News‎ > ‎


posted 30 Apr 2019, 06:03 by Cherelle Augustine
Building future leaders: Integrating Quality Improvement in a Public Health Masters Programme

The 2018/2019 ‘Quality Improvement in Healthcare’ module led by Dr Tom Woodcock and Dr Mable Nakubulwa forms part of the Health Services and Systems stream on the Master of Public Health (MPH) at Imperial College London. This 10-week long module has been developed by the Collaboration for Leadership in Applied Health Research and Care North West London(CLAHRC NWL) team, whose work involves facilitating the translation research evidence into practice to benefit patients within the NHS and social care environment.

Introduced in 2017 under the leadership of Dr Catherine French and Dr Julie Reed, the module introduces students to the complexities of improving healthcare, supporting them to develop an understanding of Quality Improvement and of how academic research can impact on the reality of health and care. This is achieved through delivery of co-produced lectures, simulated project workshops and individual and group assessments. The module draws on academic literature and research in QI, which are comprehensively illustrated with real life practical examples (including through simulation workshops run by Dr Paul Sullivan) to aid students’ learning. The module also includes an external visit to meet quality improvement teams working in healthcare, and a Q&A session with Lesley Watts, Chief Executive of Chelsea and Westminster Hospital NHS Foundation Trust. This exposure to the reality of working for improvement in healthcare systems is valued by the students.

 “[By] applying theories and taught material in lectures to the group projects week by week … we’re actually consolidating the theory by practice” (student mid-module feedback).

Over the years, CLAHRC NWL has supported and supervised a number of MPH individual research projects, some of which have resulted in publications. Many students have gone on to work in QI practice and/or research, taking with them the skills and knowledge from the MPH as they contribute to efforts to improve healthcare for populations across the globe.

Why is it important for MPH students to learn about QI? Unlike more traditional courses, the teaching and training offered is an integrated QI curriculum involving a mix of lectures, classroom discussions and project-based learning. The design of the module has two unique features intended to support students in developing a rigorous and pragmatic approach to address the challenges of improving health and care for populations.

Firstly, it draws on internationally acclaimed research conducted by CLAHRC NWL, culminating in the framework for Successful Healthcare Improvement From Translating Evidence in complex systems (SHIFT-Evidence). The lectures are structured around SHIFT-Evidence to provide a sound grounding in the scientific basis for practice of QI in healthcare systems. Secondly, the module focuses on building capacity and capability of MPH students in the use of QI methodologies through project simulation workshops. The 8-week project simulations are designed to facilitate the development of key transferable skills and methodologies in QI. Students work in groups to evaluate QI concepts for their relevancy and effectiveness in their simulated project, drawing on the published evidence on best practice and current quality of care. By the end of the module, students are expected to be able to demonstrate good understanding of key principles and techniques related to QI in health care. This is assessed through a group presentation – an applied project based assessment that complements a more traditional theory-based essay – requiring students to apply what they have learnt. Working in groups facilitated by a member of the CLAHRC NWL team, students are expected to develop: a shared aim and programme theory (action effect diagram) for a QI simulated project, a stakeholder engagement plan, process map, measures as well as simulated tests of change (plan-do-study-act cycles). Students are assessed on how well they are able to demonstrate what problem(s) they are trying to solve in their simulated project, what they hoped to achieve, what their change ideas are, how they will know a change was an improvement and how their change ideas developed.

Working in groups during the workshops promotes a setting where collaboration is valued for producing better results, teaching students valuable life-long skills that are important in the professional workplace. We believe that using group work and collaborative learning in the classroom instils students with skills valued by employers and businesses, including but not limited to – leadership skills, oral and verbal communication skills, teamwork, problem solving, autonomous working, and listening skills. Evidence-based QI theory is complex, and teaching concepts relating to applied settings can be challenging especially to students that have limited or no exposure to working in healthcare settings. During the workshops, content is broken down into smaller more digestible practical components, enabling students to tackle larger and more complex problems as well as providing an opportunity for them to apply what they have learned in a collaborative setting. Given that there are intended outcomes for each workshop, students are encouraged to plan and manage their time more effectively. This mirrors the realities of working with a team to deliver improvement in healthcare. The skills developed and adapted during the simulation project work can be applied in the workplace to effect real change in service delivery. The final assessment of the module is for students to produce a theory-based QI report. The students are expected to review existing accounts of improvement in their chosen area, using a theoretical framework as a ‘lens’. Specifically, students are expected to choose an analytical framework and use it to critically explore in a specific clinical problem (e.g. sepsis), patient group (e.g. people with learning disabilities), or setting (e.g. A&E). In combination with the group project, this gives students the opportunity to demonstrate their understanding of QI research and evidence, and QI applied methodologies applied in healthcare.

Selected student experiences from MPH QI training

Aysel Rahimli


“My project focused around using the concepts of “hard core” and “soft periphery” elements of internet delivered-cognitive behavioural therapy, for its implementation in a range of contexts. I was able to explore the intervention using 3 definitions of those concepts (Medical Research Council, Denis et al., (2008) and Greenhalgh (2004)), comparing and contrasting them. From this, I was able to present the complexity and importance of dismantling complex interventions, and how the concepts can be used to help adaptations of the intervention. Having done the project with CLAHRC NWL, I learnt significant research skills, specifically qualitative research analysis, as well as the practical implications of quality improvement and implementation science within healthcare. Attending the CLAHRC NWL Summer Collaborative Learning Event was one of the highlights of this experience.”

Jayne Yap

“I am now working as a project manager for national initiatives driving clinical quality and improving care in Singapore’s Ministry of Health where I come from. Looking back, it was my summer project, which gave me my first taste of quality improvement work in healthcare, and I found myself considering job prospects in this field. My summer project was a quantitative evaluation of an intervention to improve the diagnosis and management of patients with atrial fibrillation (AF) in primary care. I chose this project because, as an ongoing intervention, it had real and immediate impact in improving care for AF patients. I gained a greater understanding and appreciation of data-driven research to support quality improvement, which is also a big part of my work now. I received amazing support and guidance from my supervisors, Dr Tom Woodcock and Yewande Adeleke, and their team at CLAHRC. Working with them was truly enriching”.

Heather Humphreys


“Over the summer Professor Julie ReedStuart Green, and the team at CLAHRC NWL gave me invaluable guidance and fantastic research experience while working on my dissertation for my MPH from Imperial College. They helped me design my research project to determine constituent factors of Type 1 context that would fit within MUSIQ v2.0 for generation of a complete framework for objective analysis of qualitative quality improvement data. The goal of the study was to examine four representative interventions within one hospital to explore and define the factors of type 1 context in terms of the themes and interactions between project, setting, and QI context. At the end of the project, we defined fourteen contextual factors that, in conjunction with the existing framework, resulted in 50 descriptive categories that can be used for quality improvement design, implementation, and evaluation. I’m really pleased to have had this opportunity to work with CLARHC NWL in designing and following through with my own project with expert supervision and guidance. I’m grateful for the opportunity to have attended seminars, conferences, and presentations as a result of my attachment. The experience gained was fantastic and will be of great use in my further career.”

Monica Valenza

“I have really enjoyed my time at CLAHRC NWL and I am very grateful to have done my MPH dissertation with the team Lead by Professor Julie Reed and supervised by Stuart Green. The topic the title of the thesis was “Exploring the ‘hard core’ and ‘soft periphery’ of  quality improvement complex interventions: An integrative review of surgical site infections care bundles, and aimed to operationalise the theory of ‘hard core’ and ‘soft periphery’ and aimed investigate beyond the discussion of generalised success factors provided by previous studies answering, ‘is this intervention effective?’ to exploring how a balance between theory and what occurs in practice is required to elucidate the relations between the dynamic features of a Quality Improvement (QI) intervention, its implementation and the context. Completion of the thesis concluded that characterising the Hard core and Soft periphery of QI intervention allows to understand how a complex intervention can be adapted to mitigate or exploit system characteristics thus ultimately determine the acceptance of an implementation effort in routine care. I strongly recommend anyone who is interested in QI research, to work with CLAHRC NWL, as they are very supportive, they were always happy to include me in their writing days meetings so I had the opportunity to talk about my research with everyone not only my supervisors and Professor Julie Reed, so I gathered valuable advice from all the team members present.”

Neil Stillman


“Starting the Master of Public Health (MPH) degree at Imperial College in October 2015, I remember most looking forward to the lectures on quality improvement. At the time, we had introductory sessions from Professor Julie Reed and Rachel Matthews from NIHR CLAHRC NWL on improvement methodology and patient and public involvement, respectively, as part of an improving health services module – this brief exposure to improvement was enough for me to know that this was something I would like to pursue further. Luckily, I had the opportunity to complete my dissertation with Professor Reed and colleagues at CLAHRC NWL where I explored the spread of a successful quality improvement project across acute care settings.

Following the completion of my summer project, I had the opportunity to present alongside Professor Reed at the 34th international conference of the International Society for Quality in Healthcare (ISQua). We outlined the value of applying the concept of ‘hard core’ and ‘soft periphery’ to complex clinical interventions to support shared learning between QI initiatives. Working with CLAHRC NWL, it has been great to see how such research may be applied in practice to help support the rollout of several clinical interventions including medications management, heart failure and paediatric allergies.

After the MPH programme, I spent some time working at the Royal College of Psychiatrists’ Centre for Quality Improvement on the NICE/NHS England commissioned Achieving Better Access to Mental Health Services programme team. The insights gained during my project with CLAHRC NWL into the complexity of quality improvement proved useful in developing a quality assessment and improvement programme to improve health service delivery and patient experience for individuals across England presenting in a mental health crisis who require urgent and emergency mental health care.

Taking up a full-time position with CLAHRC NWL in November 2017, I’ve had the chance to return to Imperial through a recently introduced CLAHRC NWL led module (Quality Improvement in Healthcare) on the MPH, where I deliver a session on spreading improvement. It has been fantastic to watch the MPH programme evolve to take account of the changing healthcare landscape – towards greater integration and multidisciplinary working – and the need to improve quality while also delivering better value care. Being involved in facilitating an innovative group quality improvement simulation project over ten weeks demonstrates how CLAHRC NWL, in collaboration with Imperial, is well-placed to ensure that MPH students are equipped with skills responsive to employer needs.”

Below are some of the projects that CLAHRC NWL has supported and supervised over the years.

Dr Jose Mercano: Social Deprivation and Common Mental Disorders – The Case of the Westminster IAPT Service

Sonar Parmar: Influence of Quality and Outcomes Framework on diabetic foot admissions in North West London

Abdul-Azeez Osi-Efa: COPD prescribing and outcomes in North West London

Dr Luís de Sousa: Evaluation of the implementation and impact of a quality improvement project for inpatient management of acute diabetic foot disease

Tahania Ahmad: An evaluation of a COPD Care Bundle to improve outcomes and reduce variation in care

Monica Valenza: Exploring the ‘hard core’ and ‘soft periphery’ of complex interventions: A review of surgical site infections care bundles

Neil Stillman: Exploring the Spread of a Successful Improvement Project. “It’s complicated”: a qualitative study of the spread of a medicines review intervention across acute hospitals in London

Jayne Yap: Improving Diagnosis and Management of Atrial Fibrillation in Hounslow: An Evaluation of a Quality Improvement Initiative in Primary Care

James Redmore: Social Return on investment for DIMPLE project

Valencia Lim: Paediatric reattendance at ED. (Mitch Blair main supervisor)

Carolyn Sharpe: Alcohol Licencing in Southwark. (Richard Pinder main supervisor)

Talia Boshari: Alcohol and violence in Southwark. (Richard Pinder main supervisor)

Yasmin Bou Karim: Exploring the relationship between annual cycles in healthcare and their impact on the ability of Quality Improvement projects to make progress towards achieving their improvement goals

Heather Humphreys: When the Dust Settles: Determining the Factors that Constitute Type 1 Context

Aysel Rahimli: A Realist Review: Application of ‘Hard Core’ and ‘Soft Periphery’ Concepts for Implementation of Internet – Delivered Cognitive Behavioural Therapy

Lucy Miller: Roll out and organisational readiness: The spread of a heart failure care bundle in Northwest London

Juan (Sebastian) Dennis-Beron: Perceived Context and its Role in Quality Improvement Initiatives


Thank you to the authors: Dr Mable Nakubulwa, Stuart Green,  and Dr Tom Woodcock 

Thank you editors: Yewande Adeleke and Linda Eftychiou