Small steps…

“Patient first is the heart of everything we do. Patient first is our most transformative element.”

This is the mantra of Gary Kaplan MD, Chairman and CEO of Virginia Mason Medical Centre, one of the safest hospitals in the world.

At Southern Health’s 2017 Annual Meeting, a member of the Trust reported two small examples of employees putting customers first – and in one case colleagues too.

Both received a personal, handwritten note from the impressive new Chair, Lynne Hunt.

Card - Liz - Copy (3)


Lynne demonstrates an essential element of Total Quality Management: the way Directors respond to reports of adverse events is crucial to keep employees engaged and help them see the process as personally meaningful.

Directors should sincerely thank employees for reporting incidents and engage them in talking through the incident to help assess the level of urgency and determine next steps.

The Law of Marginal Gains¹:

Nor should low hanging fruit‘ be ignored. The two examples above, on their own, may seem insignificant but the aggregation of marginal gains dictates that a number of small improvements added together result in a significant overall improvement.

marginal-improvement 2Rather than try to improve one aspect of performance by say, 10 percent, instead try to improve 10 areas by 1 percent.

It sounds almost too good to be true – we could all improve by such a small margin!


In any event, whether a concern is “significant” depends on the reporter’s opinion. No act of speaking up should be dismissed until the matter is investigated and leaders know that customers and staff are safe.

Small improvements when added up mean the difference between winning and losing.

Cost and Care:

Baby Birds

Barely a day passes without NHS bodies demanding more taxpayer’s money based on the conventional wisdom that ‘you get what you pay for’. The latest is for an extra £350m/week→ – over £600/p.a.² for each income tax payer. 

This would lead to even more wastage in the knowledge that taxpayers pockets are like a bottomless pit.

However, Virginia Mason has proved that the path to lower cost is the same as the path to safer care. Underlying this is the shared assumption that cost and quality are not alternatives to be traded off, but different aspects of the same ambition to provide safe, effective care on a sustainable basis.

For example, Frontier Economics recently published a report, commissioned by the Department of Health, investigating the costs of unsafe care in the NHS.  A rapid review of existing evidence suggests that the costs of preventable (adverse) events is likely to be more than £1 billion per year, but could be up to £2.5 billion annually. Read more here→

The CQC’s ‘State of Care’ report, which shows massive variation across Trusts, despite similar input costs, also challenges conventional wisdom.

And these also challenge the other commonly held view that only large-scale change will release significant value.

Small steps big changes 2


In 2017, Southern Health made fundamental changes to the Board and published its Quality Improvement Strategy 2016 – 2021.

As they work on major projects, staff need to be encouraged to make small improvements too, which, when aggregated, will make a big difference.




Another essential element of Total Quality Management is that staff can self-report adverse events without punitive consequences. This is not related solely to traditional whistle-blowers.  

If employees realise that their own actions have caused harm to a customer – or could do so – employees should be able to report the incident without punitive action. A defect signals there’s a problem, not with the individual, but in the organization’s processes and systems that care for its customers.

A sign of a fully-effective Total Quality Management system is that Freedom to Speak Up [Whistle-blowing] Guardians are redundant because everyone in the organisation feels safe in reporting adverse events – even if they self-disclose.

We leave the final words also to Dr Kaplan of Virginia Mason:

My conclusion is that too many people still think that providing the best care is something you do only when you can afford it – and fail to appreciate that improving care is one of the best ways to control costs in financially challenged circumstances.

¹ Sir Dave Brailsford – [Harvard Business Review]          

² 30,300,000 individual income taxpayers 2017-18 [HM Revenue & Customs, May 2017]