Table 3

Original and revised QI support strategies and reported consequences

Original QI support strategiesRevised QI support strategiesPerceived or reported consequence of revised strategies
Project selection Programme approached teams with established plans for projects.
The programme originally approached project teams that had established ideas for projects and had partially developed project plans. The round 1 projects were selected as part of the initial CLAHRC NWL programme funding application process and had not been required to commit to the use of QI methods as a prerequisite.
Programme invited applications.
Rounds 2 and 3 teams were required to apply to receive support and funding. The application form required use of QI methods, including the model for improvement, and the intended use of QI methods was outlined in guidance documents. Rounds 2 and 3 projects were selected by a peer review process involving academics, clinicians, commissioners and patients.
Preapplication support and QI taster.
Preapplication workshops were run to give potential teams a taster session of the QI methods they would be expected to use within the project.
Project team members cognitively engaged with the subject matter (rather than instantly dismissing or disengaging from use of PDSA method).
Teams better understood the expectations on them being part of the CLAHRC NWL programme and receiving funding and support.
Taster sessions provided a good foundation to manage expectations.
Teaching style, content and frequency Drawing on existing teaching practice.
Teaching materials were taken from other established QI programmes.
Two days of predominantly didactic training in QI methods (including PDSA) were provided by external QI experts at the project’s formal start.
Training used some interactive elements and frequent use of non-healthcare examples (ie, improving your journey to work) to help understand and practise applying concepts.
Teaching frontloaded in to the project lifetime.
Intensive training provided at the beginning of projects and details of all QI methods described from the outset.
Thereafter, 1-day collaborative meetings took place on a quarterly basis (6 in total over 18 months); all project teams came together to receive further light-touch training and participate in peer-to-peer learning about their experiences, including discussion of QI methods.
Due to time constraints for recruitment and the need to launch the programme within a given timescale, not all project team members attended the initial 2-day training session. It was intended, however, that the clinical leads and project managers who attended the training would pass on learning to other members of their team as they joined.
Staggered teaching of methods to times relevant in the project life span.
Project teams were introduced to concepts of why to use QI methods prior to project selection, with basics of the method provided early on and more details of how to use it provided over time as projects progressed.
Initial training sessions focused on why to use the method and debates its merits and limitations, and over time evolved to details of conducting a single PDSA well (including critical appraisal of PDSAs from round 1 project teams, and peer-to-peer review of each other’s ‘plan’ stages developed in classroom), before considering iterative chains of PDSA and connection to use of data over time.
More real-life healthcare examples.
Drawing on their first-hand experience of the round 1 projects, examples of using PDSA in healthcare settings were presented and discussed, with the introduction of peer-to-peer learning as round 1 team members joined the teaching faculty.
Debate and critical thinking facilitated.
Teams were encouraged to reflect on their prior experiences of change attempts, and debates were facilitated to explore perceptions on why QI methods might be helpful to address challenges to improvement. Time and space were provided for teams to discuss the pros and cons/good and bad examples of the PDSA cycle method.
Teaching material included reflections on other scientific disciplines that used iterative learning approaches (eg, aeronautics, drug development), and interactive debates were built into teaching time to encourage people to share their views and consider why different scientific methods might be suitable for different purposes.
Exercises were introduced that promoted critical reflection, such as an interactive game that prompted teams to debate whether to use a PDSA or not in different scenarios.
Training sessions encouraged teams to practise applying PDSA to their projects.
Staggered training reduced upfront ‘cognitive load’ and instead provided ‘just in time’ training.
Examples were perceived to be of greater relevance and applicability to the new project team members, and less ‘push back’ was experienced.
Having past project team members in the room provided credibility for the approach and allowed people to ask questions and explore the reality of what it had been like using PDSA in practice, accessing a depth of ‘real world’ experience.
Facilitating debate helped to address the concerns held by some clinical academics about the lack of scientific rigour of PDSA compared with randomised controlled trials and other research methods.
Team members could feel that their prior experience and knowledge were heard and valued by the QI support team.
Increased hands on support and QI expertise External experts used for training.
External experts provided initial training to internal QI support team and project teams with little ongoing support. The internal QI support team had little or no prior practical experience in PDSA.
Light-touch advisory role.
Support to project teams predominantly offered in an advisory or coaching role before or after using PDSA.
Independent team action.
Project teams used QI methods independently outside of teaching, advisory or coaching sessions. QI support was not invested in to help QI teams use the method.
Development of QI support team.
Internal QI expertise was developed through working with projects and decreased reliance on external providers.
Training and support for internal QI support team members were increased.
Time was provided for QI support team members to engage with QI experts (from within and external to the programme) to increase their specialist knowledge about the methods.
Opportunity to debate the value of PDSA and to discuss how it should be used in practice was incorporated into internal QI support team meetings.
Hands-on, facilitator support.
QI support team members built relationships with project teams to provide more day-to-day support and active coaching as teams experienced using the method in practice. In round 3 QI support team took greater responsibility to encourage and role-model the use of PDSAs so that project teams could observe PDSA done well and therefore better understand the value of doing so and learn how to do independently.
Wide-ranging support for project teams.
Support to project teams increased to improve scoping of project aims, interventions and development of measure definitions so that data were available to inform PDSA cycles.
QI support staff were able to rehearse ‘difficult conversations’ prior to supporting project teams.
QI support staff were prepared to engage in debates in regard to the application of QI methods.
QI support staff would encourage teams to use PDSAs by identifying ideas that could be tested through a PDSA, or retrospectively reviewing PDSAs that had already been conducted.
QI support staff helped facilitate effective collaborative working within project teams, for example, asking different team members their views on what tests should be conducted or their predictions as to whether change ideas would work or not.
  • CLAHRC, Collaboration for Leadership in Applied Health Research and Care; NWL, Northwest London; PDSA, Plan-Do-Study-Act; QI, quality improvement.