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NIHR CRN NENC Quality Improvement Tools


View the PDF version of NIHR CRN NENC Quality Improvement Tools (please note this is not an accessible PDF, but the content on this page is the accessible version).

5 Whys

5 Whys is a questioning technique used to explore the root causes of a problem. This helps you target your effort and change initiatives at addressing the underlying cause of the problem and not just the symptoms. The technique involves asking the question ‘Why?’ with each subsequent answer forming the basis of the next question. By asking the question ‘Why?’ a number of times the majority of root causes can be identified. This may take fewer than 5 questions, or occasionally more, so 5 Whys should be seen as a rule of thumb.

What you need

  • Flip chart & marker pens
  • Post-it notes & pens
  • A team of participants

5 Whys Hints & Tips

How to use 5 whys

  • Before you start you must define the problem you want to address
  • Use this to form the basis of the first ‘Why’ question, for example Why did my car not start?
  • Use the answer to form the basis of the next ‘Why’ question
  • Continue asking questions until you have identified the root cause of the problem

Consider the following

  • 5 Whys will generally identify that the root cause is linked to a process. Human error or time factors can have an impact but a root cause will usually be process related. To help with this approach you can always rephrase the question to: ‘Why did the process fail?
  • 5 Whys is a simple tool to use but it does have some limitations. If you are looking at a complicated problem, potentially with many causes, it may be worth combining ‘5 Whys’ with other root cause analysis tools such as ‘Fishbone Diagrams’

Fishbone Diagram

The fishbone (Ishikawa) diagram identifies many possible causes for an effect or problem. It can be used to structure a ‘Brainstorming’ session and can be used in conjunction with ‘5 Whys’ to understand the root cause of a problem.

The benefits of a Fishbone Diagram

  • It immediately sorts ideas into useful categories
  • It helps to identify that there may be many causes to a problem or issue
  • It offers a visual representation of how the causes are related
  • It can help to identify areas to test changes or improvements

What you need

  • Flip chart and marker pens
  • Post-it notes and pens
  • A team of participants

How to use a Fishbone Diagram

  • Write your effect or problem that you want to identify causes for on the right hand side of your flipchart 
  • Draw a horizontal line to the left of the effect or problem
  • Choose categories for the causes of the effect or problem. Common categories include: Materials, Method, Environment, Equipment, People, but others can be used
  • Draw diagonal lines (fishbones) from the horizontal line and label with your categories
  • ‘Brainstorm’ to generate a list of causes for each category
  • Use branch lines off the fishbones to list the causes
  • Use ‘5 Whys’ to develop the causes and to identify the main causes from the symptoms
  • Identify change or improvement ideas from the causes identified

Aims Tool

All improvement projects need a clearly defined aim. The aim should be a description of the desired outcome for your improvement project and should answer the question, ‘What are we trying to accomplish?’ Having a clear aim helps to keep a project focused and maintain progress.

The Aims Tool is a simple approach to help you define, set and manage your improvement aims. It should be used when planning your improvement project but can also be used during your project if any changes are needed.

How to use the Aims Tool

  • Clearly state what it is that you want to achieve and what it is that requires improvement
  • An aim should be time specific, measurable and define the population your improvement project is focused on
  • Include a numerical goal when setting your aim. This allows you to establish a baseline to help you measure and understand if you have achieved your aim
  • Make the aim a challenge. Consider what you want to achieve and in what timescale and set your aim accordingly. This will provide focus to identify all the issues and barriers that need to be overcome to achieve the aim
  • It is important to have one overall aim and to focus any changes on achieving that aim. If you start with too many objectives it can become difficult to separate the causes from the symptoms of that problem • If it becomes clear that the original aim was unrealistic, did not identify the root cause of the problem, or you need to work on a smaller part of the system, refocus the aim
  • Once you have defined your aim you can use it as a starting point to design a ‘Driver Diagram'


Brainstorming is useful when you need to get your team to think creatively about problems or solutions and generate lots of ideas.

It is best to use brainstorming before you begin your project, you can then rank the best ideas for usefulness or importance.

No ideas should be discounted immediately, the more ideas the better!

You shouldn’t use brainstorming when you already have a clear idea about the issue or the relevant solutions.

What you need

  • Flip chart and marker pens
  • Post-it notes and pens
  • A team of participants

How to use Brainstorming

  • Make sure you set clear objectives for the session
  • Ask your team to share their ideas, you could ask them to either shout the ideas out loud, or write them down on the post-it notes (useful where you have more introverted team members)
  • Always make a note of everything shared
  • Do encourage participation by reframing questions, asking new questions or clarifying the objective
  • Don’t pass judgement - the more ideas the merrier!
  • Don’t evaluate anything until you have exhausted all the ideas. Once all the ideas have been captured you can rank, combine and reduce the list! 

Driver Diagrams

A driver diagram is a tool that helps translate an improvement goal or aim into a set of factors that can be used to test and implement changes to help you achieve your goal. It should make clear the steps that are needed within your improvement project and illustrates the relationship between the improvement goal and any proposed changes.

What you need

  • Flip chart and markers
  • Post-it notes and pens
  • A team of participants

How to use a Driver Diagram 

  • Decide on a clearly defined and measurable aim for your project. You can use the ‘Aims Tool’ to help finalise the aim for your improvement project
  • Identify the key factors or areas that need to be addressed to help you achieve your aim. These are called Primary Drivers and should be written as straightforward statements
  • Identify areas that will influence the Primary Drivers and can be used to plan any changes or interventions needed. These are Secondary Drivers and will contribute to at least one Primary Driver
  • The Secondary Drivers can then be used to help identify projects or change initiatives that will help you achieve your aim and will usually be focused on a specific area

The team can then decide which changes to implement. An ‘Ease and Impact Matrix’ can help you to identify which changes to prioritise and test first. This may be as part of a ‘Plan Do Study Act (PDSA)’ cycle.

Ease & Impact

The Ease and Impact Matrix is a 2x2 grid that helps you assess potential changes or projects for their relative impact given the effort required. It provides a quick way to prioritise and identify changes that might not be worth the effort.

What you need

  • Flip chart and markers
  • Post-it notes and pens
  • A team of participants

How to use an Ease and Impact Matrix

  • Have a list of the projects or changes you want to prioritise
  • Draw a 2x2 matrix on a sheet of paper
  • Label one axis ‘Ease’ and one axis ‘Impact’
  • Define a scoring system, for example for ease, 1=very difficult and 5=very easy, and impact, 1=no impact and 5=high impact
  • You can number each axis if this is easier for you
  • Score each project or change and place on the matrix. Each project or change will fall within one of four quadrants (see image)

The team can then prioritise which projects or changes they want to consider for testing or implementation. 

Process Mapping

Process mapping can be used to visualise a process, showing who is doing what, and in what order. It is a useful tool when looking for ways to improve a process, helping everyone to understand what is happening now or ‘the current state’ and to design a more effective and efficient process or ‘the future state’.

Visualising your process helps you to spot duplication of tasks, unnecessary steps, gaps and issues. These can then be discussed and changes made.

A process will always have a start and an end point with a series of activities between these points. These may be stand alone activities or may involve a decision. Processes are usually linked to others so it can be helpful to break the individual components down into bite size chunks to understand where there may be issues or problems.

What you need

  • Flip chart and markers
  • Post-it notes and pens
  • A team of subject experts

Step by step guide

  • Gather together a team of experts who represent every step in the process
  • Define a starting point for the process and prompt the group to discuss other steps in the process
  • Write the steps down on post-it notes and attach them to the flip-chart sheet
  • Where decisions are made that split processes, write these on diagonally, so they can be easily identified. Attach them diagonally to the flipchart 
  • Discuss with your team whether the steps, as displayed, are correct. If so, start to draw in lines using markers to denote the flow of the process
  • Share the process with others, ask them whether it is accurate. You may wish to enter the process on a system such as Lucidchart or Visio

Stakeholder Analysis

Stakeholder analysis is used to map out your communication and consultation strategy with those who may, or may not have either influence over or interest in your project.

Mapping your stakeholders reduces the risk of overburdening some parties or lack of engagement with key decision-makers. 

What you need

  • Flip chart and markers
  • Post-it notes and pens
  • A team of participants

How to make a Stakeholder Map

  • Step One: Identify your stakeholders. Brainstorm with your team who might have an interest or influence over your project
  • Step Two: Using a 2x2 Grid, with one axis being ‘power’ or ‘influence’ over your project, and the other axis being ‘interest’ in your project, plot out your stakeholders onto the grid. As an example, your boss may have both authority over, and interest in your project; an executive may have authority, but be relatively uninterested whilst some stakeholders may be the opposite
  • Step Three: Plot out an action plan of how you will keep your stakeholders informed. For those in the top right quadrant you will want to prioritise your efforts, whilst applying minimum effort to those in the bottom left. It is useful, at this point, to work out what might be the motivating factors for each of your stakeholder groups as this will inform your communication decisions

Collecting Data

In order to show whether the changes you implement have the desired outcome or not, it is essential to measure the current state of whatever it is you are looking to change along with the outcome.

Data comes in many forms, and can be either qualitative, which includes thoughts or opinions, or quantitative numerical data; you will need to decide what data you need to collect and how this will support your project.

Consider the following when collecting data

  • Decide what relevant data you need i.e. what will be included or excluded
  • Consider how you are going to show your data
  • Decide how often data is to be collected
  • Decide who is collecting the data
  • Integrate any measurement into the daily routine
  • Use existing data collection systems whenever possible
  • Set timelines for your project
  • Set milestones to help you monitor and manage your progress
  • Decide measures to help you track your progress
  • These should support the overall aim
  • It is important to consider what will happen once any changes have been made
  • Determine your baseline to help you understand whether any changes have led to an improvement


A survey is a tool to ask a question or a series of questions in order to gather data from a specific group of people.

Surveys can be used to assess thoughts, opinions or feelings on specific areas. A set of predetermined questions is given to a sample group and the findings can be used to identify problems and any changes that may be worth testing.

  • Define the knowledge or information you want from your survey
  • Keep it simple. Fewer focused questions are more likely to get you the information you need and ensure you get a greater response rate
  • Pick the right question type for the information you need

There are four main types of question

  • Lists of labels or names as possible answers
  • Scales such as ‘strongly disagree to strongly agree’ or ‘not important to very important’
  • Intervals - need to be ordered and the distance between values should be meaningful. For example: ‘1-10, 11-20, 21-30’
  • Ratios - for precise measurements. For example: If you asked how much respondents spent on public transport in a week you would allow numeric responses like £4.50, £33, £0, etc

Consider how you phrase your questions

  • Avoid leading questions
  • Avoid compound questions, for example the question ‘On a scale of 1-100 please rate the quality and cost of the food in the canteen’, is asking for one rating for two separate measures. Split any questions like this into multiple questions
  • Allow for neutral or not applicable (N/A) responses
  • Keep your questions short, direct and use simple language

Pareto Charts

A Pareto chart is a bar chart. The bars represent the frequency of different events with the most common on the left and the least common on the right. This helps to visualise which events are more significant and may need addressing.

Pareto charts are useful to use if you need to:

  • Analyse data about the frequency of problems
  • Identify and focus on the most important issues
  • Easily visualise and communicate your data to others

Pareto charts can be easily created using software such as Google Sheets or Excel.

Guidance on how to create a Pareto chart can be found via the link on the other side of this card.

Some things to consider when using Pareto Charts

  • Use as a guide on where to focus improvement efforts but ensure other factors are considered
  • Have at least 30 observations as fewer data points may not give a full picture
  • A Pareto chart does not plot data over time. This can be done using a ‘Run Chart’

Run Charts

A run chart is a line graph that plots data over time. A median line is usually plotted on the run chart to show the middle value of all the data points so half will sit above and half below the line. Changes made during a process are also plotted so it is easy to identify whether any impact or variation is connected to the change. A run chart can be easily created using software such as Google Sheets or Excel.

Use Run Charts to:

  • Assess existing processes to see how well they are performing and whether any changes or improvements are needed
  • Help you understand the impact of a change and whether the change has led to an improvement
  • Assess whether any improvement has been sustained over time

Some things to consider when using Run Charts

Once you have enough data points on your run chart they can be used to distinguish between random and non-random variation.

There are four identified types of non-random variation: shift, trend, too many or too few runs, astronomical data point. 

Change Management

When beginning your change activity, it is always worthwhile acknowledging how people impacted by the change may be feeling or how they may react to the potential change.

Models such as The Kubler-Ross Change Curve, Prosci’s ADKAR and the Transtheoretical Model for Change (TTM) all describe the different stages people will undergo when faced with change over time.

The charts on the other side of this card give a high level view of the three change theories above, plotted over time and against the ‘energy’ needed to handle the change (shown by the lines).

It is evident from all three models that some emotions and behaviours are positive and others negative. It is also apparent that the amount of energy available to handle change can rise and fall over time as well. Bearing these human factors in mind can help you plan your change, and communication and engagement more effectively.

Evaluating Change - Types of evaluation

Evaluation is the process by which you are able to show, using data, whether a change you make has a positive impact or not.

Using an evaluation, you can not only tell whether your change has worked, but also why and how. By not evaluating your projects you risk wasting effort and damaging the credibility of your change, especially if you want to spread the change further.


  • Summative evaluations are normally carried out at the end of a change project, when all the data is available, and allows you to sum up your project
  • This is especially useful to show that objectives have been met
  • It is also useful to show the benefits of the change against the cost, and can therefore be used to show your managers, or other audiences whether your change had value


  • Formative evaluations help you form your change and are used during the life of the project
  • You can use formative evaluation alongside summative evaluation, it will help you to understand what works, and what internal and external factors may be at play
  • Formative evaluation is useful when you’re engaging with people or trying to effect behaviour change
  • You may wish to use driver diagrams, interviews, surveys or data such as budget tracking or resource use

Rapid Check & Developmental

  • Both Rapid Check and Developmental evaluations are types of Formative evaluation, but are, in general, less widely used
  • Rapid Check’s goals are agreed at the beginning of the change project, but the methodology may be changed during the life of the project, such as in a PDSA cycle and these changes are iterative
  • Developmental evaluations’ goals and methods are subject to change depending on the real-time feedback received by the project team

Evaluating Change - Designing evaluations

When you design your evaluation, you must ensure that your evaluation will give you the information you need. This card will give you some key questions and suggestions that will allow you to design your evaluation so it is effective.

The key question...

The key question which needs to be answered in any evaluation of a change is: Has the change achieved its goal?

Answering this question will allow you to show that your project has either been successful, or not. You can find this out by asking questions such as:

  • How did the project achieve its goal? This will allow you to develop learnings from the project
  • How much resource was used? This can help you work out the cost of the project against the benefit
  • Were there any unintended consequences? These might be benefits, drawbacks or odd results

You may also wish to consider:

  • The type of change you are making. If you are pursuing a change to a process, a summative evaluation may suffice to help you understand whether the change worked, and also help you manage your stakeholders. If you were looking to engage with patients, on the other hand, a formative evaluation, looking for feedback around their experience would be more appropriate
  • Who your stakeholders are. 
  • Whether you are comparing the ‘As is’, your current state with the future state following the change; or if you will benchmark against others or begin a randomised trial. 

Other things to bear in mind...

  • Are you about to begin your project? Trying to understand the need for the project may necessitate using the Aims Tool or Root Cause Analysis
  • When monitoring your project to ensure that your objectives are being met, it is useful to use formative evaluation

How to get your innovation adopted: Rate of Adoption

In 1962 Everett M Rogers described the factors he theorised were needed to ensure that innovations are taken up both within your own organisation and beyond. Rogers argued that innovation is communicated within social organisations over a period of time and described successful adoption through the use of a bell curve.

In order to achieve saturation and widespread use, it is therefore imperative for an innovation to be adopted by those classed as innovators, early adopters and the early majority, and for them to further diffuse, or spread socially the innovation.

Social adoption personality types

  • Innovators are willing to experience new ideas and cope with unprofitable and unsuccessful innovations. Innovators are likely to introduce innovations from outside of the system
  • Early adopters are often in leadership roles within the organisation; leaders play an important role in setting the scene for change, and leading the innovation throughout the adoption cycle
  • Early majority are vitally important in the cycle of adoption as their networks allow for the diffusion of an innovation to the late majority
  • Late majority are the adopters who wait until the majority of their peers have adopted the innovation, and are persuaded to adopt thanks to having any uncertainty about the innovation reduced by their network of close peers
  • Laggards are in general more sceptical about the innovation and are reliant on viewing other members of the organisation or network having adopted the innovation successfully in the past

How to get your innovation adopted: Standard Attributes

EM Rogers theorised in 1962 that diffusion could be achieved through ensuring the innovation met a number of ‘standard attributes’. These would appeal to adopters. Further work on diffusion and adoption showed the relevance and ease of use of the innovation could improve the opportunities for an innovation to be adopted across an organisation and beyond.

Relative Advantage

Is your innovation better than what is currently in use? The ‘relative advantage’ of your innovation is positively related to its rate of adoption, so it’s important for you to have a focus on showing how your innovation is an improvement, and also on engaging with and motivating people to accept this change. 

Relative Advantage - things to consider:
  • Ensure you have sufficient evidence of the benefits to help persuade your audience
  • Ensure you present your evidence in a meaningful and relevant way
  • Consider your audience - are they data driven? Or would they be persuaded by a story of how this innovation has benefited you, or a colleague?
  • Will this innovation help the person, team or organisation achieve a strategic goal? How will it help? How can you put this forward to your audience?
  • Is the innovation relevant to the performance of the organisation?
  • Is it a good time to make a change?
  • How busy are people? Can they devote the time and effort to making the change?
  • Have you engaged with your stakeholders? (See card 2.3 Stakeholder Mapping)
  • How motivated are people for the change? If they’re not motivated, how can this be changed?
  • Be aware that ‘preventative’ innovations (where an innovation is designed to ‘lower the probability of some unwanted future event’) have a relatively slower rate of adoption, and innovations where there is a perceived advantage have a quicker rate of adoption


For potential adopters, it is important for them to be able to see how an innovation is compatible with a number of factors:

  • Existing values - both for an individual and an organisation. Can the innovation gel, for example with the organisation’s core values, or does it go against these. If so, this will negatively impact on the rate of adoption
  • The history and past experiences of adopters. Are they fatigued with change? Have innovations failed in the past? Why have they failed? Was it a lack of engagement from senior staff? Was it a lack of engagement with people on the ground? Was it just that innovation came at the wrong time?
  • Does the innovation meet the needs of adopters? Will the innovation improve performance?
Compatibility - things to consider:
  • Is the innovation relevant to the performance of the organisation? How do you know? Have you worked with stakeholders to understand their requirements? 
  • It’s also important for adopters to be able to see how the innovation can be adapted into their organisation or team
  • It is important not to be led into the ‘empty vessel fallacy’ which is the belief that the potential adopter is approaching the innovation with an open, or blank mind. The adopter has a number of receptors that may be triggered depending on how the knowledge is imparted. If your approach triggers these reactions, it can aid adoption of your innovation! 


Where an innovation can be peer-reviewed or role-modelled, then it is likely an innovation will have more chance of being adopted. Effective communication of an innovation to adopters can also have a positive impact on its adoption.

  • Consider how you capture and share the benefits
  • Is the local experience of using other innovations a positive one


The perception of how complex an innovation is to understand and use can effect its rate of adoption either negatively or positively.

  • How easy will it be to implement the innovation?
  • Can the innovation be broken down into more manageable parts to implement incrementally?
  • Ensure you have the infrastructure in place to support the change
  • Include the skills and resources needed so you’re ready to go
  • Equip trainers and coaches to pass on their skills and knowledge and any learning materials
  • How should the knowledge be passed on?
  • Factor in any disruption that may be caused by the implementation of the innovation. Have you liaised with Human Resources? With Training?


Trialability is a measure of how the innovation can be trialled in an environment. Innovations perceived to have high trialability are positively impacted in terms of their diffusion. The more an innovation is tried, the quicker its adoption will be.

  • The trialability is particularly important to early adopters. Use this to your advantage when dealing with this group
  • Some adopters will engage in trials for the benefit of those who will follow. It is possible to use this to gain feedback and further ideas as to how the innovation can be adapted and modified

Operational Attributes

There is strong indirect evidence that the following ‘Operational Attributes’ can help enable the adoption of your innovation: 

  • Task relevance - The innovation is relevant to the user’s work and can be seen as such by adopters
  • Task usefulness - The Innovation improves the task’s performance and can be proven as such
  • Feasibility - How feasible it is to adapt the innovation within the context of your team/ organisation
  • Implementation complexity - How easy it is to implement the innovation
  • Divisibility - The Innovation can be broken down into more manageable parts and adopted incrementally
  • Nature of the knowledge needed to use it - Knowledge required for the innovation to be utilised can be codified and standardised

Dissemination vs. Diffusion

It is often best to try to use a combination of approaches as both ‘dissemination’ & ‘diffusion’ of an innovation can have strengths and weaknesses. Social networks where peers communicate can be extremely effective at spreading peer influence whilst more hierarchical communications can be useful to cascade structured information or decisions.