data and output of the self-assessment is for the benefit for organisations to use it to inform their development plans.

The National Improvement Board strongly encourage organisations, and their boards, to engage with the completion of the self-assessment and creation of a development plan.

The NHS IMPACT self-assessment is designed to stimulate a discussion and debate. It will provide a starting point and enable an action plan to be developed to embed the five components of NHS IMPACT. The aim is for the self-assessment to support genuine reflection and learning and would encourage the use of the self-assessment in all organisations and systems.

Top tips and a glossary of terms to support with the completion of the NHS IMPACT self-assessment

Top tips

  • Take time out to do this properly.
  • Get the right people in the room.
  • Reflect honestly on where you are currently as an organisation – the score does not matter it is the debate and discussion that is more useful.
  • Develop an action plan to move forward.

Glossary of terms and their definitions

This can be Board, executive or senior leader level.

So that change is not ‘done-to’ people, but ‘done with’. Effective and sustainable change always involves:

  • staff (the people who do the work and want to improve it)
  • stakeholders (people in organisations, systems, and other partners, that are affected by the work done and want to share in its improvement)
  • people with lived experience. We describe co-production as “a way of working that involves people who use health and care services, carers and communities in equal partnership; and which engages groups of people at the earliest stages of service design, development and evaluation”.

A structured, systemic and measurable approach for a whole organisation to link goals to strategy to action, in the long, mid and short-term; as follows:

  • Develop goals derived the organisations vision, mission and purpose, develop strategy from those goals, and prioritise actions.
  • Describe the method by which activity at all levels (leadership, management, and delivery) is aligned with goals, how progress and performance is measured, and how to course-correct to maintain progress, i.e. should have plan, do, study, act at its heart at all levels.

Safe, effective, positive experience (responsive and personalised; caring), well-led, sustainably-resourced and equitable care, in service of better health outcomes

Teaching of a coherent and structured improvement approach that develops knowledge of the principles, method(s), and tools, and how to apply these in practice as an individual, and within teams; to note: NHS IMPACT encourages the use of any established improvement methodology.

Effective learning comes from knowledge applied, ideally frequently, to ‘close the learning loop’.

Improvement training should be available at various levels from basic through to advanced, using a ‘dosing’ approach.

An improvement specialist is responsible for leading the deployment of an improvement strategy, for training others and for providing technical expertise and coaching support for improvement. They have received training in an improvement methodology and have delivered multiple improvements over time.

This means people who deliver quality improvement training, and facilitate quality improvement sessions, and follow-up with coaching support.

An improvement method is the core part of an improvement methodology – it encourages and enables a structured trial-and-error style testing by all.

It is a defined and consistent set of actions that are repeated continuously in a cycle in order to (i) effect process change and deepen knowledge about it that can be shared (ii) practice the method to gain expertise in it, and (iii) become skilled enough in the method to teach and coach others.

An improvement methodology is a systemic, structured and consistent approach to think about, develop, and manage change that is focused on producing process improvements within the domains of; delivery, quality, resource use, and people-related factors, and across all levels of an organisation and/or system.

All improvement methodologies should have an improvement method and teamwork at their heart.

Improvement is usually:

  • focused on continuous improvement which is the ongoing, long-term improvement to processes, products and services. This can involve incremental improvements over time or breakthrough improvements made all at once. The goal is to make periodic beneficial changes.
  • about having learning at its core
  • more iterative and experimental
  • based on teamwork, in that it’s the people who do the work that can improve the work, and are full of ideas
  • done in collaboration; improvement can bring joy to work and taps into the intrinsic motivation of individuals and teams to make things better for people
  • develops a positive, collaborative and inclusive culture focused on the patient.