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Keep changes structured and simple to ensure new ideas enhance care

I am always curious. When reading journals, visiting other healthcare systems or at conferences, I’m always looking out for things to apply to my own practice. This can be anything from a new system for organising my emails to implementing multidisciplinary team huddles.

One of my favourite models for adopting change is the Model for Improvement. It has been used for improving care across the NHS.

The Model for Improvement provides a useful framework. It helps us keep changes structured and simple by asking three questions.

» What are we trying to accomplish?

» How will we know a change is an improvement?

» What changes can we make that will result in improvement?

The first question seems obvious, but how often do we start improving things without being clear on what we are trying to achieve? An example would be the huddles I mentioned above. Reasons to put a huddle in place can vary, for example, one team may focus on communication for coordinating care, and another may prioritise safety briefs.

Once the overall aim is agreed then we need to understand how we will know that “a change is an improvement”. This is where to decide which data to collect and how often. Again to use the huddle example, one measure could be simply did the huddle take place today with a yes/no answer. This is called a process measure. An outcome measure to accompany this could be if there is evidence of a multidisciplinary care plan in the patient record.

When implementing change, measures are best collected daily.

Improvement guide

The Improvement Guide: A Practical Approach to Enhancing Organizational Performance by Langley et al (2009) was first published over a decade ago. Since then the use of the authors’ model has been expanded for work on improvement efforts at multinational companies as well as in different industries, such as healthcare and public agencies. The latest edition shows how to accelerate changes, for example spreading improvements in cardiac care across hospital sites

Once the goal of the improvement has been agreed and measures identified, the next step is to decide what change to test. I have always found staff who deliver care are brimming with ideas to improve practice. The skill in this part is to keep the ideas for change focused on the aim and to start small.

Let’s use the huddle again to illustrate this using the plan-do-study-act cycle. The first change to test is perhaps to bring the multidisciplinary team together. Set a time, identify the key disciplines that need to be represented and plan for this to happen in one area for one day. At the end of the first huddle have a rapid debrief on what went well and what can be improved. Use the learning from this to adapt the test for the following day.

Changes are tested in this way and improvement measured until the overall aim is accomplished and sustained.


Erica Reid is a senior nurse at NHS Scotland, has a wide experience of frontline nursing and is a Health Foundation quality improvement fellow at the Institute for Healthcare Improvement in Boston


Langley G et al (2009) The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass.


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