Quality improvement programme at East London NHS Foundation Trust

1. Quality Improvement
Programme Launch
Event

2. Our quality
improvement programme
Why?

3. The strategic case for change

4. Changing the culture through quality improvement
Involvement of service users and carers through every step of the journey

5. The culture we want to nurture

7. Our quality
improvement programme
How?

8. Two stretch aims
Reduce harm by 30% every year
Right care, right place, right time
Quality improvement strategy
Long-term
mission and
stretch aims
The mission
To provide the
highest quality
mental health
and community
care in England
by 2020

9. Long-term
mission and
stretch aims

10. Long-term
mission and
stretch aims

11. Make-up
Functions
Programme director
(Medical Director)
Coordinate the programme
Improvement expertise to
support frontline work
Learning and sharing –
internally & externally
Deputy programme director
(Associate Medical Director)
Programme manager
Continuous improvement
and measurement lead
2 x rotating clinical
secondments
Programme support
Long-term
mission and
stretch aims
Central QI
team

12. Traditional
engagement
• Launch event & roadshows
• Through formal directorate structures
• Local champions
Grassroots
movement /
campaign
• Q30 (staff) and Q12 (service user) groups to shape our comms
• Microsite – as a central resource
• Branding & identity
Long-term
mission and
stretch aims
Central QI
team
Building the
will

13. Financial measures
Clinical audit
Real-time patient
experience feedback
Learning from
complaints
Stopping activity
of lower value
Influencing contracts
and CQUINs
Datix improvements
Reviewing our
inductions
Integrated quality data
available to all
Embedding a
structure for
listening
Outcome measures
Long-term
mission and
stretch aims
Central QI
team
Building the
will
Aligning our
systems

14. Successful
improvement
requires a specific
set of skills
Appointment of an
external partner to
build skills within our
workforce at scale &
pace
Most of us have
not been trained
in improvement
Improvement at
scale needs a
consistent
approach
Long-term
mission and
stretch aims
Central QI
team
Building the
will
Aligning our
systems
Building
improvement
skills

15. Quality Improvement in
Action

16. Anticipating and Reducing Violence
at the Tower Hamlets Centre for
Mental Health

17. Violence: The Background
• National Problem: NHS reported 59,744
violent incidents during 2012
• Incidents 3 times more likely to occur in
mental health services
• 3710 reported incidents of violence and
aggression in ELFT in 2013

18. Our Work: The context
• Serious incident on Roman Ward, April 2010,
highlighted huge problems in care at THCfMH.
• Since then significant improvements in many areas,
including leadership, environment, staffing, MDT
working and culture.
• Actual rates of violence in 2010, probably significantly
higher than reported on Datix (estimated >50%)
• Staff Feedback surveys indicate that violence is a
major issue for our staff.

19. The Plan
May 2012 Reducing Violence Strategy
The Tower Hamlets DMT made a decision to really focus on reducing violence on our
wards.
Strategy had various action points including:
Smoking balconies
Smoother pathways to PICU’s
Bed Occupancy
Regular team away days
Improved Police Liaison
Commissioning Psychology to do analysis of one months incidents
More activities Out of Hours
Safety crosses
Introduction of the Broset Risk Assessment on Globe Ward
Most of all we were trying to change to a culture which sees violence
as the unacceptable exception rather that the norm.

21. Team Reaction
1. The simplicity of the BVC made it very attractive.
2. Teething problems, especially around the idea that in a PDSA
cycle the change needs to be done reliably and consistently (this
was hard to embed in practice initially)
3. The importance of then ensuring that a BVC score > 2 triggered a
team discussion (mid-flight briefing / ‘huddle’)
4. The importance of MDT involvement / flattening the hierarchy

22. The Results

25. Reducing Harm from
Pressure Ulcers

26. Pressure Ulcers
• Anyone can get a
pressure ulcer
• Pressure ulcers are in
most cases preventable
• Key quality indicator of
care
• National CQUIN target

27. Extent of the Problem
• 4%-10% incidence depending on speciality
• Immobile and elderly most affected
• ELFT: Total of 285 reported in 2012/2013
of which 87 were acquired in our care (N=
24 grade 3/4)

28. Patient Impact: John
•
•
•
•
•
•
•
3
72 year old gentleman
Living independently
Fall and fractured femur
Developed a pressure ulcer
Pain, immobility, social isolation
Loss of independence
Timely recovery with input from
the tissue viability service

29. Financial Impact
• Accounts for £4 billion per year - 4% of
total NHS expenditure
• Poor quality care costs more – High Impact
Actions ‘Your skin matters’
• Pressure ulcers acquired in ELFT for
2012/2013 estimated cost of £541,000 to
treat

30. April 2013
• 5 grade 3&4 pressure ulcers
• Pressure ulcer training & competency
framework for relevant staff
• Secondment of TVN to EPCT in July 2013
• Launch of SSKIN bundle in October 2013

31. SSKIN Bundle-Preventing Pressure Ulcers
Surface
S
Static foam / alternating pressure relieving mattress
Mattress calibrated to correct weight of patient if required
Pressure relieving cushion
Wheelchair / cushion
Repose boot / pillow / Aderma dermal pad
Patient education on use of equipment
Skin Inspection
S
Skin assessment
Teach carers / family
Shared Care Approach to Pressure Ulcer Prevention SSKIN Bundle
Guidelines for Staff
Keep Moving
K
Regular repositioning
2 hourly or at each visit by the carers
Incontinence/
Moisture
I
Continence assessment / management
Catheter
Bowels
Incontinent pads
Barrier cream
General skin care
Nutrition
N
Nutritional assessment
Eating & drinking
Nutritional supplements / thickened fluid

32. Incidents Per Quarter
Patients with Grade 3&4 Pressure Ulcers Acquired in our
Care (2013-2014)
Q1
10
Q2
5
Q3
3
Q4
3 in January alone

33. A Different Picture?
Frontline staff support
and competency
assessments
TVN Secondment
QI methodology Use of outcome,
process and
balance measures
Launch of SKINN bundle

34. Using the QI Approach
• We identified a number of processes
essential to reducing Pressure Ulcers
• Little and often audits
• Surprising variation revealed
• % completion of risk assessment within 6
hours. Variation from 100% to 16%
between different teams within ELFT

35. Old Way versus the New Way
Old Way
(Quality Assurance)
New Way
(Quality Improvement)

36. Conclusion
• Pressure ulcers are mostly avoidable
• Prevention requires a different whole system
approach
• About using and acting on the right data at the
right time

37. Methodology
How do we deliver a consistent approach to quality?

38. Partnering with an external organisation
Why do we need an external partner?
What will they bring?
•Build improvement skills at scale and at pace over the first 2
years
•Strategic support
• How to deliver large-scale sustainable and successful
improvement
• Methodology, tools and techniques – and ensuring
fidelity
• Critical friend

39. Introduction to our external partner

40. Independent, not-for-profit organisation
Based in Cambridge, Massachusetts
Leading innovator, convenor, partner and driver of
results in health and healthcare worldwide
5 key areas of work
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•
•
•
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Improvement capability
Patient and family-centred care
Patient safety
Quality, cost and value
Triple aim for populations (improving health
outcomes, experience and per capita cost)

41. Let’s hear from the leaders at IHI

42. Model for Improvement & its impact
within a clinical team

43. The Model for Improvement

44. Improving quality of care on an inpatient female
psychiatric ward
AIM
PRIMARY DRIVERS
SECONDARY
DRIVERS
CHANGE IDEAS

45. The PDSA Cycle
“What’s next? ”
“Did it work?”
“What will happen if
we try something
different?”
“Let’s try it!”

46. You need a team
• Why?
– Need different
perspectives
– It’s a lot of work
– Increased buy-in by staff
– Different levels of support
(e.g. management)
• To come up with the
right team you have to
have an idea of what
your aim is…

47. The Aim
• A strong, measurable
aim with a clear time
frame will help keep
your project on course
• It has to be important to
those involved

48. The Steps to Change
Make part of
routine
operations
Test under a
variety of
conditions
Theory and
Prediction
Develop a
change
Test a change
Implement a
change
Spread to other sites /
groups / popn

49. How to implement Quality Improvement into
Practice
• Clear overall objective is Improving patient experience
• Gaining service user feedback in a timely meaningful manner
– issues could be acted upon immediately
• Use of tablets every two weeks – engaging staff members in
the process – used initially on Connolly and Gardner ward
included both qualitative and quantitative information.

50. Service User Feedback
1
2
3
4
No, I had lots of
problems
No I had some
problems
Yes, to some extent
Yes, definitely
a.
b.
c.
d.
e.
f.
N/A
Did you have trust and confidence in the professional that saw you today?
Did the person treat you with respect and dignity?
Did this person give you information you could understand about your care ,
treatment and condition?
When you had important questions to ask did this person, did you get answers you
could understand?
Were you involved as much as you wanted to be in decisions regarding your care
and treatment today?
Friends and family test : How Likely are you to recommend our ward/service to
friends and family if they need similar care or treatment

51. How to implement Quality Improvement into
Practice
•
•
•
•
•
•
•
•
Direct link with patient experience and bed pressures
Changes to the weekly bed management meetings
Inclusion of all clinical teams, including inpatient Nursing staff, Consultants, HTT ,
Community leads, Welfare Rights lead, Housing Lead and Social care staff.
Initially concentrated on the list of patients who were classified as a delayed
discharge.
Looked at all new admissions – early identification of social needs
Long length of stay patients – care planning
Made individuals take ownership for specific actions.
Support and advice regarding legal issues, risk issues and accommodation options.

52. Measurement and
Using Data for
Improvement

53. Service user experience
Blood results
MMSE
Waiting lists
Clinical Trials and Research
How Do ELFT Use Measurement?
Service user outcomes
BPRS
CQUINS & KPIs

54. The Three Faces of Measurement
• Research (efficacy)
• Improvement (efficiency and effectiveness)
• Accountability (reassurance, comparison)

55. Research
Aim
New Knowledge (efficacy)
Methods:
Test observability
Tests are blinded or
controlled
Bias
Designed to eliminate bias
Sample size
‘Just in case data’ (very large
data sets)
Flexibility of
hypothesis
Fixed hypothesis
Testing Strategy
One large test
Determining if a
change is an
improvement
Enumerative Statistics (t-test,
p-values)

56. Improvement
Aim
Improvement of care
(efficiency and effectiveness)
Methods:
Test observability
Tests are observable
Bias
Accept consistent bias
Sample size
‘Just enough data’, small
sequential samples
Flexibility of
hypothesis
Flexible and changes as
learning takes place
Testing Strategy
Sequential test over time
Determining if a
change is an
improvement
Analytical statistics. Run and
Control charts

57. Accountability
Aim
Comparison, choice,
reassurance, motivation for
change
Methods:
Test observability
No test, evaluate current
performance
Bias
Measure and adjust to
reduce bias
Sample size
Obtain 100% of available,
relevant data
Flexibility of
hypothesis
No hypothesis
Testing Strategy
No tests
Determining if a
change is an
improvement
No change focus

58. The Three Faces of Measurement
• Research (efficacy)
• Improvement (efficiency and effectiveness)
• Accountability (reassurance, comparison)

60. Does this represent improvement?
1.Yes
2. No

63. Why Measure?
• How can you tell if you are improving?
• Data collection and analysis are central to QI
• Helps identify quality problems but also opportunities
for improvement
• Allows us to track improvement over time
• Success of programme will hinge on the
measurements we put in place

64. Spread

65. Our challenge

66. The seven spreadly sins
If you do these things, spread efforts will fail…
1.
2.
3.
4.
5.
Start with large pilots
Find one person willing to do it all
Expect vigilance and hard work to solve the problem
If a pilot works, then spread the pilot unchanged
Require the person and team who drove the pilot to be
responsible for system-wide spread
6. Look at process and outcome measures on a quarterly basis
7. Early on expect marked improvement in outcomes with
attention to process reliability
Have you been at the receiving end of a ‘spreadly sin’?
1. Yes
2. No

67. The Steps To Change
Make part of
routine
operations
Test under a
variety of
conditions
Theory and
Prediction
Develop a
change
Test a change
Implement a
change
Spread to other sites /
groups / popn

68. So how do we spread successfully?
IHI (2009) A Framework for Spread: From local improvements to system-wide change

69. So how do we spread successfully?
Be patient…

70. BMJ Quality and East
London NHS Foundation
Trust
Dr Mobasher Butt, Clinical Lead for Quality, BMJ

71. The challenge
Make healthcare
improvement simple

72. What is the BMJ
Quality Improvement
Programme?
An online platform which supports
individuals, teams and organisations
to
work through healthcare
improvement projects and onto
publication by
providing the necessary framework
and tools to make healthcare
improvement simple.

73. 5 steps for QI
1. Help identify area for
improvement
2. Find out how others have solved it
– and what didn’t work
3. Support step-by-step through the
improvement process
4. Get advice from mentors, experts
and the global community
5. Publish and share your work

74. 1. WORKBOOK

76. Learning modules
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Systems
Introduction to Patient Safety
Human Factors
Intervention Design
Model for improvement
Bringing about Change
Using measurement for
change
Measurement for QI
Teamwork
Clinical Leadership
Stakeholder Relations

77. Additional materials:
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1) Process Flow Template
2) PDSA Cycle Template
3) Cost Saving Calculator
4) Vancouver Reference guide link
5) BMJ House Style guide
6) ICMJE guideline link
7) QR code generator for Posters

78. Videos:
•
•
•
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1) Creativity video
2) Ideas and Inspiration video
3) Functions and Navigation of My Dashboard
4) My Dashboard overview
5) Creating a project
6) Selecting a Mentor and Team members
7) Using the message board
8) Completing and Submitting

79. 2. WORKING
COLLABORATIVELY

82. 4. JOURNAL

85. 5. THE BMJ AND
EAST LONDON
PARTNERSHIP

86. Working together.....
• Inspire
• Innovate
• Improve
• Share

90. How to start an
improvement project

91. qi.eastlondon.nhs.uk

93. Key Ingredients for Success

94. Complete Project Charter
• Email to QI team
• qi@eastlondon.nhs.uk
• QI team will get in contact in a few days

95. The QI Team Will…
• Make sure you have right ingredients for success
• Help finalise charter
• Make sure your project aligns with programme
aims
• Link you with support on project and
methodology
• Provide support and access to BMJ Quality
platform

96. What Next for the Programme?
• Roadshows: Engage as many of our
remaining 3,500 staff
• IHI Open School programme available to all
staff
• Face to face training for 200 staff in next
year

97. Summary and Close