In 2007 the steering group deliberately took an ambitious approach, with multiple projects and work-streams - a mix of innovation driven from the coal-face of primary care, initiatives drilling down from the top, and enabling work to underpin the two. This allowed Quality:MK to observe progress, behaviours and hurdles across multiple projects.

Using a transparent process of priority setting, the project Steering Group chose to support work on six clinical pathways and two ‘bright ideas’ in practice and to initiate and lead an innovative programme to get evidence into practice via journal clubs, which became known as IMPACTE (Improving Medical Practice by Assessing CurrenT Evidence) groups.

The project team

Quality:MK assembled a small, part-time team which drew on the support of the programme Board and the steering group. Eight people from the latter completed leadership development training funded by The Foundation as part of the award, and joint staff team/ ‘award development’ meetings became a key problem-solving group for programme.

The team supported project leads across all the workstreams. Those setting out on large-scale pathway reviews, for example, were leading this work as part of their day job - and indeed a number of staff changes significantly slowed progress in the first 18 months of the programme. Other leads were taking forward pilot projects or developments initiated through Quality:MK. The programme looked to find flexible approaches to contribute to each project.

Three members of the team stayed with Quality:MK throughout the three years: a GP, a librarian and the progamme manager. A project information specialist was quickly recruited, and in all four GP champions worked with Quality:MK. The team itself led on the evidence-based work-stream, and on embedding the learning and new ways of working.

The project approach

The Quality:MK programme worked through:

• supporting project leads by piloting tools, techniques and approaches; allowing a small fund of £1000 - £1100 to support practice involvement; offering a wide ranging programme of continuing professional development; encouraging participants to reflect on their experience and learning
• bringing in temporary staff to support the changing needs of specific projects and to test approaches: a LEAN-trained Quality Improvement facilitator assisted the strategic development of smoking cessation services, a Clinical Effectiveness Pharmacist worked with IMPACTE to support evidence-based prescribing, a data specialist worked on a dyspepsia project
• observing enablers and barriers to quality improvement across a tranche of projects
• shaping the system, and criteria for decision making, to support the values
• translating lessons learned into explicit, systematic, streamlined guidance and processes

Building a self-improving system: the approach

Working through this portfolio of projects, an ongoing process of continual self-conscious change was applied to build the infrastructure of a self-improving system within which:

• there are multiple points through which to initiate and progress quality improvement  - evidence-based discussion; supporting and spreading a ‘bright idea’ in and from one practice; pathway review and service redesign; public and patient involvement and engagement
• enabling workstreams are identified and addressed strengthening public and patient involvement; early adoption of the Map of Medicine; continuing professional development; programme and project management
• learning is made explicit and transferred; articulating and sharing lessons learned
• Knowledge is managed to improve systems and processes - Production of a suite of products to build capability; Commissioning and Contracting Manual –setting out a systematic approach, streamlining processes and providing templates to boost efficiency; NHS Milton Keynes Model of Quality Improvement supported via action learning sets; Guidance on stakeholder engagement; www.qualitymk.nhs.uk supporting quality improvement