Embedding quality improvement in pharmacy practice: a departmental strategy at University Hospitals of Derby and Burton 

Nationally, there is a growing emphasis on embedding quality improvement (QI) and research as core components of pharmacy practice. Initiatives such as the National Institute for Health and Care Research (NIHR) support for pharmacy research professionals and the development of the Royal Pharmaceutical Society (RPS) National Pharmacy Research Strategy reflect a wider professional ambition to increase capacity and make improvement work embedded into routine practice, visible and impactful^​1,2​.

At University Hospitals of Derby and Burton, the pharmacy department identified a gap in how QI activity was being monitored and supported. Although pharmacists and pharmacy technicians were undertaking valuable improvement work that led to improvements in efficiency, cost saving and patient benefits, there was no system in place to capture, track, or celebrate these efforts at department level. This limited the ability to demonstrate collective impact, align improvement work with strategic goals, or support staff development through recognition and learning. 

To better understand the barriers to QI engagement and how to address them, two facilitated focus groups involving pharmacists and pharmacy technicians from across the department were conducted. Four pharmacists and two pharmacy technicians took part in both focus group sessions. In the first session, participants discussed their experiences of QI, explored what was limiting engagement and mapped contributing factors using a fishbone diagram. Each participant was then asked to select three to five key causes that they believed had the greatest impact. These responses were reviewed and analysed thematically, the most frequently cited barriers became the focus of the second session. This follow-up focus group centred on generating practical, achievable actions to address these priority areas. The process was intentionally collaborative, ensuring that the strategy developed was grounded in the realities of clinical practice and informed by those delivering care on the ground.

Three barriers emerged from the first focus group: a lack of system, a lack of time and a lack of incentive. Participants described not having a clear or consistent way to log, share or receive support for QI work, as well as being unaware of training opportunities, lack of supervision and mentorship, or visibility of ongoing projects. Time was also a major challenge, with participants noting that competing clinical responsibilities often left little space to take on improvement work. Finally, there was a sense that QI was not routinely expected or recognised — with little mention in job plans or appraisals, and no formal mechanism to acknowledge or reward contributions. Together, these barriers made QI feel optional and unsustainable, despite general willingness to contribute. 

Building on these findings, the second focus group generated a practical action plan to tackle each barrier and support QI engagement across the department, as discussed below.

Lack of system

To address the lack of a clear system for engaging with and recording QI work, participants suggested a range of practical interventions. These included developing a shared list of active or proposed QI projects, with clear descriptions of roles, time commitments and progress to date. This would allow staff to express interest, join ongoing projects, and avoid duplication. There was strong support for appointing QI champions across clinical areas to act as points of contact and mentors. Participants also recommended integrating QI training into induction and pairing it with audit teaching to illustrate the continuity of turning an audit into a QI project. The department has since begun working with the trust’s QI and education teams to explore training access and support the development of an internal tracking system. These changes aim to make QI more accessible, visible and collaborative within the multidisciplinary team.

Lack of time

Time constraints were widely acknowledged as a major barrier to engaging with QI, particularly in fast-paced clinical areas. Rather than suggesting formal protected time, participants proposed more flexible and realistic approaches. One idea was to introduce a buddy system, allowing individuals to contribute to specific tasks within a project rather than leading entire initiatives. This approach encouraged shared responsibility and opened opportunities across specialties and roles across pharmacy. To support this, the project list was designed to include details about time commitment, current stage, and specific tasks required — helping staff assess how and where they could contribute. Managers were also encouraged to have open conversations about QI interest and capacity, and to consider incorporating QI into non-clinical time or job planning where possible. These efforts aimed to normalise QI as something that can be built into existing roles in a manageable and meaningful way.

Lack of incentive

Many participants felt that, while QI was encouraged in principle, there were few tangible incentives to engage. It was not routinely discussed during appraisals, featured minimally in job descriptions and had limited visibility within the department. To address this, participants proposed several initiatives to embed QI into the department’s culture and recognition structures. These included showcasing QI projects at clinical updates, establishing a departmental QI board to display posters or summaries and nominating pharmacy staff for trust-wide or local awards. There was also strong interest in aligning QI participation with career progression, such as supporting portfolio development (e.g. for RPS credentialing) and highlighting QI contributions during internal interviews. By making QI more visible, valued and linked to development, these changes aimed to shift it from being seen as an optional extra to an integral and rewarding part of professional practice.

Conclusion and next steps

This project has laid the foundation for a more sustainable and inclusive QI culture within the pharmacy department. By involving staff in identifying barriers and co-producing solutions, the approach ensured that the actions taken were realistic, meaningful and grounded in everyday practice. The strategy developed not only supports staff to engage in QI but also allows the department to monitor and showcase its collective impact — reinforcing QI as a core part of service delivery and professional development. Crucially, this work aligns with the national momentum around embedding research and improvement into pharmacy. As departments across the NHS seek to build QI capacity, this model offers a practical, scalable blueprint for translating good intentions into lasting change.

The focus is now on formalising and embedding the agreed actions through a departmental standard operating procedure (SOP). This SOP will reflect the co-produced strategy, outlining clear responsibilities, governance processes and tools to support and monitor QI engagement across the team. Implementation of the SOP will be accompanied by continued staff engagement, nomination of QI champions, and alignment with professional development initiatives to ensure long-term sustainability and responsiveness to evolving needs.

Dayana El Nsouli, advanced prescribing pharmacist in acute medicine at Pharmacy Department, Royal Derby Hospital, University Hospitals of Derby and Burton and NIHR doctoral clinical academic fellow at School of Pharmacy, University of Nottingham

Dominic Moore, deputy chief pharmacist for clinical services at Pharmacy Department, Royal Derby Hospital, University Hospitals of Derby and Burton