Report to: Board of Directors (Public) FoI status: Report can be … papers… · Second year of online training certificate through the Institute of Health Improvement’s “Open

Report to: Board of Directors (Public)

Paper number: 3.2

Report for: Information

Date: 7 February 2019

Report author: Dr Fredrik Johansson, Clinical Lead for QI

Report of: Dr Vincent Kirchner, Medical Director

FoI status: Report can be made public

Strategic priorities supported:

Early and effective Intervention / Helping people to live well / Research and innovation

Cultural pillars supported:

We value each other / We are empowered / We keep things simple / We are connected

Title: Quality Improvement (QI) Programme Update: Year 2 – update no. 3

Executive Summary

The following update provides a description of on-going developments and projects of the QI programme.

There are 32 active QI projects with 14 successfully completed projects.

Training and engagement of staff has become more systematic and divisions are beginning to incorporate QI into their business and quality agendas.

This paper was considered in detail by the Quality Committee on 29 January 2019.

Recommendation to the Board

The Board of Directors is requested to:

RECEIVE, CONSIDER and ACCEPT this report for information.

Risk Implications

None.

Finance Implications

None.

Equality and Diversity Impact / Single Equalities Impact Assessment

N/A

“the most important single change in the NHS… would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end”

Berwick Report: “A promise to learn: a commitment to act” (2013)

Engaging, encouraging and inspiring

C&I Quality & Safety event took place on 24 October 2018 – 7 QI projects presented as well as 14 QI projects presented as posters celebrating QI work of frontline teams.

From Sep 2018 induction for all new staff includes an introduction to QI methodology.

QI hub drop-in sessions, visits to teams by QI hub and continuous building of relationships with stakeholders from the QI hub members.

QI has been established as a standing item at divisional quality forums/business meetings.

Twitter account established with regular activity and 89 followers.

Intranet and internet sites includes information about completed QI projects and QI resources and information https://www.candi.nhs.uk/about-us/quality-improvement-ci

Monthly QI “spotlight” newsletter distributed throughout Trust started Nov 2018.

105 registered staff using LifeQI platform for project work.

https://www.candi.nhs.uk/about-us/quality-improvement-ci

Building capacity and capability

Second year of online training certificate through the Institute of Health Improvement’s “Open School”.

Online and external training resources in QI available on the intranet site.

QI skills workshops delivered by the QI hub at request of specific teams, divisions or training programmes.

3rd 1 day QI training took place on 30 October 2018 with 40 staff attending.

We are identifying individuals with an interest and experience in improvement work, knowledge of QI and those with potential to develop these skills and seeking to engage them with the programme and to act as local QI champions.

Support for QI projects within teams and divisions (see appendix 2).

Continued supporting of Trust-wide programmes with staff engagement, measurement and implementation: 1. Red2Green programme & including recently developed admission avoidance

work-streams. 2. “Safe wards” programme started Nov 2018. 3. Supporting staff wellbeing using IHI “Joy in Work” framework.

Supporting the organisation to adopt “measurement for improvement” tools to facilitate decision-making. 2hr training session for Board took place in Nov 2018 facilitated by NHS Improvement to train in using Statistical Process Control (SPC) measures in performance reports. QI hub supporting to move to SPC charts in future performance reports.

QI team are part of C&I Digital Connections Forum bringing IT, clinical staff and QI together to improve IT clinical resources.

Appendix 1

Projects with QI Support

Safewards

The Safewards project launched in the acute division earlier this year. Safewards focuses on creating enhanced therapeutic environments through the application of 10 interventions with the outcome of a reduction in violence and aggression.

Throughout this 12 month project all 11 acute inpatient wards will implement the 10 interventions that arise from the Safewards model.

The Quality Improvement Team are supporting the projects implementation, placing emphasis on QI methodology to maximise the chances of success and shared learning amongst colleagues and teams.

The QI Hub is coaching the two Safewards practitioners to implement PDSA cycles to test small scale changes in practice and practical learning regarding data collection and monitoring improvements. Our QI coach provides weekly supervision for the two Safewards practitioners which allows for a safe, open space to discuss project facilitators and barriers, forward planning, and learning opportunities.

C&I Flu Campaign

This year‟s flu campaign sought support from the QI Hub to help the trust in reaching the national, and Trust target of 75% uptake of the flu vaccine for patient-facing C&I staff members. Whilst we are in the midst of the flu campaign the QI Hub is coaching the campaign through PDSA cycles to test the best methods of promoting and providing the flu vaccine. Our QI coach is working closely with the infection control lead to review and monitor the campaigns approaches and the uptake of the treatment. In addition to the aim of reaching the national and Trust target, through testing new approaches we intend to create an evidence base to support the planning of next year‟s campaign. In identifying the best approaches to support the uptake of the vaccine we can provide a campaign plan which should allow for a higher, and quicker uptake of the flu vaccine during the 2019-2020 flu season.

Royal Collage of Psychiatry Collaboration

Earlier this year C&I made a successful application to the Royal Collage of Psychiatry to partake in a 2 year national quality improvement collaboration focusing on reducing restrictive practice. The selected ward for this national programme is Coral Ward, C&I‟s male PICU. The Reducing Restrictive Practice (RRP) collaborative is part of a wider Mental Health Safety Improvement Programme which was established by NHS Improvement in partnership with the Care Quality Commission (CQC) in response to a request made by the Secretary of State.

The aim of the RRP is to reduce restrictive practice (measured by number of restraints, seclusions and rapid tranquilisations) by 33% in the wards that are selected to take part. With the support of the QI Hub

Coral Ward have established a multidisciplinary project team to progress the QI work and are already implementing new practices, including twice daily safety huddles, nurse-led patient activities, and patient-led safety huddles.

The QI Hub is coaching the project team through each stage of the project and has enabled the team to think creatively and pro-actively about changes in practice, provide wider learning and reflection, and increase patient involvement in creating new practices. The QI Hub will be linking in with quality improvement advisors from the Royal College of Psychiatry over the next 2 years to strengthen the project and increase learning opportunities.

C&I Digital Connections Forum

The aim of the Forum is to connect people with ideas to people who can help to realise them, promote collaboration across professional and organisational silos, learn from each other, share resources and avoid duplication. Those attending include the Chief Clinical Information Officer, individuals from the Clinical Applications Team, the Information Team, the Quality Improvement Team and our Digital Communications Manager. Assess the viability of digital projects at an early stage in the context of the available digital resource and existing work within the Trust.

7 projects have been identified or supported at this forum as well as our QI team being a conduit to frontline staff to access this resource.

Service User Involvement:

The QI Hub strive to partner with service users in every project to give C&I the opportunity of becoming a genuinely co-produced Trust. This has improved staff satisfaction and made services easier to navigate. We meet weekly with the Service User Involvement Facilitator and attend service user forums across all divisions. We are developing ways to measure the focus on recovery, the level of co-production and the quality of the relationship between staff and service users.

Appendix 2

Selection of Completed Projects

All completed projects are available to view at:

https://www.candi.nhs.uk/about-us/quality-improvement-ci/completed-qi-projects

https://www.candi.nhs.uk/about-us/quality-improvement-ci/completed-qi-projects

Appendix 3

Quality Improvement Projects – for more detail and a “live” view of our projects visit and register with https://www.lifeqisystem.com/ To help capture and communicate progress towards the project aim, the project has a progress score that is updated throughout the life of the project. The scale enables the tracking of progress right by the intent to participate with a project, right through to outstanding sustainable results. The score is based on the scale developed by the Institute for Healthcare Improvement (IHI). A debrief is completed if a project so that learning is captured for future reference. 0.5 - Intent to Participate Project has been identified, but the charter has not been completed nor team formed.

Title Team/Division Interventions tested Comments

1 Improving the time is takes for data cabling to be completed

Estates (reaching out to IT) / Corporate

Physical Health Clinic, physical health groups - handing over to new doctor to try out trying clinics at a different time.

The project lead to get sponsor agreement for this project. To get in contact with contacts in IT to explore if this is a project they are able to work on together.

2 Physical Health - Ensuring Investigation are completed for those that require monitoring

Camden CMHT / SAMHS

Mosaic - New form at discharge that helps collate the necessary standard minimum information to be included in GP letters Service user feedback forms on iPad

The team would like to use the new physical health screening tool to collect an understanding on baseline and focus on ensuring 100% of caseload have their bloods and ECG's up to date.

3 Increasing the use of the Mental Health Suite in Whittington A&E

MHLT / Acute Met with the Consultant to discuss measurement and getting a team together. She is part of the leading in excellence cohort. She plans to start receiving weekly data and update this for them before handing it back.

https://www.lifeqisystem.com/


4 Increasing the usage of electronic forms

Community Learning Disabilities service / SAMHS

Medication counselling /discharge counselling to be made part of Discharge checklist - (mandatory before discharge) Recording on Carenotes for counselling given different points of each inpatient episode

helping staff to get used to new electronic forms as part of their standard work. Team of 4 psychologists looking at using a form on Mosaic to ensure standard information in included in GP letters. The learning from this will then be applied to help the wider team collate service user feedback on tablets.

1.0 - Team Established and Planning for the Project has begun A charter has been completed and reviewed. Individuals or teams have been assigned. Organisation of project structure has begun (such as: what resources or other support will likely be needed, where will focus first, tools/materials need gathered, meeting schedule developed).

Title Team/Division Interventions tested Aim/Comments

1 Reducing time spent on paperwork

Employee Relations Human Resources

Process map drawn out.

2 Increasing attendance to OT group programmes

Huntley OT Team / Acute

Team will start by focusing on only two OT groups to test change ideas on a small scale, change ideas being developed

Aim: All occupational therapy groups at the Huntley Centre to consistently reach 100% capacity through service user attendance and engagement Project team and QI coach are meeting weekly, process maps and driver diagrams completed.

3 Inpatient referrals to South Camden Crisis team – can we facilitate early discharge from wards?

South Camden CRT/ Acute

First project meeting on 14/12/18

Aim: To reduce patient inpatient length of stay by increasing the number of referrals to South Camden Crisis team from inpatient wards


4 Improving discussions and care regarding contraception on a female PICU

Ruby Ward / Acute Plan to introduce contraception champion and make additions to admission clerking and ward round structures

Aim: For 80% of service users to have a discussion about contraception during their admission to a female PICU

5 Post Treatment provision within SMS

Substance Misuse Service

To draw out process map with team.

Project lead to focus on engaging QI team around the problem.

6 Dual Diagnosis and NPS use – Improving the care pathway for service users with substance misuse challenges within the acute inpatient setting

Jade / Topaz / Acute

Project team are meeting once weekly and have recently completed a baseline audit to understand where they are at with substance misuse care currently. Good MDT focused project team, including colleagues from SMS division

Aim: To Improve:- - SU engagement with SMS services - Increase pharmacological prescribing for substance

misuse - Enhance cross division working between acute and SMS

to improve substance misuse care - Improve physical and mental health assessments and

interventions - To reduce relapse due to substance misuse

2.0 – Activity. Changes tested, but no improvement Initial cycles for team learning have begun (project planning, measurement, data collection, obtaining baseline data, study of processes, surveys etc.). Initial cycles for testing changes have begun. Most project goals have a measure established to track progress. Measures are graphically displayed with targets included.


1 Margaret Centre project

Substance Misuse Service

To increase attendance at Margaret Centre sessions by 20% in six months.

Art group are creating visuals/video/audio to encourage participation in sessions at Margaret Centre. New welfare peer support sessions being planned.


2 Physical Health group Sapphire ward To start a weekly physical health group on Sapphire Ward with the aim of providing more holistic patient-centred patient care in six months.

Commenced a weekly physical health group to discuss how physical and mental health issues overlap. Subjects discussed so far range from the menopause to healthy eating to sleep hygiene. Provide relevant materials to patients. Discussed how they feel staff address their physical health needs.

3 Maintaining the Quality of Assessment Letters at PDS

Community Mental Health Personality Disorder Service

A mini training session has been established. The focus is on understanding what the standard of these letters should be.

The last discussion with project lead was on how to structure the project so that the interventions and measurement were aligned so that improvement within the team could be monitored by them.

4 Improving Client Satisfaction Questionnaires

Memory Service. Services for Ageing and Mental Health

A driver diagram has been completed. Focus on translating the form into other languages. To send the form out by e-mail. To completing form over the phone following the review.

Challenging project as SUs have memory problems and are often reviewed by phone.

5 SBAR handover Sapphire/Acute In six months for SBAR to be used in 100% doctor and nurse handovers, board/ward rounds, phone calls and referral casenotes.

SBAR framework introduced – training has taken place for frontline staff. SBAR information poster on ward. Planned to test staff knowledge and confidence of using this over time.

6 Documentation of VTE prophylaxis on psychiatric inpatient wards

Garnet / SAMHS Physical health clinic, physical health groups. Handing over to a new doctor to try out clinics at a different time.

Project is currently on hold waiting on IT fix - Will go to Digital Connection Forum (16th January) once team are happy with the details.


7 Enhancing the therapeutic engagement of close observations

Rosewood / Acute Introduction of therapy boxes – arts, soothing, and games Nurse-led reviews of service users on close observations

Aim: To empower nursing staff to manage service users on close observations so that it becomes a more therapeutic intervention, less aggravating for the service user, and reduces the total time spent on close observations. Plan to make a short video for staff to watch to learn about the use of the therapy boxes. Project team meeting weekly with support from QI coach, change ideas resulted from patient and staff feedback, good support from the wider team.

3.0 - Modest Improvement/Improvement Successful test of changes have been completed for some components of the change package related to the team's charter. Some small scale implementation has been done. Anecdotal evidence of improvement exists. Expected results are 20% complete. Testing and implementation continues and additional improvement in project measures towards goals is seen


1 Improving Doctors Induction

Medical Doctors & HR - Corporate

Mosaic. New form at discharge that helps collate the necessary standard minimum information to be included in GP letters. Service user feedback forms on iPad

Team have put together and are testing a new induction pack, talks are given by current doctors, site tours and induction checklist have been incorporated with supervisors for the December intake. Plans to liaise with the Digital Connections Forum to speed up the IT issues for new starters - will overlap with IT. HR project on this.


2 Jades Peaceful Place Jade / Acute Creation of „Jades Peaceful Place‟, a calming and soothing relaxation room to support self-coping mechanisms Staff and service user daily reflections on the ward atmosphere and environment

Aim: To reduce the amount of oral PRN administered to service users for anxiety or aggression by 20% by December 2019. Peaceful place is now open and is being used by service users, staff will continue to collect data to monitor how this new resource impacts the ward.

3 Identifying key flashpoints in order to reduce predictable V&A on the ward / RCP Restrictive practice collaborative

Coral / Acute Twice daily safety huddles focusing on risk management and forward shift planning. Nurse-led patient activities. Patient-led safety huddles.

Aim: To reduce incidents of violence and aggression by 33% on Coral Ward by August, 2020. Project team meeting weekly with QI Coach to review and discuss change ideas, good improvements being made and the ward report a greater sense of team work as a result of the project.

4 Improving lone-working in the community

North Islington R&R

Designing a new whiteboard to go up. Designing new local lone working policy. Security Manager to introduce lone working devices to team. Health and Safety Manager to help team cover all the bases with their local policy.

5 Increasing the usage of Physical Health Screening in CADU

Camden Acute Day Unit / Acute

Met with Consultant and Trainee who have done a lot of work around data collection and creating driver diagram. Data shows some improvement but will need some more work to reach their 95% goal. New change ideas to be tested with new doctor who will take over.

6 Increasing the use of physical health screening tool

Islington Early Intervention Service

For all Care Programme Approach (CPA) service users to have had their annual physical health screen in the next year.

Understood service users‟ journey, developed process map, shared methods for engaging service users, offered home visits, reoffered any declined interventions.


7 Increasing the presence of CRT staff at MHA assessments

CRT & AMHP Team / Acute

Senior CRT staff to attend MHA assessments in view to prevent hospital admission

Aim: For CRT staff to attend MHA assessments to prevent hospital admission where appropriate. CRT staff have been attended MHA assessments and have been able to demonstrate avoidance of admission at times but no consistent improvement noted – currently adopted screening of all MHAA by seniors clinicians and attending where impact felt to be possible.

8 Patient Journey to crisis / care planning for crisis team

CRT / Acute New service centred care plans

Aim: For 100% of service users to have a useful care plan Service users are now testing the newly developed care plans.

4.0 - Significant Improvement/Sustainable Improvement Expected results achieved for major subsystems. Implementation (training, communication etc.) has begun for the project. Project goals are 50% or more complete. Data on key measures begin to indicate sustainability of impact of changes implemented in system.


1

Increasing the Number of Medicine Review Referrals From Speech and Language Therapy (SLT) to Pharmacy for Adults with a Learning Disability (LD) and Dysphagia

Community Learning Disabilities service / SAMHS

Medication counselling /discharge counselling to be made part of discharge checklist - (mandatory before discharge. Recording on Carenotes for counselling given at different points of each inpatient episode.

Team decided to go into implementation stage as they feel that the referral rates have improved but would like to ensure that this is sustained as team changes come into effect. To Review in January.


2 Peer coaching Community To train and employ peer coaches to deliver 1,000 sessions to service users in 14months from February 2018.

Investigated what service users wanted to improve in primary care and consequently initiated a 3month pilot peer coaching programme. Peer coaching was built into the clinical Recovery Strategy and promoted via a theatre production. Collected service users‟ feedback and concluded that C&I is able to successfully train peers to deliver a service that is valued by our service users. Spread: Findings were shared with CCG, GPs and C&I colleagues. CCG is funding an extension of the project. New QI project with theatre has been group conceptualised.

3 Active Cases Form and Report

UCLH Liaison Team

To reduce cases being discussed at handover to one printed sheet.

Digital Connections Forum developed a tool to filter cases for discussion. Team was made aware of the tool and measured the number of sheets being printed for each handover.

4 Increasing occupancy at Islington Crisis House

Islington CRT/Look Ahead/Acute

Clinical director and Crisis team doctor attending weekly team meetings. Joint assessments/mid-point reviews/discharge meetings.

Aim: Achieve 90% occupancy levels at ICH by Nov 2018

5.0 - Outstanding Sustainable Results Implementation cycles have been completed and all project goals and expected results have accomplished. Organisational changes have been made to accommodate improvements and to make the project changes permanent. Consideration of spread to other areas of the organisation.


1 Physical Health Clinic: Improving efficiency of time spent on physical health needs

Dunkley Ward / Acute

Weekly physical health clinic based on the ward for non-urgent physical health needs.

Aim: To establish a physical health clinic for psychiatric inpatients in order to improve patient care, and to promote efficient use of working time for nurses and junior doctors. Plan to discuss spread for this project as other doctors have shown interest in the improvements.

2 High Dose Antipsychotic Treatment

Coral / Acute Weekly HDAT reviews of medication charts HDAT incorporated into handovers and ward rounds.

Aim: For 100% of service users to have the correct documentation to meet HDAT national guidelines. Sustained improvements demonstrated, project has now been handed on to the new ward doctors and change ideas introduced a part of the weekly routine.

3 Improving the nursing daily allocation sheet

Laffan / Acute New allocation sheet designed – this will be shared with the team and amendments made to suit the needs of the ward.

Aim: To improve staff awareness of their daily tasks and responsibilities through the development of a new allocation sheet.

Documents

Report to: Board of Directors (Public) FoI status: Report can be … papers… · Second year of online training certificate through the Institute of Health Improvement’s “Open