The Concept and Determinants of Return on Investment from Quality Improvement in Mental Health Organizations

Student thesis: Doctoral ThesisDoctor of Philosophy


Background: There is an increasing expectation to evaluate the value of healthcare Quality Improvement (QI) programmes using Return-on-Investment (ROI). ROI is an accounting method used to assess the profitability of financial investments. How the ROI concept is being translated in mental healthcare QI programmes is yet unclear. The aim of this PhD project was to develop a QI-ROI conceptual framework in the context of mental healthcare organisations. I also explored the potential determinants for why QI-ROI was conceptualised that way.

Methods: The project took a largely qualitative mixed-methods (QUAL-quant) approach. There were three phases of four studies: studies 1 & 2 were based on one integrative systematic literature review (N=68). For the review, I purposefully sampled literature on benefits of QI programmes across seven global regions. Phase two involved qualitative interviews with leaders (N=16) from a single UK mental healthcare Trust. Phase three was a Delphi study with healthcare leaders (N=23) from NHS Trusts. Phase two & three participants were purposefully sampled to include a mix of leaders; board members (N=24) as QI investors, QI leads and other directors (N=15). I performed inductive-deductive data analysis, each part of the project built on previous knowledge, as well as explored new insights. I also used theories to explain my findings. I then integrated the results to note potential determinants of the discovered QI-ROI conceptualisation, as well as developed the QI-ROI concept and its conceptual framework.

Results: The concept of ROI from QI in mental health programmes is conceptualised as any valued monetary and non-monetary benefit that contributes to organisations’ strategic visions. Predominantly, improvement in patient and organisational development outcomes were seen as most relevant to QI-ROI. For most leaders, financial outcomes were secondary, with cost-saving and financial sustainability seen as more relevant than outcomes like revenue and profit. Monetisation of QI outcomes was largely viewed with apprehension. Incentives like status and competitive advantage were not seen as relevant. Sustainability of good practice and positive outcomes, as well as sustainability of the organisation itself was seen as very important. Thus, the four main constructs of the QI-ROI concept deduced were Development, Improvement, Savings, and Sustainability, or DISS. Organisations may vary in the exact benefits sought within the main QI-ROI domains depending on their needs and developmental stage. Further, in some unique instances, certain organisations may value novel benefits such as profit.

Conclusion: ROI from mental healthcare QI programmes is conceptualised differently than ROI in commercial industries that may solely focus on financial outcomes. Organisations value several benefits for their internal and external stakeholders. Most valued benefits are not amenable to monetisation and may not be captured through the traditional ROI methodology. There were some ambiguities and uncertainties associated with this conceptualisation, with implications for the stability of the QI-ROI concept. Nonetheless, the views expressed in this project may be shared by disciplines similar to mental healthcare. Thus, a QI-ROI evaluation tool must acknowledge the inherent challenges that come with diverse goals and philosophies.

Date of Award1 Mar 2024
Original languageEnglish
Awarding Institution
  • King's College London
SupervisorClaire Henderson (Supervisor) & Kia-Chong Chua (Supervisor)

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