A Board Level Intervention to Develop Organisation-Wide Quality Improvement Strategies: Cost-Consequences Analysis in 15 Healthcare Organisations

Document Type : Original Article


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

2 University of Bangor, Bangor, UK

3 National Nursing Research Unit, Florence Nightingale School of Nursing and Midwifery, King’s College London, London, UK

4 Centre for Patient Safety and Service Quality, Faculty of Medicine, Imperial College London, London, UK

5 Florence Nightingale School of Nursing and Midwifery, King’s College London, London, UK

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


Hospital boards have statutory responsibility for upholding the quality of care in their organisations. International research on quality in hospitals resulted in a research-based guide to help senior hospital leaders develop and implement quality improvement (QI) strategies, the QUASER Guide. Previous research has established a link between board practices and quality of care; however, to our knowledge, no board-level intervention has been evaluated in relation to its costs and consequences. The aim of this research was to evaluate these impacts when the QUASER Guide was implemented in an organisational development intervention (iQUASER).

We conducted a ‘before and after’ cost-consequences analysis (CCA), as part of a mixed methods evaluation. The analysis combined qualitative data collected from 66 interviews, 60 hours of board meeting observations and documents from 15 healthcare organisations, of which 6 took part on iQUASER, and included direct and opportunity costs associated with the intervention. The consequences focused on the development of an organisation-wide QI strategy, progress on addressing 8 dimensions of QI (the QUASER challenges), how organisations compared to benchmarks, engagement with the intervention and progress in the implementation of a QI project.

We found that participating organisations made greater progress in developing an organisation-wide QI strategy and became more similar to the high-performing benchmark than the comparators. However, progress in addressing all 8 QUASER challenges was only observed in one organisation. Stronger engagement with the intervention was associated with the implementation of a QI project. On average, iQUASER costed £23 496 per participating organisation, of which approximately 44% were staff time costs. Organisations that engaged less with the intervention had lower than average costs (£21 267 per organisation), but also failed to implement an organisation-wide QI project.

We found a positive association between level of engagement with the intervention, development of an organisation-wide QI strategy and the implementation of an organisation-wide QI project. Support from the board, particularly the chair and chief executive, for participation in the intervention, is important for organisations to accrue most benefit. A board-level intervention for QI, such as iQUASER, is relatively inexpensive as a proportion of an organisation’s budget.



Supplementary File 1 (Download)

Supplementary File 2 (Download)

Supplementary File 3 (Download)



  1. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: Executive Summary. Vol 947. London: The Stationery Office; 2013.
  2. Alderwick H, Charles A, Jones B, Warburton W. Making the Case for Quality Improvement: Lessons for NHS Boards and Leaders. London: The King's Fund/The Health Foundation; 2017.
  3. Robinson R. NHS foundation trusts: greater autonomy may prove illusory. BMJ. 2002;325(7363):506-507. doi:10.1136/bmj.325.7363.506
  4. Walshe K. Foundation hospitals: a new direction for NHS reform? J R Soc Med. 2003;96(3):106-110. doi:10.1258/jrsm.96.3.106
  5. Verzulli R, Jacobs R, Goddard M. Do Hospitals Respond to Greater Autonomy? Evidence from the English NHS. York, UK: University of York; 2011.
  6. Mannion R, Davies H, Freeman T, Millar R, Jacobs R, Kasteridis P. Overseeing oversight: governance of quality and safety by hospital boards in the English NHS. J Health Serv Res Policy. 2015;20(1 Suppl):9-16. doi:10.1177/1355819614558471
  7. Millar R, Mannion R, Freeman T, Davies HT. Hospital board oversight of quality and patient safety: a narrative review and synthesis of recent empirical research. Milbank Q. 2013;91(4):738-770. doi:10.1111/1468-0009.12032
  8. Robert GB, Anderson JE, Burnett SJ, et al. A longitudinal, multi-level comparative study of quality and safety in European hospitals: the QUASER study protocol. BMC Health Serv Res. 2011;11:285. doi:10.1186/1472-6963-11-285
  9. Jones L, Pomeroy L, Robert G, et al. Explaining organisational responses to a board-level quality improvement intervention: findings from an evaluation in six providers in the English National Health Service. BMJ Qual Saf. 2019;28(3):198-204. doi:10.1136/bmjqs-2018-008291
  10. Bate P, Mendel P, Robert G. Organizing for Quality: The Improvement Journeys of Leading Hospitals in Europe and the United States. Oxford: Radcliffe Publishing; 2008.
  11. Bushe GR, Marshak RJ. Revisioning organization development: diagnostic and dialogic premises and patterns of practice. J Appl Behav Sci. 2009;45(3):348-368. doi:10.1177/0021886309335070
  12. Greenhalgh T. How to read a paper. Papers that tell you what things cost (economic analyses). BMJ. 1997;315(7108):596-599. doi:10.1136/bmj.315.7108.596
  13. Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the Economic Evaluation of Health Care Programmes. Oxford: Oxford University Press; 2015.
  14. Walshe K, Rundall TG. Evidence-based management: from theory to practice in health care. Milbank Q. 2001;79(3):429-457. doi:10.1111/1468-0009.00214
  15. Ferlie E, Fitzgerald L, Wood M, Hawkins C. The nonspread of innovations: the mediating role of professionals. Acad Manage J. 2005;48(1):117-134. doi:10.5465/amj.2005.15993150
  16. Dopson S, Fitzgerald L. Knowledge to Action?: Evidence-Based Health Care in Context. Oxford: Oxford University Press; 2005.
  17. Tsoukas H. The firm as a distributed knowledge system: a constructionist approach. Strateg Manag J. 1996;17(S2):11-25. doi:10.1002/smj.4250171104
  18. Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf. 2014;23(4):290-298. doi:10.1136/bmjqs-2013-001862
  19. Curtis L, Burns A. Unit Costs of Health and Social Care 2015. Canterbury: University of Kent; 2015.
  20. 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
  21. Curry LA, Linnander EL, Brewster AL, Ting H, Krumholz HM, Bradley EH. Organizational culture change in U.S. hospitals: a mixed methods longitudinal intervention study. Implement Sci. 2015;10:29. doi:10.1186/s13012-015-0218-0
  22. Wiig S, Ree E, Johannessen T, et al. Improving quality and safety in nursing homes and home care: the study protocol of a mixed-methods research design to implement a leadership intervention. BMJ Open. 2018;8(3):e020933. doi:10.1136/bmjopen-2017-020933
  23. Collins DB, Holton III EF. The effectiveness of managerial leadership development programs: a meta-analysis of studies from 1982 to 2001. Hum Resour Dev Q. 2004;15(2):217-248. doi:10.1002/hrdq.1099
  24. Ramsay A, Fulop N, Fresko A, Rubenstein S. The Healthy NHS Board. NHS; 2010.
  25. Jha AK, Epstein AM. A survey of board chairs of English hospitals shows greater attention to quality of care than among their US counterparts. Health Aff (Millwood). 2013;32(4):677-685. doi:10.1377/hlthaff.2012.1060
Volume 11, Issue 2
February 2022
Pages 173-182
  • Receive Date: 02 August 2019
  • Revise Date: 02 June 2020
  • Accept Date: 03 June 2020
  • First Publish Date: 01 February 2022