Special Measures for Quality and Challenged Providers: Study Protocol for Evaluating the Impact of Improvement Interventions in NHS Trusts

Document Type : Study Protocol


1 Department of Applied Health Research, University College London, London, UK

2 Research Team, The Nuffield Trust, London, UK

3 Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK


Healthcare organisations in England rated as inadequate in terms of leadership and one other domain enter the Special Measures for Quality (SMQ) regime to receive increased support and oversight. There is also a ‘watch list’ of challenged National Health Service (NHS) providers at risk of going into SMQ that receive support. There is limited knowledge about whether the interventions used to deliver this support drive improvements in quality, their costs, and whether they strike the right balance between support and scrutiny. The study will seek to determine how provider organisations respond to these interventions, and whether and how these interventions impact organisations’ capacity to achieve and sustain quality improvements over time.
This is a multi-site, mixed methods study. We will carry out interviews at national level to understand the programme theory underpinning the interventions. We will conduct 8 NHS case studies to explore the impact and implementation of the interventions that form part of the SMQ and challenged providers programme. We will use a conceptual framework based on models of organisational readiness for change and draw on board maturity research for implementing quality improvement. We will also review the use of quantitative metrics and data for tracking the progress of improvements in quality of care and sustainability upon leaving SMQ, as well as the costs and benefits of the interventions through a cost-consequence analysis (CCA).
High-quality interventions that successfully support struggling healthcare organisations are essential and an issue that is an international concern. Our study will allow a greater understanding of the programme theory, impact, and staff views and experiences of the SMQ and challenged providers regime. Formative feedback will be reported to key stakeholders.


Main Subjects

  1. Walshe K, Harvey G, Hyde P, Pandit N. Organizational failure and turnaround: Lessons for public services from the for-profit sector. Publ Money Manag. 2004;24(4):201-208. doi:10.1111/j.1467-9302.2004.00421.x
  2. Hockey PM, Bates DW. Physicians' identification of factors associated with quality in high- and low-performing hospitals. Jt Comm J Qual Patient Saf. 2010;36(5):217-223.
  3. Speroff T, Nwosu S, Greevy R, et al. Organisational culture: variation across hospitals and connection to patient safety climate. Qual Saf Health Care. 2010;19(6):592-596. doi:10.1136/qshc.2009.039511
  4. Ravaghi H, Mannion R, Sajadi HS. Organizational failure in an NHS hospital trust: A qualitative study. Health Care Manag (Frederick). 2015;34(4):367-375. doi:10.1097/hcm.0000000000000087
  5. Vaughn VM, Saint S, Krein SL, et al. Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies. BMJ Qual Saf. 2019;28(1):74-84. doi:10.1136/bmjqs-2017-007573
  6. NHS England. Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report. Available from Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report. https://www.nhs.uk/nhsengland/bruce-keogh-review/documents/outcomes/keogh-review-final-report.pdf. Published 2013.
  7. Care Quality Commission. The state of care in NHS acute hospitals 2014 to 2016: findings from the end of CQC’s programme of NHS acute comprehensive inspections. Newcastle-upon-Tyne: Care Quality Commission; 2017. https://www.cqc.org.uk/publications/major-report/state-care-nhs-acute-hospitals.
  8. Care Quality Commission. Quality improvement in hospital trusts: Sharing learning from trusts on a journey of QI. Newcastle-upon-Tyne: Care Quality Commission; 2018 https://www.cqc.org.uk/publications/evaluation/quality-improvement-hospital-trusts-sharing-learning-trusts-journey-qi.
  9. NHS Improvement. Learning from improvement: special measures for quality. A retrospective review. https://improvement.nhs.uk/resources/special-measures-quality-review/.   Published 2017.
  10. Rendel S, Crawley H, Ballard T. CQC inspections: unintended consequences of being placed in special measures. Br J Gen Pract. 2015;65(639):e640-641. doi:10.3399/bjgp15X686809
  11. Smithson R, Richardson E, Roberts J, et al. Impact of the Care Quality Commission on provider performance. The King’s Fund and Alliance Manchester Business School; 2018. https://www.kingsfund.org.uk/publications/impact-cqc-provider-performance.
  12. Beebe J. Rapid Qualitative Inquiry: A Field Guide to Team-Based Assessment. 2nd ed. London: Rowman and Littlefield; 2014.
  13. Tricco AC, Langlois EV, Straus SE. Rapid reviews to strengthen health policy and systems: a practical guide. World Health Organization, Alliance for Health Policy and Systems Research; 2017.
  14. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535. doi:10.1136/bmj.b2535
  15. Ferlie E, Crilly T, Jashapara A, Peckham A. Knowledge mobilisation in healthcare: a critical review of health sector and generic management literature. Soc Sci Med. 2012;74(8):1297-1304. doi:10.1016/j.socscimed.2011.11.042
  16. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117. doi:10.1186/1471-2288-13-117
  17. Pace R, Pluye P, Bartlett G, et al. Testing the reliability and efficiency of the pilot Mixed Methods Appraisal Tool (MMAT) for systematic mixed studies review. Int J Nurs Stud. 2012;49(1):47-53. doi:10.1016/j.ijnurstu.2011.07.002
  18. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-174.
  19. Yin RK. Validity and generalization in future case study evaluations. Evaluation 2013;19(3):321-332. doi:10.1177/1356389013497081
  20. Giacomini M. Theory matters in qualitative research. In: Bourgeault I, Dingwall R, De Vries R, eds. The SAGE Handbook of Qualitative Methods in Health Research. London: SAGE; 2010.
  21. Jones L, Pomeroy L, Robert G, Burnett S, Anderson JE, Fulop NJ. How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England. BMJ Qual Saf. 2017;26(12):978-986. doi:10.1136/bmjqs-2016-006433
  22. Harvey G, Jas P, Walshe K. Analysing organisational context: case studies on the contribution of absorptive capacity theory to understanding inter-organisational variation in performance improvement. BMJ Qual Saf. 2015;24(1):48-55. doi:10.1136/bmjqs-2014-002928
  23. Cohen WM, Levinthal DA. Absorptive capacity: a new perspective on learning and innovation. Admin Sci Q. 1990;35(1):128-152. doi:10.2307/2393553
  24. Winter SG. Understanding dynamic capabilities. Strat Manag J. 2003;24(10):991-995.
  25. Pettigrew AM. Longitudinal field research on change: theory and practice. Organ Sci. 1990;1(3):267-292.
  26. Nelson L. Managing the human resources in organisational change: a case study, research and practice. . Hum Resour Manage. 2005;13(1):55-70.
  27. Buchanan D, Fitzgerald L, Ketley D, et al. No going back: A review of the literature on sustaining organizational change. Int J Manag Rev. 2005;7(3):189-205. doi:10.1111/j.1468-2370.2005.00111.x
  28. Fulop NJ, Robert G. Context for successful quality improvement: Evidence review. London: The Health Foundation; 2015. https://www.health.org.uk/publications/context-for-successful-quality-improvement
  29. Robert G, Fulop NJ. The role of context in successful improvement. Perspectives on context. A selection of essays considering the role of context in successful quality improvement. https://www.health.org.uk/publications/perspectives-on-context.  Published 2014.
  30. Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the Economic Evaluation of Health Care Programmes. Oxford: Oxford University Press; 2015.
Volume 9, Issue 4
April 2020
Pages 143-151
  • Receive Date: 19 June 2019
  • Revise Date: 19 October 2019
  • Accept Date: 23 October 2019
  • First Publish Date: 01 April 2020