Imperial College London

Dr Laura Lennox

Faculty of MedicineSchool of Public Health

Improvement Science / Health Improvement Lead



+44 (0)20 3315 3392l.lennox Website




H4.28Chelsea and Westminster HospitalChelsea and Westminster Campus





Publication Type

15 results found

Okere NE, Lennox L, Urlings L, Ford N, Naniche D, Rinke de Wit TF, Hermans S, Gomez GBet al., 2021, Exploring sustainability in the era of differentiated HIV service delivery in Sub-Saharan Africa: a systematic review, JAIDS: Journal of Acquired Immune Deficiency Syndromes, Vol: 87, Pages: 1055-1071, ISSN: 1525-4135

Introduction: The World Health Organization recommends differentiated service delivery (DSD) to support resource-limited health systems in providing patient-centered HIV care. DSD offers alternative care models to clinic-based care for people living with HIV (PLHIV) who are stable on antiretroviral therapy (ART). Despite good patient-related outcomes, there is limited evidence of their sustainability. Our review evaluated the reporting of sustainability indicators of DSD interventions conducted in sub-Saharan Africa (SSA).Methods: We searched PubMed and EMBASE for studies conducted between 2000-2019 assessing DSD interventions targeting HIV-positive individuals who are established in ART in SSA. We evaluated them through a comprehensive sustainability framework of constructs categorized into six domains (intervention design, process, external environment, resources, organizational setting, and people involvement). We scored each construct 1, 2, or 3 for no, partial, or sufficient level of evidence, respectively. Interventions with a calculated sustainability score (overall and domain-specific) of >90% or domain-specific median score >2.7 were considered likely to be sustainable.Results: Overall scores ranged from 69% to 98%. Top scoring intervention types included adherence clubs (98%) and community ART groups (95%) which comprised more than half of interventions. The highest scoring domains were design (2.9) and organizational setting (2.8). The domains of resources (2.4) and people involvement (2.3) scored lowest revealing potential areas for improvement to support DSD sustainability.Conclusions: With the right investment in stakeholder involvement and domestic funding, DSD models generally show potential for sustainability. Our results could guide informed decisions on which DSD intervention is likely to be sustainable per setting and highlight areas that could motivate further research.PROSPERO Number: CRD42019120891

Journal article

Lennox L, Eftychiou L, Matthew D, Hanna J, Winn Tet al., 2021, What risks to sustainability are identified throughout care bundle implementation and how can they be addressed? A mixed methods case study, BMJ Open, Vol: 11, Pages: 1-10, ISSN: 2044-6055

Objectives Despite national guidance on how to identify and treat heart failure (HF), variation in HF care persists across UK hospitals. Care bundles have been proposed as a mechanism to deliver reliable optimal care for patients; however, specific challenges to sustain care bundles in practice have been highlighted. With few studies providing insight into how to design or implement care bundles to optimise sustainability, there is little direction for practitioners seeking to ensure long-term impact of their initiatives. This study explores the sustainability risks encountered throughout the implementation of a HF care bundle (HFCB) and describes how these challenges were addressed by a multidisciplinary team (MDT) to enhance sustainability over time.Design A longitudinal mixed method case study examined the HFCB improvement initiative from September 2015 to August 2018. A standardised sustainability tool was used to collect perceptions of sustainability risks and actions throughout the initiative. Observations, key-informant interviews and documentary analysis were conducted to gain in-depth understanding of how the MDT influenced sustainability through specific actions. A qualitative database was developed using a consolidated sustainability framework to conduct thematic analysis. Sustainability outcomes were explored 1-year post funding to ascertain progress towards sustainment.Results The MDT identified six sustainability challenges for the HFCB: infrastructure limitations, coding reliability, delivery consistency, organisational fit, resource stability and demonstrating impact. The MDT undertook multiple actions to enhance sustainability, including: (1) developing a business case to address infrastructure limitations; (2) incorporating staff feedback to increase bundle usability; (3) establishing consistent training; (4) increasing reliability of baseline data; (5) embedding monitoring and communication; and (6) integrating the bundle into current practices.Co

Journal article

Lennox L, Barber S, Stillman N, Spitters S, Ward E, Marvin V, Reed Jet al., 2021, Conceptualising interventions to enhance spread in complex systems: a multi-site comprehensive medication review case study, BMJ Quality & Safety, ISSN: 2044-5415

Background: Advancing the description and conceptualisation of interventions in complex systems is necessary to support spread, evaluation, attribution and reproducibility. Improvement teams can provide unique insight into how interventions are operationalised in practice. Capturing this ‘insider knowledge’ has the potential to enhance intervention descriptions.Objectives: This exploratory study investigated the spread of a comprehensive medication review (CMR) intervention to (1) describe the work required from the improvement team perspective, (2) identify what stays the same and what changes between the different sites and why, and (3) critically appraise the ‘hard core’ and ‘soft periphery’ (HC/SP) construct as a way of conceptualising interventions.Design: A prospective case study of a CMR initiative across five sites. Data collection included: observations, document analysis and semistructured interviews. A facilitated workshop triangulated findings and measured perceived effort invested in activities. A qualitative database was developed to conduct thematic analysis.Results: Sites identified 16 intervention components. All were considered essential due to their interdependency. The function of components remained the same, but adaptations were made between and within sites. Components were categorised under four ‘spheres of operation’: Accessibility of evidence base; Process of enactment; Dependent processes and Dependent sociocultural issues. Participants reported most effort was invested on ‘dependent sociocultural issues’. None of the existing HC/SP definitions fit well with the empirical data, with inconsistent classifications of components as HC or SP.Conclusions: This study advances the conceptualisation of interventions by explicitly considering how evidence-based practices are operationalised in complex systems. We propose a new conceptualisation of ‘interventions-in-systems’ whic

Journal article

Antonacci G, Lennox L, Barlow J, Evans L, Reed Jet al., 2021, Process mapping in healthcare: a systematic review, BMC Health Services Research, Vol: 21, ISSN: 1472-6963

IntroductionProcess mapping (PM) supports better understanding of complex systems and adaptation of improvement interventions to their local context. However, there is little research on its use in healthcare. This study (i) proposes a conceptual framework outlining quality criteria to guide the effective implementation, evaluation and reporting of PM in healthcare; (ii) reviews published PM cases to identify context and quality of PM application, and the reported benefits of using PM in healthcare.MethodsWe developed the conceptual framework by reviewing methodological guidance on PM and empirical literature on its use in healthcare improvement interventions. We conducted a systematic review of empirical literature using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Inclusion criteria were: full text empirical study; describing the process through which PM has been applied in a healthcare setting; published in English. Databases searched are: Medline, Embase, HMIC–Health Management Information Consortium, CINAHL-Cumulative Index to Nursing and Allied Health Literature, Scopus. Two independent reviewers extracted and analysed data. Each manuscript underwent line by line coding. The conceptual framework was used to evaluate adherence of empirical studies to the identified PM quality criteria. Context in which PM is used and benefits of using PM were coded using an inductive thematic analysis approach.ResultsThe framework outlines quality criteria for each PM phase: (i) preparation, planning and process identification, (ii) data and information gathering, (iii) process map generation, (iv) analysis, (v) taking it forward.PM is used in a variety of settings and approaches to improvement. None of the reviewed studies (N = 105) met all ten quality criteria; 7% were compliant with 8/10 or 9/10 criteria. 45% of studies reported that PM was generated through multi-professional meetings and 15% reported patient i

Journal article

Lennox L, Maher L, Linwood-Amor A, Reed Jet al., 2020, Making change last? Exploring the value of sustainability approaches in healthcare: a scoping review, Health Research Policy and Systems, Vol: 18, Pages: 1-24, ISSN: 1478-4505

Background: Numerous models, tools and frameworks have been produced to improve the sustainability of evidence-based interventions. Due to the vast number available,choosing the most appropriate one is increasingly difficult for researchers and practitioners.To understand the value of such approaches,evidence warranting their use is needed.However, there is limited understanding of how sustainability approaches have been used and how they have impacted research or practice.This review aims to consolidate evidence on the application and impact of sustainability approaches in healthcare settings.Methods: A systematic scoping review was designed to search for peer-reviewed publications detailing the use of sustainability approaches in practice. A5-stage framework for scoping reviews directed the search strategy, and quality assessment was performed using the Mixed Method Appraisal Tool (MMAT).Searches were performed through electronic citation tracking and snowballing of references. Articles were obtained through Web of Science, PubMed and Google Scholar. Six outcome variables for sustainability were explored to ascertain impact of approaches. Results: This review includes 68 articles demonstrating the application of sustainability approaches in practice. Results show an increase in the use of sustainability approaches in peer-reviewed studies.Approaches have been applied across arange of healthcare settings including primary, secondary, tertiary, and community healthcare.Approaches are used for 5 main purposes:analysis, evaluation, guidance, assessment and planning.Results outline benefits (e.g. improved conceptualisation of sustainability constructs and improved ability to interpret sustainability data) and challenges (e.g. issues with approach constructs, and difficulty in application)associated with using a sustainability approach in practice. Few articles (14/68) reported the sustainabilit

Journal article

McNicholas C, Lennox L, Woodcock T, Bell D, Reed Jet al., 2019, Evolving quality improvement support strategies to improve Plan-Do-Study-Act cycle fidelity: a retrospective mixed methods study, BMJ Quality and Safety, Vol: 28, Pages: 356-365, ISSN: 2044-5415

BackgroundThough widely recommended as an effective approach to quality improvement (QI), the Plan-Do-Study-Act (PDSA) cycle method can be challenging to use and low fidelity of published accounts of the method has been reported. There is little evidence of the fidelity of PDSA cycles used by frontline teams, nor how to support and improve the method’s use. Data collected from 39 frontline improvement teams provided an opportunity to retrospectively investigate PDSA cycle use and how strategies were modified to help improve this overtime.MethodsThe fidelity of 421 PDSA cycles was reviewed using a pre-defined framework, and statistical analysis examined whether fidelity changed over three annual rounds of projects. The experiences of project teams and QI support staff were investigated through document analysis and interviews.ResultsAlthough modest, statistically significant improvements in PDSA fidelity occurred, however, overall fidelity remained low. Challenges to achieving greater fidelity reflected problems with understanding the PDSA methodology, intention to use, and application in practice. These problems were exacerbated by assumptions made in the original QI training and support strategies: that PDSA was easy to understand; that teams would be motivated and willing to use PDSA; and that PDSA is easy to apply. QI strategies that evolved to overcome these challenges included project selection process, redesign of training, increased hands-on support and investment in training QI support staff.ConclusionsThis study identifies support strategies that may help improve PDSA cycle fidelity. It provides an approach to assess minimum standards of fidelity which can be replicated elsewhere. The findings suggest achieving high PDSA fidelity requires a gradual and negotiated process to explore different perspectives and encourage new ways of working.

Journal article

Lennox L, Reed J, 2018, Assessing Sustainability Throughout Improvement Initiatives: Exploring the Application and Impact of a Prospective Sustainability Tool Across 3 QI Programmes, Publisher: OXFORD UNIV PRESS, Pages: 32-32, ISSN: 1353-4505

Conference paper

Issen L, Woodcock T, McNicholas C, Lennox L, Reed JEet al., 2018, Criteria for evaluating programme theory diagrams in quality improvement initiatives: a structured method for appraisal, International Journal for Quality in Health Care, Vol: 30, Pages: 508-513, ISSN: 1353-4505

Background: Despite criticisms that many Quality Improvement (QI) initiatives fail due to incomplete programme theory, there is no defined way to evaluate how programme theory has been articulated. The objective of this research was to develop, and assess the usability and reliability of, scoring criteria to evaluate programme theory diagrams. Methods: Criteria development was informed by published literature and QI experts. Inter-rater reliability was tested between two evaluators. 63 programme theory diagrams (42 driver diagrams and 21 action effect diagrams) were reviewed to establish whether the criteria could support comparative analysis of different approaches to constructing diagrams.Results: Components of the scoring criteria include: assessment of overall aim, logical overview, clarity of components, cause/effect relationships, evidence, and measurement. Independent reviewers had 78% inter-rater reliability. Scoring enabled direct comparison of different approaches to developing programme theory; Action-Effect diagrams were found to have had a statistically significant but moderate improvement in programme theory quality over Driver Diagrams; no significant differences were observed based on the setting in which Driver Diagrams were developed.Conclusions: The scoring criteria summarise the necessary components of programme theory that are thought to contribute to successful QI projects. The viability of the scoring criteria for practical application was demonstrated. Future uses include assessment of individual programme theory diagrams, and comparison of different approaches (e.g. methodological, teaching or other QI support) to produce programme theory. The criteria can be used as a tool to guide the production of better programme theory diagrams, and also highlights where additional support for QI teams could be needed.

Journal article

Antonacci G, Reed JE, Lennox L, Barlow Jet al., 2018, The use of process mapping in healthcare quality improvement projects, Health Services Management Research, Vol: 31, Pages: 74-84, ISSN: 0951-4848

Introduction: Process Mapping (PM), provides insight into systems and processes in which improvement interventions are introduced and is seen as useful in healthcare Quality Improvement (QI) projects. There is little empirical evidence on the use of PM in healthcare practice. This study advances understanding of the benefits and success factors of PM within QI projects. Methods: Eight QI projects were purposively selected from different healthcare settings within the UK’s National Health Service. Data was gathered from multiple data-sources, including interviews exploring participants’ experience of using PM in their projects and perceptions of benefits and challenges related to its use. These were analysed using inductive analysis. Results: Eight key benefits related to PM use were reported by participants (gathering a shared understanding of the reality; identifying improvement opportunities; engaging stakeholders in the project; defining project's objectives; monitoring project progress; learning; increased empathy; simplicity of the method) and five factors related to successful PM exercises (simple and appropriate visual representation, information gathered from multiple stakeholders, facilitator’s experience and soft skills, basic training, iterative use of PM throughout the project). Conclusions: Findings highlight benefits and versatility of PM and provide practical suggestions to improve its use in practice.

Journal article

Lennox L, Reed J, Maher L, 2018, Navigating the Sustainability Landscape: A Systematic Review of Sustainability Approaches in Healthcare, Implementation Science, Vol: 13, ISSN: 1748-5908

BackgroundImprovement initiatives offer a valuable mechanism for delivering and testing innovations in healthcare settings. Many of these initiatives deliver meaningful and necessary changes to patient care and outcomes. However, many improvement initiatives fail to sustain to a point where their full benefits can be realised. This has led many researchers and healthcare practitioners to develop frameworks, models and tools to support and monitor sustainability. This work aimed to identify what approaches are available to assess and influence sustainability in healthcare and to describe the different perspectives, applications and constructs within these approaches to guide their future use.MethodsA systematic review was carried out following PRISMA guidelines to identify publications that reported approaches to support or influence sustainability in healthcare. Eligibility criteria were defined through an iterative process in which two reviewers independently assessed 20% of articles to test the objectivity of the selection criteria. Data were extracted from the identified articles, and a template analysis was undertaken to identify and assess the sustainability constructs within each reported approach.ResultsThe search strategy identified 1748 publications with 227 articles retrieved in full text for full documentary analysis. In total, 62 publications identifying a sustainability approach were included in this review (32 frameworks, 16 models, 8 tools, 4 strategies, 1 checklist and 1 process). Constructs across approaches were compared and 40 individual constructs for sustainability were found. Comparison across approaches demonstrated consistent constructs were seen regardless of proposed interventions, setting or level of application with 6 constructs included in 75% of the approaches. Although similarities were found, no approaches contained the same combination of the constructs nor did any single approach capture all identified constructs. From these results

Journal article

Reed JE, Stillman N, Lennox L, Barber S, Woodcock Tet al., 2017, Applying the concept of 'hard core' and 'soft periphery' of interventions to share learning from quality improvement efforts, ISQua 34th International Conference, Publisher: Oxford University Press (OUP), Pages: 47-48, ISSN: 1353-4505

Conference paper

Lennox L, Doyle C, Reed J, Bell Det al., 2017, What makes a sustainability tool valuable, practical, and useful in real world healthcare practice? A mixed methods study on the development of the Long Term Success Tool in Northwest London, BMJ Open, Vol: 7, ISSN: 2044-6055

Objectives Although improvement initiatives show benefits to patient care, they often fail to sustain. Models and frameworks exist to address this challenge, but issues with design, clarity and usability have been barriers to use in healthcare settings. This work aimed to collaborate with stakeholders to develop a sustainability tool relevant to people in healthcare settings and practical for use in improvement initiatives.Design Tool development was conducted in six stages. A scoping literature review, group discussions and a stakeholder engagement event explored literature findings and their resonance with stakeholders in healthcare settings. Interviews, small-scale trialling and piloting explored the design and tested the practicality of the tool in improvement initiatives.Setting National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Northwest London (CLAHRC NWL).Participants CLAHRC NWL improvement initiative teams and staff.Results The iterative design process and engagement of stakeholders informed the articulation of the sustainability factors identified from the literature and guided tool design for practical application. Key iterations of factors and tool design are discussed. From the development process, the Long Term Success Tool (LTST) has been designed. The Tool supports those implementing improvements to reflect on 12 sustainability factors to identify risks to increase chances of achieving sustainability over time. The Tool is designed to provide a platform for improvement teams to share their own views on sustainability as well as learn about the different views held within their team to prompt discussion and actions.Conclusion The development of the LTST has reinforced the importance of working with stakeholders to design strategies which respond to their needs and preferences and can practically be implemented in real-world settings. Further research is required to study the use and effectivenes

Journal article

Lennox L, Green S, Howe C, Musgrave H, Bell D, Elkin Set al., 2014, Identifying the challenges and facilitators of implementing a COPD care bundle., BMJ Open Respir Res, Vol: 1, ISSN: 2052-4439

BACKGROUND: Care bundles have been shown to improve outcomes, reduce hospital readmissions and reduce length of hospital stay; therefore increasing the speed of uptake and delivery of care bundles should be a priority in order to deliver more timely improvements and consistent high-quality care. Previous studies have detailed the difficulties of obtaining full compliance to bundle elements but few have described the underlying reasons for this. In order to improve future implementation this paper investigates the challenges encountered by clinical teams implementing a chronic obstructive pulmonary disease (COPD) care bundle and describes actions taken to overcome these challenges. METHODS: An initial retrospective documentary analysis of data from seven clinical implementation teams was undertaken to review the challenges faced by the clinical teams. Three focus groups with healthcare professionals and managers explored solutions to these challenges developed during the project. RESULTS: Documentary analysis identified 28 challenges which directly impacted implementation of the COPD care bundle within five themes; staffing, infrastructure, process, use of improvement methodology and patient and public involvement. Focus groups revealed that the five most significant challenges for all groups were: staff too busy, staff shortages, lack of staff engagement, added workload of the bundle and patient coding issues. The participants shared facilitating factors used to overcome issues including: shifting perceptions to improve engagement, further education sessions to increase staff participation and gaining buy-in from managers through payment frameworks. CONCLUSIONS: Maximising the impact of a care bundle relies on its successful and timely implementation. Teams implementing the COPD care bundle encountered challenges that were common to all teams and sites. Understanding and learning from the challenges faced by previous endeavours and identifying the facilitators to ov

Journal article

Doyle C, Lennox L, Bell D, 2013, A systematic review of evidence on the links between patient experience and clinical safety and effectiveness, BMJ OPEN, Vol: 3, ISSN: 2044-6055

Journal article

Musgrave H, Howe C, Green S, Lennox L, Elkin S, Wilson S, Mann B, Lai Det al., 2012, IMPLEMENTING A COPD DISCHARGE CARE BUNDLE: THE CHALLENGES AND FACILITATORS REVEALED, Winter Meeting of the British-Thoracic-Society 2012, Publisher: BMJ PUBLISHING GROUP, Pages: A190-A190, ISSN: 0040-6376

Conference paper

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