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“You have to kiss a lot of frogs to find your Prince!”

The Q Community provides a brilliant and ever-growing resource of hard-won QI experience for us to tap into.

We all love being part of it, but as it continues to grow, it’s getting harder and harder to get to know the right people and projects: people you can learn from or learn with.


Randomised coffee trials are great – but do you know how many might need to have before you found the right person?   With another 2209 Qs to meet, it could take you 184 years.  Not to mention ingesting a medically unwise volume of coffee.  Surely we can do better than simply relying on serendipity?

What if there was a smarter, more focused way to find the right Qs to learn from, or learn with?

What if we had a shared language and a common framework around QI at an organisation level which we could use to make more meaningful connections (and avoid unnecessary spending on external consultants)?

What if I could identify every Q who has the similar QI priorities to me, and we could learn together?  How much more powerful would that make our SIGs and events?

What if when I say, “We’ve done some great work in gaining leadership commitment” – you’ll know what ‘great’ and ‘leadership commitment’ means for your team, and we won’t talk at cross-purposes?

Oh, and what if we could co-produce something which will be used by the entire Q Community – something we can all feel proud of, and something which we could also use in our own organisations, beyond the Q community.

Enough of the what-ifs… hop in, and see what you can find in the Q River!

What’s the big idea?

There’s already some great academic research out there which we’ll be using and bringing to life.

We will produce a toolkit/game that every Q region and nation will be able to use to understand QI capability and stimulate the most needed learning, target-setting and connections. We’ll ensure that regional and national pictures can be built-up, supporting local sharing via partners as well as nation-wide.

We will invite Q members to pilot the use of the framework with their teams and share findings within the community.

We will create a River Diagram* to visualise the results on the Q Community platform, discover where good practices lie and to help everyone make the right connections.

All of this will give a shot of adrenaline to knowledge-sharing across Q: better connections, a simple structure for sharing tools, stories and distinctive examples, and a framework which we can align our SIGs around.

NB. Although our focus is in how to unlock the potential learning between Q members; everyone is free to use tool outside of the Q community, to support learning within their organisations too – it’s the gift that just keeps giving!

In Summary…

This project is your chance to get involved in co-creating the content of a framework for measuring QI capability, building on existing research and evidence.  We’re not looking to re-do the research, but we can add some narrative and convert it into an engaging set of resources. These will help teams to reflect on their QI capability, and through the Q community, to reach out to others and learn from them, using a cool ‘dashboard’ based on the River Diagram. The dashboard will help us all to identify where strengths lie, to multiply the value across the community and track our collective improvement over time.

*If the River Diagram is new to you, where have you been?
Not to be confused with a driver diagram – it’s a neat visualisation technique for positive deviance, and has already been used to great effect by organisations ranging from the UN (HIV/AIDS and Malaria),  the offshore wind industry (Operations), DFID (Organisational Learning) and Roche (Lean Manufacturing)

Cleo, one of the team members is planning to use the River Diagram to support her patient safety culture work and other projects. “It’s really good way of connecting those who have something to share with those who have something they want to learn. For quality improvement projects, the possibilities of the approach are endless!”

You can watch a slightly startled-looking Chris explain it in the 4-minute video below:

Further information and more gratuitous muppet action here:

How you can contribute

  • Volunteers to help add content to a QI Capability model.
  • Experience in creating resources, tools, cards, games which will engage groups.
  • Volunteers to try out the model and share their findings.
  • Patient Representative(s) to ensure full representation from the Q community.

Reviewer feedback

This is a great project because…

This project has attracted a lot of interest, not least thanks to recruiting Kermit in support! Developing ways to enhance peer sharing and learning has the potential to enhance the overall impact of the Q community and create a community-owned shared language.

By the time of the event we encourage the project team to think more about…

How the framework can effectively reflect the diverse views about what it takes to be capable of improvement and how this can interface with the core Q community infrastructure. How can we avoid this being interpreted in unhelpful ways, given the prevailing performance benchmarking culture and practice in the health sector? 


  1. Hi Everyone,
    Just to alert you that the workshop to develop our QI framework is planned for June 12th in Birmingham.

    Please come if you possibly can - we want to represent as much of the Q Community as possible so that this is truly a co-created framework.

    Evenbrite invitation here:



  2. Guest

    I love this idea and the honesty with which it is written. I love that it does not try to re-invent the wheel, but makes use of existing research on capability and adds a narrative to it. I want to be better and more efficiently connected to others, and I'd love to support the development of this idea. It reminds me a little of the issue of the sea of reporting checklists on the EQUATOR network and the dilemma of researchers not being sure which ones to select - there is literature there that might overlap with these ideas too. Looking forward to hearing more!

    1. Thanks for that comment Emma, plenty of good work out there already - we just need to get better at reusing it and multiplying the value!

  3. Guest

    Caroline Poole 3 years, 10 months ago

    What a simple concept, but could be so powerful to bring energy and impact to knowledge sharing.  Love the visuals of the river and the simple lessons it offered relating to overall system maturity.  Great to see this shortlisted, I'd be happy to help support as Q member and also link into the national AHP network if/when helpful.

    1. Thanks Caroline - we're really delighted that this has been shortlisted.

      More importantly, thanks very much for your offer of support and connection with AHP.  Gratefully accepted!

  4. I'm delighted that this idea has been shortlisted. Lots of potential for improving services.

    As QI lead in my trust, I would be happy to test the idea, particularly to determine how to use it for improvement, rather then judgement.

    How will you evaluate the impact?

  5. Great idea.  Helpful to all Qs.  Fully support the idea and happy to work with the team as a test bed for the concept at Salisbury hospital

    1. Many thanks Carol.  Great to talk with you last week and delighted that you're another enthusiastic pilot.

  6. Whoop, whoop!  Matthew and I talked about this at the inception of Q so it's great to see it hopefully get off the ground... or river bank I guess!  I worked with Chris about 10 years ago and from that we developed a rivers and stairs model for NETS (the QI approach between NHS North East and Virginia Mason) and then also for general knowledge sharing and learning across the region...and again as a patient safety tool.  I also mentioned it recently to Sources4networks as they have a framework that could easily use a river and stair tool to exploit it.

    So, I am a big fan and you have my full support.  If I can help, and find the time, I will certainly do my best to be involved.  I see some comments above about the risk of it turning into a performance management tool - that is for sure a concern but I think within this community we can rise above that and get the value out of it.  Bring it on!

    1. Of course Chris, co-opt away... and yes, it was me causing your ears to burn with Carol Read, but it's such an obvious step to take with their framework for S4N.  Good to catch up with you again.

    2. Hey Ian,

      Great to hear from you - I remember the work with Lynda Cox and the Rapid Improvement Workshops.  So you're probably the reason that Carol Read at S4N wants to talk with me!  Always nice to find the root cause... :)

      Thanks so much for such a supportive comment, and really encouraging to hear how much you've been doing with it already - Can I co-opt you onto the team?


  7. Chris, You mention a 'shared language' around QI in your idea. Can you comment on my idea regarding the language we use when talking about QI? Regards Tom

    1. I think your idea is an important bit of foundational work, and it fits really well with this as you suggested. Thanks for making the connection.

      If we both get through, let's make sure that we keep in step.  It would be great to involve you in the work to put some flesh on the bones of a model of practice - let's make sure that we have the correct tissue-type!  :)

  8. Hi

    Would be really keen to be involved in this - Q is great but completely overwhelming (and thus rather under utilised). I don't know many of these tools, but they look really good, particularly the personalised stepped approach to where people want to get.

    We are trying to build a network of patients etc involved in Q and this would also be useful for them, so would be very interested in collaborating about how this is really accessible as a resource for all

    All the best



    1. Ah great Sarah - thanks.  It would be great to collaborate on this together - I'm keen to ensure patient involvement where possible.

  9. Hi Chris - good to see this idea surfacing again - yes I think this is a great way to share learning - what has worked as well as what hasn't - shortening the adoption curve etc.

    1. Thanks Susan - good to 'see' you again!

      Shortening the adoption/learning curve by learning from what we know is exactly it.
      The underlying approach was the topic of a book, and (much more fun) this short animation.

  10. Delighted to stumble across this idea whilst casually and randomly browsing through them this evening. An innovative and smart way to connect with others but  will also be a rich resource bank of tools, ideas and learning. I fully support this (and have already clicked that blue button). My role within my organisation is building/supporting QI capability, so this idea is very welcome and I would be more than happy to pilot tools to support the development of this project, I'm already thinking of ways to use the River Diagram and will look up the stairs diagram- so thanks

    I also have a soft spot of Kermit, so love the messaging and branding of this bid!

    1. Hi Vardeep - "An innovative and smart way to connect with others but  will also be a rich resource bank of tools, ideas and learningAn innovative and smart way to connect with others but  will also be a rich resource bank of tools, ideas and learning"  you summarised it even better better then me!

      Thanks so much for offering to pilot.  I'll be in touch! :)

  11. Hi this sounds like a fantastic idea and I'd be keen to get involved in some way. We have just submitted a bid to develop a game to build QI awareness and support an improvement culture.

    We are working with a healthcare games designer who may be a useful connection. Happy to link you up if that helps?



    1. Brilliant Jem - thanks so much.  I love how the Q Exchange process is making helpful connections like this.

  12. Great idea and I can see this would really benefit the #CatchingCanaries project aim to spread its outputs network wide

    1. Thanks Elizabeth, yes, it should certainly enable better flow of knowledge in the various networks.  What with frogs and canaries, we're building up a bit of a menagerie...

  13. Guest

    Kate Hall 4 years ago

    Ever so slightly worried about whether I am a prince or a frog..... let's leave that there.

    Very happy to join this exciting venture - and keen to support an early test.

    1. :)  It was originally 'kiss less frogs'  - but I thought that was rather 'glass half empty'.  We'll find a better gender-and-amphibian-non-specific team name once we get going!

      Great to have you in the team Kate.

  14. Stop Press!

    Great to welcome Kate Hall to the +Princes -Frogs team.

    We had a great discussion this afternoon about using the River Diagram approach to provide regional and national perspectives - a set of tributaries and a confluence, if you like!  (Stop me if I'm pushing the metaphor too far?)

    Kate believes that UCLP will be keen to be amongst the early pilot groups.

  15. Hi Rachel,

    Great to see you commenting here. Do I remember correctly that you were working on 'River Diagrams' for healthcare improvement during your IHI Fellowship year?

    You mention infection control, elsewhere primary care and other things are mentioned - it certainly seems there could be manifold valuable uses of the approach that Chris/Cleo/Joy/Zoe are proposing here...

    PS Love to catch up some time.


    1. Guest

      Rachel Cooke 4 years ago

      Hi Matthew, yes I did work on the river and stairs diagram and its use in the NHS as part of my fellowship year, but my fellowship was with the NHS Institute for Innovation and Improvement, although I did complete the IHI Improvement Advisor Programme whilst on my fellowship.

      PS v happy to catch up sometime

  16. Thanks Rachel - great to hear from you - and high time you joined the Q Community too! :)

  17. Guest

    Rachel Cooke 4 years ago

    As a long term advocate of using Chris’s maturity model of the river and stairs approach in the NHS, I am excited to see it being taken up by the Q community and can see great potential for joint activities by the community and for use by Q members in their local organisations in terms of identifying improvement capabilities that already exist in the organisation and on specific areas of improvement or patient safety e.g. infection control.

    1. Guest

      Rachel Hinde 3 years, 9 months ago

      Hi Rachel

      I agree it's great to see you still around.  You helped me when I first joined the NHS and around the time I was pestering Chris to help me develop a river diagram for PCTs around world class commissioning.  How time flies.

  18. I support the idea particularly from the primary care context which needs more support and investment.There are lots of different projects from different people NHS I, microsystems, CCG work etc and some overview would be helpful.I'd also like to see the interface of QI in integrated care explored.Perhaps this idea could link with the primary care interest group.

    As an allergy Gp we give adrenaline for those with  anaphylaxis  and with systemic symptoms and it  normally works quickly to restore things. The QI work in the community really does need some wider joined up vision and  overview with encouragement and a wider systemic approach,and this has been delayed in coming round so hopefully this initiative might help.

    1. Thanks Elizabeth,

      I agree  - and hopefully the dimensions of the capability framework will provide us with some high level categories which we can use to tag/reference the various projects and interest groups - and help get us all more joined up.

  19. What a brilliant idea, so timely for my organisation as well. As we increase the QI capability, we started thinking of the infrastructure and ways to connect coaches with the right people to share and learn. This could be a great way to do that. And a personal level, it might help with my constant Q-FOMO. I fully support and would love to be involved too.

    1. Hey Hadjer, thanks so much for your support. Let's have a chat about how you can be involved. :)  Q-FOMO - I love it!

  20. Love this because it's such a creative way to help us all connect. Particularly true for those of us Qs that are interested in many areas and so like to hop around on more than one Q lilly pad. How do we connect if we have multiple interests across several QI domains or clinical areas? Equally how do we meet people that are opposite to us to help shake us up and diversify our thinking? Could your game, help us seek what we have in common and also help us seek out difference?

    I don't yet fully understand from the description how you will gamify this though and would like to know a bit more and my other challenge is whether £35K will get you what you really want?? It would be helpful to understand more about how you see this working in practice, as I love the idea.

    good luck

    best wishes


    1. Hi Anna. I totally agree - what I love most about the river diagram and the stairs diagram Chris talks about is that with a maturity matrix built around any topic - you can use the methodology to connect with others who are also interested in the same area to learn and share. There are several areas I am working on such as improving patient safety culture and developing coordinated care for patients, where I see this approach working really well.



    2. Hi Anna,

      Thanks for your support.  Lots of questions there! :)  It's hard to cover in the 800 words above, so I've included a few links here:

      Yes  - this approach certainly should help us to harness the value of diversity in the Q Community. My perspective on the NHS in general (as more of an outsider), is that there is way too much fragmentation and partitioning.  The shared language/framework should create a much better 'connection space', where we can focus on practices which are commonly defined, but learn from the nuances and differences of how we achieve success.

      To accompany the River Diagram, which shows the spread of capabilities, there is another visual tool - the stairs diagram which helps teams connect on the basis of their priorities (the side of their improvement target) for each QI dimension. So my team might have strengths to share in one dimension, and a great desire to improve in another.  The river and stairs diagrams, plus any other sharing and learning activities (liberating structures perhaps?) will help support those kind of exchanges, and also highlight where there is a distinctive practice which coudl be captured and shared more widely.

      I don't know whether this will end up as some kind of game, set of 'intervention cards', workmat, toolkit, resource pack, app or something else - but I'm sure the team, and other Qs will help us come up with a creative solution.

      Is £30K enough?
      Oh, I'm sure we could invest and spend more, but I believe it will be enough to get the right people together to refine the model and design and produce 'merchandise' which will support teams who pilot the approach.  I'm really optimistic that we can build momentum enough through the initial funding, that it then becomes part of the overall Q infrastructure. But I'm taking it one step (stair?) at a time!

  21. This sounds interesting and I have to confess I have never come across a river diagram before.  Is the proposal to look at the QI capability of organisations or teams or particular service areas?

    It will be interesting to see how we can measure QI capability and share and compare across organisations.   Testing this framework sounds like a great and exciting idea.

    1. Hi Chris,

      I think you are right at team-level seems sensible but it will also be good to be start to understand the variation across different organisations and to start to close the gap in terms of improvement capability and culture.   The big challenge will be getting the language correct to allow comparison and learning.


    2. Many thanks Robin,
      That's an important question for the team to deal with.

      Do you have a view on what would be most valuable? Woudl love to hear your thoughts.

      We had been leaning towards team-level to get wider usage, but I would hope that if we get the language right, the tool would work at multiple levels - and even enable some learning between team, organisation and service.

      Many thanks.

  22. Guest

    Matthew Mezey 4 years ago

    Hi Hesham - I had a feeling this project might interface powerfully with your Q Community Time Bank idea. I'm so glad you've pointed out how: fillings the gaps when you find - from using the framework - that a certain element of QI expertise really isn't available anywere in your organisation's ecosystem.

  23. A great idea which I would happily support and pilot. Particularly useful would be a way of easily administering the tool in teams who don't yet "get" QI and thereby nudge this from a niche activity into the mainstream.

    For those teams with an identified deficiency that they can't resolve in-house, it could nicely link with the Q Community Timebank to source that expertise from across the network

  24. Good point re the 'framework misuse' risk in the NHS.

    It doesn't seem to take long for a potentially inspiring and enabling improvement to be turned into a ghastly mandated deliverable, within a soul-destroying cauldron of gaming the figures and going through the motions.

    'Friends and Family Test' arguably suffers from some of this...

    1. Our hope would be that the framework will be “owned” by the community that chooses to use it. As a way of connecting people and measuring change (not performance!!), it will be a really invaluable way of spreading quality improvement knowledge through our network and beyond - I am really excited about this!

  25. Yes, I think Emma's so right: this could prove to be a really important way of "maximising the learning and knowledge within the Q Community".

    Though there could well be be huge benefits for individual learning - eg tools to support members to find the right connection they need to make - it feels like it may do plenty of 'bigger' things too.

    It may help the whole QI sector understand QI capability far better, and popularise a common language (I know from the Education sector that even when the evidence base is known - eg John Hattie's meta-analysis of all the impact sizes of different improvements - without a common language to talk about the evidence change remains hard).

    Q itself could keep track of the overall 'River Diagram' display of QI capability over time, to see where the biggest needs in the sector - and in Q - are, to see whether interventions seem to be having a positive effect (making the river narrower etc).

    Perhaps the biggest challenge: how to label and describe such a multi-faceted and potentially fruitful project in simple terms, when most of us have never heard of 'River Diagrams' and so on ;-)

    PS Is there a John Hattie in QI - a big list of evidenced effect sizes for all key types of QI interventions? Sorry if QI is too different from Education; looks like a lot of overlap to me though. Here's a recent effect size table from Hattie:

    1. Thanks for your support Matt.

      You're absolutely right about the description challenge - never mind 800 words, there's a whole book of possibilities to write about!  ;-)

      Yes - I really hope it catalyses some 'bigger things' too. We're also cognisant of the risks of 'framework misuse' too, and will work hard to design ad position this as a tool for surfacing strengths within a trusted community, rather than a scalar model to performance manage people with.

  26. I think this sounds like a great idea - very happy to support and would like to be involved too...

    1. Thanks for your support Sophie - I have a UCLP call with Kate Hall about this next week too.  :)

  27. Interesting idea Chris to target improvement and learn across teams and organisations. Testing the framework sounds to be a powerful positive move for organisations within Q..... I will watch this space, hope to be involved in some way.....

    1. Thanks Jude, involvement always welcome.  As is a press of the "Support this Idea" button  ;-)

  28. Absolutely fantastic idea! I would fully support this as a way of maximising the learning and knowledge within the Q Community (and would also like to volunteer to help build it!).


    1. Thanks Emma - echo Joy's comments, and perhaps there's even a way of using our framework with some of the host organisations of Q Visits to find alignment and opportunities to learn?  Oh and yes, please do press the blue button! (This all sounds a bit X-factor doesn't it!?)

    2. Thank you Emma!  Love to have your thoughts and involvement.  Please help this idea get through to the next round by pressing the 'big blue button' of support on the RHS of the title.  Thank you!!

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