Background In the Summer of 2018, a hospice undertook a cultural survey, known as CREATE 2020. One theme for improvement emerging from the survey focused around the management of projects and how services are developed. Staff reported the need for a standardised organisational approach, a range of appropriate tools/techniques and engagement of staff at all levels in change.

Aim To develop a bespoke Quality Improvement (QI) programme to support staff to deliver the hospice’s organisational strategy. It aims to be practically focused and develop capacity and capability of QI skills across the whole organisation. Staff will attain the skills and confidence to apply QI techniques in everyday practice which will result in them being able to continuously, systematically and effectively improve everything we do for the benefit of patients, families and carers (Batalden & Davidoff, 2007. BMJ Qual Saf. 16:2).

Methods September 2019 – February 2020: review the organisation’s project and change management processes, CREATE 2020 feedback, design bespoke QI organisational programme based on literature review (Ross & Naylor, 2017), best practice (Ham, 2016) and staff consultation (Langley, et al., 2009).

April 2020 to March 2022: Staff recruitment, develop and test QI programme, evaluate cohort one staff survey results, refine programme delivery.

Results Two programmes delivered. 18 staff attended - 5 clinical/13 organisational-wide non-clinical; a broad range of staff groups were represented from administration to director level. Evaluation demonstrated extremely positive feedback and support for the programme. Involvement from Board to floor demonstrated organisational commitment, supported by role modelling from the Director which had a positive impact and sense of shared purpose (Bevan, 2013. Health Service Journal Nov 4). Programme outcomes include: improved patient safety, increased retail Gift Aid, paperless HR systems, piloting nurse led beds, lottery telecanvassing, and improved patient information.

Conclusion Explore options for embedding the Quality Improvement approach to ensure long term sustainability and capturing continuous improvement. Develop central portal for sharing, learning, celebrate success, establish QI champions and future training programme.