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What is the challenge or opportunity you are focusing on?

Embedding quality improvement at the frontline is an urgent priority for the NHS. However, many Trusts are struggling to explain continuous quality improvement and make it part of the ‘day job’ rather than something only applied when a high-profile incident occurs.

There are many programmes, tools and resources available to develop QI capability and support QI projects. Unfortunately, very few of them are sufficiently accessible to enable front line teams to apply and adopt QI as a normal way of working. Some QI training may enthuse participants but when they return to their workplace they find that no one else understands what they now know, and so  QI methods are not adopted.

Research carried out into the effectiveness of QI training at CLCH tells us that without a conducive workplace learning environment 50% of training has no effect on frontline practices. Our current focus is on increasing understanding of QI among leaders and front line teams to help them make QI part of their day job. Being a geographically dispersed community Trust is a significant barrier to engaging directly with staff because we cover over 450 sites across London and Hertfordshire. This challenge is not unique to CLCH.

Our proposal

Online and traditional lectures may not reflect the complexities of real life situations in an accessible way (Bochennek et al 2007). Educational games give players the opportunity to explore new ideas in a risk-free way that encourages discussion about improvement (Akl et al 2013).

Furthermore, games enable staff to utilise higher thinking skills, such as analysis and synthesis, while the learning process is enjoyable and stress-free which may aid retention of knowledge (Akl et al 2013).

We currently use board games, developed by Focus Games Ltd, to help frontline teams reflect on performance and to co-create improvement plans. We believe that a game specifically designed to embed a systematic approach to continuous improvement will help the NHS achieve widespread adoption of QI.

Focus Games Ltd has developed over 60 educational games since 2004 and they are being used widely in hospitals, universities and care homes.

Working with Focus Games Ltd we would develop an educational board game around the CLCH QI framework. This evidence-based framework and the game would be relevant to all NHS organisations. The game would be a portable and reusable ‘workshop in a box’ that could be played by any frontline team, in the workplace, without any external support.

The game would accommodate between 4-12 players for 30-60 minutes as an informal activity or as part of structured learning. The game would be supported by online resources.

We propose to manufacture 500 games to be distributed free of charge to NHS organisations via The Q Network.

What is the benefit you hope to achieve?

Within any organisation using the game we expect:

  • A more supportive environment for quality improvement
  • A broader understanding and appreciation of a continuous improvement system
  • An increase in the number of teams that are involved in improvement projects
  • An increase in the number of improvement projects taking place across the trust
  • An increase in the proportion of QI trainees reporting active use of their learning

What benefits do you expect for the Q community?

This would be a generic game that would be applicable to teams in every setting. 500 games would be distributed free of charge to organisations agreed with the Q Community.

What would supporting and funding this initiative give to other Q members?

Members would have access to an unusual and effective tool to support their own QI activities.

How do you plan to share your work and learning with the Q community?

The game would have its own website and Twitter account.

How you can contribute

  • Whilst we are proposing to develop and pilot the game at CLCH. We would welcome involvement of others who might wish to

Further information

More_than_mere_games_A_review_of_card_and_board_ga (PDF, 175KB)


  1. Hi Jem and Anthony

    Great idea. Totally agree that more people would benefit from using QI methodology in the workplace. A board game would be an ideal platform for a Service or team to reflect on their performance and start mapping out improvement plans. Regards, Pam


    1. Thanks Pam, let me know if you are interested in trying this out with your team if we are successful in our bid.



  2. Jem, I like your idea but am a bit confused. You use both the terms continuous improvement and quality improvement. Are they the same thing? Please have a look at my B2B idea page. I'd be very interested in your views on it's content.

    Regards Tom.

    1. Hi Thomas,

      Thanks for your comment - I do differentiate between QI and CI. I use the term QI to refer to the principles and methodologies that define a way to go about making changes for the better. I use CI to refer to the process of continuous application of QI as part of the day job so that it is a systematic way of working across a whole organisation. I think this is related to the big Q/little Q concept you are referring to in your idea? I agree that the terminology is often used interchangeably, it would be helpful if we were all using the same definitions.

      In my opinion, QI (and QP to an extent) is an under-utilised side of the Quality circle as there seems to have been more of an emphasis on Quality Control and Assurance in previous years.

      In my experience, we have been training people in QI for years, but we rarely tackle the environment in which these people are expected to apply their skills. There are often systematic issues related to leadership beliefs/behaviours and governance/policies/processes that prevent CI becoming an embedded approach. This often leads to QI being seen as an ad-hoc approach to be used on priority issues, rather than part of an embedded, systematic way of managing Quality across an organisation.

      The aim for this project is to focus on developing a supportive working environment where all teams are empowered to apply QI methods to tackle local issues on an incremental basis, rather than just using QI for breakthrough change.

      Hope that helps.



  3. Hello Jem!

    We need to catch up, has been eons.

    Love this idea.. and would be really keen to collaborate and support. Wonder if we could ensure this is something we can use as part of the training and peer support we are trying to roll out with patients in QI (see side by side bid)...

    We are always looking for ways to make QI training fun, so would love to chat about this more

    Shall i email you?



    1. Hi Sarah,

      That sounds like a great idea - lets catch up and see how we might combine these ideas.





  4. Hi Simon,

    I use a lot of games in my QI training, but I haven't seen any specific games for enabling a QI related conversation that don't require a facilitator. Do you know of any? I'd appreciate any links.

    I haven't put much in the bid regarding evaluation as I don't know that we have the funding to do a proper evaluation of the game within this bid and we haven't been able to progress this idea so far due to a lack of funding. I would like to do this if there were resources available however... We will do some local evaluation as part of our wider evaluation process for QI in the Trust, but this will be using the principles of measurement for improvement rather than research.

    With regard to efficacy, I have personally used the 'Teams that Care' game to good effect in the past and have spoken to several people who have used others within our trust. However, these were not specifically around embedding QI. There is a limited amount of literature about the efficacy of games in healthcare, but Focus Games have helpfully provided a suite of relevant documents which hopefully address your query:
    Burns Game – ‘An educational board game for learning and teaching burn care: A preliminary evaluation’. Alexander M. Whittam and Whitney Chow. Scars, Burns & Healing First Published January 31, 2017

    Disruption Game – ‘A gamified approach to improving customer service delivery in a train operating company’ EUROMA2017 – paper was highly commended. EUROMA PDF

    Dysphagia Game – Summaries of pilot studies carried out by Queen Margaret University Edinburgh Potsdam University.
    Sepsis Game – ‘Getting it right: The current state of sepsis education and training for healthcare staff across England’ specifically mentioned/recommended by Health Education England
    Genomics Game – Developed for Health Education England’s Genomic Education Programme. Not an evaluation but a public vote of confidence in a game from HEE by posting on their website Genomics Edu
    Dr Bertalan Mesko – Review of several board games by Dr Mesko who is also known as The Medical Futurist Mesko Review
    Dr Jargon - BBC World Service Health Check programme reviewed this game. The Game Encouraging Medics to not use Jargon

    There are some 3rd party studies here:


    Akl EA, Kairouz VF, Sackett KM, Erdley WS, Mustafa RA, Fiander M, Gabriel C, Schünemann H. Educational games for health professionals. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD006411. DOI: 10.1002/14651858.CD006411.pub4.
    Bochennek K, Boris Wittekindt, Stefanie-Yvonne Zimmermann & Thomas Klingebiel, More than mere games: a review of card and board games for medical education, Pages 941-948 | Published online: 03 Jul 2009
    Zagal JP, Jochen Rick, Idris His, Collaborative games: Lessons learned from board games, Simulation & Gaming. Vol 37, Issue 1, pp. 24 – 40 March 1, 2006



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  5. Great stuff. The use of "generic" games in QI is pretty widespread. Evaluation as to their utility is less so, mostly because they tend to be introduced as a part of a broader Improvement package.

    There is little in your "pitch" about measurement and evaluation. It would be really useful to know whether games work before buying and distributing one!

  6. Guest

    Tracey Wakeling 2 years, 11 months ago

    This is a great way of engaging staff and we often use quizzes to bring together education sessions not only for nursing, therapies, medics and other colleagues.

    We are active in QI methodology as a member of the EAHSN and have been successful in relation to reducing length of stay for over 65s, family carer involvement of which we were a PENNA finalists for two submissions and presented at the National Frailty conference last year. We are about to embark on reducing antimicrobials.

    I would very much like to hear more about this initiative and how we can become involved

    Please reply



    1. Hi Tracey,

      I've been trying to get this idea off the ground for about a year now and have always come to a funding barrier. This is a great opportunity to build something that everyone could benefit from. If you can support this (and encourage others to do so as well), we'd be happy to collaborate on the development and testing of the toolkit.

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