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High impact actions

How nurses can implement the high impact actions to improve quality and cost effectiveness

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As part of the drive to increase quality and effectiveness, a new report aims to inspire clinicians to undertake initiatives to achieve the high impact actions


Katherine Fenton, MA, RCNT, RM, RGN, is chief nurse and director of clinical standards and workforce, NHS South Central; Lynne Maher, DProf, MBA, RGN, is interim director for innovation, NHS Institute for Innovation and Improvement; Liz Ward is associate, high impact team, NHS Institute for Innovation and Improvement.


Fenton, K et al (2010) How nurses can implement the high impact actions to improve quality and cost effectiveness. Nursing Times; 106: 26, early online publication.

In November 2009 the NHS Institute for Innovation and Improvement published a list of eight high impact actions for nursing and midwifery. It said that, if implemented across the NHS, the actions could save over £9bn a year while improving the quality of care.

The NHS Institute has now published a selection of case studies from different settings demonstrating successful initiatives relating to each action and a range of other supporting material. This article, the first in a Nursing Times series summarising the key information on how the high impact actions can be achieved, sets the context for the initiative. Subsequent articles will discuss the individual actions and offer practical information on implementation.

Keywords: High impact actions, Quality, Cost effectiveness

Download a print-friendly PDF file of this article here



Although spending on the NHS was protected in the recent emergency budget, rising costs of drugs and equipment, and the growing number of people living with complex healthcare needs, means substantial cost savings are still required. Last year the Dame Christine Beasley, the chief nursing officer for England called on nurses and midwives to suggest potential savings that could be achieved by changing the way patient care is delivered. Over 600 suggestions were submitted, and from these, eight high impact actions (HIAs) were identified (see Box).

The HIAs are not new – all relate to areas that are well known sources of frustration to nurses and midwives, for which there is evidence of inefficiencies in care provision and poor patient experience. The NHS Institute for Innovation and Improvement (2009) estimates that if all the HIAs were addressed across the NHS, over £9bn a year would be saved. In order to support nurses and midwives in implementing the HIAs, the Institute (2010) has now published The Essential Collection, a selection of case studies from the original suggestions submitted in 2009, demonstrating successful initiatives relating to each action. The case studies are accompanied by a comprehensive literature review and analysis of the potential economic benefits for each of the HIA areas and a detailed economic analysis of some of the case studies to understand the return on investment they achieved (NHS Institute, 2010). An online “opportunity estimator” enables teams or organisations to calculate potential cost savings they could make by working on the HIA areas (

Disseminating innovations

While many nurses and midwives across the NHS come up with innovative ideas to improve efficiency and care, comparatively few of these are known beyond the immediate area of care. In order to achieve the required cost savings and the highest standards of patient care such innovations need to be applied systematically across the NHS. This involves disseminating, adapting and implementing examples of good practice.

The Essential Collection provides details not only of what was done in the selected case studies, but also how this was achieved. It is not designed to be prescriptive and tell nurses and midwives how to make the necessary changes in their own areas, but aims to signpost them to some of the many excellent resources already available that relate to the HIAs.


In order to ensure HIA initiatives are implemented successfully, it is crucial to measure their impact on costs and quality so that changes can be made where necessary. However, this involves collecting the right data and feeding it back to people implementing the initiatives in a meaningful format so that they can use it to adapt their practice. Two types of measure are required: outcome measures – these reflect the impact on patients, such as reduction in the number of falls, and process measures – these reflect the way systems and processes work to achieve desired outcomes, such as the percentage of high risk patients given a falls risk assessment.

The Essential Collectioncontains an extensive section on measurement, which includes a detailed explanation of the seven steps to measurement (summarised in Fig 1). This process helps to identify what data needs to be collected before, during and after implementing a HIA initiative in order to measure what improvements are needed and have been made.

Seven steps to measurement

1. Decide aim

Before collecting any data it is crucial to define why data is being collected. In order to avoid unnecessary workload, all collected data must provide useful information to aid decision-making.

2. Choose measures

The next step is to decide what measures may be useful. These may be outcome measures, process measures, or others relating to specific planned changes, and can include data already being collated, for example through the Productive Series or Essence of Care work.

3. Define measures

Once measures have been decided they need to be clearly defined so that everyone is clear what is included and what is excluded. This means collection and analysis of data will be comparable and consistent over time. Responsibility for collecting data must be allocated and the collection process must also be defined.

4. Collect data

Before implementing any HIA initiatives it is important to collect baseline data so any changes in outcomes can be identified.

5. Analyse and present

The form in which data is presented presentation can significantly affect how it is reacted to. Line graphs plotting data over time can be a powerful way to determine how systems and processes of care are performing. Displaying this information on a wall that everyone can see means people get immediate feedback on the data they are collecting

6. Review measures

It is a waste of time collecting and analysing data if the results are not acted on. This involves setting time aside to look at what the measures are illustrating, and disseminating the right information to the relevant people. For example, the board may only need to know about key outcome measures such as falls rates, but frontline staff will also need to know about the relevant process measures.

7. Repeat steps 4-6

This step is relatively simple but is often left out. However, it is important to continually think about what data is being collected, ensuring it is both robust and useful – and making improvements wherever necessary.

The institute has created a checklist to help practitioners to work through the seven steps for each measure they are using, which can be downloaded from the High Impact Action measurement

section at

Assessing return on investment

When carrying out improvement initiatives, it is vital to assess whether the outcomes achieved are worth the cost of making the improvement. This can be determined through a simple return on investment (ROI) calculation, which is typically a cost benefit analysis that gives the net gains as a percentage of the costs.

Usually, the main costs involved in making a service improvement will be staff time and training, along with any materials and equipment purchased. The benefits to be measured should include, as a minimum, any changes in quality, patient experience and cost, and should be assessed against the aims of the initiative.

For example, an initiative aimed at reducing the number of falls will need to measure the status before the start, during and on completion of the work will need to assess its benefits. The number of falls is a relatively straightforward indicator, captured ideally along with the different grades of harm resulting from a fall. Since there is always natural variation within any system it is important to ensure enough data is collected to be really sure the initiative has made a difference.

Once the benefits are clear, it is possible to calculate the ROI. For example, if an initiative to reduce falls has cost £20,000 in staff time and materials but has saved £30,000 by reducing falls

that would otherwise have happened, the ROI is: £30,000 ÷ £20,000 = £1.50 – this means for

every £1 spent, £1.50 is saved. It is also important to document any quality gains alongside the ROI, as the HIAs focus on both reducing costs and improving quality.

A practical resource

The Essential Collection contains a selection of case studies relating to each HIA, demonstrating different approaches to improving practice in different settings. It also offers a range of practical resources and sources of information and support. It aims to inspire nurses to undertake similar initiatives, adapted to their area of practice, to ensure the best possible standards of practice become the norm across the whole of the NHS so that all patients receive high quality, cost effective care.

  • The next article in this series, to be published next week, focuses on the HIA Keeping nourished – getting better


Box 1. The high impact actions

  • Keeping nourished – getting better
  • Staying safe – preventing falls
  • Protection from infection
  • Your skin matters – ensuring no avoidable pressure ulcers
  • Important choices – where to die when the time comes
  • Fit and well to care
  • Promoting normal birth
  • Ready to go – no delays


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