Leading effective and sustainable Quality Improvement within a Primary Care Network: A How To Guide (PDF file, 479 KB)
Plain text of document (infographics not included):
Peer review meetings checklist
It is important to take some time ahead of a peer review
meeting to plan how to deliver the meeting and what
you want to achieve from it. This checklist of key steps is
designed to help you do this.
Choose the right format and set clear rules.
- When meeting online select a platform familiar
to participants and make it clear how you want
them to participate (e.g. all cameras on, mute when
not speaking, requesting to speak via raise hand
function).
- Identify key meeting roles (e.g. chair, recorder, timekeeper, facilitator) and ensure they are allocated to participants.
Ensure that everyone has a voice.
- Have you included key stakeholders? Think about why you are inviting each participant, and make sure they have the knowledge and support to participate in a meaningful way. This is particularly important for patient and public participants.
- Send meeting agenda and papers to participants in advance so that they can prepare properly for the meeting.
- Consider using small break out groups to build relationships and confidence.
Set clear and realistic goals.
Focus on what it is possible to achieve during the meeting
and beyond it. It is good to be ambitious, but be conscious
of the other calls on participants’ time. If the goals are too
demanding, enthusiasm and commitment will soon ebb
away.
Think about how:
- your goals will be delivered, and:
- progress will be measured.
Make sure the right data is available.
To fully understand a problem, you need to look at it
through the widest possible lens, before trying to tackle it.
- Have you used a mix of qualitative as well as
quantitative data, to bring in perspectives from a
diverse range of people and settings?
- Think about how best to share and present these
data with participants so that it can be used to
inform your discussions e.g. who will be involved
or effected by any changes (stakeholder analyses),
how the work usually gets done (process diagrams),
baseline data and the impact of any previous/future
change interventions (audit data and annotated run
charts) and questionnaire results (staff satisfaction,
patient satisfaction etc).
Focus on creating trust and respect.
To get the most from meetings, participants need to listen
carefully and respectfully to the views of others and value
their respective experiences and expertise.
- Ask questions and seek reflections from others in
order to involve everyone and create an effective
dialogue.
- Provide measured feedback that builds on the points
on which you agree, to create trust and a positive
meeting environment.
Encourage learning from experience.
Participants should be encouraged to share their
experiences. Identify and discuss:
- what has not worked as planned
- examples of success.
Barriers to and facilitators of success.
Take the time to identify and reflect on the learning from
these experiences, and think about how this learning can
be shared more widely to inform future improvement
interventions.
Identify priorities for action and next steps.
End each meeting having:
- set clear action plans that identify the next
easiest steps
- ensured that participants know who is responsible
for delivering them
- prioritised feasible completion dates
- taken a few minutes at the end to ask participants
what they think worked well in the meeting, and
what they’d like to see done differently.
Introduction
About this guide
This guide describes how to plan, deliver and sustain
Quality Improvement (QI) across Primary Care Networks
(PCNs). Drawing on learning from across primary care
and the wider NHS, it sets out the skills, behaviours
and actions that underpin successful QI interventions.
It also offers practical tips on how to lead and manage
improvement, as well as links to supportive resources.
Who is this guide for?
This guide is primarily aimed at those involved in leading
PCNs. However, the description of the skills, behaviours
and actions needed to deliver QI interventions will be
of interest to anyone connected to PCNs who wants to
get involved in QI. QI is a team activity and works best
when people from a range of professional backgrounds,
and, of course, patients, collaborate to tackle the quality
challenges that matter most to them.
Furthermore, anyone can lead a QI activity: enthusiasm,
commitment, and relevant expertise are what count, not
their level of seniority.
What does this guide add?
There are lots of training resources to develop an
individual’s QI skills. How these skills can be effectively
and efficiently used within Primary Care is less clear.
PCNs offer an opportunity to work collaboratively,
share knowledge, skills and passion to change how care
is organised and experienced by staff and patients.
This guide outlines how you can maximise efficient QI
collaboration within your network.
Where you are at on your PCN improvement journey?
In planning an improvement activity, it is important to take
stock of what skills, expertise and support you will need at
each step of the journey. It is also useful to think about the
challenges you might encounter, and what opportunities
you could utilise. These steps are explored in greater detail in sections 3-7
of this guide.
How can your network get the most impact from
collaborative quality improvement?
You have specialist knowledge of local needs, strategic
priorities, and network members’ expertise. This puts
you in a unique position to bring these people together to
improve care efficiently. Wherever possible:
- Look for opportunities to coordinate QI initiatives.
- Capitalise on clinical knowledge and QI skills.
- Learn from those doing well.
Leading collaborative Quality
Improvement activities
You have a vital role to galvanise, support and align
effective improvement activity within your network.
Make the most of team members from different practices
(including clinical, administrative, and additional
workforce members) to undertake QI. Collaborative
working across practices will support everyone to meet
the contractual arrangements outlined in the Primary Care
Network directed enhanced service (DES) and the QOF QI
domains. Here are five things to consider when thinking
about how to effectively lead PCN QI:
3.1. Create a shared improvement ambition:
Fostering a sense of shared QI purpose across your
network can help to encourage collaborative improvement
activities that span the system and promote the sharing
of learning from improvement. To feel authentic to people
in all parts and at all levels of the system, you need to be
aware of the improvement culture and history of each
practice in the network. Working together take the time
to listen to the aspirations of staff and patients; this will
help to build your understanding and add to improvement
efforts’ value and authenticity.
3.2. Instil a culture of learning:
An improvement culture that enables people to give their
best because they feel listened to, valued and supported,
is vital. We know that teams are more likely to think
creatively and try new things when they feel a sense of
psychological safety. This comes when there is a culture
of learning in place, rather than one of blame, and when
the responsibility for initiating and leading improvement
is distributed across the organisation, and not vested in
the hands of a few senior leaders. A positive attitude to
diversity and inclusion, so that improvement is shaped by
a representative range of voices and perspectives from
within the community, is equally important.
3.3. Protect time for improvement:
It is important to consider the extent and pace of
improvement that can be delivered. Time is needed to
identify, prioritise, plan and deliver improvement(s). In
time-pressured clinical environments, it can be hard for
practice staff to switch gear and realise the importance of
planning (prior to thinking about implementing solutions).
Remove the pressure to get started and demonstrate
impact. Taking time to identify the smallest change most
likely to have impact, will be more efficient. Regularly
reinforce the importance of effective preparation and
engagement to understand why current processes are not
optimal; and what the easiest and most impactful next step
to be tested should be. Identify opportunities to carve out
time away from clinical, administrative and management
duties so that improvers can meet at relevant points on
their improvement journey to plan and reflect.
3.4. Developing capability:
While awareness of QI methods and tools is growing in
primary care and the wider NHS, it’s still the case that a
majority of practice staff have little or no experience in
using common improvement methods, such as Plan Do
Study Act (PDSA) cycles. As well as signposting them
to external resources and training, identify existing
improvement expertise within the system and finding
ways to share it with practices with limited improvement
experience. There may also be an opportunity to
strengthen improvement capability by organising shared
training.
3.5. Connecting and aligning improvement interventions:
Spotting connections between different improvement
interventions, both within and beyond their local system,
and the opportunities they present for collaboration and
joint learning is important. Equally necessary is the ability
to address interventions that may be out of step with local
strategies or lead to variations in care that may have safety
or equity implications.
The core dimensions of leadership behaviour are
described in detail in the Healthcare Leadership Model
developed by the NHS Leadership Academy considering
each of these aspects can help with the planning and
delivery of collaborative improvement activities.
Harness the expertise
across the network
6
To effectively and efficiently lead population health
improvement in your network you need to assemble
a core team to share this responsibility and deliver
improvements. Identify what you ‘know’ and what you
‘don’t know’, but others in different roles do know. To
accelerate progress identify:
- Who fully understands the networks current
performance data to identify priorities for
improvement across the PCN or within individual
practices?
- Who has the specialist clinical knowledge of the
areas outlined in DES and QOF QI domains to
inform improvements?
- Who has previously undertaken improvement
projects or training in QI methods?
- Who can effectively facilitate practice peer review
meetings to initiate and sustain improvement?
- Who has the service delivery expertise to identify,
adapt or design change interventions such as EHR
searches, computerised templates and prompts?
- Those with relevant skills needed for effective
improvement
Identifying where there
is room for collaborative
improvement
5.1. Convey why everyone should act now:
As well as being clear about why you’re trying to improve
something, you also have to think about why it matters
now. At any one time there are lots of priorities for
improvement in primary care. So what is it about this
problem that means you need to act now? What evidence
do you have to show that it’s urgent and important? If you
can convince people of the necessity for action, they are
more likely to ‘buy into it’ and find the time to get involved
and go the extra mile to make it work.
5.2. Use data to identify higher and lower achievers.
Capitalise on what is working well that may be possible to
scale efficiently across the network. Identify practices who
need specific support to do things differently.
- Where possible review existing population data
(e.g. Atlas of Variation) or use local public health
profiles (ask your CCG / local public health team to
provide them if they don’t already)
- Next, identify where there is a need to collect or
share ‘current’ or ‘practice-specific’ data?
- Where can you source ready-made computerised
searches to collect patient-specific data?
- Who has the skills to adapt or develop patient identifiable
searches?
5.3. Engaging the right skills and expertise in
improvement prior to meeting enable practices to
explore the area for improvement:
Use practice achievement data to inform which practice(s)
are doing well, and which practices should be supported to
improve. Ask each practice to:
Create a brief flowchart showing how this work is
undertaken by each staff member.
Can those doing well identify resources (e.g. patient
searches, computerised prompts, templates or
patient resources) that could be implemented across
the network?
Can those who need support identify areas of
frustration or duplication?
5.4. Build a coalition of support:
Who is best placed to influence each of the professional
groups and patients whose support you need to get the
idea off the ground? And remember it isn’t always the
most senior person who’s best equipped to help. Having
the support of senior, experienced staff is vital, not least
in terms of unlocking access to any resources needed or
resolving any teething issues. But as well as people with
the right seniority to support improvement work and
change, you want people with the right ‘influencing skills’,
such as the ability to ‘read others’ and work out what will
- and what won’t - convince them to back the idea. And
these skills exist at every level of primary care system. It’s
important not to rush this engagement work. Time spent
at the start in building a coalition of supporters, will almost
certainly save you lots more time further down the line.
5.5. Use existing meetings:
Such as PCN board meetings or locality based CPD events.
You need to balance the pressures on staff’s time with
providing sufficient headspace to reflect, get to know each
other, create ideas and make plans.
Some may use phone or e-mail to get things started and
maintain momentum. If appropriate and following all
relevant (Covid-19) guidelines consider whether meeting
face-to-face or online would work best once you have
considered the people who need to come together to
improve, what will work best for individuals in your team
and how well they know each other.
5.6. Consider who should attend each session to ensure
the right mix of skills and expertise:
- Specialist clinical knowledge
- Systems and service delivery experience
- Improvement methodology expertise
- Patient experience
- Knowledge of effective interventions to change
practice
Regularly review who else could support the improvement
work: focus on who you could ask to support the team,
who is already working to address this topic or a related
type of behaviour. Consider the different skills and
expertise the team needs, and how to get these people to
share the work. Think about the relevance of different
types of professional, administrative and management role
and the patients likely to be affected by the intervention.
Engage with those in leadership positions when official
approvals to change are required. A useful model to help
you think about the behaviours and skills needed within
the team to sustain an improvement intervention is Bill
Lucas’s Habits of Improvers model.
Facilitating improvement sessions
In the context of COVID-19 there are many more options
for how, when and how often to meet (e.g. Microsoft
Teams, Zoom, Google Meet).
6.1. When meeting online:
- Identify what platform(s) are available, what are
your members most familiar with (e.g. Microsoft
Teams, Zoom, Google Meet or others)?
- Make it clear how you would like everyone to show
up (e.g. all cameras on)
- Provide guidance on how you wish everyone to
participate (e.g. mute whilst others are talking, raise
hands on the task bar to ask questions or respond,
use the conversation box to provide content on a
one-to-one or group basis).
- Indicate likes/dislikes or pace too fast/too slow using
taskbar icons
- Consider break-out rooms if technology allows (e.g.
MS Teams or Zoom)
6.2. Ensure improvement teams are built on trust and
mutual respect:
The way in which improvement team members relate
to each other and work together has a vital bearing on
the success of the intervention. Treating each other with
respect, listening carefully to views of others, trusting each
other, and valuing everyone’s ideas, regardless of their
position or level of experience, are all behaviours that can
help the team to gel and get the best out of people.
Equally important is a willingness to learn in partnership
with others and a sense of humility, founded on an
awareness that no single person has the skills and
experience to solve a problem on their own. Other vital
attributes are the ability to ask questions clearly and
frequently, and to share your own knowledge and thoughts
in a focused and timely fashion: these ‘teaming’ skills will
help to ensure that the team is able to interact effectively
from the off and make the most efficient use of what time
it is able to spend together.
6.3. Set realistic goals:
Think about what realistic improvement targets would be
in the time available for each practice. It’s important to
stretch practices, but the team’s energy and motivation
will soon melt away if the targets are too demanding in
terms of time and resources, or require changes that lie
outside the control of those involved. Identifying some
‘early wins’ to build confidence within the team and with
other stakeholders can be very useful and build motivation
to progress.
6.4. Sequence and prioritise agenda items during peer
review meetings
- Use assertive inquiry to both give advice (advocate)
and actively listen (enquire) to all attending.
- Focus on developing a culture of problem solving.
It’s important to look at a problem through the
widest possible lens. As well as analysing data that’s
most directly relevant to the problem, look at other
related data sets that could give you a different
perspective and provide you with a more nuanced
understanding of the problem. Exploring these
‘neighbouring possibilities’ is, as Stuart Kauffman
described, key to the successful development of
new ideas. Generate a rapid but long list by asking
everyone to generate ideas in the form of ‘we could
do this, and this…’. Take time to identify the single
easiest action that could make a difference and start
there.
- Share experiences of what has worked and what
hasn’t worked.
- Set clear priorities for action.
- When agreeing actions – record What, By When, By
Whom?
- Sequence and prioritise agenda items during peer
review meetings
6.5. Consider what needs to be done next?
- Did it work? If so, Adopt.
- Did you have problems? If so, Adapt.
- Did it go wrong? If so, Abandon and learn from
the setback and decide how to act going forward.
Celebrate the progress that
you are making together.
7.1. Celebrate success:
As well as taking time to learn from setbacks, it’s
important that the team pauses to acknowledge and
celebrate progress and moments of success. Marking
success is not just about building confidence and morale.
It’s also about highlighting the expertise and experience
that team members gain from taking part in improvement,
such as leadership, problem solving and relational skills, all
of which will stand them in good stead in other aspects of
their job and their career development.
7.2. Collate examples of the important work:
Continually remind everyone of the progress being made
e.g. PCN QI newsletter or WhatsApp group. Use this
‘Done’ wall (or newsletter or presentation) suggested by
Scott Belsky to showcase what has been achieved and
motivate others to make similar progress.
7.3. Maintain a culture of improvement:
Initiating improvements can require time, patience,
persistence and skill. Finding those who are passionate
(or frustrated) and harnessing their energy to improve
can allow simple changes to have great effect. Keeping
momentum going in the following weeks and months,
while maintaining your own enthusiasm and commitment,
may be demanding given competing pressures.
7.4. Expect uncertainty and risk:
The path of every improvement intervention is littered
with obstacles, some of which are predictable, others less
so. Sometimes the full complexity of the solution required
only becomes clear when a project is well underway. This
means that an ability to tolerate uncertainty and ambiguity
is a key skill for any improver. Another is a willingness to
take reasonable risks as new possibilities emerge, and
the best one to pursue is hard to identify. It’s important
to weigh any such risks against their potential impact
on safety, but it’s also worth remembering that avoiding
or delaying a decision can pose the greatest risk of all to
patients.
7.5. Resilience is crucial:
The uncertainty and unpredictability of improvement
means that not everything you do will go as planned. On
occasion it might feel that you are going backwards rather
than forwards. It’s important to respond in the right way
to setbacks. Seeing them as an inevitable part of the
improvement process and factoring in enough time to
learn from them and to use that knowledge to strengthen
the intervention is critical. Remaining optimistic about
what you can still achieve, particularly if you are an
improvement leader, will also help the team to stay
positive and resilient in the face of temporary adversity.
Supportive resources