How to do a quality improvement project

By Kirsty Mahoney, Clinical Manager, Wound Care People

Abstract

Quality improvement (QI) is a structured approach to enhancing patient care and healthcare systems. For nurses, QI is particularly important as it empowers them to identify gaps in practice, implement evidence-based changes, and measure the impact of those changes. By engaging in QI, nurses play a vital role in improving patient outcomes, ensuring safety, and driving sustainable improvements across healthcare services. This article highlights the importance of QI and gives an insight into how to conduct a QI project using the Model for Improvement framework, which uses small-scale, iterative plan–do–study–act cycles. This method minimises disruption, enables structured learning, and facilitates incremental, sustainable change.

Why is quality improvement important in health care?

Improving healthcare quality within the NHS is both a necessity and a challenge (The King’s Fund, 2017). With demand for services continually rising and resources remaining finite, healthcare organisations must find ways to maintain and ideally raise standards of care while ensuring better value for money (The King’s Fund, 2017). If undertaken robustly, quality improvement (QI) projects provide a structured approach to achieving this goal (Improvement Cymru Academy, 2024). They aim to enhance patient outcomes, optimise use of resources, and create practices that are safer, more efficient, and more equitable. QI can deliver meaningful and lasting benefits for patients, clinicians, and healthcare providers (The Health Foundation, 2021). Yet, the journey from concept to sustained change is rarely straightforward (Jones, 2019). Healthcare professionals contributing to QI projects often face complex challenges, particularly when it comes to designing effective interventions, implementing them in real-world settings, and ensuring improvements are maintained over time (Jones, 2019).

An effective QI project should begin by identifying areas where care is inconsistent, where treatments are overused, underused, or misused, or where processes are inefficient. The Institute of Medicine (2001) outlines six domains of quality (Figure 1) that should be considered to guide a QI project. By using these domains as a framework, healthcare organisations can prioritise areas of need and design targeted interventions (Improvement Cymru Academy, 2024). QI is therefore a systematic and continuous effort to enhance the quality and safety of healthcare services and patient outcomes.

Figure 1. Six domains of quality (Institute of Medicine, 2001).

Platform 6 of the Nursing and Midwifery Council (2024) standards of proficiency for registered nurses highlights that nurses are required to demonstrate an understanding of the principles of improvement methodologies, participate in all stages of audit activity and identify appropriate quality improvement strategies. It is therefore important for nurses to have the right knowledge and understanding to either be involved with or conduct small QI initiatives within their area of practice.

This article explores the key processes and methodologies involved in undertaking a QI project, with particular attention to enablers and barriers or challenges that can influence its success or lead to potential setbacks or failure.

How do I get started?

You don’t need to be an expert in QI to undertake a QI project, and it doesn’t need to be big or complex (The Health Foundation, 2021). Small improvements can have a significant impact on patients, but to be successful you will need to know about improvement methodology, so your approach is both a systematic and continuous process (The Health Foundation 2021). Backhouse and Ogunlayi (2020) indicated that successful improvement comprises 20% technical and 80% human skill.

Some key skills you will need include:

Good project and time management
Ability to collaborate with stakeholders and all participants
Good communication skills
Good understanding of improvement methodology
Ability to understand the data that you will capture to measure the impact of your improvement intervention

(Jones, 2019).

There are a number of established improvement frameworks available to guide QI projects (The Health Foundation, 2021). One widely used within NHS organisations is the Model for Improvement (Improvement Cymru Academy, 2024). This straightforward approach encourages starting on a small scale, making the work less disruptive to practice while supporting continuous change (The Health Foundation, 2021). It uses short, structured cycles of testing, known as plan–do–study–act (PDSA) cycles (Figure 2), in which potential improvements are trialled, reviewed, and refined. Each cycle offers an opportunity to gather insights and learn from outcomes in a structured and continuous way (Improvement Cymru Academy, 2024). Each PDSA cycle is linked to three key questions which need to be considered throughout your QI project:

What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?

(Improvement Cymru Academy, 2024)

Understanding the problem

The first stage of any improvement project is to clearly define the problem and use data to identify gaps in current performance and practice, as well as the underlying causes (The Health Foundation, 2021). This can involve drawing on various types of information and data which will also give a clear baseline to assess the impact of your improvement project both during and following implementation (NHS England and NHS Improvement, 2023b). Data can include quantitative data, qualitative data or a mixture of both.

Figure 2. Model for Improvement.

Measuring data before starting QI - let’s look at an example.

Consider a situation where there appears to be a high incidence of infection among patients with indwelling catheters, and you would like to use a new care bundle to reduce infection rates. The first step is to establish whether a problem truly exists and to understand its underlying causes. Where available, prevalence data should be reviewed to determine the scale of the issue; if such data are lacking, a local prevalence study may be needed. Data collection can be undertaken retrospectively, by reviewing past patient records, or prospectively, by assessing current care practices at the point of delivery.

You could look at antibiotic prescribing for catheter infections – how many courses were prescribed and what was the cost?

You may also want to look at the process of catheterisation to highlight any shortfalls that may be contributing to high infection rates. An audit, using a recognised tool, can be valuable in examining the equipment used and determining whether catheterisation procedures are performed in line with established standards.

Including the patient perspective provides a more holistic, patient-centred approach. Patient-reported experience measures (PREMs) can highlight the personal impact of infection, while cost analysis can demonstrate the financial burden on healthcare services. In addition, administering a knowledge and skills questionnaire can help identify whether infection rates are linked to gaps in staff training or competence.

A range of tools can be used to investigate a QI issue in greater depth (Improvement Cymru Academy, 2024). For example, a cause-and-effect (fishbone) diagram can help identify potential contributing factors, while process mapping allows these factors to be explored in more detail (Improvement Cymru Academy, 2024). Collaboration with other healthcare professionals is often essential during this stage, making early engagement with the wider team a key part of the process. Further information on QI Essentials toolkits can be found on the Institute for Healthcare Improvement website (https://www.ihi.org/library/tools/quality-improvement-essentials-toolkit).

Reflect on your own practice:

Is there an area in your place of work that needs improvement and a change in practice to meet the six domains of quality?

What data could you collect to identify if there is a problem / gap in practice?
How would you collect the relevant data?

Engaging stakeholders

Engaging stakeholders such as staff, patients, and senior management is vital for gaining insight, building commitment, and ensuring the success of a QI project (Pazzaglia and Ivany, 2025). This should be an ongoing process, underpinned by open communication and a shared understanding of the project’s aims and objectives (The Health Foundation, 2021). Early collaboration with the research and development department (and the QI team if available) can provide valuable guidance and support (Jones, 2019).

It is equally important to maintain clear communication with senior management, demonstrating how the project contributes to wider organisational priorities (The Health Foundation, 2021). If possible, gaining support from a mentor or supervisor who can help signpost you to useful people and resources can help with implementation of the project (Jones, 2019). This alignment not only strengthens engagement but also supports the long-term sustainability of the improvement.

Defining the aim of your improvement project

Once you have identified the problem, the next step is to establish a clear aim and set of objectives. These should be concise, well-defined, and aligned with your organisation’s priorities and quality domains (Jones, 2019). Aims and objectives are most effective when framed using the SMART approach:

Specific – focused on a single, clearly defined issue
Measurable – supported by data that can be practically collected and analysed
Achievable – realistic in scope and feasible within available resources
Relevant – meaningful to both staff and patients, addressing a genuine need
Timely – capable of being measured and evaluated within a reasonable timeframe

Thinking about our QI example, your aim may be:

To reduce the incidence of urine infections by 50% for hospital inpatients with indwelling catheters. This will be achieved by:

Introducing a catheter care pathway for all patients who have an indwelling catheter
Ensure all staff caring for indwelling catheters attend a new training programme that accompanies the care pathway and achieve a competency certificate

All patients with suspected urinary tract infections having an antibiotics checklist completed by a clinician before being prescribed antibiotics

Testing changes on a small scale: using the PDSA cycle

Once you understand the problem and have a clear aim, it is time to test your change on a small scale to evaluate the impact and learn from the data using PDSA cycles (Improvement Cymru Academy, 2024). Using a recognised project management template such as those from NHS England and NHS Improvement (2023a) can be useful and help to ensure that all tasks required are included and acted on within a recognised timeframe.

Plan

The planning stage will be the longest as it is so important to get it right (Improvement Cymru Academy, 2024). At this stage you can use some recognised planning tools to see how you might implement your project. For example, a driver diagram is a visual tool that shows how a project’s main goal connects to the key factors that influence it, the smaller parts of those factors, and the ideas you can test to make improvements (NHS England and NHS Improvement, 2023b).

Figure 3. An example of a driver diagram.

Figure 4 outlines some key components that need to be considered in each stage of the project. Think about the processes involved in the project you want to instigate and identify how you might achieve this and what may be enablers or barriers to implementation.

Figure 4. Key actions in each phase of your QI project.

During the do phase, the change idea should be introduced on a small scale, such as within a single ward or department. Trialling the intervention in a limited setting minimises disruption and allows for close monitoring, recognising that the initial approach may not be perfect. Ongoing feedback is essential – regular check-ins or midpoint meetings can provide opportunities to discuss progress, identify challenges, and share successes (NHS England and NHS Improvement, 2023b; Improvement Cymru Academy, 2024) (Figure 4).

Supporting staff throughout this stage is critical. Motivation, reassurance, and encouragement help to build confidence and foster engagement with the project. At the same time, continuous data collection is required to evaluate outcomes and inform next steps (NHS England and NHS Improvement, 2023b; Improvement Cymru Academy, 2024).

Thinking of our example, our project focused on catheter-related infections, by introducing a catheter care pathway and accompanying education programme on one ward. Outcome measures could include:

Tracking infection rates among catheterised patients
Monitoring antibiotic prescribing
Gathering patient feedback on their experience of care
Collecting staff evaluations of both the care bundle and the training programme

Study

In the study phase, the focus shifts to analysing the data collected during implementation and comparing it with baseline measurements. This step allows you to evaluate whether the intervention has achieved its intended aim and to reflect on what has been learned throughout the process. Consider both the successes and the challenges: Did the change lead to measurable improvement? If not, why? Identifying the factors that influenced outcomes, whether positive or negative, provides valuable insight to guide the next cycle of improvement (NHS England and NHS Improvement, 2023b; Improvement Cymru Academy, 2024) (Figure 4).

Thinking about our example:

Were catheter infections reduced by 50%? If not, why?
Was antibiotic prescribing for urinary tract infections reduced?
Was the care bundle easy to implement? What did staff/patients think about the experience? Did they like it – if not, why?
What did staff think about the educational programme? Was it easy to implement?
Were there any cost savings or reduction in antibiotic prescribing
Do I need to change anything within the project?

Act

The act phase is about deciding on the next steps based on what has been learned (Figure 4). If the intervention was successful, you may choose to adopt the change more widely, scaling it up across additional wards or departments. If the results were mixed or the aim was not achieved, the intervention may need to be adapted and retested in a new PDSA cycle. In some cases, it may be necessary to abandon the original idea altogether and explore alternative approaches.

Key considerations during this stage include:

How can successful elements of the intervention be sustained over time?
What modifications are needed to address challenges or barriers that have been identified?
Is further staff training or support required before spreading the change?
How will ongoing data collection ensure improvements are maintained?
How will I present findings to staff and senior management to facilitate engagement?

By making evidence-based decisions at this stage, you can ensure that learning from the project is translated into lasting improvement, with clear plans for sustainability and spread (NHS England and NHS Improvement, 2023b; Improvement Cymru Academy, 2024).

Think about our project

Do I need to tweak the care bundle or educational programme?
Can I role it out across the organisation?
Did I reduce catheter-acquired infections and antibiotic prescribing?
Does my project meet organisational goals and fit within the six quality domains?
What is the best way to share my findings both within my organisation and with colleagues in other organisations (e.g. presentations, publications, posters)?
If my results showed positive outcomes, who do I have to present my findings to get engagement and support the role out and sustainability across the organisation – for example directors of nursing, chief executives, ward managers, staff meetings)?

Why some QI projects fail

Not all QI projects achieve their intended outcomes, and several common factors can contribute to failure (Backhouse and Ogunlayi, 2020). These include unclear or poorly defined aims and objectives, inadequate planning, and a lack of visible support or leadership from senior management (Madu, 2022). Poor communication and limited engagement with key stakeholders, such as staff, patients, and managers, can also undermine progress (Madu, 2022). In addition, projects that do not follow a systematic, structured approach or fail to align with local and national priorities are less likely to succeed (Backhouse and Ogunlayi, 2020). Finally, the inability to collect, analyse, or effectively use data can prevent teams from demonstrating impact or sustaining improvements (Backhouse and Ogunlayi, 2020).

Conclusions

Quality improvement is a continuous, structured process that relies on clear aims, effective stakeholder engagement, and robust use of data. Using the PDSA cycle provides a practical and evidence-based framework for testing change on a small scale, learning from the outcomes, and adapting interventions to achieve meaningful results. Success depends not only on careful measurement and analysis but also on collaboration, communication, and a shared commitment to improving patient care. By embedding these principles into practice, nurses and healthcare teams can drive sustainable improvements that benefit patients, staff, and the wider organisation.

References

Backhouse A, Ogunlayi F (2020) Quality improvement into practice. BMJ. 368:m865. doi: 10.1136/bmj.m865

Improvement Cymru Academy (2024) What is quality improvement? https://performanceandimprovement.nhs.wales/functions/quality-safety-and-improvement/improvement/improvement-cymru-academy/resource-library/academy-toolkit-guides/qi-toolkit/ (accessed 18 September 2025)

Institute of Medicine (2001) Crossing the quality chasm: A new healthcare system for the 21st century. Washington, DC: National Academy Press

Jones B (2019) How to get started in quality improvement. BMJ. 364:k5408. doi: 10.1136/bmj.k5437

Madu A (2022) Challenges in conducting quality improvement projects: reflections of a junior doctor. Future Healthc J. 9(3):333-334. doi: 10.7861/fhj.2022-0076

NHS England and NHS Improvement (2023a) Online library of Quality Service Improvement and Redesign tools: Seven steps to measurement for improvement. https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-seven-steps-to-measurement-for-improvement.pdf (accessed 18 September 2025)

NHS England and NHS Improvement (2023b) Online library of Quality Service Improvement and Redesign tools: Plan, Do, Study, Act (PDSA) cycles and the model for improvement. https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-pdsa-cycles-model-for-improvement.pdf (accessed 18 September 2025)

Nursing and Midwifery Council (2024) Standards of proficiency for registered nurses. https://www.nmc.org.uk/globalassets/sitedocuments/standards/2024/standards-of-proficiency-for-nurses.pdf (accessed 18 September 2025)

Pazzaglia MD, Ivany E (2025) Achieving sustainable quality improvement in nursing practice. Br J Nurs. 34(8):432-433. doi: 10.12968/bjon.2024.0461

The Health Foundation (2021) Quality improvement made simple. https://www.health.org.uk/resources-and-toolkits/quick-guides/quality-improvement-made-simple (accessed 18 September 2025)

The King’s Fund (2017) Making the case for quality improvement: lessons for NHS boards and leaders. https://www.kingsfund.org.uk/insight-and-analysis/long-reads/making-case-quality-improvement (accessed 18 September 2025)