Intended for healthcare professionals


How do I develop a quality improvement project?

BMJ 2019; 367 doi: (Published 21 October 2019) Cite this as: BMJ 2019;367:l6041
  1. Abi Rimmer
  1. The BMJ

Quality improvement projects can require a lot of time and effort but they can also be very rewarding. Abi Rimmer speaks to four experts about how to make them a success

Don’t be afraid to start small

Kirsty Brownlie, GP specialty trainee year 3 and quality improvement fellow, says, “Make it something you care about. Instigating change in the NHS is tough but incredibly rewarding to achieve. To make a success of your quality improvement (QI) project, start with something you feel strongly about. Gone are the days when trainees were mandated to perform dreary audits with no clear benefit to the wider system. QI is about producing tangible change.

“Don’t be afraid to start small. Many of the most successful and sustainable projects began as small scale changes which have been rolled out to other areas within a trust, a region, or the entire country. If you are new to QI, starting with a manageable project helps you to learn and apply the methodology without getting too bogged down in the intricacies of wider system change.

“Research what’s been done before. A similar project may have been done in another region and offer valuable groundwork for your own venture. Having some existing evidence that the project could be a success helps to get key stakeholders on board.

“Be collaborative. People like to be consulted about their experiences and ideas, especially if your project is something which will affect them, and you may find that their support helps to drive your project forwards when you hit obstacles along the way. Having a team of people involved helps to share the workload, which can be significant alongside your clinical duties.

“Share your learning. Whether or not your project is successful, reflect on and share the lessons you have learnt. If you are able to demonstrate a positive impact, make sure you write up your project—for your local trust, for medical education publications, and conferences. Not only is this beneficial for the wider NHS but it also looks great on your CV.”

Persevere through problems

Bryan Jones, improvement fellow at the Health Foundation, says, “Take your time. Factoring in enough time at the outset to fully understand the problem you’re trying to solve and what’s causing it is vital. Making the wrong assumptions can derail your intervention before it’s even started. Time spent planning, and avoiding the temptation to rush towards identifying a solution, is essential.

“Share your enthusiasm. Persuading colleagues to get involved in improvement when there are so many other calls on their time isn’t easy. And keeping them engaged once the intervention is up and running can be just as hard. A compelling story that appeals to their emotions, and makes it clear why this intervention matters to them and their patients, can really help. The more emotionally invested they are, the more likely it is they will stay involved.

“Keep listening. The ability to listen with an open mind to what patients, colleagues, and other stakeholders want from your intervention, rather than just focusing on what you think they want, is a key improvement skill. Getting their feedback as your intervention progresses, and being ready to adapt and refine it, is also important.

“Be strategic. Ensuring that your intervention is aligned with your organisation’s strategy and doesn’t duplicate anything will help to win the support of senior leaders. This will increase the chance of your intervention being sustained and spread if it proves successful.

“Keep at it. Almost every improvement intervention, however well planned and executed, will encounter a problem at some stage. The ability to reflect and learn from it is a key skill. When the setback is because of factors beyond your control, a willingness to persevere, and work hard to keep people engaged, is also necessary.”

Do your groundwork

Rammya Mathew, GP and Islington GP Federation quality improvement co-lead, says, “Successful QI projects need buy-in from stakeholders so if you don’t have this to begin with, you need to work on getting it. Part of this is about being able to talk passionately and succinctly about why you are doing your project—so be armed with an elevator pitch which you can share with anyone and everyone who will listen.

“Although it may sound obvious, don’t underestimate the importance of setting a clearly defined aim from the outset. This gives your team clarity of purpose and ensures your efforts are centred around a mutually agreed ambition. It’s all too easy for your aim to keep expanding and then quickly feel out of reach.

“Do your groundwork; spend time researching what approaches have been tried and tested elsewhere, what worked, and what didn’t. And if there are ready made resources out there which you can use for your project, make the most of them. Don’t waste time reinventing the wheel.

“Continuous measurement is key to quality improvement. Remember that there is no such thing as the perfect measure; data will always be subject to inaccuracies but try and mitigate this by having as consistent an approach to data collection as possible.

“Be prepared to have setbacks. Even seemingly simple changes can feel challenging to implement. It’s important to consider how you maintain your resilience through the setbacks and how you keep both yourself and your team motivated when things are not going to plan. QI is not just about knowing the methodology. It’s about having vision, building relationships, and, most importantly, it’s about steering a team.”

Engage key stakeholders

Tamar Koch, GP and Islington GP Federation quality improvement co-lead, says, “The first consideration when leading a QI project is to ensure that the topic has been scoped out thoroughly. Look at whether the matter at hand is amenable for a change to be trialled using QI methodology. It’s always worth thinking about whether it aligns with local or national imperatives to ensure backing from relevant organisations. Run a search of the available literature to look at existing evidence and to see whether there’s any evidence about benefit, impact, equity, and cost effectiveness of similar tests of change undertaken elsewhere.

“The next step would be detailing the project using the NHS Model for Improvement as a framework, and really defining the problem and the possible means for change. It is at this stage that a team would think about the aim of the project, the means for change, and the measures used to demonstrate any change. Making sure that there are data that can be collected to evidence any change the team is aiming for is key, as well as ensuring that baseline data can be collected at the outset. It is always prudent to think at inception about how the project will be evaluated at the end; using outcome, process, and balance measures are essential. It’s at this point that driver diagrams and risk registers can be drawn up.

“Finally, and arguably most importantly, engage all stakeholders involved in the project. Time, energy, and resources must be devoted to this activity, and a communications plan ought to be devised, otherwise the best planned project can fail.

“Regular reviews of data analysis, using the ‘plan, do, study, act’ cycle1 and ‘adapt, adopt, amend’ approaches, alongside continuous management of the team and stakeholders, are key to keeping a project on track, maintaining the energy of the team, and the engagement with all those involved.”