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Leadership practices and behaviours that enable and inhibit a continuous improvement culture in an NHS trust
  1. Claire Benjamin1,
  2. Daisy Chung2
  1. 1 Transformation and Improvement Team, St George's Healthcare NHS Trust, London, UK
  2. 2 Bayes Business School, City University of London Bayes Business School, London, UK
  1. Correspondence to Claire Benjamin, Transformation and Improvement Team, St George's Healthcare NHS Trust, London SW17 0QT, UK; c.m.benjamin{at}


Background Healthcare providers and systems globally are increasingly recognising the benefits of adopting continuous improvement methods to transform hospital services. Creating a continuous improvement culture relies on giving frontline staff the support and freedom to identify opportunities for positive, sustainable, change and the skills to enable action. This paper analyses the leadership behaviours and practices that support or inhibit the adoption of a continuous improvement culture, drawing on a qualitative evaluation within the outpatient directorate at one National Health Service (NHS) trust.

Objective Identify key leadership behaviours and practices that enable and inhibit a continuous improvement culture in healthcare settings.

Methods Results from the 2020 NHS staff engagement survey informed the development of an original survey and interview protocol aimed at uncovering factors that enable or inhibit a continuous improvement culture in this directorate. All staff within the outpatient directorate at all NHS banding levels were invited to take part.

Results 44 members of staff took part: 13 members of staff were interviewed, and 31 members of staff completed a survey. Of the factors that are perceived to inhibit a continuous improvement culture, ‘Not feeling listened to or supported to find the right solution’ was the most frequently occurring theme. Conversely, the most common enabling factors were ‘leaders and staff solving problems together’ and ‘leaders making time to understand the challenges of their staff’. The findings suggest that the most important behavioural changes leaders can make are: proactively taking the time to listen to and understand the challenges staff face; and supporting them to find the root cause of problems.

Conclusion Continuous improvement cultures depend on high staff engagement; leaders who show curiosity, invest time in listening, and act as partners in problem solving are more likely to elicit engagement and thereby enable a continuous improvement culture.

  • continuous improvement
  • medical leadership
  • behaviour
  • leadership assessment
  • engagement

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  • Contributors CB is the guarantor for this qualitative evaluation. CB developed and conducted the survey and semi-structured interviews. CB analysed the primary data and conducted the initial literature search. CB and DC converted the original qualitative evaluation into a BMJ Leader piece.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.