Building a culture of continuous quality improvement in healthcare

Globally, healthcare leaders are increasingly looking to embed the principles of continuous quality improvement in their own organizations. Empowering staff to deliver safe, high quality, and reliable care can provide a step-change in results. From improved patient experience to enhanced staff satisfaction, adopting proven methodologies from other industries offers a powerful opportunity for organization-wide change. The challenge remains understanding how to lead this successfully and sustainably across large-scale and often complex healthcare organizations.

Creating the right conditions, setting the strategy, and communicating this remain key, but how have successful organizations built on this to change culture? What can they teach us about implementing change at scale?

In order to answer this, KPMG recently hosted senior health system leaders from fourteen hospitals across North America and Europe at recent a two-day discussion event. Our meeting aimed to describe how organizations have successfully achieved excellence, including how leadership, culture and data and analytics can contribute to this. We also explored the opportunities, challenges and key factors in successful implementation.

Prior to our full report, this briefing shares the initial learning from their successful journeys towards achieving operational excellence in healthcare in their institutions.

Closeup of business meeting with eatables and glasses on table

What is 'Operational Excellence'?

The term 'operational excellence' describes a way of working for healthcare organizations and systems. At the heart of this is delivering improvements in care quality and safety by the everyday, ongoing use of continuous improvement techniques that are driven and owned by frontline staff. Operational excellence must be fully and durably supported by the entire organization and board; by specialized and ongoing training; and where necessary, by external facilitators and supporters.

“Operational excellence is best understood as a way of working ... a culture and a philosophy about how to deliver healthcare.”

Correctly understood, operational excellence is a culture; a philosophy about how to deliver healthcare. It is a learning journey for an organization in how to improve by becoming sustainably self-analytical and self-critical. Like a video game, once your organization successfully achieves one level of operational excellence, the next, more challenging level up always awaits. At a practical level, it works by identifying problems in healthcare systems and processes, and encouraging and empowering frontline staff to develop and implement solutions that address the root causes.

“To genuinely embed operational excellence in healthcare is a long-term project (think ten years) that requires commitment, investment and persistence.”

It is also helpful to clarify what operational excellence is not. First and foremost, operational excellence is not a time-limited project. And it is very definitely not a turnaround-type `quick fix'. To genuinely embed operational excellence in healthcare is a long-term project (think ten years): one that requires commitment, investment and persistence. Operational excellence is not for the faint-hearted or the fad-chasing.

Operational excellence is also not easy. It involves specific challenges to traditional cultural expectations and ways of working for senior executives and clinicians alike. To achieve operational excellence, the heroic, all-knowing problem-solver and answer-provider model of senior executive/clinician must evolve into a coach, facilitator and supporter of staff throughout the organization, helping them learn how to identify problems, ask questions about root causes and develop, implement and review solutions.

Operational excellence is a challenge and an opportunity - but not an easy one. Organizations wanting to consider introducing this approach need to review their commitment and capacity to make a set of fundamental challenges and changes to the way they work.

Our full report will provide a self-analysis tool to help healthcare organizations understand where they currently are, the work that needs to be done, and what support might be helpful for this.

Full view of roundtable conference with a big screen on wall


The outputs from our facilitated group discussions with hospital and health system leaders will be summarized in the final report, which proposes a set of operational excellence ground rules and requirements for successful and sustainable implementation. Some of the key themes are included below.

Making operational excellence work is all about behavior - A key element is knitting the organization together in a new way: helping frontline staff develop a new working system, see the bigger picture, and connecting the organization's strategy to daily improvements in quality and safety.

Communications are important - Both to explain the changes that are coming as the work is rolled out, and to celebrate the successful improvements that follow from this work. Operational excellence work involves getting leaders to change behaviors: this may seem confusing unless it is explained to the rest of the organization. A change of this scale has to come with a communications plan.

Middle management matters, a lot - There is a big challenge in cascading the strategy of operational excellence throughout organizations so that it is consistent. Plugging in middle management is easier said than done: it requires real alignment and focus at all levels of an organization. The role of middle management is in getting this work from the operational realm to becoming cultural. Middle management needs to be bought into this approach, and to understand it; similarly Boards need to understand middle management work as it is done on the front line, rather than as the Board may imagine it.

Clarity about accountability and about goals - Operational excellence requires organizations to have focus and accountability around what they are working towards. It can be loose as to how to achieve this, but should be tight on what the organization needs to achieve. This is why getting the management/measurement system right is crucial.

Technology and IT - These can be an important companion and a differentiator for operational excellence work. Technology should equip and enable operational excellence management work, for example through displaying real-time performance metrics, but it is not an end in and of itself.

Round table conference with screen on wall

How KPMG can help build a sustainable approach

KPMG's experience brings a unique approach to sustainable transformation. Shifting your improvement culture to one of continuous improvement means moving from `top down change' through command and control to `bottom up change', enabling and empowering front line staff. KPMG's tried-and-tested approach to delivering this is made up of three components;

  1. Operational improvement (OI)
  2. Operational management (OM)
  3. Operational design (OD)

Operational Improvement (OI) - is the more traditional use of continuous improvement methodology which redesigns pathways and processes to eliminate waste and variation to standardize care. It embeds new capabilities with front line staff to enable them to solve problems and improve care on a daily basis.

Operational Management (OM) - is a fundamentally different way of managing. OM creates a new “Board to ward” management approach and culture. Staff are trained to work with new tools and routines and they are coached to adopt new behaviors. This creates a “golden thread” that drives performance improvement, delivers sustainable results and creates a culture of continuous improvement.

Operational Design (OD) - is the redesign of enabling processes, such as technology and systems, infrastructure and people roles and reward systems within an organization. The design is based on the performance led approach and hence comes last in the OE approach.


The deployment of the elements within the OE program is built around our principles of Training, Practice and Coaching. We use a “boots on the ground” approach to ensure new skills and techniques are fresh in the minds of trainees as they deploy improvement tools and develop their capabilities.

Pyramid Operational Excellence

Key contacts

For further information on this report, or to discuss our global experience in building a sustainable culture of continuous improvement, please contact:

Gordon Burrill, Partner and Global Operational Excellence co-lead, KPMG Canada (

Jason Parker, Partner and Global Operational Excellence co-lead, KPMG in the UK (

Dr. Ed Fitzgerald, Global Healthcare Executive, KPMG International (

< Back to Healthcare Review

Connect with us