City & Hackney CAMHS: Access and Flow project

Here’s the fourth story of the Improving access and flow within Child and Adolescent Mental Health Services series. In the newsletter below, find out how the City & Hackney team changed the way they operate to improve the experience of young people in the crisis pathway. Click to read:

CAMHS Access and Flow series – access all stories here >>

If you want to learn more about this project, visit LifeQI – Project Code: 107103

Newham Child and Family Consultation Service in: The Busy Bees

Here’s the third story of the Improving access and flow within Child and Adolescent Mental Health Services series. The Newham Emotional & Behavioural Team share their journey of reducing cancellation rates and other improvements as part of their QI project.

The team also recently threw open their doors for a week-long CAMHS festival, reaching out into their community, with immediate access to some interventions pathways. They are continuing to look for creative ways to improve the experience of their service.

CAMHS Access and Flow series – access all stories here >>

If you want to learn more about this project, visit LifeQI – Project Code 107105

‘Mission Improvable’: an entirely factual and anonymous blog

Here’s an honest and humorous account of the highs and lows of a QI project journey in the Tower Hamlets CAMHS triage pathway. This is the second story of the Improving access and flow within Child and Adolescent Mental Health Services series. Click below to read:

CAMHS Access and Flow series – access all stories here >>

If you are part of ELFT you can learn more about this project on Life QI here – Project Code 107104

Improving access and flow within CAMHS: the ADHD service story

This is the first story of a series dedicated to improvement work in ELFT’s Child and Adolescent Mental Health Service (CAMHS). Each week you will be able to learn more about a different QI project through their learning and achievements. Here’s the first one…

City & Hackney CAMHS reduced the waiting time from referral to assessment in the Attention Deficit Hyperactivity Disorder (ADHD) pathway from 28 to 12 weeks. Here’s their story:

Stay tuned for the next CAMHS project story next week!

CAMHS Access and Flow series – access all stories here >>

If you are part of ELFT you can learn more about this project on Life QI here – Project Code #107101

Improving access and flow within Child & Adolescent Mental Health Services

Graeme Lamb, Clinical Director for Children’s services, and Jamie Stafford, Improvement Advisor, reflect on the journey of teams who took part in a learning system to improve access and flow within the Child and Adolescent Mental Health Services directorate. Over the coming weeks, we will be sharing some of these teams’ stories.

Graeme Lamb

Since June 2017, we have been using Quality Improvement to try and improve access and flow across Child and Adolescent Mental Health Services (CAMHS) community services in ELFT. Across the five services in the trust, seven separate teams set out to better understand their demand and capacity, and to improve an aspect of the quality of care they provide. They were asked to consider what matters to them and their service users, and were encouraged to use QI to make meaningful and impactful changes.

The seven pathway teams that participated have come together regularly to learn from each other, and to reflect on the progress being made. Although leading and supporting this work across the directorate has been challenging at times, it’s been fantastic to see teams come together in the spirit of collaboration, and to hear them talk passionately about how it has felt to make positive changes within their pathways. With some projects now showing great outcomes too, I look forward to hearing and celebrating the stories of the projects in our weekly series.

I’d like to thank all of the staff and service users who have been involved in these projects for your dedication and thoughtful hard work. While demand and capacity continue to be a challenge for CAMHS both locally and nationally, your keenness to improve quality, use data effectively, try new ideas and work together have helped the Trust start to address these issues, whilst at the same time ensuring that we continue to provide the highest standard of care.

Read all of the recent CAMHS stories below:

Improving access and flow within CAMHS: the ADHD service story

‘Mission Improvable’: an entirely factual and anonymous blog

Newham Child and Family Consultation Service in: The Busy Bees

City & Hackney CAMHS: Access and Flow project

Improving access and flow: Luton CAMHS story

Tower Hamlets Neurodevelopmental CAMHS pathway

Developing a Learning System to support improvement work across CAMHS

Jamie Stafford

On the commencement of the ‘Access and Flow’ projects in CAMHS we faced a simple question – with seven teams looking to improve, how can they work together?

The pathways that were selected were geographically dispersed, had different internal structures, and provided a range of different clinical functions. Despite this, some of the challenges to providing quality of care across CAMHS were shared. Using the learning system framework devised by the IHI (Provost, 2013), we considered the seven components that would support shared learning.

1. Clarity of your healthcare system

Each team began their projects by developing a process map of their pathway, and collecting and reviewing data describing demand and capacity. This allowed teams to consider their pathways through a different lens, and to start to identify quality issues that they wanted to work on, and theories for how they might improve. Teams were asked to find a meaningful focus for their improvement projects, and many worked with service users and families to think this through.

For greater depth, some teams modeled the demand and capacity of their pathway, highlighting variation and showing how their clinical capacity is currently used.

An example of the output and analysis is as follows:

Where C&H ADHD clinical capacity is used (click to enlarge).

2. System level measures

A dashboard of key relevant measures was developed to allow teams to monitor data while they test changes in their pathway to determine whether they were improvements. The dashboard comprised of some data collected manually by teams and some pulled directly from electronic patient records (RiO). For the teams involved, the data is still available here.

For all teams combined, the following shows the overall impact on waiting times for appointments across the specialist pathways that were involved in the learning system:

The improvements seen across the teams continue to be maintained, with the changes in data aligning with teams’ process mapping and testing changes in their pathways

3. Explicit theory or rationale for system changes

Each team created a meaningful aim statement using their knowledge of their pathway combined with information from service users, available data, and literature sources regarding flow (Mayer and Jensen, 2009). They used Nominal Group Technique and Affinity Diagrams to build Driver Diagrams. They were encouraged to learn from each other and steal ideas shamelessly!

The following high-level driver diagram encompasses the individual project level theories of change:

4. Appropriate segmentation of your patients

The CAMHS Directorate Management Team invited services to express an interest to work on demand and capacity. Pathway teams met with members of the QI team to initiate their project charters.

5. Sequential learning methods

Project teams democratically selected change ideas to test using multi-voting. They based their decisions on their prediction of potential impact. They reviewed data and other feedback loops to determine whether changes were improvements, and to explore the broader impact of changes. Some teams were able to have service users as regular attendees in team meetings.

Using PDSA cycles, teams tested their change ideas, incrementally building confidence in their effectiveness.

6. Multiple feedback loops and regularly scheduled learning events

The QI team supported the running of a 6-weekly learning set bringing the teams together with the directorate leadership for co-learning and co-coaching. The content was designed with the CAMHS leadership in response to how teams were progressing, and was an opportunity to develop a learning community around the projects.

We published a 6-weekly newsletter circulated to all CAMHS staff keeping them updated of progress. Each project was registered on the ‘Life QI’ web platform making data, driver diagrams and updates visible to all trust staff. This helped develop a community around the project. Team leads added monthly updates which formed a monthly report to sponsors.

7. Leadership to keep the organization focused on learning

In addition to the learning system and coaching support, each project had the support of a local sponsor, a directorate sponsor (Clinical Director – Graeme Lamb) and an executive sponsor (Chief Operating Officer – Paul Calaminus). These people ensured that teams were supported to overcome barriers, but also to create the right conditions for the improvement projects to flourish.

While some teams saw fantastic improvements, as can be seen in the dashboard above, it is certainly true that QI projects rarely progress without bumps in the road. Indeed failure is a fundamental part of trying new things, without which we would struggle to learn. The role of leadership is to understand the value in learning from failure, and ensure we are testing in as safe an environment as possible.

References:

Provost, L. (2013) Building a Learning Health Care System. Available from: http://app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-10006/Document-7652/Lloyd_Provost.pdf [Accessed 21st July 2018]

Mayer, T. and Jensen, K. (2009) Hardwiring Flow: Systems and Processes for Seamless Patient Care. Pensacola: Fire Starter Publishing.

Improving access to services through a collaborative learning system at East London NHS Foundation Trust

The focus on this project was to improve access to community-based services, one of four priority areas of improvement work at ELFT between 2015 and 2017. Quality improvement (QI) at ELFT operates on the ethos that improvement efforts should be identified, initiated and led by teams that have the closest proximity to the quality problem.

Click on the image to read more.

Achieving Hospital-wide Patient Flow – The Right Care, in the Right Place, at the Right Time (IHI whitepaper)

While health care systems are making progress toward more value-based, person-centric care practices, the majority of hospitals are experiencing significant operational and financial stress. This IHI White Paper shares strategies, promising change ideas, and resources to help leaders and improvement teams take on the challenge of achieving hospital-wide patient flow.

Click on the image to read the full paper.

Improving access to City and Hackney adult mental health services (BMJ Open Quality)

City and Hackney Adult Mental Health Referral and Assessment Service (CHAMHRAS) is the single point of entry for all mental health referrals to secondary services, with the exception of perinatal referrals, in the City and Hackney region of London, UK. The service was established in 2013 and it was noted that the waiting time for the majority of patients was exceeding the 28-day target set by local commissioners. Indeed, in December 2014, only 30% of patients were being seen within this time frame. The aim of this quality improvement project has been to decrease the average waiting time from referral to first face-to-face assessment, and concomitantly increase the proportion of patients being assessed within the 28-day target period.

Click on the image to read the full paper.

Reducing Time Taken to Complete Neuropsychological Assessments in Memory Assessment Services in Luton and Bedfordshire

Memory Assessment Services in Luton and Bedfordshire have been working hard to reduce time taken to complete  neuropsychological assessment. Read more about their journey and achievement below.

The Psychology members of four multidisciplinary Memory Assessment Service (MAS) Clinics across Luton and Bedfordshire, collaborated on a cross-clinic project to reduce the time taken to complete a neuropsychological assessment to six weeks.

The team, made up of Clinical Psychologists, Trainee Psychologists and Assistant Psychologists used a nominal group technique to build their driver diagram. The team found this method to be inclusive of everyone in the team and an efficient way to decide on the important factors which made up their primary drivers.

Click on the image to see the flow chart ion full size

Since the QI Project spanned over four MAS Clinics, it was vital that operational definitions were clarified so that the data collected were comparable across teams. To do this the team decided to flow chart their assessment process to ensure that all teams were following the same procedures and to clarify when and how data would be collected.

Through process mapping it became apparent that each Clinic had difficulties in different parts of the process. Therefore, the teams decided on testing some ideas across all teams, as well as some change ideas which were specific to their Clinic.

The teams started with change ideas in areas which they felt they had most control over. For example, they wanted to reduce the delay between the assessment taking place and the draft report being available by allocating specific time for this as close as possible to the assessment appointment. Initially this was trialled with one Assistant Psychologist, using a number of Plan Do Study Act (PDSA) cycles to refine the changes to account for competing priorities, before scaling up to all Assistant Psychologists utilising this method.

Implementing this change led to greater efficiency in writing reports, as the information was clearer in mind. Assistant Psychologists report that the new structure helped to manage the workload and clear backlog. Since testing this change, all four MAS clinics have seen reductions in time from assessment to draft report ranging from 52% – 92%.

Click on the Image to see the charts in full size.

The teams have also been testing team specific change ideas through PDSA cycles and have already seen significant reductions in the time from referral to final report. Mid Bedford are already averaging 38.5 days; Luton at 42 days, Bedford is averaging at 39 days and South Beds is at 44 days. Although the aim was to reach 42 days, teams believe more can be done to reduce this time further and are now looking to gain service user feedback to inform their next change ideas.

The project team used a force field analysis to reflect on challenges they faced, such as the changeover in Assistant Psychologists. They also identified that working in small teams meant having to take on multiple roles and manage workloads with competing priorities. However, they found the QI meetings to be a useful platform to discuss these difficulties, which helped the team stay focussed and motivated.

Initially the team struggled to understand the progress of the project in the context of the wider team. However, having clear operational definitions helped them to develop a consistent data collection plan, which led to having visible data to illustrate how the changes had affected their system. This helped them to celebrate their successes and to consider the bigger picture by taking into account balancing measures to provide more clarity on how the system was performing.

The team also shared learning on their experience of running a project across four different Clinics. They recognised that each Clinic had differences in their process, which had to be considered when thinking of change ideas and developing a data collection plan. The project team found QI life to be a useful platform, as it could be accessed from anywhere. Together with Skype and disseminating minutes QI project meetings were made more accessible.

The team also appreciated the energy and enthusiasm bought to the project meetings by the Assistant and Trainee Clinical Psychologists. Project Lead, Emma Ellis has also bought forward great leadership skills to the team, moving the project forward through setting meetings and keeping on top of the process. We look forward to hearing how the project develops over the next couple of months.

Improving access to Learning Disability Occupational Therapy services in Beds and Luton

Please learn more about this completed ELFT QI project from the adjacent poster.

ELFT staff, service users and carers can access full details of this project on Life QI

The project code is 101269 , please log onto your QI Life account before clicking the image below.

How having a solid QI strategy can help teams persevere

Charles Kennedy-Scott QI Coach – Forensics

QI Coach Charles Kennedy-Scott was involved in the Improving Access in City and Hackney Adult Mental Health project, which aimed at allowing 95% of patients to be given a face-to-face appointment by April 2017. In this blog, Charles reflects on how having a solid QI strategy in place can help teams persevere.

In 2015-2016 the biggest struggle with the QI meeting seemed to be consistency. The attendees varied from week to week and there was no fixed nor rolling agenda, so items discussed and agreed one week were often discussed and agreed (differently) the next week by a different set of attendees.

The enthusiasm to keep going seemed to remain though, and this meant that, though slightly haphazardly, progress began to be made. Some of this was due to decisions that were made outside of the QI group. Decisions that had to be made for business reasons, but little by little, progress resulted from ideas put forward by the group. Around this time, more emphasis began being placed on consistent attendees and recording of actions.

When we had QI coach involvement, the project also progressed forward more strongly than when it was absent. The coach provided a focus for the group and she persuaded the group to think clearly and focus on goals and purpose. Whether the group realised it or not, the introduction of measures and tests began to have a positive effect.

The project continued. It was one that had to succeed as it was trying to achieve a strict target set on the Trust. Interestingly, without QI I think it is unlikely that the group would have continued to meet every two weeks over such a long period. But the QI backbone provided structure and almost ‘enforced’ a reason to continue meeting. This was positive. The persistence paid off, and by now good results were being achieved. But not only this, they were being understood better than had they been imposed or simply implemented, as would be usual in an absence of a quality improvement methodology.

At the beginning, with the group and project somewhat in disarray, success seemed far off and unlikely. But the group had to learn and did learn. Not giving up, continuing to meet, brought real and sustained success.

Read more about the project by clicking on the image below:

Flowcharting Guide for Understanding Demand and Capacity

This guide has been created for Improvement Advisors, QI Coaches and/or Project Teams to act as support/guidance when facilitating flowcharting exercises with the aim to develop a deeper understanding of demand and capacity through a service/pathway.

Click on the image to open the guide

Improving the patient booking service to reduce the number of missed Community Musculoskeletal Physiotherapy Service appointments (BMJ Quality)

The East London National Health Service Foundation Trust (ELFT) Community Musculoskeletal (MSK) Physiotherapy Service had reported a high rate of non-attendance at scheduled appointments. This was leading to delayed access to treatment for patients and a reduced capacity for service users, as well as a waste of clinical resources. The aim of this quality improvement project was therefore to reduce the percentage of missed appointments within this department.

Click on the image to read the full article

QI Newsletter – July 2017

Click here to open

Celebrating 2 years of Improving Access to Services Collaboration!

The improving access to services learning system was formed in March 2015. The aim of the learning system has been to bring together quality improvement projects from across the trust working on:

• Reducing Wait Times – Average days from referral accepted to first face-to-face contact
• Reducing DNA Rates – DNAs (Did Not Attend) before first face-to-face contact / total number of appointments booked (excluding cancellations)
• Increasing New Referrals – Total number of referrals received from external referrers (non-ELFT)

Over the past two years, the teams have tested out a variety of different change ideas with the aim to develop a change bundle that can be shared across the wider trust. The learning system has incorporated teams from two different Child & Adolescent Mental Health Services (CAMHS), Adult Community Mental Health Teams, services from Community Health Newham, Memory services and services from Children’s Community Health.

(This graphic shows all teams in the collaborative. Blue are current teams. Green previously involved in the learning system)

Initially these teams came together to meet every six weeks for a learning set, which later transitioned to a six weekly WebEx (web conference), both joined by the learning system’s executive sponsor. All teams would be represented on the WebEx and a couple of projects were asked to present their learning during the calls. The learning sets often focused on specific topics for example; process mapping, text message reminders and implementation. The primary focus was to provide opportunities for teams to connect, share ideas and support each other with overcoming challenges and potential barriers.

Outside of these six weekly learning sets the teams committed to meeting regularly as a project team to focus on their project with support from the QI Lead and tested a variety of change ideas. In addition the learning system developed a bundle of measures and developed an ‘access to services’ dashboard. This dashboard is shared with the services and project teams on a monthly basis and included control charts on the three measures listed above. This provided the teams with an easy way to observe and understand variation in their system and see whether the changes resulted in improvements.

To date the teams have achieved some remarkable results. Across the aggregated teams within the learning system we have seen a 19% reduction in average wait times despite an increase in demand and a 26% increase in the number of new referrals (see figure 1). In addition the teams have achieved an incredible 40% reduction in first face to face DNAs (see figure 1). Almost all of the teams have seen an improvement in one or more of the three measures. (see figure 2)

Figure 1

Figure 2

Improving Access in Children’s Services

The Sickle Cell and Thalassaemia Service

The Sickle Cell and Thalassaemia Service started their QI project in December 2015. The service dedicates time every Friday afternoon to focus on quality improvement and this time has involved teaching sessions on the methodology, presentations and project team meetings. All members of the service are part of the QI project team and this includes, nursing staff, administrative staff, student nurses and service users.

When they initially started the QI project they were focused on reducing waiting times with a large aim to improve all pathways in their service by achieving the following:

• 90% of 0-5 years children have been referred to the service and seen within the 10 working days.
• 89% of children 0-5 have received combined health visiting and nursing assessment and care plan by March 2016.
• 99% of the children 0-5 would have commenced treatment and treatment adherence monitoring 4-6 weeks to 5 years by March 2016.
• 90% of the parents of those children to have received counselling, education with regards to their baby by March 2016

They developed detailed process maps for each of the pathways involved and manually collected extensive data. During one of their QI project team meetings they spent time reviewing the different process maps and identifying areas of particular concern. The team expressed that many of the delays in their processes were dependent on external services for example receiving blood results. Through the use Nominal Group Technique and Affinity Diagram the team highlighted that they were most concerned about referrals that they receive for service users who are over twenty weeks of gestation due to the limited amount of time available to ensure all tests are complete, results received and the service user is able to make an informed decision.

The team reviewed their aim and decided to focus on seeing all women over 20 weeks of gestation but under 22 weeks and 6 days within 48 hours (2 working days) of receiving the results/referral. The team decided to test an emergency clinic and they predicted that this would enable them to be able to offer appointments to any referrals received over 20 weeks of gestation but under 22 weeks and 6 days. The emergency clinic slot took place twice a day, morning and afternoon on Tuesday, Wednesday and Thursdays. They tested this for one week and then decided to send a text message reminder. The team tested different ways to word the text message reminders and finally decided to send text messages that emphasised the importance and urgency of the appointment. Through multiple PDSA cycles the team also developed a plan for those who DNA and were able to identify those who the clinic would not be suitable for.

The team went on to change the wording of the text message reminders sent to all ANC (Ante Natal Clinic) first appointments to be similar to the texts sent for the emergency clinic appointments.  Following the change in text message reminders and the introduction of emergency clinics the team achieved a fantastic 22% reduction in first appointment non-attendance. This improvement in DNAs has been sustained for since August 2016.

The team went on to test the same text message wording with all follow up appointments and this resulted in a remarkable 43% reduction in DNAS. The team are now collecting qualitative feedback on services user’s thoughts regarding the text message wording and are in the process of writing up their project for publication.

The QI Project team also produced a poster based on their project which they presented at the 2017 Annual QI Conference in London. View their poster by clicking the image below

The Sexual Health Service

In addition to the Sickle Cell and Thalassaemia Service another Children’s service has been working on reducing DNAs as part of the Improving Access to Services Learning system. The Sexual Health Team has also tested text message reminders and has achieved a 21% reduction in non-attendance for their specialist clinics.

Psychotherapy services improve access for service users…

All three of the Trust’s Psychotherapy Services have been part of the Improving Access to Services Learning System. They have all been primarily working on improving the wait times and/or non-attendance rates for assessments/first face to face contacts. More recently the services have moved to focus on improving the wait to treatment.

C&H Psychotherapy Service

City and Hackney’s Psychotherapy Service’s QI project has two aims:

1. Reduce the length of time from referral to first face to face to less than 8 weeks in the next 6 months
2. Reduce the wait time from referral to assessment by 25% in 6 months.

The team’s theory was that the current DNA (Did Not Attend) rates may be related to the long wait for assessments. Therefore the team have been working hard to develop a new intervention that they predict will help reduce the wait time to assessment but also reduce the non-attendance rates. They have introduced and tested information and enrollment sessions. These sessions take place after a referral has been screened but before a formal assessment session. The purpose of the information and enrollment session is to provide service users with information about the service they have been referred into and the type of therapy they offer, they also provide information about crisis and manage expectations around the current wait times. Ten service users are invited to attend a session and at the end of the session service users are booked into available assessment slots.

At the end of the information and enrollment session service users are asked to complete a service user feedback form which asks whether they feel the session was useful and whether they are more likely to attend the next appointment. Since they started testing this change idea over 200 service users have attended the information and enrollment sessions and have then been offered an appointment. 90% of service users have fed back that they found the session useful, they appreciate the information and that it had helped them to understand the waits for assessments. Furthermore, of the first 60 service users to have experienced this new pathway, non-attendance has reduced to less than 15%, which is fantastic!

The team are now working on reducing the wait time for treatment. They are currently redesigning the treatment pathways and planning to introduce psycho-education groups.

Newham Psychotherapy Service

Newham’s Psychotherapy service has been working on improving their wait times and non-attendance rates for assessments for the past two years. Alongside MSK Physio they were one of the first teams within the learning system to test text message reminders and ran small scale PDSA (Plan Do Study Act) cycles using a manual mobile phone. The introduction of text message reminders resulted in an incredible 49% reduction in first appointment DNAs. The teams fantastic results created the evidence base for text message reminders reducing DNAs, which assisted in ensuring that the automated text message system became available to other services.

In addition to improving the DNAs for assessments, Newham PTS have achieved an 18% reduction in wait times from referral to assessments. They achieved this reduction by testing a variety of change ideas:

• Reducing the number of queues into the service by reducing the number of specialist assessments. Where possible the team would conduct generic rather than specialty specific assessments as this enabled them to be more flexible with capacity.
• The Referrals Coordinator was able to screen referrals to ensure there was adequate information prior to the referrals meeting. This would enable the referrals coordinator to contact the referrer and gather any further information rather than waiting to do this after the referrals meeting. This allowed the team to make an informed decision about a referral.
• Tested a new referral form which helped reduce the amount of inappropriate referrals and be more objective about the screening process.

In addition to the excellent results that the team has seen, this project is a great example of service user and carer involvement. Thana, an Expert by Experience has been working with the team for a number of months as a key member of the project team. He has been assisting the team in thinking about ways in which they can improve their waiting times but also ensure that the service provides a holistic approach to care. The team developed a leaflet which they believed would help reduce DNAs by reducing inappropriate referrals and improving engagement by providing service users with information about the service that they have been referred into. Thana, alongside the Service User and Carer Steering Group reviewed the leaflet and provided feedback to the project team. Thana was also involved in a session where the team brainstormed a potential new pathway design and he describes this in his blog (https://qi.elft.nhs.uk/quality-improvement-qi-what-drives-this/).

Tower Hamlets Psychotherapy Service

Tower Hamlets Psychotherapy Service has two projects working on improving access to services. The first is focused on improving the length of time from referral to assessment, with the aim to have 100% service users seen within 11 weeks. The team have tested a variety of different change ideas:

• Referral form
• Increasing capacity for assessments
• Call and Book

The call and book change idea was focused on providing service users with the choice of appointments. Previously when the service received a referral the service user would be sent a letter requesting that they get in contact with the service within two weeks. However with the call and book change idea the administrative staff contacted the service user straight away to book them into an assessment appointment. The change ideas tested by the team resulted in an incredible 63% reduction in wait times for assessments. Following the initial testing of the call and book PDSA the team agreed for administrative staff to call the service user a second time if they did not answer the first call.

The team noticed that as the wait time for assessment decreased the number of people on the wait list for treatment increased. Therefore the team started a second QI project focusing on reducing the wait time for treatment with the aim for 95% of service users to be seen within 18 weeks of referral. The team are currently focusing on checking in with service users to see if they are still interested in being on the wait list for treatment.

Improving interventions for parents of children and Young People with Autism Spectrum Disorders in CAMHS

Please learn more about this completed ELFT QI project from the adjacent poster.

ELFT staff, service users and carers can access full details of this project on QI Life.

The project code is 101119 , please log onto your QI Life account before clicking the logo below.

Improving access to Primary Care Psychological services for people over the age of 65

Please learn more about this completed ELFT QI project from the adjacent poster.

ELFT staff, service users and carers can access full details of this project on QI Life.

The project code is 100936, please log onto your QI Life account before clicking the logo below.

Improving access to newham CFCS front door service (CAMHS)

Please learn more about this completed ELFT QI project from the adjacent poster.

ELFT staff, service users and carers can access full details of this project on QI Life.

The project code is 101032 , please log onto your QI Life account before clicking the logo below.

Improving Patient Flow in Memory Clinics

Please learn more about this completed ELFT QI project from the adjacent poster.

ELFT staff, service users and carers can access full details of this project on QI Life.

The project code is 100982 , please log onto your QI Life account before clicking the logo below.

Improving Patient Flow in Memory Clinics

This projected presented at the 2017 Annual QI Conference is aiming to achieve the Prime Minister’s target which is to ensure that 65% of the expected dementia population have a diagnosis of dementia, but we receive high levels of referrals for people who do not have a severe cognitive impairment, our processes mean that the flow from referral to diagnosis falls well outside of the 18week national target, and we often discharge the patient without recording correctly on RiO what the diagnosis is.

Improving Access in City and Hackney Adult Mental Health

This projected was presented at the 2017 Annual QI Conference during the world cafe session.

The project initially focused on reducing waiting times, so that: 95% of patients to be given an appointment for face-to-face contact with any HCP within non-specialist services in City & Hackney within 28 days by April 2017. We are now focusing our testing on reducing DNAs, so that: • We reduce 1st appointment DNAs of referrals to CHAMHRAS to 20% by September 2017

Improving Patient and Staff Experience of Ward Rounds

Please learn more about this completed ELFT QI project from the adjacent poster.

ELFT staff, service users and carers can access full details of this project on QI Life.

The project code is 101090, please log onto your QI Life account before clicking the logo below.

Richmond Wellbeing Service Access Strategy for Older Adults (BMJ Quality)

IAPT (Improving Access to Psychological Therapies) is a national programme aimed at increasing availability of evidence based psychological therapies in the NHS. IAPT is primarily for people who have mild to moderate, common mental health difficulties such as depression, anxiety, phobias and post traumatic stress disorder (PTSD). The programme seeks to use the least intrusive method of care possible to treat people at the time when it will be of most help to them. Individuals are able to self-refer into most IAPT services or alternatively can request to be referred by their GP or other services in the community.

Shewhart Control Chart Selection Flowchart

Improving access to competitive employment for service users in forensic psychiatric units (BMJ Quality)

Employment has been proven to be an effective recovery tool and therapeutic intervention for those with severe and enduring mental health conditions. Aside from monetary reward, employment is a means of structuring time and provides a sense of worth and achievement, which enhances self-esteem and confidence. A social identity is developed through employment, encouraging social support and increasing social networks. Securing employment can bring about improved quality of life and positive change in one’s social circumstances; therefore it can reduce symptoms associated with mental illness and potentially prevent re-offending, as the individual develops a sense of independence, self-efficacy, and value.

The enterprises are underpinned by the philosophy of the Individual Placement and Support (IPS) model; empirical evidence suggests that the IPS model is the most effective intervention, based on the ‘place then train’ philosophy. The model recommends a focus upon rapid job search to achieve competitive employment for those who want to work; opportunities sourced should be consistent with individual preference and benefits counselling offered. Support should be time unlimited and integrated with mental health treatment. A person-centred and strengths-based approach is also adopted to support people to build on their strengths, establish goals, and encourage motivation.

Please click the PDF to the left to read more about this ELFT QI Project published in BMJ Quality

Psychological Medicine in Bart’s: improving access and awareness (BMJ Quality)

Providing good quality psychiatric services to patients who attend general hospital has been an area that has attracted a lot of interest.(1)(2) We know that more than one quarter of general hospital patients have a mental disorder, mental ill health impedes recovery from physical illness, and mental disorders are often unrecognised in patients with physical illness. By improving the quality of our service we hope that we can achieve better integration with the medical teams and thus tackle the aforementioned problems. In our trust, relevant work has been completed by the clinical health psychology team in Cardiac Rehabilitation wards.

Education improves understanding and awareness of mental illness and a care pathway focuses attention on this area, improving patient safety and quality of care.

Improving Access to Tower Hamlets Early Intervention Service (THEIS)

The aim: We will complete assessment, allocate a Care Coordinator and initiate NICE concordant treatment for 95% of patients referred with first episode psychosis within 14 days of referral receipt by April 2016

Whiteboard Flow Chart 2

Robert Lloyd, Vice President, Institute for Healthcare Improvement, uses his trusty whiteboard to dissect the science of improvement.

Whiteboard Flowchart

Robert Lloyd, Vice President, Institute for Healthcare Improvement, uses his trusty whiteboard to dissect the science of improvement.

Flow Diagrams

Creating Flow Diagrams and Process Mapping is used to develop a ‘map’ of a process within a system. It will help you to map the whole patient journey or diagnostic pathway with a range of people who represent the different roles involved. Process mapping can be used to help a team understand where the problems are and identify areas for improvement.

How to use it

The aim of process mapping is to make things clear and to provide insight. The best map is often the simplest map.

There are different approaches to process mapping. Which one you select will depend upon what you need to know, what level you are working at (whole pathway or a small part of it), resources available and timescales.

Start with a high level process map of say 5 to 10 steps which you set a time limit to achieve e.g. 20 minutes. This helps to establish the scope of the process and identify significant issues. Here is a simple example of a high level process map.

Key to process mapping

There is software that can help you to develop process maps but in a group setting you can use rolls of paper (lining paper from a DIY store); marker pens, post-it notes in different colours to represent the four different symbols, flip chart to ‘park’ issues and display ground rules for your session.

Once you have your high level process map you will start to be able to understand how the process works and where there are problems, drilling down into these with more detailed process maps. Further work maybe required to analyse the problem areas identified e.g. seek stakeholder feedback or further data collection. The information and level of detail required will depend on the scope of your project. The Aims Tool and the Driver Diagram may be useful tools to help you clarify this.

Scope

• What do you need to know?
• How simple can you go?
• Are you working at a high-level or focusing in more detail?

Knowing whose views you will need to inform the improvement is important. You should consider:

• Whose views do you need?
• How will you engage those individuals?
• How will you capture their views?

Ideally you will know what your problem areas such as the point in your process where a constraint causes flow to be slowed. This may already have been identified right at the start of the improvement journey when developing your project charter.

© NHS Education 2012

The Science of Improvement on a Whiteboard with Robert Lloyd, Vice President, Institute for Healthcare Improvement