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1. Why is this important? Identified challenge or opportunity

People with long term conditions often struggle to manage their conditions proactively, often because the lifestyle changes they are expected/ advised to make are so overwhelming that they feel powerless to change anything. Using Quality Improvement as a means to supporting people with their health and well-being is a way that individuals can take one small measurable change at a time and define their own aims. People becoming their own project managers of their health conditions and embedding their small changes into their daily lifestyles.

This type of approach to managing long term conditions fits in with the Five Year Forward view, chapter 2

“Second, we will do more to support people to manage their own health –staying healthy, making informed choices of treatment, managing conditions and avoiding complications. With the help of voluntary sector partners, we will invest significantly in evidence-based approaches such as group-based education for people with specific conditions and self management educational courses, as well as encouraging independent peer-to-peer communities to emerge.”

NELFT’s own clinical strategy also states that there will be a “greater co-design with patients and carers- implementing more defined and agreed pathways that have been co-designed with patients, carers and staff using QI processes, reducing waste, not delivering paternalistic care.”

It follows on with “better understand needs of patients particularly complex work with patients and carers to define expectations, goals and outcomes at the outset of treatment, activate them and ensure they are active partners with health coaching approaches, measuring outcomes that are important to people”.


Using a QI approach in managing long term health conditions could therefore further enhance the NELFT’s clinical strategy.

2. What we are going to do? Our proposed idea.

We will:

  • Teach patients QI methodology for them to apply to improving aspects of their health and wellbeing to help manage their long term conditions.

  • Enable Lay Quality Improvement facilitators to support graduates from the Chronic Disease Self Management Programme (CDSMP ), also known as the Expert Patients Programme, to look at what they want to improve or the challenges they face in managing their conditions and then to support them with Quality Improvement Tools to put it into practice.

  • Enable our QI facilitators and mentors to share their own experiences of using QI in our daily lives to bring about behaviour change.

  • Encourage people to take their driver diagrams to consultations so making better use of their appointments, as they would have a means of explaining what is important to them.

  • Explore the development of a mobile phone app to keep further manage conditions and data.

  • Consider after the initial pilot with patients with long term conditions, how we can take the concept one step further to use QI as a tool for personalised care planning where the person identifies their goals, needs and how they can best be met. It could involve an overview of the stakeholders in their life, family, friends, health professionals, voluntary sector and social services. It could also integrate personal budgets and direct payments.   


    3. What do we think the impact and learning will be?

    QI will give patients a different way of managing long term conditions. This may encourage clinicians to be more engaged in supporting self-management and using driver diagrams and PDSA’s as part of a care plan. This could also encourage better health care – patient relationships and a more equal balance of power.

  • Small behaviour changes tend to become more embedded in people’s day to day life.

  • Patients will identify their goals and aim. They will therefore have ownership of these     and be focused on what matters most to them.

  • Patients will be able to see how improvements are happening through their own data and feel more activated. Often the follow-up of goal setting in the NHS is poor so patients being able to measure their improvements or blips, will continue to be self-motivated.

  • A higher level of patient involvement in trust wide QI projects through patients gaining QI knowledge.

  • The workforce becomes inspired to use QI as a tool for managing their health and wellbeing.


    We will measure the impact using the following measures:

  • Outcome measures

    • We will be able to measure against patients’ individual aims. For example this may reduce weight, to increase exercise, to stabilise blood sugar levels.

    • Patient Activation Measures

    • We could have something about QI knowledge – this could be even be a pre and post rating scale

  • Process measures

    • Number of patients engaged in the programme

    • Number of patients with active QI projects related to self-management

  • Balance measures

    • Patient involvement in other QI projects

How you can contribute

  • • Support our project
  • • Share ideas and thoughts about the project


  1. This idea is brilliant as combining QI and self management. Also good to see the PAM being used to measure how active a person is in self management.

    Our idea is using PAM to redesgin TIA service pathway so people recieved a person centred apporach. Do you feel people at  different PAM levels will use QI methods differently or use some more than others?

    1. Guest

      Stephen O'Connor 2 years, 10 months ago

      Thanks for your comments Carl.

      We are not sure if people with different PAM scores will engage differently with QI methodology. I guess that's one of the things we can look into if we are able to proceed with our project. Interesting question.

      We have seen some of our staff apply QI methodology to personal rather than work based projects during their QI training and this has worked well.  So we see no reason why patients can't use the techniques to improve their health and wellbeing.

      Also, if they are interested, the programme would eqip patients to work on other QI intiatives in the future.

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