Improving Service User Experience of the Crisis Pathway

Learn more about this QI project presented at the ELFT Quality Conference in April 2018

Please find the team’s poster available here>>

How to access CAMHS QI dashboard

Most teams in the learning system now have access to a dashboard displaying information about how the pathway is working. Please click on the image for more information on how to access the dashboard.

Related Resources

Improving RiO recording of physical monitoring of children taking antipsychotic medication in the Community

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 101037 please log onto your QI Life account before clicking the logo below.

Child and Adolescent Mental Health Services learning set using Skype for Business

The communication platform allowed teams working in various locations to connect and share their experiences. Words by James Stafford (QI Darzi Fellow) and Marco Aurelio (Improvement Advisor)

The number of referrals to community Child and Adolescent Mental Health Services (CAMHS) continues to rise nationwide, posing challenges to teams across the country. Over the past six months, seven of our CAMHS teams have been working to better understand the movement of service users in their system and how they are using their capacity to meet this demand.  Teams are using a range of tools to think through:

• The demand and capacity of the service
• How service users experience the pathway
• The application of improvement methodology to improve their service

The work in CAMHS forms part of a wider trust priority around improving access to community services. In support of this we have worked with CAMHS teams to establish a learning system to bring teams together to share learning and challenges.

Bringing teams together

One feature of the learning system is a six-weekly learning set which allows teams to come together and connect around their work, with the first one held in December 2017. With CAMHS services being geographically dispersed, we wanted to find a way that everyone could come together and be a part of this.

As a result we designed a part-virtual, part-face-to-face meeting model.  Teams had the option to either come to trust HQ at Alie Street or to dial in to the meeting using the Skype for Business function available to the trust via their nhs.net account.  Once we’d worked through setting up and testing how it worked, it allowed us to easily share content and have meaningful conversations. We were able to connect with around 30 staff across five different sites.

We had a combination of whole-group and local discussions, and considered why this work was important for service users, staff members, and for the trust.  Below are some of the things that the teams talked about:

Teams also thought about how they might engage with service users to get more feedback on their pathways, and think about which parts directly add value. It also provided an opportunity to celebrate the progress they have already made, and think about the next steps for their work.

What’s next?

Using technology to bring people together in different geographical locations felt like a challenge, but was a really powerful way to develop connections between staff across the trust. We plan to use Skype for Business for our future learning sets, the next of which is on 31st January. We look forward to hearing from teams about how the work is going and also thinking about what services users experience while waiting for a service.

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.

Improving interventions for parents of children and young people with Autism Spectrum Disorders (ASD) in CAMHS

Laura Roughan, Psychologist, in our City and Hackney Child & Adolescent Mental Health Service, writes about her team’s QI project aimed at Improving interventions for parents of children and young people with Autism Spectrum Disorders (ASD) in CAMHS

Background

In 2015, City and Hackney Child and Adolescent Mental Health Service (CAMHS) devised a pathway model for assessment and treatment. Resources within pathways were limited and the autism pathway comprised of a Child and Adolescent Psychiatrist (5 sessions) and a clinical psychologist (10 sessions) with some additional sessions from clinicians in different pathways for Autism Spectrum Disorder (ASD) assessments. The autism pathway has a large caseload with young people and their family’s presenting to CAMHS for specialist assessment and treatment. There was a need to develop innovative interventions to meet the needs of a large client group, with limited clinician’s time.

Research and guidance in working with children and young people with ASD highlights the importance of timely psycho-education about ASD for parents of recently diagnosed children. Groups such as Early Bird are run in the borough, but have long waiting lists which meant parents were waiting for the initial support following diagnosis. As part of our pathway offer we devised a 2 session psycho-education group for parents. The service user feedback from these groups suggested that meeting other parents of children and young people with ASD was very helpful. However, many parents reported they needed further advice and support to manage their child with autism and wanted on-going access to professional support from a range of professionals (e.g. Occupational Therapy, Speech and Language Therapy, psychology).

In collaboration with colleagues in the multi-agency service (e.g. OT and SLT), we started to develop groups, covering different topics relevant to ASD (e.g. managing challenging behaviour, developing social skills, how to talk about ASD) to see whether this offered parents access to an intervention that helped them feel more able to cope with their child’s autism. Initially there was positive feedback, but attendance dropped and referrals into CAMHS for ASD specific concerns increased. Without a regular offer, parents still wanted individual support which was a challenge with high numbers of families and low staff resource. There was a need for a system to ensure parents had knowledge of the groups, were able to access the groups as well as feel that when they did, the group was relevant and helpful to parents.

We wanted to make the groups more relevant, accessible and effective for families. The Quality Improvement (QI) methodology was implemented to support this process.

Design and Method

The Aim of the QI Project was therefore to develop an ASD parent group intervention that is relevant, accessible and effective for families as measured by:

1) An increase in number of parents attending groups and ensure 50% of parents attend at least one group per a year

2) An increase parent’s perceived ability to manage their child’s difficulties (Supporting parents so they do not need individual work within CAMHS)

3) Parent reported satisfaction in the intervention

The main measure for the project was the number of parents attending each group over a specific period of time (from February 2015- May 2017). In addition, the project aimed to ensure at least 50% of parents of children receiving an ASD diagnosis from the autism assessment clinic had access the psycho-education groups. A service-user questionnaire was devised and given to parents at the end of each group asking parents for feedback about the group (e.g. “How enjoyable did you find the group?”; “How much more confident do you feel in managing your child’s autism?”).

Throughout the project a number of Plan Do Study Act (PDSA) cycles and change ideas (e.g. to run a focus group with parents within the ASD; email reminder system) were  completed, monitored and evaluated in the QI framework to assess the impact change ideas had on parent attendance, satisfaction and confidence in parenting a child with ASD.

Results

A total of 20 groups have been run since the start of the QI project in February 2015 and number of parents attending each group was collected. In total out of 295 attendees, we received feedback from 190 questionnaires were completed out of a total of 295 attendees (a response rate of 64.4% of parents providing feedback).

Quantitative and qualitative responses from the service user questionnaire were analysed. Overall 91% of the attendees were either “Quite Satisfied” or “Extremely Satisfied” with the groups. 82% of parents reported increases in their own confidence in managing their child with ASD following attendance at a group.

Learning

The QI approach allowed us to systematically develop efficient systems and cost-effective ways run interventions within an ASD pathway. The monthly parent groups have been successful in increasing parent’s perceived ability to cope with their child with ASD. From a service perspective it has been a helpful way of managing a large number of parents of children with ASD in the context of limited resources. The monthly groups are providing on-going support where otherwise parents might require costly individual intervention in specialist CAMHS. Using systematic research methodology (QI) is a helpful way to monitor changes and improve clinical practice.

Click here to view the project team’s poster showcasing their work

ELFT CAMHS Services Quality Conference

On Wednesday 28^th June 150 colleagues from across the Trust’s CAMHS services came together to dedicate time to further develop their understanding around capacity and demand issues. Identified as a priority area for the directorate, the aim of the day was to take a deep dive into understanding flow through the services, identify what works well, problem areas and bottlenecks.

The morning began with a creative session, full of musical instruments and arts and craft, to help the services think through what works well and what they are particularly proud in their services. Rounding off the morning Dr Navina Evans, trust CEO, delivered some words of encouragement and opened up the floor to questions from staff.

In the afternoon, teams got together and spent time understanding their services in depth using process mapping. With post-it notes flying everywhere, the teams began to discuss and explore problem areas and bottle necks in their treatment pathways.

An information disco, where staff rotated and connected in small groups, provided an interactive way of sharing learning between the different services. This helped the local services to identify similarities and differences in their pathways, share challenges, key themes and learn from each service about what has been previously tested and implemented.

As an important part of the directorates drive to improve, over the next few months CAHMS will be supported by the QI team to understand the problem more deeply and begin developing some targeted projects to tackle this.

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.

ELFT Experience Day

On 26 April 2017 ELFT hosted 150 international visitors on an Experience Day as part of the International Forum on Quality & Safety in Healthcare event in London. Visitors attended from a variety of countries, including; Angola, Australia, New Zealand, Scotland, Singapore, Denmark, Sweden, Canada, Finland and Norway

During the morning session delegates heard more about the East London Quality Improvement journey, the QI programme itself, our approach to Service User & Carer involvement and got a view from senior leaders on our Board.

In the afternoon delegates visited East London NHS FT sites including:

• Adult Mental Health services in Tower Hamlets, Newham and Hackney
• Children’s Mental Health services in East London
• Community Health Services in Newham
• A low secure Forensic Mental Health facility
• Our Mental Health care for Older Adults service
• Trust Headquarters to learn how QI is used being used by our Corporate Services
• Psychological Therapy services

Visitors learnt how directorates are implementing QI to make improvements in their services. This was a fantastic opportunity for our visitors to engage with staff and service users and hear first hand of their QI experience and learning. Guests were inspired by staff’s enthusiasm and commitment to making their services better.

Some feedback from visitors:

“Excellent to see CAMHS putting QI into practice, excellent projects, enthusiastic speakers. Coburn unit a joy to see, again enthusiastic staff.”

“Excellent work all round. I was very impressed with the enthusiasm and diversity of your staff”

“Thank you for the inspiration and keep up the good work!”

The QI team would like to thank all staff and service users at ELFT who were involved in making the experience for our guests so fantastic!

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.

Improve the quality of care, outcomes and journey for sickle cell & thalassaemia babies and children 0-5 years

A combined specialist Health Visiting & Sickle Cell /Thalassaemia service to improve the quality of care, outcomes and journey for sickle cell & thalassaemia babies and children 0-5 years

This projected was presented at the 2017 Annual QI Conference.

The aim changed over the course of the project and the team have recently focused on the following aim: To see all women over 20weeks of gestation but under 22 weeks and 6 days within 24 hours (2 working days) of receiving the results/referral.

PDSA of the month: Testing out how to collect your project data

By Emma Binley, QI Lead for Newham & Children’s Services 

The Coborn Centre for Adolescent Mental Health is currently running a QI project within the team who work on their Psychiatric Intensive Care (PICU) ward. Their project is focusing on reducing the number of incidents of physical aggression. Since the project first began, data collection has been problematic and the team has attempted to collect data in multiple different ways. The team found that when looking at the number of incidents happening across the PICU as a whole, there appeared to be a frequent spike in the data each time a new young person was admitted/transferred to the ward.

More recently the team decided to start using hourly safety crosses to document incidents of physical aggression, near miss incidents and incident free days. They are running PDSA cycles to find out whether safety crosses are a useful and/or preferred tool for recording incidents. The team are now on their second PDSA cycle and they are hoping that their PDSA cycles will provide them with information on the following:

• Staff members understanding of the safety cross, why they are using it and how to use it.
• If any amendments need to be made to the operational definitions of the colours and/or if any changes need to be made to the cross itself.

This is a fantastic example of how PDSA cycles can be used to test out how teams will collect data before beginning testing out any change ideas.

Active QI Projects – April 2020

This is the monthly report generated from Life QI, showing all active projects within all the directorates.