Background Our organisation believes ‘quality is everyone’s responsibility’ (Deming. Out of the crisis. 2000). Nonetheless, quality improvement projects (QIPs) analysis identified minimal diversity in project teams, with representation from limited range of professions and levels of practice, aligning with traditional views of hierarchy in healthcare (Nembhard, Edmondson. J Organizational Behav. 2006;27(7):941–66). Exploration indicated a culture of ‘not my role’ in taking part in quality improvement (Mannion, Davies. BMJ. 2018;363(363):k4907; Harte, Hayward Giles. Quality improvement: everyone’s responsibility [Internet]. Chartered Society of Physiotherapy. 2022) grounded in lack of confidence, as no formalised support or information for process and requirements, which excluded parts of the workforce with limited previous exposure to project management. We created a tool to formalise the process and requirements, as well as support users, for QIPs.

Aims To encourage Quality Improvement (QI) culture by developing a tool to guide, plan, monitor progress, and evaluate QIPs. The tool aims for suitability for standardisation across all organisational QIPs. To support engagement with QI, service development and leadership across all roles and levels of practice (Harte, Hayward Giles. 2022).

Methods Oct. 2022 – Nov. 2022: Analysis of engagement with QIPs, literature review, consensus decision of methodology for tool, developing PDSA tool (NHS England. Plan, Do, Study, Act (PDSA) Cycles and the Model for Improvement. [Internet] 2021). Dec. 2022: Small scale project pilot testing of tool, pilot evaluation. Jan. 2023 – Apr. 2023: internal consultation using purposeful sampling (Palinkas, Horwitz, Green, et al. Adm Policy Ment Health. 2015;42(5):533–44), thematic analysis of feedback, revision of tool leading to approval, support through inclusion of tool in annual quality improvement priorities.

Results Following pilot and internal consultation feedback, four themes identified:

1. Suggestions for change/additions.

2. Initially appeared overwhelming, but felt logical and supportive when used.

3. Suitable to standardise for all organisational projects.

4. Suggestions for increased scope of tool.

Conclusions Evaluation of pilot and feedback from internal consultation demonstrates successful production of PDSA tool to use for all QIPs, across the organisation. Project continuation through a Quality Improvement Priority for 2023/24:

• Embed the PDSA cycle further.

• Evaluation and revision of tool based on user experience.

• Thematic analysis of feedback.

• Review and implementation of policy to promote culture change.