Strategies that promote sustainability in quality improvement activities for chronic disease management in healthcare settings: a practical perspective

Alexander Evans, Seyi Soremekun, Brooklyn Stanley, Francis Appiagye, Amy Couper, Oliver Taylor, Thao Le, Rachel Pullen, Sophie Jones, Victoria Carter, Chris Price, Rupert Jones, Kerry Hancock, Sinthia Bosnic-Anticevich, Dermot Ryan, David Price

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Healthcare providers recognise the value of quality improvement (QI) activities that enhance the care received by service users. QI is particularly effective for the management of long- term conditions requiring linked care. However, starting and sustaining QI programmes in practice can be time-consuming and difficult and may produce inconclusive and/or inconsistent results. As a not-for-profit social enterprise, Optimum Patient Care (OPC) has been delivering effective and sustainable QI since 2005 in healthcare systems in several countries.

This paper provides a roadmap for the implementation of collaborative QI programmes in a range of settings across three countries. It summarises the barriers we have experienced in the QI cycle and solutions we have identified in our history of working with healthcare providers to deliver QI programmes in primary and secondary care. Key lessons include the strategic involvement of partners in the fields of medicine, health IT, data science and epidemiology, to harness, understand and act on the insights gained from patient and practice electronic health data (EHR) alongside crucial input from patients and practicing clinicians themselves.

QI aims resource-poor healthcare providers to increase the precision of identifying key patient groups requiring further follow-up – such as those at risk of worsening health outcomes using risk prediction tools. Parallel goals are to increase the proportion of patients receiving prompt and appropriate treatment and to increase patient engagement. We achieve this by providing customised software tools and disease management algorithms to our healthcare partners to allow for automation of aspects of QI that have traditionally involved a manual process. Sharing our experience of these methods helps to embed a sustainable programme of QI in many systems in varied settings.
Original languageEnglish
Pages (from-to)55-60
Number of pages6
JournalQuality in Primary Care
Issue number6
Publication statusPublished - 28 Nov 2020
Externally publishedYes

Bibliographical note

Copyright the Publisher 2020. Version archived for private and non-commercial use with the permission of the author/s and according to publisher conditions. For further rights please contact the publisher.


  • Quality Improvement
  • Chronic Disease
  • Patient Care
  • Patient Reported Outcomes
  • Electronic Medical Records
  • Sustainable Development


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