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A four-year evaluation of Q: What we’ve learnt and how we’re responding

Q Initiative Director, Penny Pereira, shares key themes from RAND Europe's four-year evaluation of Q and how we're responding to what members told us.

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Don Berwick’s vision of a ‘system devoted to continual learning and improvement’ has guided Q since we started in 2015 and feels as relevant today as it did then. As those of you who generously gave time and insights to Q’s various co-design and feedback activities over the years know, the Health Foundation invested considerably in evaluation: making sure we practice what we preach as a team.

RAND Europe’s final evaluation report of Q is published this week. The 411-page conclusion of nearly 200 interviews and focus groups, 13 surveys, social network analysis, case studies and more is available to read in full on the RAND website, alongside a summary report and a slightly more granular list of findings and recommendations.

I’ll explain how Q is responding to what members told us, and encourage you to reflect on what more Q and its members can achieve over the years ahead

In this blog I draw out some of the highlights that I think are interesting to all of us as improvers, whether we’re seeking to align and accelerate change across a whole country, region or organisation. I’ll explain how Q is responding to what members told us, and encourage you to reflect on what more Q and its members can achieve over the years ahead.

You’ll continue to hear more from us on this topic in the months ahead, as we consider the detailed findings further and agree how we will take steps to improve what we do within each area of our work.

Supporting the skills, relationships and confidence of improvers

Q seeks to enhance the sustainability and reach of efforts to improve care in the health system by paying serious, long term attention to the underlying enablers of learning and improvement across boundaries. That means Q has started with our members: the people actually doing the – often hard – work of designing and implementing improvement.

RAND’s evaluation concludes that Q has become ‘a respected and appreciated home for improvers’. In a turbulent, siloed world, with massive challenges ahead, you’ve told us Q is a ‘warm and supportive community’ that has enabled members to feel ‘better connected, more visible and more confident in their work’. The success of Q ‘both reflects and reinforces’ a trend where QI is ‘becoming more prominent’. Q enables ‘practical knowledge mobilisation on the ground’, with numerous examples in the full report of ways in which insights and support gained through Q are helping members in their work.

The Q team will continue to provide a flexible range of opportunities that reflect the varied preferences of members

Q’s learning, development and networking offers are consistently highly regarded. The Q team will continue to provide a flexible range of opportunities that reflect the varied preferences of members. We will, as RAND advises, be working with you over the years ahead to understand more about which offers are most valuable. The Coronavirus pandemic (COVID-19) has also prompted us to address more rapidly one of the other key findings: that we need to provide more activity online and widen access to meet the needs of a growing community. We’ll be investing in Q’s digital infrastructure over the next few years, and this year will see our first virtual annual Q community event.

As membership grows, nurturing the self-organising community spirit that characterises Q at its best is at least as important as having sufficient central offers. We will continue to support those who help to lead and energise the community: building on last year’s Communities of Practice development programme and our upcoming Network Weaving online course. We also recognise the need to develop a more consistently vibrant presence for Q locally: we’ve provided small grants for Special Interest Groups (SIGs)  and others leading local work, and will continue to develop our regional and national partnerships.

We perhaps didn’t need the evaluation to tell us that improvers are busy, with lack of time identified as the main reason why members struggle to engage with Q as much as they’d like. As with many large networks, most members have relatively limited contact with Q, and this ultimately limits the benefits we can offer. One of RAND’s key recommendations is that we should be more explicit about not just what Q members get from Q, but what members offer back to each other as part of a peer community. There’s also more to do before improvers consistently use the connections and opportunities available through Q to learn and deliver change. We’ll be exploring how we can effectively support members to participate actively in Q and ‘what good looks like’ as membership numbers grow, so that the community becomes a richer resource for all involved.

Enabling collaborative change at scale

[…] we have together raised our sights to ask how Q can really enable more substantial system-wide change

Based on what they’ve seen over the last four years, RAND anticipates that ‘Q will help improvement be more impactful, sustained and better understood’. Buoyed and inspired by the energy members and partners have brought to Q over the years, as well as the challenge from our evaluators, we have together raised our sights to ask how Q can really enable more substantial system-wide change. In pursuing this, we’re conscious of focusing on what Q is uniquely well placed to do.

As highlighted below, in a complex world of independent actors, aligning and accelerating change efforts is about more than bringing people together from different organisations. It’s about finding a generative space that brings together different forms of insight, with respect for formal evidence and emerging ideas, and connecting the cutting edge into the core work needed to achieve reliable quality care at scale. It’s about forming new connections, while nurturing the established links you need to thrive, and balancing central and local priorities. These principles characterise the way that Q has been responding to this next stage challenge of system-wide impact:

Five principles for Q over the coming decade

Q Lab, an approach to tackle complex challenges, and Q Exchange, a funding programme, were introduced in response to member and partner calls to support collaboration that leads to more direct and visible benefits for patients, and doing this in a way that’s rooted in pooling diverse perspectives. The evaluation finds that the funding and collaborative structure of Q Exchange is highly regarded and leads to tangible benefits: watch this space for details of this year’s programme. Following the findings from RAND’s work and a separate evaluation of the Lab, this year sees the wider community getting access to some of the methods and ideas honed through the Lab’s work, such as our rapid learning and improvement work in response to COVID-19 and a map of the skills needed for collaborative change due for publication later this year. Q Lab Cymru is a bold response to one of the other findings: embedding the Lab methodology within a health care system to achieve clearer routes to impact.

RAND concludes that Q represents a considerable asset for the system, which will likely continue to be under-utilised unless we now raise the profile of Q with local organisation and system leaders and more actively engage in the priorities for the system. Helping people understand Q and the value that members can bring to local work – and learning from what we hear back from local and system leaders – will be a priority for the team over the months and years ahead. I’d love to hear what you think would work, so that Q helps collaborative improvement become central to how we tackle big challenges in health and care.

[…] more than ever we need broad-based, joined up and lasting change at scale

During COVID-19, the need for adaptive spaces to connect learning across areas and between different levels of the system has become particularly clear. ‘If we hadn’t already created Q, we’d be doing so rapidly now’ reflects Karen Fechter from NHS England and NHS Improvement, Q’s long-term funding partner.

The evaluation helps demonstrate the value of long term, flexible ways for individual improvers to learn, share, support each other and achieve collaborative change. With the huge challenges we now face to respond to the long-term impact of COVID-19, let’s make sure we really capitalise on all we’ve invested as members, funders and supporters of Q over the last four years: more than ever we need broad-based, joined up and lasting change at scale.

Q’s members have been helping shape the initiative over the years. Please keep going: evaluation and co-design will continue to be critical even as RAND’s work comes to an end. And I encourage you to use this milestone to help promote what’s been achieved to potential future members and leaders in your organisation. Let’s make the most of this globally unique infrastructure for improvement and learning.

Visit RAND Europe’s website to read more about our four-year evaluation.


  1. Guest

    David Evans 2 years, 1 month ago

    There seems to be a new wave of improvement enthusiasts across health and social care. We want to find ways to engage with them and encourage them to apply to join the Q community to maintain and sustain their enthusiasm, so they can network and collaborate more widely outside of their 'local system.'

    A buzzword of the last year or so is 'innovation' which many see as different to QI - but our local experience suggests they are inter twinned and many of the methods and tools are the same or similar. Digital innovation and digital transformation opportunities are on the increase - offering more potentially opportunities for Q members to be involved with and/or champion better ways of delivering patient care.

  2. Hi Dave - thanks a lot for this.

    You're quite right, this feels like a great time to be widening applications to Q.  Applicant numbers are a bit more up and down than usual, which probably just reflects everything else going on.

    The way we describe the criteria for Q is deliberately broad, to certainly include those who see themselves as 'innovators' as far as 'improvers', though your help is needed to reach into the right groups.

    Just on the relationship between innovation and improvement, in general and where there's a digital dimension, I wonder if you've seen this from Healthcare Improvement Scotland: - some interesting models in there and I know they're keen to get feedback.


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