Background Previously, the hospice instituted changes in the light of national guidance and themes from incidents, but the manner in which these changes were implemented lacked quantitative proof that the change was an improvement. Also, insufficient attention was paid to defining the root cause of an issue and the possibility of unintended negative consequences.

Aim For any clinical improvements to be pursued using the Institute for Healthcare Improvement (IHI) model of quality improvement (QI). This includes clearly defining the aim, using a baseline measure to clarify the issue, putting a specific intervention into place and using outcome and balancing measures to check whether the change constituted an improvement.

Method A ‘Quality Improvement and Clinical Governance Lead’ post was created and filled in November 2018.

The post holder:

• Delivers QI teaching on a monthly basis, with the aim of 60% of clinical staff being trained by March 2020;

• Attends all clinical incident review meetings and assists the team to address themes using QI methodology;

• Oversees all patient feedback in the same manner;

• Supports individuals and teams to run QI projects.

Results By June 2019, 17 members of staff had been trained. The initial session was delivered to multi-professional managers and then rolled out to all clinical staff. The feedback from the sessions was positive;

‘Step by step process to support QI’.

‘Will enable me to measure QI improvement’.

‘Helped to organise some of my own ideas and study my own PDSA cycle’.

This training, together with the presence of the QI lead in all patient quality meetings, has led to proposed changes across the hospice being designed and evaluated using the QI model.

Conclusions The use of QI methodology has led to more sustainable and effective interventions and has given the hospice clearer evidence of our improvement journey.