Table 1 A description of each of the seven specified steps

Step 1:

 Aims: To address trust and credibility and prepare for action planning

 Who: Clinical lead.

 When: Undertaken before the National audit report is received.

 Preparation step has two parts:

  1. Draft section of report that gives a brief description of:

   a) Source, advisory group representation and external drivers for participation

   b) How data were collected and experienced difficulties with reliable measurement

   c) Refer to later description of triangulation with other data

  2. Prepare for next stage by:

   a) Identify influential members of the specialty and Trust governance groups

   b) Gather Trust board and governance group minutes, quality account, quality strategy and regulator’s (Care Quality Commission (CQC)) report

   c) Identify stakeholder group and arrange meeting(s) to discuss data and improvements

 Note: This step was amended after phase 3 so as to provide draft brief description and include governance lead familiar with minutes, strategies and regulator reports as a workshop participant.

Step 2

 Aim: To identify priorities for action from within the hospital feedback.

 Who: Clinical lead and Clinical governance lead

 When: Month 0-1.

  1. Review full data set for potential priorities, where potential priorities are those:

   a) With lower quartile performance

   b) Low absolute performance, where not undertaking target care behaviour might result in significant impact on patient/carer/organisation

   c) For which there is not more robust data that indicates acceptable performance

  2. Identify high performance to celebrate success

  3. Discuss full data set with stakeholder group, targeting on: risks to patient; risks to organisation; triangulation with other data; and successes to be celebrated. Generate a final list of priorities for action with:

   a) Lower quartile performance which is considered unacceptable to stakeholder group

   b) Absolute performance and impact on patient/carer and organisation which is not considered acceptable

  4. Discuss target care behaviours with stakeholder group to identify relationship to other data (e.g. performance, complaints, CQC inspection, length of stay, cost) and organisational priorities (e.g. Trust board, commissioner, CQC).

Step 3

 Aim: To align messages about data to organisational priorities

 Who: Clinical lead and Clinical governance lead

 When: Month 0–1

  1. Review the quality account and minutes from quality committee and organisational board that describe organisational priorities. Consider links to national audit priorities for action

  2. Identify other stakeholders to seek to involve, based upon audit findings and related organisational priorities. Discuss the audit data and the relationship to their priority, whether there is data and/or existing actions that relates to both with these stakeholders.

 Note: This step was amended after Phase 3 so as to draw upon the clinical governance lead’s knowledge of organisational priorities, rather than review documents.

Step 4

 Aim: To present prioritised data items in a way that increases motivation to commit organisational resources

 Who: Clinical lead and Clinical governance lead

 When: month 1–2.

  1. Present loss-framed data (e.g. 40% patients did NOT get…)

  2. Present comparison

  3. Identify position compared to own previous performance, national and peer group to be able to give verbal feedback at meeting.

 Note: This step was amended after phase 3 so as not to recommend loss-framed data due to lack of acceptability.

Step 5

 Aim: To seek evidence about influences upon performance and potential actions to address barriers

 Who: Participants as described below

 When: Month 1–3

 Seek evidence of influences and actions to address barriers by, for example:

  1. Literature search by hospital librarian of impacts upon performance of target care behaviour

  2. Clinical governance lead reviews Trust data for internal high-performers and national audit data for those beyond the Trust. Ask those identified about what helps performance.

  3. Observe care delivery: Look for possible causes of performance and possible waste (e.g. unnecessary dual data entry) that could be removed to create capacity for change. Observations of care delivery. Findings fed back to clinical lead.

  4. Clinical governance lead: Share findings on noticeboards and ask for reasons via email/anonymous comments. Collate and feedback comments to clinical lead.

  5. Clinical lead: Review list of potential strategies [22]. Ask stakeholder group about barriers and what has been done by others to understand the reasons for current performance (e.g. as part of improvement project, incident review)

Step 6

 Aim: To model the link between barrier, action and organisational priorities

 Who: Clinical lead

 When: Month 3–4.

 Duration: 6 h

  1. Draft logical improvement plan

  2. Discuss draft improvement plan and whether could/should adapt existing actions with service improvement lead, stakeholder group (including deputy director of nursing and influential voices on governance groups) and potential action owners.

  3. Ask whether they agree with the choice of action to address barrier, or whether a different action might be more effective.

  4. Ask potential action owner to take responsibility for completion of the action

Step 7

 Aim: To present to governance group in order to gain approval for the action plan.

 Who: Clinical lead

 When: Month 4–5.

 Describe, verbally and in an accompanying written report:

  1. Data quality;

  2. Prioritisation method and how plan developed;

  3. Successes to celebrate

  4. The logical improvement plans, including relative and loss-framed performance.

  5. The action plan that specifies the target care behaviour, the action to improve detailing: what will be done and the rationale for action; by whom; to whom; by when and how it will be monitored

 Note: This step was amended after phase 3 so as to provide draft brief description of the method.