Embedding QI in any organization requires a new narrative from regulators and boards, strategic intent, investment in training leaders and staff, a more distributed leadership model that empowers frontline teams, and a meaningful role for patients so that improvement activity is aligned to what they most need and value.

It also requires courage and patience from the most senior leaders as they commit to new management practices. Their incentives must depend not only on delivery of topdown targets but also on building a culture conducive to long term quality improvement, which could be personally uncomfortable for them.Quality management systems have an important role.

Taichi Ohno, architect of the Toyota Production System (popularised as “lean”), would instruct managers to spend hours “watching” from within a chalk circle on the factory floor. He wanted managers to learn to see waste and opportunities to improve quality and flow.