QUALITY IMPROVEMENT

HANDBOOK FOR TRAINEES

CNWL Improvement Academy

cnw-tr.improvementsupport@nhs.net

https://www.cnwl.nhs.uk/ia
Table of Contents
Introduction ........................................................................................................ 2

Why get involved in QI? (The will) ............................................................................. 3

Getting Started (The Idea) ....................................................................................... 6

The Model for Improvement (The Execution) ................................................................ 8

Aims: What are we trying to accomplish? ...................................................................... 9

Measures: ......................................................................................................... 10

How will we know that change is an improvement? .................................................. 10

Change ideas: .................................................................................................... 12

What change can we make that will result in an improvement? .................................... 12

Creating a driver diagram ..................................................................................... 13

Forming a team ................................................................................................. 15

Service user & carer involvement: .......................................................................... 16

LifeQI .............................................................................................................. 17

Support Available ............................................................................................... 18

QI Clinics: ................................................................................................... 18
Opportunities for celebration ................................................................................ 19

Safety Conversation ....................................................................................... 19

Academic programme trainee QI awards ............................................................... 19
External Conferences ...................................................................................... 19
Sources ........................................................................................................... 20

Appendix 1 - Project Checklist ............................................................................... 21

Appendix 2 – Writing a Project Report ...................................................................... 22

Title & Abstract .............................................................................................. 22

Introduction ................................................................................................... 22

Methods ........................................................................................................ 23

Results ......................................................................................................... 23

Discussion ..................................................................................................... 24

Conclusions ................................................................................................... 24

Appendix 3 – Exemplar Posters............................................................................... 25

1
Introduction
In the world of improvement science, there is a common saying – “every system is
perfectly designed to get the results it gets”. This means that only way to get a
different result is to change the system - but changing systems can be difficult,
especially in the complex landscape of the NHS. Quality improvement (QI)
methodology equips us with the tools and authority to make such changes and
improve our working environments, one project at a time. Over 5 years ago CNWL
started a Trust QI Programme and have worked to develop an Improvement
Academy with the aim of spreading QI knowledge, skills and opportunity across the
trust. As a result, CNWL is a fantastic place for trainees to get involved in QI.

The Institute for Healthcare Improvement recognises that all quality improvement
work is an interplay between will, ideas and execution1. We hope this handbook
will provide a simple guide you to consider why you might want to get involved in
QI at CNWL (the will), how to get started (the idea) and how to apply the model
for improvement and complete a successful project (the execution).

2
Why get involved in QI?
(The will)

Curriculum Requirements

It is becoming commonplace for modern postgraduate healthcare curricula to

include engagement with QI as a desired competency and this is certainly the case
in the UK. Most royal colleges require trainees to demonstrate engagement with QI
work to varying degrees (see your college curriculum for further information).
Designing or joining a well-structured QI projects can have many additional
benefits beyond simply being a tick box requirement.

Building your Portfolio

Engagement with QI is a domain in most core and higher training portfolio scoring
systems and the degree to which you demonstrate change and present your
findings can score big points. Typically, maximum points are awarded for
completing a whole project or PDSA cycle and presenting your findings at a
regional or national meeting. Often, QI is one of the easier domains to maximise
your score in and can provide trainees with a low-hanging fruit to score more
points on their applications. For further information, see the person specification
for your chosen specialty here.

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 Posters & Presentations

The results of a well-structured QI project can easily be translated into a poster

format for presentation at local, regional and even national conferences. This can
further improve your CV & portfolio and presenting posters can often be counted
towards other domains in core & higher training applications. At CNWL we’re
happy to support trainees in presenting and celebrating their work and provide
many in house opportunities to do so (see pg 20). A CNWL poster template can be
found here and examples of previous poster submissions can be found here.

Developing Skills

QI projects are also a great way to develop leadership and management skills
through activities such as forming teams, chairing meetings, liaising with
stakeholders, handling data and presenting results. These skills are not only useful
for your development as future healthcare leaders, but also provide great
examples to draw upon in professional settings, from core training applications up
to consultant interviews. As QI methodology becomes even more widely adopted,
it is becoming increasingly common for employers to seek employees who can
deliver change projects, and a well-structured QI project can be one easy way to
demonstrate this.

Patient Safety

One IHI professional described QI as having two jobs: doing your job and improving
your job. Through participating in QI, we help to make the services offer more
efficient and effective, and ultimately improve care for the people we serve and
contribute to a culture of patient safety.

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 Teambuilding

Quality improvement always occurs in a team and getting involved in a QI project

is a great way to network with the extended members of your clinical team.
Multiple perspectives are hugely beneficial when working on a project with
multiple stakeholders, so teamworking can be linked with success.

Training & Education

For those who want to expand on their QI knowledge, there are plenty of
education and training opportunities available at CNWL. These include: a QI
Masterclass for trainees in Autumn and Spring, the bitesize QI course, QI coaching
and more. Further information on available training opportunities can be found on
page 19 of this guide and the CNWL improvement academy website.

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Getting Started
(The Idea)
All projects begin with an idea for how something might be improved. Current QI
philosophies such as continuous quality improvement (CQI) recognise that QI is
within the purview of all staff members in an organisation, and often front-line
staff are best placed to identify areas for improvement. Most QI projects are born
from one of three areas:

1. A personal experience
2. A serious incident or near miss
3. An audit

Once you have identified an area for improvement, there are tools such as process
maps, fishbone diagrams and driver diagrams that you can utilise to better
understand the system you are working in and generate change ideas that you can
apply to try to generate improvement.

We recognise that there are many demands placed on trainees in the NHS and
limitations such as short rotations, time allocation and X can put trainees off
starting their own QI project. If you find that you are unable to start your own
project, you can still get involved in QI…some suggestions below:

• Discussing ideas within your local team

• Discussing ideas with your clinical/education supervisor
• Discussing project ideas with your local tutor
• Looking at previous projects on LifeQI and considering whether these can be
applied to your local workplace
• Discussing with the CNWL QI fellow
• Joining an existing project in the CNWL improvement academy Collaborative
• Join a QI clinic to discuss ideas for improvement
• Taking over an existing project from a previous local trainee
• Looking at the ‘QI menu’ of ongoing projects at CNWL
• Browse previous posters on the Improvement Academy Website
• Look at the common project themes on pg 7 of this handbook

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Common themes for QI projects:
Below is a list of common themes for QI projects at CNWL, with bullet pointed
examples of previous projects. If you are struggling to think of an idea for a
project, these examples may provide inspiration. Further details of previous
projects can be found by logging into Life QI.

Physical Health
• Management of the deteriorating patient
• Optimising cardio-metabolic screening
• Increasing timely VTE screening in inpatient settings
• Improving cancer screening; achieving parity with screening of people living
with Severe Mental Illness
• Other priority areas include:

Pharmacy
• Improving recording of allergy status on prescription charts
• Improving prescription, administration and recording of as required
medications
• Medicines reconciliation

Documentation
• Discharge summaries
• Referrals from primary care providers
• Note audits

Handover
• Improving verbal handover
• Improving handover documentation
• Standardisation of handover processes

Education & Training

• Supervision & support for supervisors
• Induction
• Teaching timetables/Academic Programme

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The Model for Improvement
(The Execution)
There are numerous quality improvement methodologies available to use, and at
CNWL we advocate the model for improvement2. If you are unfamiliar with this
tool and would like to learn more about it, we offer training through the CNWL
improvement academy as well as QI Masterclasses for trainees (see pg 19).

The model starts by asking three questions, which translate to your aim, your
measures, and your change idea/s. Once you have defined these, you move into
iterative tests of change using Plan, Do, Study, Act (PDSA) cycles to generate
learning, all the while plotting data to evaluate whether improvement is occurring
as a result of your change. This guide will now examine each section of the model
in a little more depth. More information on the model for improvement can be
found on the CNWL Improvement Academy website here.

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Aims:
What are we trying to accomplish?

Your aim statement acts as a compass for you and your team, focussing you on a
common goal. We recommend ensuring your project aim is SMART: Specific,
Measurable, Achievable, Relevant and Time-bound. Using this structure will ensure
you are clear about your project and what you want to achieve. Another common
way to frame your aim is to make sure it considers the following three metrics:
“how good” “for whom” and “by when”.

Non-SMART aims:
“We aim to reduce harm and improve patient safety for all of our inpatients”

“We will opportunistically screen patients at Townside GP surgery for diabetes and
heart disease”

SMART aims:
“We aim to reduce the number of falls on Maple ward by 50% by December 2023”

“By March 2023, we will reduce the incidence of pressure ulcers in the critical care
unit by 25%”

EXAMPLE:
If we were looking at reducing post-operative wound infection rates our
SMART aim might look something like:

“We aim to reduce the incidence of surgical site infections on Deming Ward
by 30% by March 2023”

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Measures:
How will we know that change is an improvement?

This question helps you to consider what data you will be collecting. Understanding
what you are measuring and why, forms the foundation of your QI project and
influences all the rest of your decisions surrounding data collection. Typically, in
QI we consider a ‘family’ of measures. You have to have an outcome measure
which is usually linked to your aim, but you may also find process and balancing
measures helpful.

Outcome measure/s: These measures reflect the end result of your project
and are a way to gauge success. They will directly reflect your project aim. They
answer the question “has there been any improvement?”.

Process measure/s: These measures look at the ways in which processes and
systems are working and how they contribute towards achieving your desired
outcome. They answer the question “are we doing the right things to achieve our
goal?”. Process measures are often aligned with your PDSA cycles and tests of
change.

Balancing measure/s: These measures look at whether the changes you have
introduced have had unintended effects (positive or negative) in other parts of the
system. For example, if you have introduced an intervention to improve staff
satisfaction, has it had an impact on patient satisfaction? They answer the question
“are the changes we are making causing problems elsewhere?”.

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 EXAMPLE: To continue with our example of reducing post-operative wound
infection rates, our measures might include:

Outcome measure: Number of surgical site infection cases on Deming ward

Process measures: % of patients receiving post-operative antibiotic

prophylaxis on time, % of handwashing compliance among staff, number of
ward admissions

Balancing measures: Readmission rates for post-operative patients, length

of stay for post-operative patients, patient satisfaction scores

Run Charts
In quality improvement data is plotted over time on Run Charts or Statistical
Process Control Charts.

Run charts are a visual tool used to display time series data over time, rather than
in a RAG (red, amber, green) format. Plotting data over time helps us monitor and
evaluate the impact of improvement work by looking at any changes in the data,
such as shifts or trends.

Measurement is crucial in every QI project and we’d recommend you use run
charts, wherever possible. There are rules to interpret run charts. These charts
can be developed and plotted on Life QI. Life QI will also interpret your charts
using Run Chart Rule. If you’d like more information on run charts, the IHI have a
great video or take a look at pg 19 of this guide for training & support.

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Change ideas:
What change can we make that will result in an improvement?

At this stage in the model for improvement, you have a clear aim and you have
some baseline data to know what you’re going to improve, and by how much. The
next step is to consider what change/s you are going to make to try to achieve
your project aim. As previously mentioned, you do not have to know what your
change idea will be at the beginning of your project, you just have to identify an
area for improvement and apply some of the tools below. Many QI projects start
with a change idea and work backwards, whilst this approach can be successful
teams sometimes struggle if that change idea isn’t successful in driving
improvement as they haven’t considered other approaches. There are many tools
available to help you better understand the system you are looking at and inspire
change ideas to achieve your project aim:

• Forcefield analysis
• Process maps
• Fish bone diagrams
• Pareto charts
• Root cause analysis
• Ask stakeholders
• Nominal group technique (silent brainstorming)
• Borrow from other QI projects (eg look on life QI)
• Adapt from the API list of change concepts
• Driver diagrams (see pgs 12-13)

EXAMPLE: For our project on reducing post-op wound infections, after completing
a driver diagram, our top three change ideas might look like:

1. A new training intervention for all staff working in post-operative wards

focussing on handwashing
2. Introducing a new post-operative care bundle in which post-operative
antibiotics prophylaxis is included
3. Trialling a new daily ward round with an antimicrobial pharmacist

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Creating a driver diagram
The CNWL Improvement Academy team is skilled in using all the aforementioned tools and
techniques, and if you would like to learn a little more about how to apply them, local QI
coaches and improvement advisors will be happy to help you. However, for now we will
focus on driver diagrams as these are great for generating change ideas and lifeQI even
has a space for you to create one when adding a project.

Driver diagrams can help visualise the system and identify change ideas:

1. Primary drivers are the big areas that have to be addressed to achieve the outcome
2. Secondary drivers are more specific and contribute to at least one primary driver
3. Change ideas are the practical solutions that can be implemented that contribute
to at least one secondary driver

There is no right or wrong driver diagram – it should represent your team’s understanding
of the system you are trying to improve. Your driver diagram will often change throughout
your project – as you get to understand your system and processes in more detail. The IHI
Open School has a great video brief tutorial on Driver Diagrams here.

Examples of driver diagrams:

Secondary Change Ideas

Driver
Primary
Driver
Secondary Change Ideas
Driver

Secondary Change Ideas

Driver
Primary
Aim Driver
Secondary Change Ideas
Driver

Secondary Change Ideas

Driver
Primary
Driver
Secondary Change Ideas
Driver

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14
Forming a team

An improvement team can be made up of many individuals, each bringing different

personal and professional perspectives. A typical QI team is made up of 4-8 people
and might include the following roles:

• Senior Sponsor
• Leader
• QI Coach
• Process Owner(s) (subject matter experts)
• Clinical Experts
• Service User and Carers (Big I and Little I)

At CNWL we recommend that all projects have a ‘senior sponsor’ attached. This is
another term for a ‘project supervisor’. This person is a senior member of staff in
the area that your project is based, and their role is to keep your project moving
forward by removing barriers and monitoring progress. Providing regular updates to
your senior sponsor can provide some project accountability and ward off project
inertia. A guide to the role of senior sponsor can be found here.

Successful teams make time to meet every 2-4 weeks, even if it’s just for a catch
up. Setting up and chairing these meetings can be a great way to develop
managerial skills as a trainee, particularly if you’ve not held similar roles (eg
trainee representative). These experiences look great on your CV and can provide
you with plenty of experiences Providing regular updates to your senior sponsor
can also offer some accountability to ensure your project doesn’t suffer inertia and
fatigue.

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Service user & carer involvement:

We strongly encourage service user and carer involvement in QI wherever possible.

It is now widely recognised that modern healthcare is co-produced between
providers and service users, and patient perspectives are a valuable resource that
should be sought. There is evidence to suggest that QI projects with service user
involvement are more successful.

If you aren’t sure how to involve patients in your QI project, CNWL have produced
handy guide which can be found here.

What do we mean by ‘little i’ and ‘big I’?

Involvement with a little i means asking the people who use your service
for ideas, what needs improving, have they noticed the improvements.
This can be done through a survey, focus groups etc. It is a periodic
partnership.

Involvement with a Big I means involving service users and carers directly
in your project and QI development and delivery. It is a full and
continuous partnership.

It is recommended you always consider little i and Big I when developing

your project.

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LifeQI

At CNWL we use a system called lifeQI to log and track all QI projects across the
trust. It is a simple and intuitive system to use and a guide to setting up your
account (with instructional videos) can be found on the improvement academy
website here.

When you are creating an account, make sure to use your NHS email account to
speed up the verification process. Once your account has been verified, simply log
in and you will be able to add a QI project.

On your first login, the website will offer a tour of available functions. There are
also instructional videos on the lifeQI support page as well as a 24/7 chatbot
function to help you with any queries. You can also reach out for support from the
CNWL Improvement Academy team if you are ever stuck (see pg 18).

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Support Available

QI Clinics:
The Improvement Academy offer weekly QI clinic slots where you and your team
can discuss any aspect of your project with qualified QI coaches. The clinic slots
are 30 minutes long and currently occur on Fridays between 12:00 – 13:00. To book
a slot, simply email: cnw-tr.improvementsupport@nhs.net

You will be asked to complete and return a short form to give a little background
to your project and what issues you’d like to discuss at the meeting. Anyone can
book a QI clinic slot and there’s no limit to how many times you can return to QI
clinic. If your project is particularly complex or would benefit from a dedicated QI
coach, this can also be discussed at QI clinic.

Common issues that people bring to QI clinic include: help in applying QI

methodology to an idea, refining project aims, discussing and optimising data
collection and help with the lifeQI system. If your project is encountering any of
these issues or something else entirely, don’t hesitate to book a clinic slot and
we’ll see how we can help!

Training:
The improvement academy offer a range of QI courses which can be booked via
their website. These courses cater to a range of prior knowledge and experience in
QI. If want to brush up on the fundamentals of QI including theory, methodology,
tools, data handling and top tips – then the level 1 bitesize course is a great place
to start.

The CNWL QI fellow also organises a bespoke QI Masterclass for trainees, which is
delivered in September and March. This course is led by the improvement academy
leads and covers the essentials of QI through a trainee lens. This includes topics
like how to use QI for portfolio points, maximising your QI experience in
interviews, translating projects into posters/publications and more.

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Opportunities for celebration

Safety Conversation
The goal of QI is to share learning, and this is something we encourage for all
projects. CNWL run an annual trustwide conference for all members of staff and
encourage all QI teams to submit their work in the form of posters. All posters
submitted receive a certificate and there are even Improvement Awards for teams
that can evidence sustained improvement in CNWL services. These awards are
recognition of excellence in improvement achievements and there is an award
specifically for the best submission by a trainee!

Academic programme trainee QI awards

At the end of the academic programme in January and July, the team organises
local opportunities to present any QI work that you might have been involved in.
We have embedded these sessions into the Academic Programme to make
attendance easier than ever. Certificates are awarded for all presenters, with
prizes for the top projects!

External Conferences
The majority of QI work can be easily translated into poster format and submitted
to outside conferences. Any conference that includes themes of innovation,
improvement or patient safety is a great place to present your work and can earn
you extra portfolio points. The improvement academy team can support you in
making posters (template available here) and can even signpost you to appropriate
meetings and conferences.

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Sources

1. Nolan TW. Execution of Strategic Improvement Initiatives to Produce

System-Level Results. IHI Innovation Series white paper. Cambridge, MA:
Institute for Healthcare Improvement; 2007.
2. Langley, G.J., Moen, R.D., Nolan, K.M., Nolan, T.W., Norman, C.L. and
Provost, L.P., 2009. The improvement guide: a practical approach to
enhancing organizational performance. John Wiley & Sons.
3. Swanwick, T., 2018. Understanding medical education. Understanding
Medical Education: Evidence, Theory, and Practice, pp.1-6.
4. England, N.H.S., 2021. Plan, Do, Study, Act (PDSA) cycles and the model for
improvement.
5. Wong, B.M. and Sullivan, G.M., 2016. How to write up your quality
improvement initiatives for publication. Journal of Graduate Medical
Education, 8(2), pp.128-133.
6. Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F. and Stevens,
D., 2015. SQUIRE 2.0 (Standards for QUality Improvement Reporting
Excellence): revised publication guidelines from a detailed consensus
process. American Journal of Critical Care, 24(6), pp.466-473.
7. Holzmueller, C.G. and Pronovost, P.J., 2013. Organising a manuscript
reporting quality improvement or patient safety research. BMJ quality &
safety, 22(9), pp.777-785.

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Appendix 1 - Project Checklist
When planning a project, you can use this brief proforma as a framework:

THE PROBLEM (A concise description of what it is you are planning to improve and why it needs
improvement – include baseline data if available)

THE TEAM (A list of team members and roles)

OUR AIM (What is your SMART aim for the project?)

OUR MEASURES (What is your primary outcome measure? Have you considered process/balancing
measures?

CHANGE IDEAS (A list of your top ideas for change. A driver diagram might help to generate these)

BARRIERS (What barriers might obstruct your path to success and how might you overcome them?)

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Appendix 2 – Writing a Project Report

This section is a suggested guide to writing QI case reports, with a lean towards
the academic reporting style. This is consistent with SQUIRE 2.0 guidelines and
Journal of Graduate Medical Education recommendations 5,6,7.

Title & Abstract

• Title should clearly indicate that this a QI report
• Your title should closely describe your project whilst remaining concise
• Check any available author guidelines to determine specific formatting
instructions (eg word counts)
• Typically 250 – 500 words
• Avoid abbreviations
• Write in the past tense
• In the abstract you should try to include: the project aim, study design,
population, setting, intervention, primary outcome measure and the method
of analysis, important findings and brief conclusion

Introduction
• Include a description of the issue you are targeting
• Include any baseline data you might which contributed to undertaking this
project
• Mention if you used any frameworks, concepts or theory in developing your
intervention
• You can include any tools you used in developing your change idea (eg: team
discussions, driver diagrams, service use involvement)
• Include a short summary of any existing knowledge related to this work (eg:
previous QI, studies, grey literature)
• Outline your intervention and your SMART aim

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Methods
• Describe the context of your work (eg: setting, target audience,
timeframes, tools used)
• Discuss your particular intervention with enough detail that others could
replicate it
• Mention the team involved in the QI project
• Discuss your measures (see pg 10 of this handbook) and data collection
method
• Discuss any statistical analysis you have performed and your chosen
approaches to data handling
• To write up an academic case report it is usual that you have performed
(and generated learning from) at least 2 PDSA cycles
• If there are any ethical considerations to your project, you should mention
them in this section

Results
• Report any findings and data you have generated in this project
• In this section you should report facts and data only - and not offer opinions
or conclusions (that goes in the discussion section)
• When reporting the processes of a project and how it evolved over time,
often a flow chart or table is helpful
• Include any graphs you have generated, ideally a run chart with time on the
X axis and your measure/s on the Y axis with any interventions you
performed clearly labelled on the graph (see pg 11 of this handbook for
more information)

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Discussion
• Here, you should interpret your findings and explore any inferences that can
be drawn from your work
• Always try to relate your discussion back to your project aim
• It is also good practice to relate your findings back to any existing
knowledge on the subject that you identified in your introduction (eg:
previous QI work/academic literature)
• Discuss the strengths of your project and its generalisability
• Discuss any limitations of your project (and what you did to mitigate them)
• Consider finishing with a summary of lessons learned or implications for the
future

Conclusions
• This section should be a short summary all the key findings of your work
• Try not to introduce any new ideas or concepts at this stage, aim to simply
outline your key results and their implications
• You can comment on the generalisability of your project and potential
spread to other contexts if applicable

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Appendix 3 – Exemplar Posters

Please find below links several links to exemplar QI project posters, which you
might use to guide you in formulating your ideas and formatting a poster:

1. Improving the screening and diagnosis of delirium for

older adult patients admitted to Hillingdon Hospital
(Trainee Improvement Award Winner - Safety Conversation 2022)

2. Lets get physical

(Expert by Experience Improvement Award Winner - Safety Conversation 2022)

3. Improving Quality with Handover at the Riverside

Centre

4. Improving Team Meetings

5. Improving the Milton Keynes CAMHS ADHD Pathway

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Created by Dr Samuel Chequer (Quality Improvement & Medical Education Fellow)
Last Updated: 23/01/22

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