title: Understanding quality improvement at scale in general practice: a qualitative evaluation of a COPD improvement programme.
abstract: BACKGROUND
  A growing body of knowledge exists to guide efforts to improve the organisation and delivery of health care, most of which is based on work carried out in hospitals. It is uncertain how transferable this knowledge is to primary care.
  
  
  OBJECTIVE
  To understand the enablers and constraints to implementing a large-scale quality improvement programme in general practice, designed to improve care for people with chronic obstructive pulmonary disease.
  
  
  METHODS
  A qualitative study of 189 general practices in a socioeconomically and ethnically-mixed, urban area in east London, UK.
  
  
  METHODS
  Twelve semi-structured interviews were conducted with people leading the programme and 17 in-depth interviews with those participating in it. Participants were local health system leaders, clinicians, and managers. A theoretical framework derived from evidence-based guidance for improvement programmes was used to interpret the findings. A complex improvement intervention took place with social and technical elements including training and mentorship, guidance, analytical tools, and data feedback.
  
  
  RESULTS
  Practice staff wanted to participate in and learn from well-designed collaborative improvement projects. Nevertheless, there were limitations in the capacities and capabilities of the workforce to undertake systematic improvement, significant problems with access to and the quality of data, and tensions between the narrative-based generalist orientation of many primary care clinicians and the quantitative single-disease orientation that has characterised much of the quality improvement movement to date.
  
  
  CONCLUSIONS
  Improvement guidance derived largely from hospital-based studies is, for the most part, applicable to improvement efforts in primary care settings, although large-scale change in general practice presents some particular challenges. These need to be better understood and addressed if improvement initiatives are to be effective.
authors.affiliation: University College London, London.
authors.forename: Martin
authors.initials: M
authors.lastname: Marshall
authors.affiliation: UCLPartners, London.
authors.forename: James
authors.initials: J
authors.lastname: Mountford
authors.affiliation: Patients Know Best, Cambridge.
authors.forename: Kirsten
authors.initials: K
authors.lastname: Gamet
authors.affiliation: NHS Redbridge Clinical Commissioning Group, Ilford.
authors.forename: Gulsen
authors.initials: G
authors.lastname: Gungor
authors.affiliation: Barking and Dagenham, Redbridge and Havering Clinical Commissioning Groups, Romford.
authors.forename: Conor
authors.initials: C
authors.lastname: Burke
authors.affiliation: Peter MacCallum Cancer Centre, Melbourne, Australia.
authors.forename: Robyn
authors.initials: R
authors.lastname: Hudson
authors.affiliation: University College London, London.
authors.forename: Steve
authors.initials: S
authors.lastname: Morris
authors.affiliation: University College London, London.
authors.forename: Nishma
authors.initials: N
authors.lastname: Patel
authors.affiliation: UCLPartners, London.
authors.forename: Phil
authors.initials: P
authors.lastname: Koczan
authors.affiliation: Barking and Dagenham, Redbridge and Havering Clinical Commissioning Groups, Romford.
authors.forename: Rob
authors.initials: R
authors.lastname: Meaker
authors.affiliation: UCLPartners, London.
authors.forename: Cyril
authors.initials: C
authors.lastname: Chantler
authors.affiliation: UCLPartners and consultant respiratory physician, Barts Health NHS Trust, London.
authors.forename: Christopher Michael
authors.initials: CM
authors.lastname: Roberts
mesh_terms: D058006:General Practice / Q000458:organization & administration*; D006801:Humans; D008131:London / Q000453:epidemiology; D011320:Primary Health Care / Q000458:organization & administration*; D015397:Program Evaluation; D029424:Pulmonary Disease, Chronic Obstructive / Q000628:therapy*; D036301:Qualitative Research; D058996:Quality Improvement / Q000458:organization & administration*
keywords: chronic obstructive pulmonary disease; general practice; large-scale improvement