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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.
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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.
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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
4.3 Human dimensions of QI
4.4 Leadership and project
management
4.5 Effective teamwork for QI
4.6 Measurement for QI
� 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
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
4.3 Human dimensions of QI
4.4 Leadership and project
management
4.5 Effective teamwork for QI
4.6 Measurement for QI
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
5
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
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
10
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
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
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
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
4.1 Collaboration and networking
4.2 Effective communication
4.3 Human dimensions of QI
4.4 Leadership and project
management
4.5 Effective teamwork for QI
4.6 Measurement for QI
� Data analysis
� Data interpretation
� Data presentation
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
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
1.2 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
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
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
FOUNDATION Dimension Level Indicator
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
PRACTITIONER Dimension Level Indicator
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
� 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
24
� Data collection
� Data sampling
3.9 Innovation and Creativity
FOUNDATION Dimension Level Indicator
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)
PRACTITIONER Dimension Level Indicator
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)
LEAD PRACTITIONER Dimension Level Indicator
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
4.1 Collaboration and networking
4.2 Effective communication
4.3 Human dimensions of QI
4.4 Leadership and project management
4.5 Effective teamwork for QI
4.6 Measurement for QI
� Data analysis
� Data interpretation
� Data presentation
FOUNDATION Dimension Level Indicator
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)
PRACTITIONER Dimension Level Indicator
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 PRACTITIONER Dimension Level Indicator
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
5.1 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
FOUNDATION Dimension Level Indicator
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)
PRACTITIONER Dimension Level Indicator
� 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)
LEAD PRACTITIONER Dimension Level Indicator
� 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)