qi.elft.nhs.uk

qi@elft.nhs.uk

@ELFT_QI

Building an improvement

system and movement

@DrAmarShah

Amar.Shah@elft.nhs.uk

Mental health servicesNewham, Tower Hamlets, City & Hackney, Luton & Bedfordshire

Forensic servicesAll above & Waltham Forest, Redbridge, Barking, Dagenham, Havering

Child & Adolescent services, including tier 4 inpatient service

Regional Mother & Baby unit

Community health services Newham & Tower Hamlets

IAPTNewham, Richmond and Luton

Speech & LanguageBarnet

Challenges and

opportunities

Cultural diversity

Social deprivation

Geographical diversity

Commissioningarrangements

Financial stability and

strong assurance systems

@ELFT_QI

QualityBetter

Reject defectives

Requirement,Specification or Threshold

No action taken here

Worse

The old way (Quality Assurance)

Performing well?

The strategic case for change

Make quality our absolute priority

• Improving quality of care is our core purpose

• Of greatest importance to all our stakeholders

• Build on the excellent work already happening to improve quality

National drivers

• The need to focus on a more compassionate, caring service with patients first and foremost

• More structured and bottom-up approach to improvement

Enable our staff to lead change

• The desire to engage, free and support our staff to innovate and drive change

• Engaged and motivated staff leads to improved patient outcomes

The economic climate

• The need to do more with less

– improving quality whilst reducing cost

@ELFT_QI

First, let’s define what we mean by…

Quality improvement

improvingquality

quality improvement

=

© 2016 Institute for Healthcare Improvement/R. Lloyd

Priorities, structures (e.g. Quality Directorate), data systems, learning

system, sense making, strategic deployment, building capability

Leadership and Management

Components of quality

Quality

ImprovementMotivation/Leadership

Efficient Systems

Reflective Data

Context-sensitive

learning

• Internal monitoring –

continuous measurement

• External Inspection –

intermittent inspection

• Internal and external

regulations

Quality Control IMPROVED

OUTCOMES

New Designs, re-designs

Innovations, new tools in response

to customer needs and experience

Quality Planning

© 2016 Institute for Healthcare Improvement/R. Lloyd

Three Dimensions of Quality

Quality

Improvement

Control

Assurance

QualityBetter

Old Way

(Quality Assurance)

QualityBetter Worse

New Way

(Quality Improvement)

Action taken on

all occurrences

Reject

defectives

Quality assurance versus Quality improvement

Source: Robert Lloyd, Ph.D.

Requirement,

Specification or Target

No action

taken

here

Worse

QI: in a

nutshell!

(large)

Research & innovation

Quality improvement

Assurance, control &

performance management

@ELFT_QI

Trust board bespoke learning sessions

Visits to other organisationsSentinel event

Developing the strategy through engagement

Building the case for change

Early small scale tests

Long-term business case approved

Assess readiness for change

Identify strategic partner

Change in Executive

behaviours

Executive WalkRounds

Use of data to guide decision-making

Stop solving problems at the top

Give people time and space to solve complex problems

Manage the expectationsPaying

personal attention

A force-field analysis helps identify the forces driving and resisting a change.

Try to identify:a) The things that are currently supporting or driving

your organisation to become more improvement-focused

b) The things that are resisting this shiftc) The actions you could take to either strengthen driving

forces or negate restraining forces

Building the case for change

Table Exercise – force-field analysis

Force Field Analysis

Driving Forces (+) Restraining Forces (-)

Actions to reduce the Restraining Forces:

•

•

•

Actions to strengthen the Driving Forces:

•

•

•

Designing a quality

improvement programme

Make it feel meaningful

Make it feel possible

Make it feel valued and permanent

Provide skills and support

AIM:

To support ELFT to improve

health and healthcare

for the population

it serves

Engaging, encouraging &

inspiring

Developing improvement

skills

Embedding into daily

work

Projects

1. Targeting / segmenting comms for different groups (community-based staff, Bedfordshire & Luton staff)

2. Sharing stories – newsletters, microsite, presenting internally3. Celebration – awards, conferences, publications, internal

presentations4. Share externally – social media, Open mornings, visits, microsite5. Work upstream – trainees, regional partners, key national and

international influencers

1. Pocket QI for anyone interested, extended to Beds & Luton2. Refresher training for all ISIA graduates3. Improvement Science in Action waves4. Online learning options5. Develop cohort and pipeline of improvement coaches6. Leadership and scale-up workshops for sponsors7. Bespoke learning, including Board sessions & commissioners

1. Learning system: QI Life, quality dashboards, microsite2. Standard work as part of a holistic quality system3. Job descriptions, recruitment process, appraisal process4. Annual cycle of improvement: planning, prioritising, design and

resourcing projects5. Support staff to find time and space to improve things6. Support deeper service user and carer involvement

Directorate-level priorities- Defined through annual cycle of planning- Most local projects aligned to directorate priorities

Trust-wide strategic priorities1. Reduce harm from inpatient violence2. Improving access to community services3. Joy in work4. Recovery-focused community mental health5. Cost reduction

AIM:

To support ELFT to improve

health and healthcare

for the population

it serves

Engaging, encouraging

and inspiring

QI Stories at Trust Board

QI Visibility Wall

Electronic & paper newsletters

qi.elft.nhs.uk

Visits to see QI at ELFT

Influencing national policy and thinking

Staff experience and engagement

3,5

3,6

3,7

3,8

3,9

4

2010 2011 2012 2013 2014 2015

Sco

re

Overall Engagement Score

ELFT Score

National Median

3,5

3,6

3,7

3,8

3,9

4

4,1

4,2

2010 2011 2012 2013 2014 2015

Sco

re

Staff Motivation to Work

3,3

3,4

3,5

3,6

3,7

3,8

3,9

4

4,1

2010 2011 2012 2013 2014 2015

Sco

re

Staff job satisfaction

55

60

65

70

75

80

85

90

2010 2011 2012 2013 2014 2015

Sco

re (

%)

Staff able to contribute towards improvements at work

Bu

ildin

g w

ill

Build a broad coalition for

change

Take time to bring people

with you

Shift decision-making to the

edge

Develop a compelling narrative

Find some clear signals

of change

Use the power of stories

Take every opportunity to

celebrate

Building the willTable exercise

Consider what you might try to engage people (staff, patients, stakeholders) with QI.

AIM:

To support ELFT to improve

health and healthcare

for the population

it serves

Developing improvement

skills

Experts by experience

All staff

Staff involved in or leading QI projects

Sponsors

Board

Estimated number needed to train = 4000Needs = introduction to QI & systems thinking,

identifying problems, how to get involved

Estimated number needed to train = 1000Needs = Model for improvement, PDSA,

measurement and using data, leading teams

Estimated number needed = 50Needs = deep understanding of method & tools,

understanding variation, coaching teams

Needs = setting direction and big goals, executive leadership, oversight of improvement,

understanding variation

Estimated number needed to train = 10Needs = deep statistical process control, deep

improvement methods, effective plans for implementation & spread

363 completed Pocket QI so far. All staff receive intro to QI at

induction

690 graduated from ISIA in 6 waves. Wave 7 in 2017-18.

Refresher training for ISIA grads.

47 QI coaches trained so far, with 35 currently active. Third cohort of

20 to be trained in 2017

All Executives have completed ISIA. Annual Board session with IHI &

regular Board development

Currently have 6 improvement advisors, with 3 further QI leads in

training

Internal experts (QI

leads)

Bespoke QI learning sessions for service users and carers. Over 95

attended so far. Build into recovery college syllabus

Needs = introduction to QI, how to get involved in improving a service, practical skills in

confidence-building, presentation, contributing ideas

QI coaches

Needs = Model for improvement, PDSA, measurement & variation, scale-up and spread,

leadership for improvement

58 current sponsors. All completed ISIA. Leadership, scale-up & refresher QI training in 2017

Psychology trainees – Pocket QI, embedded into QI project teams with 4 bespoke learning sessions

Nursing students – Intro to QI delivered within undergraduate and postgrad syllabus, embedded into QI project teams during student placements

Wo

rkin

gu

pst

ream

QI capability building

• In-depth training• Course length is 6 months.

• 3days intensive training; 4 WebEx teleconferences; 2 full day learning sets

• Applying learning to their QI projects in ‘action periods’

• Flexible, online training resource available to the whole Trust.

• Essential skills to support in leading

QI• Certificate which

can be added to CPD portfolio.

• Apps for phone or tablet, or use browser

• Brand new modular

introduction to QI

• For anyone involved in

QI or wanting to learn

core QI skills

• Overview to using QI,

PDSAs and testing,

Using measurement &

data for improvement,

QI Tools

• One-stop shop

• Learning

resources

• Seminal papers,

guidelines,

whitepapers

• Videos

• QI tools

PreworkWorkshop

9/29-10/1

Webex 1

10/14

Webex 2

11/2

Supports:

• Listserve

• Assignments

AP-1 AP-2Webex 3

11/30AP-3

Project

PlanningReliability

Sustaining

Gains

Workshop

(3 days)

Webex #2Webex #1

• Faculty consults• Webex calls• Coaching calls

Webex #3 Learning Set 2 &

graduation

AP-5AP-4

The two learning sets will be focused on sharing the participants’ work on their projects and learning from each

other. These sessions also will reinforce the content from the Webex calls and the ISIA workshop.

Improvement Science in Action - 6 month learning path

Learning set 1

Workshop 1

Overview to using QI

Workshop 3

PDSAs and testing

Workshop 4

QI Tools

All 4 workshops are between 2-3 hours in a classroom format and rotate in location throughout the

geography of the Trust.

Workshop 2Using

measurement for improvement

Pocket QI- 2 month learning path

QI Coaches

Intro to QI - for service users & carers

Bu

ildin

g ca

pab

ility

&

cap

acit

y

Be prepared to invest

Train all levels and across disciplines

Realign existing

resources

Stop lower value work

1. What capacity do you need to get going? How can you release this?

2. What existing capability do you have? How could you shuffle existing resources to bring this together into a single quality improvement team?

3. How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement?

Building Capability

Table Discussion

AIM:

To support ELFT to improve

health and healthcare

for the population

it serves

Embedding into daily

work

AIM:

To support ELFT to improve

health and healthcare

for the population

it serves

QI ResourcesService User Input

Support around every team

Project Sponsor QI Coach

QI Forums

QI Team

Governance Improvement

Little i Big I

Surveys

Focus groups

Community meetings

Service user

forum

Changing the way we use data to guide decision-making

Safety trust wide excluding Beds and Luton(London)

Clinical Effectivenesstrust wide excluding Beds and Luton

Patient Experiencetrust wide excluding Beds and Luton

Complaints June and July 2016.

Our Stafftrust wide excluding Beds and Luton

Reasons given by staff leaving June to July 2016

Changing the way we look at data

Data at Trust, directorate or team level

Alig

nm

ent

& in

tegr

atio

n

Start at the topCreate a support

structure

Build a learning system

Ensure patients and carers are

integral

Ensure the context is ripe

Line of sight from team to system goals

1. What will you need to redesign in order to align your organisation around systematic continuous improvement?

2. What can you change, stop or review to create space for improvement?

3. What structures and processes will you need to support quality improvement work?

Alignment

Table Discussion

AIM:

To support ELFT to improve

health and healthcare

for the population

it serves

Projects

Make it feel meaningful

Make it feel possible

Make it feel valued and permanent

Provide skills and support

Our QI Projects

60

70

80

90

100

110

120

130

140

150

sep.14 okt.14 nov.14 des.14 jan.15 feb.15 mar.15 apr.15 mai.15 jun.15 jul.15 aug.15 sep.15 okt.15 nov.15 des.15 jan.16 feb.16

No

. of

ne

w p

roje

cts

No. of active projects per month

155Active

Projects

REDUCE HARM BY 30% EVERY YEAR

9

PHYSICAL HEALTH

ACCESS TO SERVICES

PRESSURE ULCERS

VIOLENCE REDUCTION

3 19 18

26

RIGHT CARE, RIGHT PLACE, RIGHT TIME

129

Our QI Projects47 projects have shown sustained improvement

Our QI Projects

1 2 1 23

6

1

5 6

2 2 1 2

7

5

1

11

42 3

3

1

2

4

13

5

1

52

1

3

4

46

3

1

34

72

1

1

1

1

8

2

2

2 1

1

2

1

1

2 1

1

2

1

2

7

3

4

2

Closed, Successfully Completed 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5

Violence reduction

150

200

250

300

350

400

450

500

550

2013 2014 2015

No

. of

Inci

den

ts

Physical violence to patients (per 100,000 occupied bed days)

300

400

500

600

700

800

900

2013 2014 2015

Physical violence to staff (per 100,000 occupied bed days)

Over three years, physical violence has reduced compared to other mental health

providers

Impact across all 35 East London wards =

25% reduction

60% reduction in violence across three older adult wards with highest

level of violence

40% reduction across all six wards in Tower Hamlets

50% reduction in Forensic learning disability service

UCL

67,79

51,13LCL

20

30

40

50

60

70

80

90

100

06-

Jan

-14

03-

Feb

-14

03-

Mar

-14

31-

Mar

-14

28-

Ap

r-14

26-

May

-14

23-

Jun

-14

21-

Jul-

14

18-

Au

g-14

15-

Sep

-14

13-

Oct

-14

10-

No

v-14

08-

Dec

-14

05-

Jan

-15

02-

Feb

-15

02-

Mar

-15

30-

Mar

-15

27-

Ap

r-15

25-

May

-15

22-

Jun

-15

20-

Jul-

15

17-

Au

g-15

14-

Sep

-15

12-

Oct

-15

09-

No

v-15

07-

Dec

-15

04-

Jan

-16

01-

Feb

-16

29-

Feb

-16

28-

Mar

-16

25-

Ap

r-16

23-

May

-16

20-

Jun

-16

No

. of

Inci

de

nts

Incidents resulting in physical violence (Trust-wide, excluding Luton and Beds) - C Chart

Improving access to services

32,21%

25,23%

26,30%

UCL

LCL

20%

25%

30%

35%

40%

Jan

-14

Feb

-14

Mar

-14

Ap

r-14

May

-14

Jun

-14

Jul-

14

Au

g-14

Sep

-14

Oct

-14

No

v-14

Dec

-14

Jan

-15

Feb

-15

Mar

-15

Ap

r-15

May

-15

Jun

-15

Jul-

15

Au

g-15

Sep

-15

Oct

-15

No

v-15

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-16

May

-16

Jun

-16

Jul-

16

Au

g-16

Sep

-16

DN

A /

%

% of 1st face to face appts DNAs (Collaborative, 10/12 teams) - P Chart

UCL

1 021,711 213,13

1 331,17

LCL700

900

1100

1300

1500

1700

jan

.14

feb

.14

mar

.14

apr.

14

mai

.14

jun

.14

jul.1

4

aug.

14

sep

.14

okt

.14

no

v.1

4

des

.14

jan

.15

feb

.15

mar

.15

apr.

15

mai

.15

jun

.15

jul.1

5

aug.

15

sep

.15

okt

.15

no

v.1

5

des

.15

jan

.16

feb

.16

mar

.16

apr.

16

mai

.16

jun

.16

jul.1

6

aug.

16

sep

.16

No

. of

Re

ferr

als

No. of referrals received (Collaborative, 10/12 teams) - I Chart

30% increase in referrals across 10 community services

20% reduction in non-attendance at first appointment across 10 community services

50% reduction in waiting time from referral to first

appointment across City & Hackney community mental

health teams

60,77

40,05

UCL

LCL

20

30

40

50

60

70

80

90

Ja

n-1

4

Feb

-14

Mar-

14

Apr-

14

May-1

4

Ju

n-1

4

Ju

l-14

Aug

-14

Sep

-14

Oct-

14

No

v-1

4

De

c-1

4

Ja

n-1

5

Feb

-15

Mar-

15

Apr-

15

May-1

5

Ju

n-1

5

Ju

l-15

Aug

-15

Sep

-15

Oct-

15

No

v-1

5

De

c-1

5

Ja

n-1

6

Feb

-16

Mar-

16

Apr-

16

May-1

6

Ju

n-1

6

Ju

l-16

Aug

-16

Sep

-16

Avera

ge W

ait

ing

Tim

e /

Days

Average waiting time from referral to 1st face to face appt (City and Hackney CMHTs) - X-bar Chart

@ELFT_QIqi.elft.nhs.uk qi@elft.nhs.uk