Improvement, Innovation and Effectiveness at DCHS

Our Improvement, Innovation and Effectiveness team support colleagues to help keep Derbyshire Community Health Services NHS FT an 'Outstanding' place to work and receive care.

What we do:

  • Support all staff & teams (clinical & non-clinical) in DCHS with any improvement, innovation & effectiveness projects
  • Enhance the development of our DCHS Quality Improvement culture
  • Offer guidance to help to grow ideas
  • Manage & offer training for AMaT (Audit Management & Tracking) system

 How we can help:

  • Help staff develop their ideas
  • Assist with data collection & inputting
  • Assist with analysis of project results
  • Support in the implementation of mandatory audits to evidence compliance
  • Advise on the development of surveys and questionnaires
  • Offer expertise to enable you to get meaning from your results
  • Support teams to identify improvements that lead to real benefits for patients and staff

Quality Improvement & Innovation

Quality improvement is about the people closest to the problem being able to think differently to explore creative ideas.

By giving you the permission, time, skills, network and resources, you need to pause, think, test out and make your ideas happen. 

8 QI Principles

  • Staff Lead
  • Permission
  • The Heart of What We Do
  • Easy
  • Share
  • No Red Tape
  • Drop The Jargon
  • Safe To Fail

Clinical Effectiveness is defined as:

“The application of the best knowledge, derived from research, clinical experience and patient preferences to achieve optimum outcomes of care for patients.” - Department of Health, 1996

When carried out in accordance with best practice, clinical effectiveness, improves the quality of care and patient outcomes. It provides assurance of compliance with clinical standards and identifies and minimises risk, waste and inefficiencies.

IIE Team stood behind sign photo
Name Role Email
Hayley Grice Improvement, Innovation & Effectiveness Co-Lead
Amanda Kerry Improvement, Innovation & Effectiveness Co-Lead
Vicki Barsby Improvement, Innovation & Effectiveness Facilitator
Neesha Rawal Improvement, Innovation & Effectiveness Facilitator
Chelsea Madin Improvement, Innovation & Effectiveness Facilitator
Paul Lund Data Analyst
Cassie Dye Data Analyst
Lauren Gascoyne Communication, Engagement & Project Officer
Sharon Sandhu Improvement, Innovation & Effectiveness Assistant
Helen Barratt Improvement, Innovation & Effectiveness Assistant
Annie Culley Improvement, Innovation & Effectiveness Assistant

Planning your own project? If you are planning your own project, whether it is a clinical audit, a service evaluation, or a staff experience survey (to name a few!), you should register your project on AMaT.

  • Click on the AMaT icon on your desktop or go to If you're not already registered as a user click on 'Register Now' to enter your details; remember to use your NHSMail email address. You will receive an email from AMaT prompting you to set up a password - please follow the instructions in the email.
  • Once you are registered as a user, login to AMaT and go to the "Clinical Audit & Improvement" module, followed by the "Register an audit" tab. Follow the instructions on the page and behind the ? icons to complete the registration form and submit it to the IIE team.
  • Once your project has been approved you will be able to manage your project through each stage using AMaT to guide you. For more information, please contact the team!

Not sure what type of project it is? Use this tool to help you find out!

Clinical Audit - Will your project add value?  Many people struggle to determine if a potential clinical audit project is worth undertaking. The Clinical Audit Support Centre have developed this tool to evaluate a project proposal - have a go at putting your idea through this tool! CASC Ready Reckoner Tool 

8 Principles of QI - V2.jpg

8 Principles underpinning Quality Improvement @DCHS Key themes


  • Everyone has permission to feel safe.
  • Try an idea.
  • Try something new.

Drop the jargon

  • Clear, simple language.
  • Say what it is.

Safe to fail

  • Grow a healthy attitude towards failure.
  • Learn from failure and share.

The heart of what we do

  • Make it integral to our work.
  • The way we do things round here.

Staff lead

  • Staff take forward their ideas.
  • Be creative & curious about how they do their work.


Internally, locally & nationally.

  • Share ideas.
  • Develop networks.

No red tape

We need to:

  • Remove barriers.
  • Have freedom to take things forward.
  • Do what is right.
  • Champion supportive governance.


People want to know:

  • Where to start?
  • Who can help?
  • What's the process?

It shouldn't be scary!

Services often wish to use surveys (questionnaires) to seek the views of patients, service users and carers or families.

If you wish to conduct a questionnaire/survey of either staff or patients/service users, please complete the Questionnaire Panel Template and send it to the Improvement, Innovation & Effectiveness team.

All proposed surveys/questionnaires must be submitted to the Questionnaire Panel for approval prior to use.

At DCHS we value evidence based practice and clinical effectiveness. 

In order to support you to continue to develop your knowledge and expertise you have free access to an OpenAthens account.  This will support you to gain access to electronic resources such as e-journals , databases and point of care tools. OpenAthens is a management system which authenticates access to these resources.

Please contact the Derbyshire NHS Library service to find out more or for help registering, logging in or navigating around the resources available through OpenAthens.  

E: T: 01246 513 035 W:

Got more ideas? Want to share? Join our QI Community!

Email to join now!

Click HERE to find out more about the QI Community.

All of the QI projects that have been shared with us are in our DCHS QI Work Book HERE

Have you completed some QI work that you want to showcase in the flipbook? Complete one of the QI templates below and email it to

Donwload and complete a template with your QI work and send it to us at so that we can share and celebrate your work with you!

I'd like more information on AMaT .....

Audit Management and Tracking (AMaT) is a software that helps us manage our clinical audit and service improvement projects.

The Improvement, Innovation and Effectiveness team (IIET) has overall responsibility for AMaT and will advise and support you to use AMaT wherever your audit journey may take you.

All DCHS staff can register to use AMaT. Click on the AMaT icon on your desktop or go to

If you're not already registered as a user you can click on 'Register Now'; remember to use your NHSMail email address for this. You will receive an email from AMaT prompting you to set up a password - please follow the instructions in the email.


There are lots of video tutorials on how to use AMaT in the AMaT Academy.

To access these, please log into AMaT and then click on the 'AMaT Academy' tab next to home.

If you need further support using AMaT, please contact us -

We manage our NICE Guidance through the AMaT platform to ensure we meet the relevant NICE standards.

If you have a responsibility for NICE in your area you should have received an email informing you that you have been added as the guidance lead for specific NICE guidance that has been published since January 2020. You will receive a notification from AMaT once you are required to complete a review to record your speciality and/or DCHS’ compliance with this guidance.

You can use the following handy guides to help you get to grips with managing NICE Guidance on AMaT:

We are gradually rolling out clinical effectiveness projects including clinical audits using AMaT. Here are some of the projects (including instructions) and frequently asked questions.

These two new audits are helping the Infection Prevention and Control team gather evidence and assurance that best practice is being implemented across the organisation. Every clinical team is required to complete one audit cycle each quarter. 

The DCHS hand hygiene audit went live on 01/08/20. Every clinical team is required to complete one audit cycle each quarter. The audit cycle must include the observation and assessment of as many different staff members as possible, in a variety of roles (including non-clinical e.g. porters and housekeepers). The number of observations each team must complete for one audit cycle will vary according to the size of the team as follows:

  • For teams that have fewer than 5 members of staff please complete 5 observations to complete one audit cycle.
  • For teams that have 6 - 10 members of staff, please complete 10 observations to complete one audit cycle.
  • For teams that have 11 - 20 members of staff, please complete 20 observations to complete one audit cycle.
  • For teams that have 21 or more members of staff, please complete 30 observations to complete one audit cycle.

Inpatients End of Life Audit

A revised version of the End of Life audit for Inpatient Rehab wards only went live on AMaT on 01/07/20. The audit should be completed for any patient who dies during admission to a DCHS Rehabilitation Ward. The audit can be found in Clinical Audit & Improvement on AMaT.

Pilot projects

Before an audit goes 'live' you may be asked to help pilot the audit tool using AMaT. We currently have a number of templates we are piloting with teams for the new Effective Documentation Review. If your team needs to be involved in a pilot we will contact you and arrange training and support as required. 

I'd like more information on current audits ...

All of our current audits are now being managed on AMaT (Audit Management and Tracking). 

Mandatory clinical audits such as the Hand Hygiene audit or Effective Documentation Review can be found in the "Ward, Area and Service Audits" module.

Service level projects and national audits can be found in the "Clinical Audit & Improvement" module. 

Our most recent Learn@Lunch session have now been recorded for you to watch as you please! 

Use the fast forward button to browse through the 4 sessions we currently have avaliable.

I'm interested in finding out more about clinical research at DCHS ...

NHS trusts are actively encouraged by Government to get involved with clinical research.

The National Institute for Health Research (NIHR) is the nation's largest funder of health and care research and provides the people, facilities and technology that enables research to thrive. NIHR works in partnership with NHS trusts, universities, local government, other research funders, patients and the public, to deliver and enable world-class research that transforms people's lives, promotes economic growth and advances science.

Involving our patients in research

  • Be Part of Research - information for our patients and their families or carers about clinical trials which might be beneficial to them.  This site provides accessible information on studies that are running at the moment but also explains what it’s like to be in a trial.
  • I want to help with research - this page contains information on involvement in research, what it might look like and also contains links to useful resources and places to find involvement opportunities.  

Local research
DCHS is actively involved in research where appropriate and possible. We publish information about our research on the NIHR platform. This information has been published on a quarterly basis since January 2015. The criteria for submission is that the trial was approved within the previous twelve months and fell into one of the following criteria

  1. A clinical trial of an investigational medical product.
  2. Clinical investigation or other study of a medical device.
  3. Combined trial of an investigational medicinal product or an investigational medical device.
  4. Other clinical trial to study a novel intervention or RCT to compare interventions in clinical practice.

The information to be supplied is known as ‘Performance in Initiation’ or PII. In addition performance information is supplied about the ‘Performance in Delivering’ industry trial or PID and the number of participants recruited by DCHS.