The document presents a conceptual framework for delivering improvements in healthcare developed by the NIHR CLAHRC for Northwest London. It identifies 12 objectives across 3 perspectives that must be considered: what improvements should be made, where and who is involved in improvements, and how improvements should take place. It emphasizes understanding existing knowledge, producing new knowledge through research, and iterative development through active engagement and understanding variation. The framework recognizes the complexity of healthcare systems and the need for transdisciplinary work and multiple perspectives. It provides implications for moving the research agenda to understanding how improvements work in practice and the necessity of its counter-cultural approach.

1. From Theory to
Improvement: A conceptual
framework for delivering
improvements in healthcare
Julie Reed, Cathal Doyle, Cathy Howe, Derek Bell
NIHR CLAHRC for Northwest London

2. Collaboration for Leadership in Applied Health
Research and Care
National (~£90 million, 9 programmes)
• Conduct high quality applied health research
• Translate the findings from research into practice
• Increase the capacity of NHS organisations and public,
private and third sector partners to engage with and apply
research
Northwest London (£10 million 2008-2013)
• Systematic approach to delivering improvements
NIHR CLAHRC for Northwest London

3. Northwest London
Population = 2 million
Budget = £3.4 billion
400 GP practices
14 different NHS Trusts
Most ethnically diverse
population in UK
Very wealthy and very
poor = 17 years difference
in life expectancy

4. CLAHRC NWL Approach
Quality
Improvement
Quality Improvement Methods
Patient and Public
Involvement
Engaging Patients and Staff
Research
Rigorous Design and Use of
Data
Education
Training, Support and
Collaboration
A collision of different worlds…
NIHR CLAHRC
For Northwest London
Health Outcomes
Patient Experience
Improve health outcomes and patient experience through delivery of
clinically effective care.
Primary aim:
4 Rounds: 21 Projects
over 55 Sites engaging
over 500 NHS staff
systematic approach

5. CLAHRC NWL Achievements
Beneficial impacts on care quality, outcomes, experience and costs
• COPD discharge care bundle:
– Improved compliance with „best care‟ (from 0% baseline - 70%)
– reduced length of stay (e.g. by 2.5 days)
– costs savings (e.g. estimated at £123,410/year)
• Medicines Management:
– ADR identification (e.g. 70% potential ADR)
– medication reduction (e.g. 52% meds)
– cost avoidance (e.g. estimated net £145,000/yr)
– co-designed “My Medication Passport” (paper & app, c.9,000 copies)
• Diabetes Improvement through Peer Led Education (DIMPLE):
– Built capacity: 31 “community champions‟, 6 peer educators and 9 peer mentors
– engaged over 9,182 people through 352 events inc BME groups,
– Social return on investment estimated at £11 for every £1 invested.
Demonstrated Patient & Public Engagement & Involvement benefits
Include (3 examples):

6. Cycle for
Improvement
1.
Patients &
Carers
Experience
&Outcome
2.
Identify
needs
3.
Priorities
4.
Identify
Solutions
5.
Implement
Experimental
Medicine
Randomised
Controlled Trials
Basic
Sciences
Public Health
StatisticsSociology
Psychology
Management
Education
Epidemiology
Health
Economics
Engineering

7. What did the literature say?
• What, where, who & how?

8. What improvements should be made to
improve care?
• Translating Medical Research into Practice
• Multiple evidences need to be considered at once –
continual growth of EBM
• Evidence needs to be relevant to local context
considerations
• Staff and patients are not passive recipients,
individual, group perceptions affect uptake,
acceptance & behaviour
• Translation is not a linear process

9. Where does improvement take place
and who is involved?
• Healthcare systems and context
• Healthcare complex multi-level system
• Healthcare is an organic/social system –
relationships, identity, power, emotion (inc stress)
• Quality of care is dependent on collaboration
between multiple individuals as well as individual
behaviour
• Care is delivered by many individuals and
organisations
• Perpetually evolving and adapting, unpredictable

10. How should improvement take place?
• Change management and high performing
organisations
• Knowledge management and valuing knowledge –
external and internal
• Value staff and patients – necessary engagement
• Political alignment (shifting political landscape)
• Continued learning and feedback loops –
responsive and dynamic

11. What? Where and who? How?
3 separate perspectives on improvement
What should be done to improve care/improvements
should be made?
Where does improvement
take place and
who is involved
How change
and
improvement
should take
place
Considering 3
perspectives
together….

12. What should be done to improve care/improvements should be made?
Where and who
How
Understand and
utilise existing
knowledge
Capture and
Produce new
knowledge
Iterative development
Reveals the complexity and overlap/interdependency of these 3 different perspectives
(shows the 12 objectives plus 4 extra concepts (internal knowledge, org memory, external knowledge, research
and evaluation) which help expand the knowledge/acting scientifically theme)
Internal
knowledge
External
knowledge
Organisational
memory
Research and
evaluation
Understand system
and services
Understand Variation
Identify Systemic
Issues
Freedom to act and
learn
Active engagement
Facilitate dialogue
ResourcesandHeadroom
PoliticalandStrategic
Alignment
Invest in Continual
Improvement

13. Conceptual Framework
for delivering improvement in healthcare
Act scientifically
and
pragmatically
Engage and
empower
Embrace
Complexity
Support for long
term success
Understand and utilise existing knowledge
Iterative Development
Capture and produce new knowledge
Active engagement
Facilitate dialogue
Freedom to act and willingness to learn
Understand services and processes
Understand variation
Identify and act on systemic issues
Provide headroom and resources
Political and Strategic Alignment
Invest in continual improvement
Values
Principles

14. Implications
• Recognition of the complexity of the
problem
• Need to move the research agenda to the
‘black box’ of improvement
• Value (necessity?) of transdisciplinary
working and multiple perspectives
• A framework that is applicable in all
situations but it’s counter-cultural!

15. CLAHRC NWL QI tools and methods
Systematic and
scientific
approach to
implementation
using quality
improvement
tools and
techniques

16. NIHR CLAHRC
for Northwest London
Find us at…
W: www.clahrc-northwestlondon.nihr.ac.uk/home
E: clahrc.nwl@imperial.ac.uk
T: @CLAHRC_NWL
Find me at…
W: www.cathyhowe.net
E: c.howe@imperial.ac.uk
T: @cathgreenhalgh