title: Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant literature.
abstract: BACKGROUND
  Formal evaluations of programmes are an important source of learning about the challenges faced in improving quality in healthcare and how they can be addressed. The authors aimed to integrate lessons from evaluations of the Health Foundation's improvement programmes with relevant literature.
  
  
  METHODS
  The authors analysed evaluation reports relating to five Health Foundation improvement programmes using a form of 'best fit' synthesis, where a pre-existing framework was used for initial coding and then updated in response to the emerging analysis. A rapid narrative review of relevant literature was also undertaken.
  
  
  RESULTS
  The authors identified ten key challenges: convincing people that there is a problem that is relevant to them; convincing them that the solution chosen is the right one; getting data collection and monitoring systems right; excess ambitions and 'projectness'; organisational cultures, capacities and contexts; tribalism and lack of staff engagement; leadership; incentivising participation and 'hard edges'; securing sustainability; and risk of unintended consequences. The authors identified a range of tactics that may be used to respond to these challenges.
  
  
  CONCLUSIONS
  Securing improvement may be hard and slow and faces many challenges. Formal evaluations assist in recognising the nature of these challenges and help in addressing them.
authors.affiliation: Social Science Applied to Healthcare Improvement Research Group, Department of Health Sciences, School of Medicine, University of Leicester, 2nd Floor, Adrian Building, University Road, Leicester LE1 7RH, UK. md11@le.ac.uk
authors.forename: Mary
authors.initials: M
authors.lastname: Dixon-Woods
authors.forename: Sarah
authors.initials: S
authors.lastname: McNicol
authors.forename: Graham
authors.initials: G
authors.lastname: Martin
mesh_terms: D055317:Evidence-Based Practice / Q000379:methods*; D005582:Foundations; D006801:Humans; D019982:Organizational Case Studies; D015397:Program Evaluation; D011785:Quality Assurance, Health Care; D012196:Review Literature as Topic