What this looks like in practice:

• Create a vision and shared purpose in an inclusive and transparent way ensuring meaningful input from all, including those with lived experience. The executive leadership of the organisation must drive this work, but it cannot be designed and created by one team.
• Find ways to involve diverse communities, people with lived experience and staff as partners in the design of the vision and shared purpose.
• Find ways to make the shared purpose and vision practical, so that they are lived everyday by its people and are underpinned by core values.
• Ensure all improvement work is focused on the shared purpose and vision and question any work which does not align to these. Start by focusing on the current NHS priorities and your own organisation’s context, including the pressures it is facing.
• Create a powerful, purpose-driven context and narrative for improvement work so that people are more likely to engage, based on commitment to the purpose rather than compliance with a process.
• Understand the world in which your staff are working, their challenges, their successes, and the improvement they’d like to see to guide this shared purpose and vision through methods of co-design and collaboration.
• Take account of the current quality indicators (for example, staff survey scores, Care Quality Commission well-led framework, value-based healthcare) and where there are areas for improvement.
• The shared purpose and vision should allow staff to understand the importance of their work and to see it from the patient or service user’s perspective. Celebrate and share good practice where possible.

1. Board and executives setting the shared purpose and vision

Starting: We are starting to develop a shared vision aligned to our improvement methodology, although only known by a few and not lived by our Board. Our organisational goals are not yet aligned with the vision and purpose in a single, strategic plan.

Developing: Our Board, executive leaders and senior management team can describe a shared vision and purpose that is the start of the process to align these with our organisational goals.

Progressing: Our Board, executive leaders and senior management team are active and visible in promoting the shared vision and translating it into a narrative that makes it meaningful and practical for staff. Measures have been agreed and defined with a small number of key metrics (for example, operations, quality, financial and people/workforce).

Spreading: Our vision and shared purpose inform our journey and plans, and operational and clinical leaders and teams across our organisation know how they are contributing to, and own, our organisational goals. All employees have been communicated with and understand our shared vision in a way that means something to them.

Improving and sustaining: Our vision and shared purpose is well embedded and often referred to by the board and all leaders, who can bring it to life and make the link between their team’s priorities and improvement plans and the agreed organisational goals. Most of our staff can describe our vision and shared purpose in their own words and what they can do in their role to contribute.

2. Improvement work aligned to organisational priorities

Starting: Our organisational purpose, vision, values and strategic priorities are in development, but not yet widely communicated to staff. Organisational goals are yet to be defined in a way that enables them to be cascaded to all our teams.

Developing: Our organisational purpose, vision, values and strategic priorities are understood by some within our organisation, but generally seen as organisational goals rather than something which is directly meaningful to them.

Progressing: Our organisational purpose, vision, values and strategic priorities have been translated into agreed organisational goals, and measurement systems have been established. The priorities are well understood by most leaders and managers, which is helping to create organisational alignment.

Spreading: Our organisational purpose, vision, values and strategic priorities are visible and understood by leaders, managers and most staff. Our organisational goals have been agreed and measurement systems have been established and are being used across most areas.

Improving and sustaining: Our organisational purpose, vision, values and strategic priorities are role modelled and actively reinforced and communicated by leaders and managers, widely understood by most staff across our organisation and translates into improvement activity at team level.

3. Co-design and collaborate – celebrate and share successes

Starting: We are at the early stages of working out what quality or continuous improvement means in our context and how we will apply it systematically. So far engagement has been largely focused at Board level.

Developing: The Board has set a small number of bold aims with measurable goals for improvement, and a communications and engagement plan ensures that staff have at least heard about these goals.

Progressing: Our improvement goals are developed and refined through a collaborative engagement process, which at least involves senior leaders and most managers and a two-way feedback process.

Spreading: We have an agreed plan for delivery at organisational level which is cascaded through line managers down to team level, based on an established engagement and co-development process and a common approach to improvement. Celebration and learning events are used to recognise and share improvements.

Improving and sustaining: Our senior leaders and managers model collaborative working as part of the organisation’s continuous improvement approach. We have an agreed plan for delivery at organisational level that we can systematically track to team level. Celebrate and learning events are an established practice to recognise and share improvements widely.

4. Lived experience driving this work (patients, staff, communities)

Starting: There is an aspiration or stated commitment to engage people using services, unpaid carers, staff and the community in further design of our shared purpose and vision, but it is not yet fully worked through or systematic.

Developing: People using services, unpaid carers, staff and the community are involved in the design and communication of our shared purpose and vision and may have a role in setting improvement priorities.

Progressing: Patients, carers, staff and public are actively engaged in co-designing organisational purpose, vision, values and setting strategic priorities for improvement.

Spreading: Patients, carers, staff and public are actively engaged in setting improvement priorities, including at service, pathway or team level, and in evaluating the impact of improvements from a user perspective.

Improving and sustaining: Patients, carers, staff and public have a voice which influences the strategic improvement agenda and decision making at Board level, including setting the strategic direction of the organisation and any working with the wider system.

What this looks like in practice:

• Set the expectation (for example, through new joiners’ welcome and induction process) that all staff should have a common understanding of improvement, that it is a priority for the organisation and that they will be supported to make improvements in their own area of work.
• Engage with people who work in healthcare roles and organisations and those with lived experience to design and implement the improvements based on what matters to them.
• Facilitate opportunities for people to visit other organisations to understand different ways of operating and different organisational cultures.
• Invest in and support people to understand and own their work, enabling them to make improvements in their own area of work.
• Undertake planned and deliberate cultural readiness work prior to any improvement programme or activity, to establish and maintain a shared set of values that everyone can align to.
• Use a coaching-based approach to leadership in areas where improvement is required, encourage idea generation and run PDSA (plan, do, study, act) cycles regularly. Encourage the use of measurement to evaluate improvements and to learn.
• Have a locally agreed method to measure and assess organisational improvement culture, including drawing on current quality indicators (for example, staff survey scores, Care Quality Commission well-led framework) to support organisational development and learning.

5. Pay attention to the culture of improvement

Starting: There is an aspiration or stated commitment at Board level to establish an improvement culture, but it is yet to be worked through even at Board and executive level.

Developing: Our Board is committed to establishing an improvement culture and has plans to put this into practice, including Board development. The organisation has ways of measuring culture change (for example, using a cultural survey or the NHS staff survey) and readiness for improvement.

Progressing: Our improvement approach considers culture as an integral aspect involving all functions of the organisation, recognising the value they bring to enabling organisational improvement. Most improvement activity starts with ways to actively engage staff and teams from all areas in supporting improvement goals and effective delivery of care. Our organisation has ways of measuring culture change and readiness for improvement at departmental or team level.

Spreading: Senior leaders and managers at all levels understand their part in establishing a culture consistent with improvement. We consider measures and markers of culture change alongside other ways of evaluating improvement, down to team level. We have established a culture where our staff feel confident and empowered to take part in improvement activity in their own area and talk openly and honestly to senior leaders and managers when they are ‘walking the floor’.

Improving and sustaining: We have a reputation for having established a culture consistent with improvement, and we can evidence that with data (for example, NHS staff survey). Teams and departments work collaboratively across organisational boundaries to deliver improvement which benefits people using services and carers. We recognise leaders, managers and staff who are role models for the kind of behaviour and culture we want to create.

6. What matters to staff, people using services and carers

Starting: Our ways of understanding what matters most to staff, people using services and carers tend to be reliant on formal mechanisms (for example, surveys) and the link to improvement is not strong or systematic.

Developing: We understand well as an organisation what matters most to staff, people using services and carers and this helps to shape our overall improvement priorities and our approach. Picking up on what matters most to our staff helps to bring us together around a common agenda and creates energy for improvement.

Progressing: Most of our services and functions have a good understanding of what matters most to staff, people using services and carers, and this informs their local improvement priorities and activity. Our staff have a voice at Board level to provide feedback on how it feels to work here (for example, through staff stories, informal interactions, staff networks). Leaders and managers help to translate the needs of patients and carers into improvement priorities or goals.

Spreading: Most of our teams have a good understanding of what matters most to staff, people using services and carers, and this informs their local improvement priorities and activity. Most staff feel invested and excited about the opportunities they have available to participate in improvement activity which matters to them.

Improving and sustaining: Most of our staff can describe what matters most to them, people using services and carers, and how this translates into their local improvement priorities and activity.  There is a strong and direct connection between their improvement activity and making things better for people using services. People with lived experience often work in close partnership with our teams on improvement activity, helping to focus on what will make the greatest difference.

7. Enabling staff through a coaching style of leadership

Starting: There is some recognition of how a coaching style of leadership helps to encourage improvement, but it is not widely applied.

Developing: There is an organisational endorsement of a coaching-style of leadership, but it is not applied systematically (for example, through leadership training). There are some good examples of how a coaching-based approach can bring about improvement, and this is increasingly recognised and encouraged. Staff are often supported to make changes when doing improvement activities.

Progressing: A coaching style of leadership is well established with training available for leaders and managers who request it. Leaders and managers are widely engaged in improvement and regularly sponsor improvement activities to help unblock issues. Senior leaders participate in improvement celebration and learning events on a regular basis. Staff generally feel supported and empowered.

Spreading: Senior leaders and line managers are trained systematically in coaching and enabling teams to solve problems for themselves. Our executive leaders act as coaches and teachers of the improvement method for all levels, including role modelling a coaching style. Managers/clinicians/staff participate in improvement celebration and learning events on a regular basis. Staff talk about feeling more trusted and empowered.

Improving and sustaining: A coaching style of leadership is embedded as the default approach throughout the organisation, and it is applied to our greatest challenges. Staff and teams thrive in this environment and take greater ownership of improvement. Our senior leaders and managers are recognised as effective improvement coaches and are often sought after to lead and support improvements beyond our own organisation.

8. Enabling staff to make improvements

Starting: Improvement activity is limited and may be centralised (for example, led by a discrete ‘improvement team’ operating independently). Staff do not generally feel able to make improvements in their own area of work.

Developing: Some staff and teams feel able to make improvements (for example, if they have been trained or are supported by a central team). There may be learning locally but it is generally not shared across teams and departments.

Progressing: Most staff are actively involved in improvement activity and feel able to suggest ideas for improvement and to make changes in their own area.

Spreading: Most teams feel empowered and trusted to carry out improvement activity in their own areas, applying a consistent approach. Our staff understand the factors driving progress (whether positive or negative) and can solve problems effectively.

Improving and sustaining: Staff and teams are systematically engaged in improvement activity as part of their day-to-day work and are proactive in sharing the learning, and in looking for ways to collaborate with people with lived experience and other teams and organisations in improvement programmes.

What this looks like in practice:

• Have a clear leadership and management development strategy in place, outlining capability requirements and access to training.
• Understand current leadership styles and approaches through Board and executive development sessions identifying strengths and gaps for each individual and as a team.
• Create Board and executive leadership stability and continuity of approach.
• Support senior leaders and managers to live and breathe the values and behaviours of the organisation focussing on enabling all staff to improve their daily work. Regularly visit staff in their place of work.
• Hold senior leaders and managers to account for behaviours, not just improvement outcomes through a clear framework and agreed expectations.
• Clearly agree and outline the support which is in place for people to improve their own services.
• Provide induction, training and development for everyone who has a formal leadership or management role so they have skills and experience of delivering improvements and can role model leading for improvement.
• Encourage Board development to better understand how current senior leadership and management behaviours are demonstrating organisational values, identifying strengths and gaps.
• Engage with peer support networks to understand different approaches to the issues, as well as leadership and management behaviours.
• Empower teams delivering on the ground to carry out and test improvement projects.

9. Leadership and management development strategy

Starting: Our Board, executive and senior leaders and line managers are not yet trained in a consistent and defined improvement approach which they are expected to apply and role model.

Developing: Our executive and senior leadership team have started to develop their improvement knowledge and are gaining an understanding of how it can impact their role.

Progressing: Our executive and senior leadership works with managers and teams across the organisation to develop improvement skills and enable and co-ordinate improvement.

Spreading: Our executive and senior leadership and management teams actively enable staff to own improvement as part of their everyday work, and all teams and staff have had training in improvement.

Improving and sustaining: Our Board focus on constancy of purpose through a multi-year journey and executive hiring and development, including succession planning. Our Board is visibly linked to future planning at a system level.

10. Board, executive and senior leadership and management values and behaviours

Starting: Our executive and senior leadership values and behaviours and our expectations of managers are not explicitly defined, or do not include reference to an improvement-based approach. Existing behaviours could do more to promote the health and wellbeing/psychological safety of staff.

Developing: Executive and senior leadership values and behaviours (that acknowledge the health and wellbeing/psychological safety of staff) are agreed across our organisation.

Progressing: Executive and senior leadership values and behaviours (that acknowledge the health and wellbeing/psychological safety of staff) are agreed, and role modelled by leaders and managers across the organisation.

Spreading: Executive and senior leadership values and behaviours are agreed, role modelled and supportively challenged when not lived up to. Existing behaviours actively promote the health and wellbeing/psychological safety of staff.

Improving and sustaining: A clear framework and expectations for executive and senior leadership and management values and behaviours which are consistent with an improvement-based approach are applied throughout the organisation.

11. Senior leadership and management acting in partnership

Starting: The goals our executive and senior leadership are working to could benefit from greater clarity and alignment.

Developing: Most of our executive and senior leaders work in partnership with their fellow leaders and managers.

Progressing: Our executive and senior leadership team have shared goals with the organisations they work with in their wider systems.

Spreading: Our executive and senior leadership team has shared longer-term goals with network partners and/or commissioners, as well as collaborative involvement over the wider health economy.

Improving and sustaining: Our Board and wider system focus on constancy of purpose through multi-year journey with improvement at its core.

12. Board development to empower collective improvement leadership

Starting: Our Board discusses improvement at Board meetings, but it is not a regular occurrence.

Developing: Our Board has received some improvement training and visits parts of the organisation at least monthly. Improvement is discussed at every board meeting.

Progressing: Our executive and senior leadership works with managers and teams across the organisation to enable and co-ordinate improvement.

Spreading: Our executive and senior leadership and management teams actively enable staff to own improvement as part of their everyday work.

Improving and sustaining: Our leaders – chief executive officer and chair through to front line demonstrate their commitment to change by acting as champions of the improvement and management method, by removing barriers and by maintaining a visible presence in areas where direct care/operational work is delivered.

13. ‘Go and see’ visits

Starting: Some senior leaders spend time engaging directly with staff from time to time, but it is not routine or widely practised. This can be in person during ‘go and see visits’ or virtually.

Developing: Our executive and senior leaders understand the importance of engaging directly with staff, but we have variation in leader participation; some leaders and managers use our improvement tools.

Progressing: Our executives regularly engage directly with staff; they incorporate the tools and methods into their meetings, strategic planning and daily management.

Spreading: All levels of leadership and management engage directly with staff as a matter of routine and the insights they gain inform decision making and problem solving to support improvement.

Improving and sustaining: All levels of leaders and managers undertake regular learning or ‘go and see’ visits at external bodies to visit their site and to observe different ways of working.

What this looks like in practice:

• Identify or create an improvement methodology to use across your entire organisation, ensuring a local and systemic way of practising improvement.
• Give all people access to induction, improvement training and support, so that everyone can run improvement projects and continuously improve their daily work.
• Determine how success will be measured at an early stage, use appropriate tools and frameworks, and include feedback from people working at the point of care and people with lived experience.
• Demonstrate the impact of co-producing improvements with people who use services as an integral part of daily work.
• Set an expectation that there is an organisational focus on data and all staff are empowered to make and track changes in their workplace.
• Create and embed a training strategy to increase improvement capability.
• Senior leaders and managers attend team huddle boards and work to unblock issues which teams are facing.

14. Improvement capacity and capability building strategy

Starting: We do not have a structured training or capability building approach for improvement skills. Training is ad hoc and focused on small central teams. We have some use of external resources (for example, academic health science networks and Institute for Healthcare Improvement Open School).

Developing: Our improvement methodology has been agreed and the Board has undergone its own development to build literacy around improvement. Staff have access to induction on joining, improvement training and a small group of staff support capability building.

Progressing: Training is a balance of technical skills, behavioural attributes and data analysis. Coaching support is available during and post training and time is given for staff to undertake training and development in the adopted improvement methodology. Some learning is shared across the organisation. A system exists to identify, engage and connect all those people that have existing improvement capability.

Spreading: Sustainability is addressed via ‘in-house’ training and development approaches including train the trainer models. Improvement capability building for ‘lived experience’ service user partners is underway; they are seen as contributors to improvement teams. The programme is working towards being self-sustaining through developing its own improvement coaches.

Improving and sustaining: There is a systematic approach to improvement, and induction and training are provided to every member of staff as part of learning pathways and career progression, including induction and line manager training with more than 80% coverage. Capability building is self-sustaining, meeting the improvement needs of the organisation. The organisation shares capability, building learning with other sites, regionally and nationally.

15. Clear improvement methodology training and support

Starting: No single improvement methodology has been adopted and only limited sharing of improvement gains/learning is cascaded beyond the immediate area where improvement is underway.

Developing: There are pockets of capability built by motivated staff with an interest in improvement. We have a training needs analysis which is underway to understand staff development and training needs for NHS IMPACT components, alongside a dosing formula and training strategy to support capability building ambitions.

Progressing: Clarity exists on which improvement methodology and approach is being consistently applied. There is a longer-term commitment to training and development system for building capability at scale. Service users and carers are recognised as key stakeholders.

Spreading: Training and development are undertaken by all leaders, managers and staff. Learning from all improvement activity is effectively shared across the organisation. Staff, people with lived experience and wider teams are using their skills and knowledge to deliver improvement and cascade improvement techniques to their peers.

Improving and sustaining: Learning from improvement activity is driving continuous improvement. There is a common improvement language across the organisation. Knowledge and learning from improvement is highly visible, harvested, collated and shared widely as part of a scaling up and spread strategy.

16. Improvements measured with data and feedback

Starting: Our organisational approach to reviewing and tracking progress against goals has yet to be defined. At present improvement doesn’t feature in whole organisational measures.

Developing: We are seeing minimal improvement in our organisational measures. We have developed some elements of our organisational approach to reviewing and tracking progress, however this is ad-hoc and stakeholders do not feel it supports them to deliver.

Progressing: We are tracking improvement over time for some of our organisational measures. We have a holistic approach to achieving our goals, evidenced by data, centred on problem solving, and management that stakeholders feel is supportive.

Spreading: Improvement is sustained for most organisational measures. Our goals are reviewed regularly at organisational level and our plans are adapted to ensure they meet the clearly defined goals if required. Data analysts and business intelligence teams are integral to tracking improvement.

Improving and sustaining: Sustained improvement over time for all system measures. We understand what is driving performance, (whether positive or negative), and problem solve effectively. Our goals around longer-term sustainability are reviewed regularly at organisational level.

17. Co-production

Starting: We have small discrete teams with relevant skills operating independently from one another. They are working in silos reporting to various senior leaders with no lived experience partners co-producing improvement.

Developing: People with lived experience are infrequently co-producing improvement. Learning is captured when doing improvement, but this is rarely shared across departments.

Progressing: People with lived experience and wider stakeholders are strongly involved in co-designing and co-producing the capability building approach. Staff, people with lived experience and other stakeholders have access to improvement capability development.

Spreading: Stakeholders including people with lived experience are both supported and challenged to ensure success. We understand the factors driving progress (whether positive or negative), and problem solve effectively together.

Improving and sustaining: Stakeholders are both supported and challenged to ensure success. People with lived experience and wider stakeholders are embedded within teams and are an integral part of the capability building process.

18. Staff attend huddles

Starting: Any huddles are only traditional legacy mechanisms (for example, shift change clinical handovers).

Developing: There is a plan in place for team huddles to focus on continuous improvements in some areas with clinical and operational staff in attendance.

Progressing: The majority of areas have continuous improvement team huddles established. There is a plan in place to establish continuous improvement team huddles in all clinical/operational/support areas.

Spreading: All clinical/operational/support areas have continuous improvement team huddles established.

Improving and sustaining: There is a cascade of huddles for all teams from executive to frontline teams (clinical/operational/support) which hold regular continuous improvement huddles using a standardised format and process.

What this looks like in practice:

• Develop an explicit management system that aligns with the strategy, vision and purpose of the organisation at Board level, throughout and across all services and functions.
• Put systems in place to identify and monitor early warning signs for all organisational process and quality risks. Ensuring clear standard processes of how to respond to these.
• Set up the management system as a standard way of operating that enables ongoing continuous improvement of access, delivery, quality, experience, value and outcomes whilst ensuring financial sustainability.
• Build a management system with a consistent and coherent set of systems and processes that enables the organisation to respond to system and national priorities more easily and with greater agility.
• A committed Board and senior leadership team who own and use this approach to manage the everyday running of their organisation, including simple and visual ways of understanding performance with tracking progress.

19. Aligned goals

Starting: Where improvement plans exist they are very locally determined and driven. Our strategic planning is an activity conducted at Board and senior leadership level but executives’ and functions goals are often not well aligned with each other.

Developing: We do not share improvement planning across our organisation with departments and directorates feeling siloed. Our business planning is an activity conducted at executive leadership level to produce goals that are cascaded top-down to the rest of the organisation.

Progressing: Our organisational goals are established to support our overall vision; our department/team goals align systematically with those of our organisation. Our business planning process is based on two-way engagement leading to greater local ownership of the goals.

Spreading: Our organisational and departmental goals are systematically aligned to our overall vision; and we are working to align goals across our system. Our organisational goals are developed using a consistent management system, based on two-way engagement leading to strong ownership of the goals and greater transparency between areas.

Improving and sustaining: Our organisational and departmental goals are systematically aligned to our overall vision and that of our system. Individual objectives are clearly linked to the strategic plan through the team, departmental and organisational goals and improvement plans.

20. Planning and understanding status

Starting: Our business planning and performance management processes do not make it easy for us to understand status or progress against our goals. We do not have visibility of what we are working on across the organisation.

Developing: Our business planning and performance management processes give the executive leadership team reasonable visibility of status and progress against our goals. There are some routines for selecting and prioritising improvement work. Although we have some resource available there is no defined process for prioritising and allocating resource.

Progressing: Our business planning and performance management processes give the executive and senior leadership team and most line managers good visibility of status and progress against our goals. There is good visibility of what we are working on across the organisation. We have an agreed approach for selecting and prioritising improvement work. Staff from enabling services (for example, human resources, finance, communications, information) understand our improvement priorities and embed them within and across their work across the organisation.

Spreading: Our business planning and performance management processes give good visibility of status and progress against our goals across all departments and teams. We have an agreed and transparent approach for selecting and prioritising improvement work. Our supporting resources are assigned to supporting delivery of improvement goals across the organisation in a way that is perceived to be fair and effective. Staff from enabling services understand our improvement priorities and embed them within and across their work across the organisation.

Improving and sustaining: Our business planning and performance management processes give good visibility of status and progress against our goals across all teams and is considered the ‘one version of the truth’ across the organisation. We have an agreed and transparent approach for selecting and prioritising improvement work which works well and can flex to meet changing needs. There is complete and timely visibility of what teams are working on across our organisation. There is a co-ordinated approach to review, prioritise and co-ordinate allocation of resources to support pathway-level improvement.

21. Responding to local, system, and national priorities

Starting: We do not yet have a coordinated or consistent management approach to how we respond to changing needs, address problems or deliver against our plans. Instead, it is perceived as reactive or firefighting.

Developing: Across the organisation, we believe having a management method (for example, lean) is important to our success. Some of our leaders are using management methods, which is recognised to be helping.

Progressing: Most senior leaders and managers in the organisation use our management methods to manage and run their areas, including responding to problems that may arise or to take account of changing priorities.

Spreading: Our management method is well embedded in how we work in all parts of the organisation, to team level. As an organisation we are using run charts and statistical process control (SPC) charts not just RAG (red, amber, green – a risk management rating system) or tables. Our business decisions are aligned with our management system goals.

Improving and sustaining: All teams use the management method to understand, run and improve each aspect of our organisation; we use data effectively (for example, SPC) to understand and improve performance. Whether our work is succeeding or is challenged, we strive for continuous improvement.

22. Integrating improvement into everything we do

Starting: Improvement is seen as separate to the day-to-day delivery of services. Our performance management system is seen as separate from any improvement activity or methods we apply and may be sending conflicting signals within the organisation.

Developing: Improvement is starting to be more integrated with day-to-day delivery and targeted towards particular performance priorities or risks. Improvement activity is contributing to performance in some areas.

Progressing: Improvement is generally well integrated with day-to-day delivery across the organisation and is increasingly the basis of how we deliver against our performance goals. Improvement activity is contributing to performance in many areas across the organisation.

Spreading: As part of our management system, all parts of the organisation are using improvement methods, and learning occurs between areas (for example, to understand and reduce waste). We have multiple examples of sustained improvement over months and years, not just month-to-month variation.

Improving and sustaining: The way we understand, manage and improve performance across the organisation, including how we use and report data, is consistent with our approach to improvement and based on an improvement cycle.  We have many examples of sustained improvement, including reference cases recognised beyond our organisation.