Quality Improvement - A View from General Practice

Dr Joanna Bircher, CIRC Quality Improvement Clinical Support Fellow

In October last year I was selected to be a Generation Q Fellow of the Health Foundation. Generation Q is a part time, fully-funded leadership programme for senior leaders from health care policy and practice, and the charity sector developing our skills for effective quality improvement (QI). There are 18 of us in the current cohort from a wide range of working environments from all four nations, though I am the only GP.

Prior to my involvement with the Health Foundation I had never heard of the concept of 'Improvement Science'. In General Practice over the last 20 years we have focussed our quality improvement work using two key methods - Clinical Audit and Significant Event Analysis. The programme has shown me there are so many more routes we can take to improve the quality and efficiency of what we do and in these days when we are being asked to do 'more with less' this is more important than ever. I am being taught techniques used in manufacturing and other industries that can dramatically change how we view problem solving in general practice.

Most of my working week is spent at my practice, Lockside Medical Centre, with some time spent as Tameside and Glossop CCG Clinical Lead for Quality Improvement and RCGP Clinical Support Fellow. My partners, staff and CCG colleagues have allowed me to test out the new learning in my work environment. I have applied a range of improvement philosophies to look at issues at the practice including same-day access, results handling and maximising QOF achievement applying concepts such as Lean and Value stream mapping; Six sigma; PDSA cycles; Run charts and SPC charts. These terms were a foreign language to me six months ago and yet they have been used in other settings for many years to maximise productivity and efficiency.

Rapids on a Wednesday since October 2012 (Figure one)


My early experiences have shown me how powerful these tools can be. Clinical audit has always used data to monitor for change, but there are so many more ways that data can be gathered and used to drive improvement. A run chart of the number of patients we were seeing as 'extra' before and after our project to improve same day access demonstrated a dramatic reduction and proved to be a powerful motivator for more change. Our reception team are gathering data on the number of times patients are asked to ring back for results that have not yet been commented on. This has allowed the GPs to see to the reality of what our patients and staff experience every day and will drive another improvement project, encouraging us to move towards an SMS results service. Using a new approach to QI has allowed us to be brave and test out new approaches to delivering care without worrying constantly about what might happen.

There will be many practices over the UK who are already using a wider range of QI methods than Clinical Audit and SEA, especially those who have implemented the Productive General Practice tools that draw on Lean and the IHI Model for Improvement. My dream is that over the next few years the College can help the majority of GPs and practice teams to develop QI skills and encourage every CCG to have skilled Quality Improvement Advisors.


The Health Foundation, Inspiring Movement. Generation Q.

Womack J., & Jones, D. (2003). Lean thinking: Banish waste and create wealth in your corporation. Simon & Schuster.

George, M., Rowlands, D., & Kastle, B., (2004). What is lean six sigma. McGraw-Hill.

Langley, G., Moen, R., Nolan, K., Nolan, T., Norman, C., & Provost, L. (2009). The improvement guide: A practical approach to enhancing organizational performance. Jossey-Bass.

Carey, R., & Lloyd, R. (1995). Measuring Quality Improvement in Healthcare. Quality Resources, New York.

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