Posted on: 17 December 2021

December 2021                                                                         



Photo: Holy in Kew Gardens, Peter Smith

Festive Greetings

December and the close of the year is with us already and in this edition of the Newsletter we look back over the range of subjects and articles covered in the past 12 months.  We have included aspects of work in improvement projects across the lifespan of a project from understanding an issue or problem to interpreting data.  In the near future we intend to turn each of these articles into resources on the QI intranet pages, so they will be readily available to staff in CNWL.

The most exciting news this month is the opening of bookings for Level 2 (Silver) QI Project Lead training, which is aimed at staff who already have experience of using the model for improvement and want to progress to develop the skills and knowledge needed to be a QI project Lead.  The new course is now available via LDZ with a start date in early February.  Read on to find out more...

Reporting from the CNWL QI Practicum, we hear about teaching on Statistical Process Control (SPC) charts and the importance of story telling in both engaging people and stakeholders and in reporting on project progress.

Our final QI Tip of the Month for 2021 is about Progress Scores on Life QI and how to change your score as you develop your project.

Rounding off with the usual update on available dates for Bitesize QI Training, we wish all our readers a joy-filled and peaceful festive season.  Take care and stay safe everyone!

We welcome your feedback and if there is anything you would like to see in future editions of the newsletter, do please get in touch by e-mailing


Review of the Year 2021

As we approach the end of 2021, let us look back at what the QI Newsletter has covered as we bring together an almanac of subjects included over the last 12 months.  We think this is the basis of a QI library of resources that we shall be transferring to the QI intranet pages in the near future!


Articles and QI Tips

January 2021

Central QI Programmes: Falls and Violence Reduction

February 2021

Rapid Tests of Change and PDSA cycles

March 2021

Applying QI thinking/methodology in practice

April 2021

Returning to business as usual

May 2021

QI Coach Forum: A timely reminder about Service User & Carer Involvement

June 2021

QI Coaching: What’s it all about?

How does being a QI Senior Sponsor support a QI project team?

QI Tip of the month: Adding a coach to your Life QI project

July 2021

Starting your QI project: Knowing your problem

Fishbone Diagrams (aka Cause and Effect diagrams)

QI Tip of the month: The 5 Whys Strategy

August 2021

Starting your QI project: Developing your Aim Statement

QI Tip of the month: Chartering your project on Life QI

September 2021

Why is data so important to Quality Improvement?

QI Tip of the month: Book into the NEW QI Clinic

October 2021

Using Plan Do Study Act (PDSA) Cycles

November 2021

Interpreting QI Run Charts

December 2021

Review of the Year 2021

QI Tip of the Month: Progress Scores on Life QI


Over the year, the newsletter has introduced articles across the lifespan of a QI project from knowing your problem, through tests of change and using PDSA cycles to interpreting run charts. We have brought you 5 QI tips giving you practical advice on ‘how to do something’ and discussed the importance of the roles of coaching and sponsorship in a QI project.

It has been a busy year with hellos, goodbyes and ‘hello again’ to staff in the central QI Team as well as keeping readers up to date with the availability of QI training in CNWL.

We are looking forward to exciting developments in 2022, but more of that later.  The Newsletter will continue to keep you informed of what’s new in improvement at CNWL as we move into the new year.

To read any of the articles mentioned above, please find the relevant edition of the QI Newsletter under QI News at:

News from the Practicum 2021


The latest learning session for projects tems on the QI practicum took place on 15 December


We also heard about the work of the Serious Indecent Review Team and their successful use of process mapping and service user involvement to understand what matters to both internal customers to the process and to patients and families.

The Tasman Ward project team presented their work to bring co-production to the heart of their project and we loved their closing quotation about Service Users:

"Don’t be afraid to GIVE POWER TO SUs"


Booking now open for the CNWL Level 2 Silver QI Project Team Leader QI Training Course starting 3 February 2022 



We are delighted to announce that booking for the CNWL Level 2 (Silver) QI Project Team Leader training course is now open for any member of CNWL staff who is ready to take the next step in their QI journey.

This course is aimed at CNWL staff who wish to use improvement methodologies in their role and need to develop skills as a QI project leader. The course is a workshop-based programme, delivered over 4 months with 1.5 days formal training and also forms part of the 21st Century Leadership Programme (Level 2).

Staff are suited to this course where their job needs them to lead a QI project, but especially those working in a team or service lead role at experienced Band 6, Band 7 or 8a level.  Participants will be expected to lead a QI project in their service through the course, so that they can apply learning in practice and applicants should have an idea for an aspect of their service that they need to improve.

Participants will receive intense virtual training on the QI model for improvement and how to apply it to their chosen project.  The initial training will be followed by two group QI clinics, where progress discussion and reflective learning will support the project team leadership role.  Training will also cover the skills and knowledge needed to lead a QI project and conclude with the development of a peer-reviewed QI poster and presentation.  The course will focus on your learning about applying QI methodologies and leadership, rather than the outcome of a QI project, although the course is designed for you to also evidence an improvement in your service.  Attendees will have the opportunity to access a QI Coach as they work on their QI project.

Previous QI training or experience is not essential, but highly recommended.  Applicants may wish to undertake the Bitesize QI training or some pre-reading about QI on the CNWL QI web pages at if they have not previously done so.  Applicants will need to include an outline title of a QI project that they will work on during the course when applying on LDZ.

Training Dates





Learning Session 1

The model for improvement and skills for leading a QI project team

03 February 2022

6 hours total:

9.30am – 12.30pm

1.00pm – 4.00pm

Group QI Clinic 1

Project discussions and coaching

08 March 2022

Afternoon between 1 pm and 4 pm

1 hour

Timings to be confirmed with each trainee

Group QI Clinic 2

Project discussions and coaching

19 April

Afternoon between 1 pm and 4 pm

1 hour

Timings to be confirmed with each trainee

Learning Session 2

Poster submission deadline

Project presentations and peer review

31 May 2022

3 hours

Timings to be confirmed with each trainee

How to book

To book your place on the CNWL Quality Improvement (QI) Project Team Leader Training Course, head over to LDZ (Link to LDZ login) and search/look for the Quality Improvement block, which will take you to the range of QI training available and select The QI Project Lead course.


Please discuss your training with your line manager before booking and you will see that you need to answer some questions before booking.  These are required to ensure that the training is right for you, but if you have any questions regarding the course, please get in touch with the QI team on


The deadline for booking on the first cohort starting in February 2022 is 5pm on Friday 21 January 2022.


The QI Clinic is bookable for you to discuss your improvement work

This is a quick reminder that the QI Team run regular short (20 minute) sessions that are bookable in advance to help staff with any questions or issues relating to your improvement work.


The QI Clinic runs every Friday with bookable slots at 12.00 noon, 12.20 pm and 12.40 pm and in each slot, you will get the exclusive attention of an improvement advisor and coach to help you think about your issue.

To book, send a request stating your preferred Friday and time to and we shall confirm back to you with a diary invite and link to your QI clinic slot.

We look forward to talking with you!


QI Tip of the Month: Progress Scores on Life QI

Did you know that your project on Life QI has a progress score on the general tab?

The progress score is designed for you to assess how far your project has developed against a standard range of score numbers from 0.5 through to 5.0.  There is sometimes a little confusion in that project teams do not realise (or have never been told) that the progress score is not set by the Life QI system; it is not an automatic progression and it is up to the project team to review and manually move their project score onwards by updating the score on the system.

The benefits of keeping your QI Progress Score up to date are twofold: it helps the project team feel that they are moving forward with their project, so it can be very motivating and it shows external viewers where you are in your QI journey.

First, let us look at what the scores mean.

Here is a table of the scores and their definitions as they appear on Life QI:

It can be useful to think about each score in relation to the parts of the model for improvement that a project team would be working on to satisfy that score and what evidence a team might have included in Life QI, so the following table sets this out:

Progress Score


Which part of the Model for Improvement is actively being worked upon?

What evidence would you be able to add to your QI story?


Intent to participate


Project has been identified, but the charter has not been completed nor team formed.

  • The QI project team has considered what is known about the issue or problem that the project is intended to improve.
  • A project has been registered on Life QI, awaiting approval by Divisional QI Improvement Advisor.


Charter and team established


A charter has been completed and reviewed. Individuals or teams have been assigned, but no work has been accomplished.

  • Project has been approved on Life QI.
  • Team members have been invited to the project on Life QI.
  • A project aim has been established.
  • The project team have considered and started to involve service users in the project.


Planning for the project has begun


Organisation of project structure has begun (such as: what resources or other support will likely be needed, where will focus first, tools/materials need gathered, meeting schedule developed).

  • The project team has begun to meet on a regular basis with protected time devoted to work on the project.
  • Story telling (e.g. via a physical story board in the service environment) has begun with allocated roles to maintain the story as the project progresses.  The story telling is engaging wider staff in the service and more staff may be joining the QI project.



Activity, but no changes


Initial cycles for team learning have begun (project planning, measurement, data collection, obtaining baseline data, study of processes, surveys etc.).

  • A data collection plan has been established and baseline data is being collected or historical data has been obtained to provide a baseline.
  • The team have used tools to fully understand their problem, e.g. forcefield analysis, process mapping, 5 whys.
  • Planning for first PDSA cycle(s) has taken place.


Changes tested, but no improvement


Initial cycles for testing changes have begun. Most project goals have a measure established to track progress. Measures are graphically displayed with targets included.

  • Initial PDSA cycles have been concluded.
  • Data is being collected and placed on Life QI, covering Outcome, Process and Balance measures; a full measurement for improvement set of data is in place.


Modest improvement


Successful test of changes have been completed for some components of the change package related to the team's charter. Some small scale implementation has been done. Anecdotal evidence of improvement exists. Expected results are 20% complete.

  • A small range of PDSA ramps has been completed and some movement of the outcome data can be evidenced on the outcome measure chart on Life QI.
  • The project t story boards have been updated with information about PDSAs, data and qualitative information.




Testing and implementation continues and additional improvement in project measures towards goals is seen.

  • The project team are systematically working through their change ideas and testing each in turn using PDSA cycles/ramps.
  • Improvement is evidenced in continuous improvement of data measures.


Significant improvement


Expected results achieved for major subsystems. Implementation (training, communication etc.) has begun for the project. Project goals are 50% or more complete.

  • Quantitative data (charts on Life QI) evidence that the project is at least half way to achieving the improvement aim.
  • The project team are starting to consider how to ‘hold the gains’ of improvement by implementing permanent change or ‘the new way of working’.


Sustainable improvement


Data on key measures begin to indicate sustainability of impact of changes implemented in system.

  • Having reached the anticipated level of the project aim, data is evidencing that the improvement is continuing to stay at these new levels.


Outstanding sustainable results


Implementation cycles have been completed and all project goals and expected results have accomplished. Organisational changes have been made to accommodate improvements and to make the project changes permanent.

  • The project aim has been achieved and maintained over a significant length of time and the project team have put in place changes to make the new way of working permanent (e.g. revised policies, procedures are written down and distributed). 
  • Ongoing control of the project aim is put in place to ‘keep an eye on’ the improvement and prevent the aim from slipping back to where it was before the QI project began.
  • The QI project team has formally ‘stepped down’ and ceased meeting.
  • The service has returned to Business As Usual (BAU).


So how do you update your progress score on Life QI?  It is a simple action to take and should not take you more than a few minutes to do.  You will be prompted to add a summary of your rationale for the change in score and this gets alerted to your Divisional Improvement Advisor, so that they are aware and can offer support if needed.  And to congratulate you on your progress!

Here is a step by step guide on how to change your Progress Score on Life QI: