Quality Improvement Curriculum Framework 03.10 - QI Hub improvement curriculum... · Quality...

Quality Improvement Curriculum Framework

Supporting an NHSScotland Workforce to deliver care that is:

Safe

Person-centred

Effective

Contents

1. The NHSScotland Quality Strategy............................................................................................................... 1

2. Quality Improvement in Healthcare ............................................................................................................ 1

3. Introduction to the Quality Improvement Curriculum Framework............................................................. 1

4. Quality Improvement Workforce Development Model .............................................................................. 2

4.1 Board Level (Executive and Non Executive).......................................................................................... 2

4.2 Foundation Level .................................................................................................................................. 2

4.3 Practitioner Level .................................................................................................................................. 3

4.4 Lead Practitioner Level ......................................................................................................................... 4

5. Purpose of the Framework .......................................................................................................................... 4

6. Key educational principles of the Framework ............................................................................................. 5

7. Uses and applications of the Framework .................................................................................................... 5

8. Learning Resources for Quality Improvement............................................................................................. 5

9. Indicative mapping to Knowledge and Skills Framework (KSF) ................................................................... 6

10. Indicative mapping to the Scottish Credit and Qualifications (SCQF) Framework .................................... 6

11. Final Learning Outcomes ........................................................................................................................... 6

12. Quality Improvement Curriculum Framework Model ............................................................................... 7

13. Final Learning Outcomes ........................................................................................................................... 8

13.1 Board Members .................................................................................................................................. 8

13.2 Foundation Level ................................................................................................................................ 8

13.3 Practitioner Level ................................................................................................................................ 8

13.4 Lead Practitioner Level ....................................................................................................................... 8

14. Stage Learning Outcomes.......................................................................................................................... 9

14.1 Stage Learning Outcome Table ......................................................................................................... 10

15. Quality Improvement Glossary of Terms................................................................................................. 14

15.1 Introduction ...................................................................................................................................... 14

15.2 Glossary ............................................................................................................................................ 14

Appendix I – Indicative Mapping to KSF ........................................................................................................ 21

1

1. The NHSScotland Quality Strategy

The Quality Strategy is the NHSScotland blueprint for improving the quality of care that patients and

carers receive from the NHS across Scotland. It sets out ambitions which acknowledge:

� Putting people at the heart of everything the health service does;

� A focus on providing the best possible care;

� Recognition that real improvement in quality of care involves all staff, both clinical and non clinical,

working at all levels in all roles.

In the NHSScotland Quality Strategy, the ambition for healthcare that is person-centred, safe and effective

is underpinned by the need to ‘embed the mutual approach of shared rights and responsibilities into every

interaction between patients, their families and those providing health services’ (pg 17, Quality Strategy).

This requires a renewed focus on building capacity and capability for all staff to ensure that they have the

knowledge, skills and attitudes necessary to deliver high quality services.

2. Quality Improvement in Healthcare

The definition below seeks to describe what improving health services means and the part that we all play

in continually improving the care provided.

“The combined and unceasing efforts of everyone – healthcare professionals, patients and their

families, researchers, payers, planners, administrators, educators – to make changes that will lead to

better patient outcome, better system performance, and better professional development.”

Batalden P, Davidoff F. Qual. Saf. Health Care 2007;16;2-3

To improve services effectively we need to be able to set clear aims, establish measures, test changes and

implement these changes. There are many well-tested tools and techniques that support improvement in

designing services that provide maximum benefit to the patient in an effective and safe way.

3. Introduction to the Quality Improvement Curriculum Framework

In the last number of years, NHS Boards have been developing expertise in applying quality improvement

thinking and techniques to healthcare improvement, through both locally driven projects and through

national improvement programmes, such as the 18 Weeks Referral to Treatment and the Scottish Patient

Safety Programme.

The Quality Improvement (QI) Curriculum Framework aims to provide ongoing support for the

development of learning in quality improvement by describing the knowledge and skills needed to

continuously improve services and enable the NHS workforce to access appropriate learning and

development resources.

The QI Curriculum Framework, Figure 1 – page 7, aims to support staff across all of NHS Scotland to access

learning in quality improvement thinking and techniques. The Framework has been developed and refined

with a group of quality improvement leads from health boards who have subject matter expertise along

with an understanding of how the framework may support capacity building in practice.

The Framework reflects the priorities of the NHSScotland Quality Strategy, and is intended to provide a

scaffold for enabling structured and systematic professional and educational development in quality

2

improvement. It is designed to support capacity building for everyone in NHSScotland in improvement of

person-centred care, continuing improvement of patient safety and increase clinical effectiveness of care

and treatment.

It is intended that the Framework will enable staff with different roles in the organisation to identify the

gaps between their current knowledge and skills and future requirements and to support them to plan

their own learning and development.

For all staff, the aim of the Framework is to:

� enable individuals to reach a broader and deeper understanding of their roles in quality improvement;

� enable individuals to gain a broader and deeper understanding of the knowledge, skills and behaviours

expected/required by their roles in quality improvement;

� facilitate individuals to identify their professional development needs to effectively carry out their

quality improvement role;

� provide benchmark statements against which individuals can gauge themselves.

4. Quality Improvement Workforce Development Model

Figure 4 describes the NHSScotland workforce development needs in building capacity and capability in

quality improvement.

FIGURE 4

4.1 Board Level (Executive and Non Executive)

A focus on quality and improvement of the services delivered is at the heart of the role of NHS Boards. The

focus on continuous improvement is vital as evidence shows that even high performing healthcare

organisations can improve their quality of care by focussing on safety and efficiency and putting the

patient at the centre of how we design our services.

The final learning outcomes for NHS Boards on page 8 indicate the attributes NHS Board members may be

expected to demonstrate in relation to quality improvement.

4.2 Foundation Level

All staff working in healthcare settings should be encouraged to take a reflective approach in their role.

This will be achieved by raising awareness of the principles that underpin quality and ensuring that

everybody involved (and this should include the patient and carer) has an appropriate level of

understanding of the significance of quality and its part in service delivery.

In particular the Foundation learning will involve:

� recognising that everyone has a responsibility to enable quality care and everybody has a voice;

� pursuing quality at every opportunity, at every health intervention, by everybody;

� becoming familiar with the philosophies and aims of the most widely used approaches to quality

NHS STAFF (ALL)

LEAD

PRACTITIONER

NH

S BO

AR

DS

NHS STAFF (ALL)

LEAD

PRACTITIONER

NH

S BO

AR

DS

3

improvement in healthcare;

� recognising the relevance of healthcare systems and pathways;

� reflect on individual roles and responsibilities in delivering high quality care.

The Foundation level learning would provide opportunities for staff new to the workforce to learn

about quality improvement and be included, for example, in induction programmes, practice

development programmes or undergraduate courses. The education could also inform the continued

professional development (CPD) of staff currently employed and be integrated into existing

opportunities for CPD.

4.3 Practitioner Level

This level is applicable to a wide range of staff with different roles whose work should be informed by a

clear understanding of the principles and practice of continuous improvement in healthcare.

In particular the Practitioner level will involve:

� acting as a knowledgeable and informed practitioner of quality improvement within their local

environment;

� actively pursuing increased understanding of quality improvement methodologies and approaches;

� leading change through quality improvement initiatives within their working environment;

� facilitating the understanding of quality improvement amongst their colleagues/team;

� acting as an implementation (project manager) lead at local level to embed quality improvement tools

and approaches;

� working collaboratively to be identified as a cohort of quality improvement champions with relevant

experience to promote quality improvement locally;

� encouraging the sharing of experience amongst their group of quality improvement practitioners;

� fostering cultural change within their employing organisation.

It is envisaged that:

� practitioners will approach the role with some knowledge of quality improvement techniques, but are

unlikely to have wide and varied experience;

� individuals will be supported by Leads (acting as facilitator and mentor) and via structured learning

interventions to acquire relevant wider knowledge, skills and behaviours as they undertake the role

described above;

� they will be allowed bounded time and resources to increase their knowledge, skills and behaviours of

quality improvement techniques within their local setting;

� Individuals will be encouraged to see their personal development as career progression, perhaps

moving into the Lead level in time.

The Practitioner level reflects a leadership role in quality improvement. Practitioners are seen as role

models and should champion a culture of change and innovation within their own local environment.

They can signpost others to learning resources and ensure that access to learning about quality is

available to their teams. The Practitioner level will include staff working in clinical settings, for

example charge nurses, as well as those working in support services, such as administration and

finance.

4

4.4 Lead Practitioner Level

The Lead Practitioner Group will represent an expert resource to promote quality improvement in

healthcare settings, able to contribute to knowledge in the field and to lead, along with others, a culture

of change and innovation throughout the healthcare organisation in which they work.

In particular Lead Practitioners will be involved in:

� promoting quality improvement at strategic level within the organisation;

� representing the business case for quality improvement at regional and local levels in the range of ways

that this may require;

� leading (along with others) and supporting the delivery of high quality healthcare improvement within

their workplace;

� supporting the integration of quality improvement projects at all levels in the organisation;

� advancing innovative and new applications of healthcare improvement science in the workplace;

� supporting the development of other practitioners in quality improvement science to enable them to

deliver healthcare improvements or enable others to do so;

� supporting the advancement of knowledge related to improving the delivery of health services

including enhancing access to quality improvement tools and techniques;

� providing a potential resource to the Scottish Quality Improvement Hub and contributing to shared

learning from the implementation of quality improvement projects.

It is envisaged that:

� they will have bounded time within their working pattern to allow them to focus effectively on this role;

� their contribution is seen as a significant element of their job specification and is included in appraisal

discussions;

� they will, at the outset, be already highly trained and experienced in a large number of the areas of

capability that describe quality improvement practice, although they will not be expected to cover all

elements;

� each Lead will be required to undertake ongoing Continual Professional Development in order to

improve their knowledge and skills and to remain current with the dynamic nature of quality

improvement;

� at each Health Board there will be a team of Lead Practitioners and they will work collaboratively to

cover the wide range of knowledge, skills, attributes required, and, whilst focusing on their individual

strengths as quality improvement Leads, they will nevertheless support each other in developing areas

where their capability is less well developed.

The quality improvement Lead Practitioners will deploy their skills across the organisation and will be

part of structures and teams which vary across individual health board settings.

5. Purpose of the Framework

It is intended to enable NHSScotland staff to enhance their knowledge of quality improvement and related

professional and personal skills so they may effectively contribute to the continual improvement of the

health service. It is intended to support the development of all staff and, for ease of reference and

purposes of capacity building, incorporates four levels to support staff in delivering quality improvement:

Lead Practitioners, Practitioners, Foundation and NHS Scotland Health Boards (both executive and non

executive members). For the purposes of capacity building, at ‘Foundation’ level the learning resources

are intended to provide baseline Continued Professional Development (CPD) in quality improvement for

5

all staff. Those who have further quality improvement-related responsibilities will be interested in

resources at Practitioner, Lead Practitioner and Board levels.

The Framework should also enable effective commissioning of quality improvement learning opportunities

with providers in the further and higher education sector.

6. Key educational principles of the Framework

The construction of the framework has been underpinned by these key educational principles:

� respecting and building on prior knowledge and experience of each individual;

� enabling staff to take control of their own development, providing opportunity for choice and selection

of most suitable educational opportunities;

� emphasis on relevance of learning to the context of the workplace;

� valuing learning through work-based activity and collaboration with colleagues;

� acknowledgement of individual potential and career development;

� valuing reflective self-evaluation and self-direction;

� transparency of expectations and standards of achievement for each group.

7. Uses and applications of the Framework

The Framework outlines the attributes that NHSScotland members of staff might expect to achieve as a

result of undertaking learning opportunities aligned to key stages and topics. The Framework includes five

developmental stages, and within each stage are a number of learning outcomes and related topics.

Progression through the Framework model is illustrated left to right from Stage 1: Introduction to Quality

Improvement, through to Stage 5: Sustaining Improvement.

The Framework outlines the knowledge, skills and behaviours expected of staff working at different levels

of the organisation and with defined roles. It describes the depth and breadth of each attribute as a

measure of the standards expected of staff at each level.

It is intended that the Framework may be used in the following ways:

� for individuals to gauge their own strengths and development needs in order to contribute

effectively to quality improvement within their roles;

� to enable individuals and groups to plan and/or engage in educational development activities;

� to enable managers to support their teams in profiling their quality improvement knowledge and

skills and plan further development;

� to assist with commissioning of educational activities and resources;

� to enable individuals to plan their own continuing professional development;

� to assist educational providers responsible for pre-registration training and education in articulating

their provision with the framework.

8. Learning Resources for Quality Improvement

Each stage of the framework will be supported by learning resources which will be clearly linked to the

subject topic and enable the learner to access learning resources which are tailored to their needs. The

Framework is designed to support all staff in planning and participating in CPD for quality improvement

and in choosing those elements most appropriate for their roles, responsibilities and prior learning and

6

experience. It is envisioned that individuals, perhaps in discussion with their line manager, will plot their

own pathway through the Framework, therefore individual learning journeys will differ. The Framework is

flexible enough to allow individuals to have considerable engagement if the subject is relatively new to

them, to 'dip in' for refresher study, to infill gaps in their knowledge, to accommodate a change in post or

location or to provide baseline CPD for new groups of staff. The resources will be available on the Quality

Improvement Hub website in the Education and Learning section and will include media such as e -

learning, podcasts, case studies, websites, books and articles.

9. Indicative mapping to Knowledge and Skills Framework (KSF)

In this section, each of the learning outcomes associated with Stages 1 to 5 of the Foundation, Practitioner

and Lead Practitioner levels is mapped to the NHS Knowledge and Skills Framework. This information

offers an indicative guide to the links between the learning outcomes and KSF dimensions, levels and

indicators. It should be noted that the Level corresponding to a particular dimension relates specifically to

the Indicators shown and not the overall Level.

Appendix 1 provides detailed KSF mapping information.

10. Indicative mapping to the Scottish Credit and Qualifications (SCQF) Framework

The Curriculum Framework has been devised with a view to linking the learning outcomes to the SCQF

Framework thereby leading to possible accreditation of CPD. Initial scoping is underway to determine the

best way in which to map the frameworks and more information will be available by the end of 2011.

11. Final Learning Outcomes

The final learning outcomes indicated on the far right of the diagram are the overall outcomes expected

after progression through the Framework; the final learning outcomes for each group of staff are listed in

detail in section 13.

7

12. Quality Improvement Curriculum Framework Model

FINAL

LEARNING

OUTCOMES:

Foundation

Practitioner

Lead

Board

Stage 2

LEARNING MORE ABOUT

QUALITY IMPROVEMENT

2.1 The Policy Context

2.2 Key principles of QI

� Healthcare systems and

processes

� Person-centred care

2.3 Reflecting on own role

� Teamwork

� Improvement in practice

2.4 Learning for QI

� Connecting to resources

� Mapping own journey

2.5 Measurement for improvement

� Common tools and techniques

Stage 3

PLANNING IMPROVEMENT

3.1 Investigating systems and

processes

� Identifying improvements

� Tools for planning

3.2 Organising information

3.3 Human dimensions of QI

3.4 Leadership and project

management

3.5 Effective teamwork for QI

3.6 Evaluating success

3.7 Planning for sustainability

3.8 Measurement for QI

� Setting baselines

� Data collection

� Data sampling

3.9 Innovation and Creativity

Stage 4

TESTING AND IMPLEMENTING

IMPROVEMENT

4.1 Collaboration and

networking

4.2 Effective communication



management



� Data analysis

� Data interpretation

� Data presentation

Stage 5

SUSTAINING

IMPROVEMENT

5.1 Knowledge

dissemination

5.2 Evaluation

� Benefits realisation

5.3 Human dimensions of

change

5.4 Leadership for QI

� Embedding QI

� Business case for QI

5.5 Education and

mentoring

5.6 Coaching for

improvement

Stage 1

INTRODUCTION TO QUALITY

IMPROVEMENT

1.1 Understanding our purpose

and our values

1.2 Definition of Quality

1.3 What is QI and what are the

benefits

1.4 Person-centred Healthcare

1.5 Understanding our

responsibilities for Improvement:

individuals, teams, the

organisation

1.6 Introduction to Healthcare

systems

1.7 Introduction to the science of

improvement

� Model for improvement

� PDSA

� Process mapping

� Lean in healthcare

1.8 Introduction to measuring

improvement

1 2 3 4 5

Figure 1

8

13. Final Learning Outcomes

13.1 Board Members

It is proposed that an NHS Board executive and non executive member responsible for quality

improvement should be able to:

� align local policy and strategy for quality improvement to national priorities for improvement;

� ensure a person-centred approach to the delivery of all services;

� demonstrate clear understanding of the difference between managerial and governance

responsibilities;

� demonstrate commitment to a focus on quality across the organisation;

� understand the business case for service improvement;

� demonstrate knowledge of the science for improvement and its application to supporting improved

quality of service;

� understand the use of data and be able to interpret information to support effective scrutiny and

quality assurance;

� promote a critically reflective scrutiny of outcomes;

� promote a culture of continuous quality improvement across the organisation.

13.2 Foundation Level

It is proposed that all staff should be able to:

� discuss how quality improvement benefits patients, health care staff and the organisation as a whole;

� describe their role and responsibility for improvement of services;

� explain the general principles of quality improvement, the most widely used methodologies and the

human dimensions of quality improvement;

� identify a problem which could be improved through quality-based approaches and anticipate issues

arising;

� contribute, as appropriate, to quality improvement initiatives and projects within the workplace;

� contribute to the knowledge of others by sharing ideas about quality.

13.3 Practitioner Level

It is proposed that the quality improvement Practitioner should be more able to:

� incorporate and use knowledge of quality improvement principles and practices for improvement of

day to day service delivery;

� initiate, plan and manage quality improvement projects at a local level within the organisation to

improve service;

� apply understanding of the human dimensions of change to management of projects;

� collaborate with others to apply and embed quality improvement within daily working practice;

� share knowledge and experience of quality improvement with colleagues;

� apply a problem-solving approach to delivering service improvements;

� reflectively evaluate their role in fostering and implementing quality improvement and engage in CPD.

13.4 Lead Practitioner Level

It is proposed that the quality improvement lead practitioner should be more able to:

� utilise broad and deep knowledge of quality improvement theories and methodologies to lead and

support service improvement in healthcare;

� apply deep understanding of relevant theories and professional practice to lead and support

organisational change for the improvement of services;

9

F P L B

Foundation Practitioner Lead Board

FF PP LL BB

Foundation Practitioner Lead Board

� advance understanding of the application of quality improvement science to improve services;

� critically appraise merits and limitations of quality improvement methodologies in a healthcare context;

� design, manage and facilitate quality improvement projects;

� coach and mentor colleagues in quality improvement implementation;

� engage with multi-disciplinary teams to deliver improvement of services;

� influence strategy and policy development which champions and incorporates quality improvement;

� critically reflect on own role, capabilities and development needs for leading quality improvement;

� promote and demonstrate a collaborative approach to delivering quality improvement;

� promote and defend the value of data collection and analysis for improving services.

14. Stage Learning Outcomes

The learning outcomes at the bottom of Table 1 pages

10- 13 are those that relate specifically to the topics

included in each stage of the framework, so that

individuals can check progress. These learning outcomes

describe the breadth and depth of engagement with the

content; therefore, individuals can be clear about what is

expected of them. In Figure 2 on the right, the different

levels of engagement are represented by the length of

the arrow.

Note: There are no stage learning outcomes mapped to the NHS Board section at present.

Figure2

Figure 3

FINAL

LEARNING

OUTCOMES:

Foundation

Practitioner

Lead

Board

Stage 2

LEARNING MORE ABOUT

QUALITY IMPROVEMENT



healthcare systems and processes

Person-centred care


Teamwork

Improvement in practice

2.4 Learning for QI

Connecting to resources

Mapping own journey


Common tools and techniques

Stage 3

PLANNING IMPROVEMENT


processes

Identifying improvements

Tools for planning




management





Setting baselines

Data collection

Data sampling


Stage 4

TESTING AND IMPLEMENTING

IMPROVEMENT

4.1 Collaboration and networking




management



Data analysis

Data interpretation

Data presentation

Stage 5

SUSTAINING IMPROVEMENT

5.1 Knowledge dissemination

5.2 Evaluation

Benefits realisation

5.3 Human dimensions of

change


Embedding QI

Business case for QI

5.5 Education and mentoring

5.6 Coaching for

improvement

5

Stage 1

INTRODUCTION TO QUALITY

IMPROVEMENT

1.1 Understanding our purpose and

our values



benefits


1.5 Understanding our

responsibilities for Improvement:

individuals, teams, the organisation


systems


improvement

Model for improvement

PDSA

Process mapping

Lean in healthcare


improvement

1 2 3 4

QUALITY IMPROVEMENT

F P L B

Learning Outcomes Learning Outcomes Learning Outcomes Learning Outcomes Learning Outcomes

F P L B F P L B F P L B F P L B

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14.1 Stage Learning Outcome Table

The following details the learning outcomes for each Stage for each role in quality improvement (not NHS Boards):

Table 1

Stage 1. Introduction to Quality

Improvement

Stage 2. Learning more about Quality

Improvement

Stage 3. Planning improvement Stage 4. Testing and implementing

improvement

Stage 5. Sustaining improvement

Top

ics

1.1 Understanding our purpose and

our values



benefits


1.5 Understanding our responsibilities

for Improvement: individuals, teams,

the organisation


systems


improvement


� PDSA

� Process mapping

� Lean in healthcare


improvement



� Healthcare systems and processes



� Teamwork


2.4 Learning for QI






processes






management






� Data collection

� Data sampling






management



� Data analysis




5.2 Evaluation


5.3 Human dimensions of change


� Embedding QI



5.6 Coaching for improvement

11

Fou

nd

ati

on

Le

arn

ing

Ou

tco

me

s

� Discuss the values shared by staff

of the organisation and relate

them to own workplace values

� Discuss with colleagues the

meaning of quality improvement

� Discuss with others the benefits of

QI for patients, carers, staff and the

organisation

� Give reasons why a person-centred

approach is important for quality

care

� Describe own responsibilities for

improvement as an individual and

as a member of a team

� Talk with others about potential

areas where care and/or service

could be improved

� Explain how we would know

whether or not we have improved

our services

� Explain the relevance of the

current policy context to Quality

� Give examples of improvement

policies which apply to own

workplace

� Discuss with others examples of a

familiar Healthcare systems

� Explain why it is important to

collect and study data before

making changes

� Contribute to a team-based

exercise using a PDSA approach

� Contribute to a team-based

process-mapping exercise

� Discuss with others what can be

learned from run charts and

control charts

� Explain own ways of helping

patients and the difference it

makes to them

� Outline own learning journey and

set goals for learning about quality

� Contribute to the identification of

areas needing improvement

� Contribute to planning an

investigation for improvement

� Contribute to the collection of

data, when appropriate

� Reflect on own contributions to QI

as a member of a team

� Consider own role and

responsibility in ensuring QI

continues into the future

� Given some sample data, explain

what can be learned from it

� Discuss with others the roles and

responsibilities of team members

in helping to ensure a successful

outcome for improvement

� Talk to colleagues about the results

and implications of QI projects

� Contribute to collaboration with

other QI projects when

appropriate

� Talk to colleagues about the

importance of continual

improvement

� Talk to patients and carers about

their experiences of QI

12

Pra

ctit

ion

er

Lea

rnin

g O

utc

om

es

� Discuss own workplace values and

relate them to those of the

organisation

� Discuss the meaning of QI and the

benefits for patients, carers, staff

and the organisation

� Discuss the improvement

responsibilities of self, workplace

teams and the organisation

� Relate person-centred Healthcare

to the science of improvement

� Explain how the model of

improvement could apply to own

service area

� Explain how the PDSA approach

might (or might not) be used in

own workplace

� Discuss how a known workplace

process could be mapped

� Discuss key principles of lean such

as variation, waste and value

� Critically discuss the relevance of

QI to the NHSS Quality Strategy

� Comment on the effectiveness of

improvement policies which apply

to own workplace

� Diagram and annotate a typical

system within the organisation

� Discuss and critique with

workplace colleagues the merits

and limitations of PDSA

� With team members, map,

annotate and critique a typical

workplace process

� Reflect on own work and identify

areas for improvement

� Appraise own strengths and

development needs relating to QI

� Using the QI Framework, plan and

participate in CPD

� Facilitate identification of area for

improvement in the workplace

� With team members, diagram and

annotate a plan for local pathway

analysis using either process-

mapping or value stream mapping

� With team members, plan a local

QI project, choosing the most

appropriate tools for organising

and collecting meaningful data

� Involve patients and carers as well

as staff in planning

� Respond to human dimensions of

project management and support

effective teamwork

� In consultation with colleagues,

determine how project success will

be evaluated

� Discuss with colleagues how QI can

become sustainable in the

workplace

� Contribute innovative and creative

ideas relevant for QI

� Reflect on and in practice about

own contribution to improvement

� For local projects manage and

facilitate the implementation of

data collection, analysis and critical

evaluation of data/results

� Allocate tasks to team members

and monitor progress

� Manage meetings effectively,

promoting sharing of information,

collaboration and cohesive

teamwork

� Facilitate reporting of results in a

clear and meaningful manner

� Communicate effectively with

colleagues about improvement

initiatives and local projects

� Support team members to adapt to

changes resulting from

improvement and champion peer

support

� Collaborate with other projects to

share and disseminate knowledge

and experience of QI

� Support establishment of QI

networks

� Adopt and promote the integration

of a process perspective into daily

working practice

� Collaborate with others to embed

QI in daily working practice

� Periodically evaluate and review

improvements

� Collect and share case studies of QI

� Seek and disseminate knowledge

of good QI practice from elsewhere

� Support colleagues to learn more

about QI

� Contribute to the planning and

delivery of educational events

� Mentor colleagues in the practice

of QI

13

Lea

d P

ract

itio

ne

r Le

arn

ing

Ou

tco

me

s

� Demonstrate comprehensive

knowledge of the organisation, its

purpose and its values

� Demonstrate understanding of and

commitment to QI and person-

centred HC

� Critically reflect on the QI

responsibilities of self, workplace

teams and the organisation

� Explain the nature of Healthcare

systems and processes, and give

examples

� Educate others in the features,

applications and benefits of the

model for improvement

� Help others to understand the

meaning and application of PDSA

and process mapping

� Help others to understand the

principles of variation, waste and

value

� Question the status quo and/or

unsubstantiated change

� Contribute expertise to creation of

QI related policy and strategy

� Facilitate others' understanding of

Healthcare systems and processes

and the importance of person-

centred care for QI

� Promote and facilitate others to

identify areas for improvements

� Facilitate others' knowledge and

understanding of common tools

and techniques for measuring

improvement

� Promote the integration of QI in

day-to-day work and the

importance of multi-disciplinary

collaboration

� Promote, support and engage in

CPD for quality improvement

� Share knowledge and experience

of quality improvement

� Propose new initiatives for

improvement

� Advise on best methods and tools

for planning QI according to

context

� Advise and mentor colleagues in

choosing the most appropriate

tools for measurement including

an understanding of trends in data

� Account for and respond to human

factors in improvement initiatives

� Lead and manage improvement

projects when appropriate

� Deal with challenging behaviour by

influencing and supporting

‘difficult’ conversations

� Promote and facilitate continual

Improvement and forward

planning

� Promote and monitor integration

of an evaluation framework into

practice

� Mentor and support teams to plan

for sustainability

� Recognise and encourage

innovation and creativity in

improvement initiatives

� Lead process analysis appropriate

to context

� Advise on most appropriate tools

for data collection and analysis

� Manage the collection, analysis

and interpretation of data

� Supervise or mentor the reporting

of results

� Manage change resulting from

improvement of services

� Manage risk associated with QI

processes

� Initiate and support opportunities

for sharing of QI knowledge and

experience

� Promote and engage in internal

and external collaborations to

extend the breadth and depth of

QI experience

� Champion a sustainable approach

to QI

� Promote integration of QI into the

business of the organisation

� Use knowledge to influence policy

and strategy for continuing

Improvement

� Collect and disseminate case

studies of good practice and

success and support

mainstreaming improvements

� Share expertise across the

organisation and beyond

� Publish and present findings from

QI initiatives within the

organisation

� Suggest and facilitate opportunities

and resources for learning

� Coach and mentor others in the

application of QI

� Appraise own strengths and

development needs

� Remain updated in knowledge of

quality

� Share and encourage others to

share

14

15. Quality Improvement Glossary of Terms

15.1 Introduction

There is a wide variety of terminology and language used to describe quality, improvement and the

science of improvement methodologies and techniques. This can make it difficult for the learner to

understand and target their specific development needs and the glossary of terms, whilst by no

means exhaustive, is intended to clarify some of the commonly used terminology.

15.2 Glossary

6S (5S): workplace organisation methodology drawn from Japanese roots- sort, set, shines,

standardise and sustain. (Sometimes safety, security, and satisfaction are included and it is termed as

6S).

A3 Problem solving: A means of capturing all stages of a problem - identification, analysis, review,

and solution planning and project management - on one piece of A3 paper. Facilitates visual tracking

of a project.

Accountability: A concept in ethics or governance, often used with concepts such as responsibility,

answerability, blameworthiness, liability and other terms associated with the expectation of account-

giving.

Adverse Event: Harm to structure or function of the body and/or any negative effect which arises

from that.

Care bundles: A selected set of elements of care gathered from evidence-based practice guidelines

that, when implemented as a group, have an effect on outcomes beyond implementing the individual

elements alone.

Cause and Effect diagrams (Ishikawa/Fishbone): A technique to organise and display various theories

about what may be the root cause of a problem designed to encourage innovative thinking (but not

solutions, only possible causes).

Checklists: Designed to improve the safety of care, for example surgical checklists, by ensuring

adherence to proven standards of care; improves compliance with standards and decreases

complications.

Competencies: A set of descriptors outlining the skills, knowledge and behaviours (attitudes) needed

by those concerned with quality improvement.

Consent: The provision of approval or assent particularly and especially after thoughtful

consideration.

Continual Professional Development (CPD): A process of ongoing learning for all individuals and

teams which enables professionals to expand and fulfil their potential and which also meets the needs

of patients and delivers the health and health care priorities of the national health system.

15

Control Charts: Control charts, also known as Shewhart charts or process-behaviour charts, in

statistical process control are tools used to determine whether or not a process is in a state of

statistical control.

Data for Improvement: Statistical tools and techniques to measure the impact of improvements.

Demand, Capacity, Activity, Queue (DCAQ): The process of determining the maximum amount of

work that an organisation or part of an organisation is capable of completing in a given time period to

meet changing demands for its products or services.

Education: A systematic course of instruction designed to provide intellectual or moral support,

knowledge and understanding.

Error: Failure to carry out a planned action as intended or application of an incorrect plan.

Failure Mode Event Analysis (FMEA): An analytical method which highlights probable failures and the

severity of their consequences allowing effort to be directed where it will produce the greatest value.

Feedback: The situation when output from (or information about the result of) an event in the past

will influence an occurrence of the same event in the present or future. When an event is part of a

chain of cause-and-effect that forms a circuit of loop the event is said to "feed back" into itself.

Five Whys: A question-asking method used to explore the cause/effect relationships underlying a

particular problem. Ultimately the goal of applying the 5 Whys method is to determine a root cause of

a defect or problem.

Flow charts: A type of diagram that represents an algorithm or process showing the steps as boxes of

various kinds and their order by connecting these with arrows - can give a step-by-step solution to a

given problem.

Formal learning: Generally has a set learning framework within a period of time, and is conducted in

the presence or under the direction of a designated trainer or teacher. Formal learning involves the

external specification of outcomes and may lead to the award of a qualification or credit.

Handover: This is the time between the last customer-focused activity by a departing team and the

first customer-focused activity by an arriving team.

Hazard: A circumstance, agent or action that can lead to or increase risk.

Healthcare Associated Infection (HAI): infections that are acquired as a result of healthcare

interventions.

High Reliability Organisation: An organisation that has succeeded in avoiding catastrophes in an

environment where normal accidents can be expected due to risk factors and complexity.

Histograms: A graphical representation showing a visual impression of the distribution of data; an

estimate of the probability distribution of a continuous variable. Commonly known as a bar chart.

16

Human Factors: the scientific discipline concerned with the understanding of interactions among

humans and other elements of a system, and the profession that applies theory, principles, data and

methods to design in order to optimize human well-being and overall system performance.

Infection Control: The discipline concerned with preventing healthcare-associated infections.

Informal Learning: Is continuous, incidental, lifelong, personal and based on experience, and is not

bounded by formal parameters.

Information Technology: The application of science to the processing of data according to

programmed instructions in order to derive meaning. Includes all information and all technology.

Innovation: The process by which an idea or invention is implemented in practice, resulting in a

change or improvement.

Leadership: The process of social influence in which one person can enlist the aid and support of

others in the accomplishment of a common task.

Lean: A management philosophy centred on preserving value with less work, by reducing waste to

improve overall customer satisfaction.

Lean principles:

1. Specify value

2. Identify the value stream

3. Make the process and value flow

4. Develop pull systems

5. Pursue perfection

Learning context: interplay of all the values, beliefs, relationships, frameworks and external structures

that operate within a given learning environment.

Learning organisation: organisation which places a high priority on enabling individual learning, in

matters which will directly benefit the organisation. Learning and sharing of new knowledge is

typically encouraged among all employees, on the assumption that active participation will result in

the development of a more responsive workforce.

Learning styles: Various approaches or ways of learning, allowing the individual to learn best, by

identifying and following an identifiable method of interacting with, taking in, and processing stimuli

or information.

Measures: Output measures - quality, delivery, lead time; resource measures - cost and inventory

levels, stock turns; flexibility measures - customer satisfaction, reduction in back / late orders, ability

to accommodate new services.

Medication error: A preventable adverse effect of care, whether or not it is evident or harmful to the

patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury,

infection or other ailment.

17

Mistake-proofing (Pokayoke): A mechanism that helps avoid mistakes by preventing correcting or

drawing attention to human errors as they occur, ie behaviour-shaping constraints designed to

prevent errors.

Mitigating Factor: an action or circumstance that prevents or moderates the progression of an

incident towards harming a patient.

Model for Improvement: An approach to process improvement which helps teams accelerate the

adoption of proven and effective changes. A framework for improvement that involves asking three

key questions - What are we trying to accomplish? How will we know that a change is an

improvement? What changes can we make that will result in an improvement?

Monitoring: To be aware of the state of a system; to observe a situation for any changes which may

occur over time, using a measuring device of some sort.

Occupational Knowledge: Practical knowledge and understanding mostly gained through experience

within a job or occupation.

Pareto Principles: The concept that, in many situations, some 80% of the outputs will be generated by

only 20% of the inputs. For example, 20% of users will make 80% of the calls to a service desk. In

problem management, Pareto charts identify the areas of an organisation or process that will deliver

maximum benefit when improved or when failures or weaknesses are addressed.

Person-Centeredness: A focus on respect; choice; empowerment; involvement of patients, carers and

staff in health policy; access and support; information.

Person-Centred Healthcare: A system that is designed and delivered to directly address the

healthcare needs and preferences of patients, in a cost effective manner. To achieve patient-centred

healthcare, the focus must be on the following five principles: respect; choice; empowerment; patient

involvement in health policy; access and support; information.

Patient Safety: Freedom, for a patient, from unnecessary harm or potential harm associated with

healthcare.

Plan-Do-Study-Act (PDSA) Cycle: Another name for a cycle designed to test a change. The PDSA cycle

includes four phases: Plan, Do, Study and Act. PDSA Cycles are small scale, reflective tests used to try

out ideas for improvement.

Process Mapping: Activities involved in defining exactly what an organisation or part of an

organisation does, who is responsible, to what standard a process should be completed and how

success can be determined.

Quality: Refers to the inherent or distinctive characteristics of properties of an object, process or

other thing which may set apart a person or thing from other persons or things, or may denote some

degree of achievement or excellence. In terms of quality improvement in healthcare, quality is about

learning what you are doing and doing it better.

18

Rapid Improvement Events (Kaizen): Also known as Kaizens. These are a structured way of bringing

together people who are involved in all parts of the process of delivering a service to allow detailed

sharing of all actions undertaken (the current state) process and opportunities to define a future state

and the improvement action plan needed to get there.

Reflection: Thinking about past experiences in a structured way such that future actions are informed,

enabled and improved.

Reliability: In general, reliability is the ability of a person or system to perform and maintain its

functions in routine circumstances, as well as hostile or unexpected circumstances. Reliability theory

describes the probability of a system completing its expected function during an interval of time.

Risk assessment: An assessment of the probability that an incident will occur and the consequences.

Root Cause Analysis: A class of problem solving methods aimed at identifying the root causes of a

problem or events predicated on the belief that problems are best solved by attempting to address,

correct or eliminate root causes, as opposed to merely addressing the immediately obvious

symptoms. By identifying measures at root cause, it is more probable that problem will not occur

again.

Run charts: A run chart, also known as a run-sequence plot, is a graph that displays observed data in a

time sequence. Used to show changes in a process over time.

Safety culture: A term often used to describe the way in which safety is managed in the workplace,

and often reflects the attitudes, beliefs, perceptions and values that employees share in relation to

safety.

SBAR: Situation - Background - Assessment - Recommendations - an easy to remember mechanism to

frame conversations especially critical ones; enables clarification of information to be communicated

between team members.

Simulation: The imitation of some real thing, state of affairs, or process; the act of simulating

something generally entails representing certain key characteristics or behaviours of a selected

physical or abstract system. Used in many contexts, including the modelling of natural systems, such

as weather systems, in order to gain insight into their function.

Six Sigma: Seeks to improve the quality of process outputs by identifying and removing the causes of

defects (errors) and minimising variability using statistical methods and following a defined sequence

of steps (DMAIC: Define, Measure, Analyse, Improve, Control) and has quantifiable targets.

Skills Mix: The learned capacity to carry out pre-determined results often with the minimum outlay of

time, energy or both. Can be divided into general skills (eg time management, teamwork etc) and

domain-specific (eg those useful only to a certain job). Across any team, we need to have balanced

capability of general and specific skills.

Spaghetti diagram: A means of tracking movement in a specific area for the purpose of identifying

wasted activity and movement.

19

Spread: The intentional and methodical expansion of the number and type of people, units, or

organisations using the improvements.

Standard Work: An agreed method of following a process that maximises value whilst minimising

waste.

Statistical Process Control (SPC): The application of statistical methods to the monitoring and control

of a process to ensure that it operates at its full potential.

Supply Chain management: The management of a network of interconnected organisations involved

in the ultimate provision of product or service packages required by end-users - from point of origin to

point of use.

Sustainability: The capacity to endure - the potential for long-term maintenance of well being which

has environmental, economic and social dimensions.

System: A set of relationships which are differentiated from relationships of the set to other

elements. Systems have structure, behaviour and interconnectivity.

Takt time: Aims to match the pace of production with the customer's demand and thus sets the rate

at which each step in the process should be completed.

Teamwork: Work performed by a team towards a common goal; advocated by agreed activities and

behaviours as a means of assuring quality and safety in the delivery of services.

Team working: A dynamic process involving two or more colleagues with complementary

backgrounds and skills sharing common goals and exercising concerted physical and mental effort in

assessing, planning or evaluating service delivery.

Test: A small-scale trial of a new approach or a new process. A test is designed to learn if the change

results in improvement, and to fine-tune the change to fit the organisation and patients. Tests are

carried out using one or more PDSA Cycles.

Theory of Constraints (TOC): Contends that any manageable system is limited in achieving more of its

goals by a small number of constraints; the TOC process seeks to identify these barriers and

restructure rest of the organisation around them.

Time Out: Refers to a stoppage in a procedure for a short amount of time. This allows for team

members to communicate to determine action or inspire morale. Teams usually call timeouts at

strategically important points in a process to avoid members being misled or work against conflicting

assumptions.

Total Productive Maintenance (TPM): A maintenance process developed for improving productivity

by making processes more reliable and less wasteful.

Trigger Tools: A means of conducting rapid structured case note review to measure the rate of harm

in healthcare. Because they are metric they can be used to track improvements in safety over time.

20

Value and Waste: A process adds value by producing goods or providing a service that a customer will

receive. A process consumes resources and waste occurs when more resources are used than are

necessary to produce the goods/services that the customer actually wants.

Value Stream Mapping: Used to analyse the flow of materials and information currently required to

bring a service to a customer/patient.

Variation: A departure from a former or normal condition or action or amount or from a standard or

type and the amount by which this occurs.

Visual Management (Kanban): Also know as Kanban. Tells what to produce, when and how much.

Five core properties - visualise the workflow; limit the work in progress; manage flow; make process

policies explicit; improve collaboratively.

Waste: The identification of which steps in a process add value and which do not. Seven categories of

resource are commonly wasted - overproduction; unnecessary transportation; inventory; motion;

defects; over-processing; and waiting.

Work flow analysis: A technique for gathering information about the possible set of values calculated

at various points in a work flow process. A process's flow graph is used to determine those parts of a

process to which a particular value assigned to a variable might propagate. The information gathered

is often used by managers when optimizing a process.

Workplace learning: Workplace learning happens as an integral component of working. This is the

kind of learning that occurs as we think about what we are doing, and how we might do it better. It

has been called “reflection-in-action” and it is also classified as “informal” learning - see above.

21

Appendix I – Indicative Mapping to KSF

Stage 1: Introduction to Quality Improvement

1.1 Understanding our purpose and our values


1.3 What is QI and what are the benefits


1.5 Understanding our responsibilities for Improvement: individuals, teams, the organisation

1.6 Introduction to Healthcare systems

1.7 Introduction to the science of improvement


� PDSA

� Process mapping

1.8 Introduction to measuring improvement

FOUNDATION Dimension Level Indicator

Discuss the values shared by staff of the organisation and

relate them to own workplace values

C4

C5

1

1

(a) (e)

(c)

Discuss with colleagues the meaning of quality

improvement

C4

C5

1

1

(a) (e)

(c)

Discuss with others the benefits of QI for patients,

carers, staff and the organisation

C4

C5

1

1

(a) (e)

(c)

Give reasons why a person-centred approach is

important for quality care C6 1 (b) (c) (d)

Describe own responsibilities for improvement as an

individual and as a member of a team

C2

C4

1

1

(a)

(a)

Talk with others about potential areas where care and/or

service could be improved C4 1 (a)

Explain how we would know whether or not we have

improved our services

C4 1 (c)

PRACTITIONER Dimension Level Indicator

Discuss own workplace values and relate them to those

of the organisation

C4

C5

1

1

(a) (e)

(c)

Discuss the meaning of QI and the benefits for patients,

carers, staff and the organisation

C4

C5

1

1

(a) (e)

(c)

Discuss the improvement responsibilities of self,

workplace teams and the organisation C4 2

(a) (b) (c)

Relate person-centred Healthcare to the science of

improvement C6 2 (a) (b)

Explain how the model of improvement could apply to

own service area C4 2 (d)

Explain how the PDSA approach might (or might not) be

used in own workplace C4 2 (d)

Discuss how a known workplace process could be

mapped C4 2 (e)

22

LEAD Dimension Level Indicator

Demonstrate comprehensive knowledge of the

organisation, its purpose and its values C5 Level 3 (b)

Demonstrate understanding of and commitment to QI

and person-centred HC

C5

C6

Level 4

Level 3

(e) (f)

(d) (e)

Critically reflect on the QI responsibilities of self,

workplace teams and the organisation C4 Level 4 (a) (b) (c) (d)

Explain the nature of Healthcare systems and processes,

and give examples C1 2 (a)

Educate others in the features, applications and benefits

of the model for improvement C2 3 (e)

Help others to understand the meaning and application

of PDSA and process mapping C2 3 (e)

Stage 2: Understanding More about Quality Improvement



� Healthcare systems and processes



� Teamwork


2.4 Learning for QI






Explain the relevance of the current policy context to

Quality C5 1 (a)

Give examples of improvement policies which apply to

own workplace C4 1 (e)

Discuss with others examples of a familiar Healthcare

systems

C4

C5

1

1

(a) (e)

(c)

Explain why it is important to collect and study data

before making changes C4 1 (b) (c)

Contribute to a team-based exercise using a PDSA

approach

C4

C5

1

1

(a) (b)

(b) (c)

Contribute to a team-based process-mapping exercise

C4

C5

1

1

(c)

(c)

Discuss with others what can be learned from run charts

and control charts C4 2 (c)

Explain own ways of helping patients and the difference

it makes to them

C5

C6

1

2

(b) (d)

(b) (c)

Outline own learning journey and set goals for learning

about quality C2 2 (b) (c)

23


Critically discuss the relevance of QI to the NHSS Quality

Strategy C4 3 (e) (g)

Comment on the effectiveness of improvement policies

which apply to own workplace

C4

C5

3

3

(a)

(e)

Diagram and annotate a typical system within the

organisation C5 3 (f)

Discuss and critique with workplace colleagues the

merits and limitations of PDSA C4 3 (e) (b)

With team members, map, annotate and critique a

typical workplace process

C4

C5

3

3

(b) (e) (f)

(c)

Reflect on own work and identify areas for improvement C5 3 (e) (b)

Appraise own strengths and development needs relating

to QI C2 2 (a)

Using the QI Framework, plan and participate in CPD C2 2 (c) (e)

LEAD PRACTITIONER Dimension Level Indicator

Question the status quo and/or unsubstantiated change

C4

C5

3

4

(e)

(g)

Contribute expertise to creation of QI related policy and

strategy C4 3 (g)

Facilitate others' understanding of Healthcare systems

and processes and the importance of person-centred

care for QI

C4

C6

4

3

(a)

(d) (e)

Promote and facilitate others to identify areas for

improvements C4 3 (b) (e) (f)

Facilitate others' knowledge and understanding of

common tools and techniques for measuring

improvement

C2 3 (f)

Promote the integration of QI in day-to-day work and

the importance of multi- disciplinary collaboration

G7

C4

2

3

(a)

(b)

Promote, support and engage in CPD for quality

improvement C2 4 (b) (e) (f)

Share knowledge and experience of quality improvement C2 4 (h)

Stage 3: Planning Improvement

3.1 Investigating systems and processes





3.4 Leadership and project management






24

� Data collection

� Data sampling



Contribute to the identification of areas needing

improvement C4 1 (a) (b) (d) (e)

Contribute to planning an investigation for improvement

C4

C5

1

1

(c)

(c)

Contribute to the collection of data, when appropriate IK2 1 (a) (c)

Reflect on own contributions to QI as a member of a

team C5 1 (c)

Consider own role and responsibility in ensuring QI

continues into the future C2 1 (a) (c)


Facilitate identification of area for improvement in the

workplace C4 3 (a) (b) (e)

With team members, diagram and annotate a plan for

local pathway analysis using either process-mapping or

value stream mapping

C4 3 (c) (e)

With team members, plan a local QI project, choosing

the most appropriate tools for organising and collecting

meaningful data

IK2 2 (a) (b)

Involve patients and carers as well as staff in planning

G5 3 (a)

Respond to human dimensions of project management

and support effective teamwork

G5

C5

3

3

(a) (b) (g)

(c)

In consultation with colleagues, determine how project

success will be evaluated C4 3 (f)

Discuss with colleagues how QI can become sustainable

in the workplace C4 3 (b) (e)

Contribute innovative and creative ideas relevant for QI C4 2 (e)

Reflect on and in practice about own contribution to

improvement C5 3 (e)


Propose new initiatives for improvement C4 3 (a)

Advise on best methods and tools for planning QI

according to context G5 4 (a) (c)

Advise and mentor colleagues in choosing the most

appropriate tools for measurement including an

understanding of trends in data

C2

IK2

4

4

(e)

(g)

Account for and respond to human factors in

improvement initiatives

G5

C5

3

3

(a) (b) (g)

(c)

Lead and manage improvement projects when

appropriate G5 3 (a)

Deal with challenging behaviour by influencing and

supporting ‘difficult’ conversations C1 3 (c)

25

Promote and facilitate continual Improvement and

forward planning C4 4 (c)

Stage 4: Testing and Implementing Improvement




4.4 Leadership and project management



� Data analysis




Given some sample data, explain what can be learned

from it IK2 2 (d)

Discuss with others the roles and responsibilities of team

members in helping to ensure a successful outcome for

improvement

C4

C5

1

1

(a)

(c)

Talk to colleagues about the results and implications of

QI projects C4 1 (a) (d) (e)

Contribute to collaboration with other QI projects when

appropriate C5 2 (c)


For local projects manage and facilitate the

implementation of data collection, analysis and critical

evaluation of data/results

IK2 3 (b) (c) (d) (e) (g) (h)

Allocate tasks to team members and monitor progress G6 2 (c)

Manage meetings effectively, promoting sharing of

information, collaboration and cohesive teamwork C1 3 (b)

Facilitate reporting of results in a clear and meaningful

manner IK2 2 (e)

Communicate effectively with colleagues about

improvement initiatives and local projects C1 3 (a) (b) (c)

Support team members to adapt to changes resulting

from improvement and champion peer support

G6

C4

3

3

(a) (c)

(c)

Collaborate with other projects to share and disseminate

knowledge and experience of QI

C5

C1

2

3

(c)

(b)

Support establishment of QI networks G7 2 (d) (e)


Lead process analysis appropriate to context C4 3 (b)

Advise on most appropriate tools for data collection and

analysis IK2 3 (a)

Manage the collection, analysis and interpretation of

data IK2 3 (a) (f) (g)

Supervise or mentor the reporting of results C2 3 (e)

26

Manage change resulting from improvement of services C4 4 (a) (b) (c) (d) (e) (f)

Manage risk associated with QI processes C5 4 (d)

Initiate and support opportunities for sharing of QI

knowledge and experience C2 4 (e) (f)

Promote and engage in internal and external

collaborations to extend the breadth and depth of QI

experience

G7 2 (d) (e)

Stage 5: Sustaining Improvement


5.2 Evaluation


5.3 Human dimensions of change


� Embedding QI



5.6 Coaching for improvement


Talk to colleagues about the importance of continual

improvement

C4

C5

1

1

(a) (e)

(c)

Talk to patients and carers about their experiences of QI C4 1 (d) (e)


� Adopt and promote the integration of a process

perspective into daily working practice

C5

C4

3

3

(e) (g)

(b) (c) (d) (e)

� Collaborate with others to embed QI in daily working

practice

C5

C4

3

3

(e) (g)

(b) (c) (d) (e)

� Periodically evaluate and review improvements C4 3 (e)

� Collect and share case studies of QI C2 3 (e) (f) (g)

� Seek and disseminate knowledge of good QI practice

from elsewhere C1 3 (b)

� Support colleagues to learn more about QI

C2

G1

3

2

(e) (f) (g)

(c)

� Contribute to the planning and delivery of educational

events G1 2 (c)

� Mentor colleagues in the practice of QI C2 3 (e) (f)


� Champion a sustainable approach to QI

C5

C4

4

4

(c)

(a) (b) (c) (d) (e) (f)

� Promote integration of QI into the business of the

organisation C5 4 (f) (g)

� Use knowledge to influence policy and strategy for C4 4 (d) (f)

27

continuing Improvement

� Collect and disseminate case studies of good practice

and success and support mainstreaming

improvements

C2

G7

3

3

(e) (f) (g)

(b) (c) (d)

� Share expertise across the organisation and beyond C5 4 (b) (d)

� Publish and present findings from QI initiatives within

the organisation IK2 3 (h)

� Suggest and facilitate opportunities and resources for

learning C2 4 (c)

� Coach and mentor others in the application of QI C2 4 (e)

� Appraise own strengths and development needs C2 4 (a) (b) (d)

� Remain updated in knowledge of quality C2 4 (b)

� Share and encourage others to share C4 3 (e)

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