Looking back and looking forward: the Forensics Violence Reduction Journey

Nynn-Hui Chang – 
Improvement Advisor

This is the story of how eight Forensics wards worked hard to achieve and sustain a reduction of 8% in physical violence and a 16.6% reduction in non-physical violence incidents per 1000 occupied bed days as part of the violence reduction collaborative. Words by Improvement Advisor Nynn Chang.

Last month, Forensics celebrated not only their 2 year anniversary since embarking on the violence reduction journey but also the positive impact noted as a result of the improvement work.  This month, we are going to look back and reflect on how it all started for Forensics, the challenges, and what helped to transform the culture and perceptions towards violence in the directorate.

Why was reducing violence and aggression important to Forensics?

The nature of the service meant that there were higher levels of violent and aggressive incidents compared with the adult mental health wards across ELFT. Reflecting on serious incidents in Forensics, evaluating the leavers’ profiles and staff sickness rates, it was apparent that violence and aggression was centre to it all. Staff did not feel safe at work. It was therefore a priority for the service to improve on safety because the negative impact of violence is not only costly on an operational level but also psychologically for the victims, witnesses, team and ward’s morale. It is a very much a downward spiral for both staff and service users as highlighted in Figure 1 (please click to enlarge).

Fig:1 Negative impact as a result of violence for staff (left of the spiral) and service users (right of the spiral). Please click on the image to enlarge it.

Attending wards’ away days during the early phase of this violence reduction work, it was evident that some wards have reached the tip of the downward spiral. Staff morale was very low, and bank staff will not take shifts on certain wards where a poor reputation has developed from housing very high levels of violence and aggression.

Forensics had trialled different interventions since 2012 such as using the Broset Violent Checklist (BVC) and involving local police post violent incident. However, the impact of these interventions was minimal. Learning from colleagues in Tower Hamlets who succeeded in making remarkable reductions on their inpatients ward, Forensics adopted their change package (safety cross, safety huddles, and safety discussion in community meetings) to test in Summer 2016. Four wards with the highest number of violent incidents in Forensics were selected to be part of this quality improvement (QI) initiative, and together they formed the violence reduction collaborative with one united aim – to reduce violence and aggression by 30% by December 2017. The collaborative expanded to five wards in January 2017, then to a total eight wards by July 2017. The latter three wards came forward on their own initiative wanting to also tackle violence and aggression on their wards using the change package. The aim was then extended to March 2018 to account for the new wards joining the collaborative.

On a collaborative level (aggregate data for seven wards, one ward stopped collecting data in April 2018), they achieved and sustained a reduction of 8% and 16.6% in physical violence and non-physical violence incidents per 1000 occupied bed days respectively. Although it is not a 30% reduction as envisioned, the improvement seen to date means that on a weekly average, there is 1 less physical violence, and 17 less of non-physical violence happening across the seven wards, compared to baseline.

On a ward level, there was a greater degree of success with reaching the aim for a number of wards. Three wards achieved at least 30% reduction with their physical violence incidents each week. Five wards also attained at least 30% reduction with their non-physical violence incidents each week. See table below for the summary of these reductions (please click to enlarge):

Please click on the image to enlarge it.

Did Forensics achieve what they set out to achieve?

Despite not all wards meeting their aim, there were still some significant improvements that the violence reduction work has brought, which cannot be quantified solely by numbers. For example, wards describe a culture shift towards collaborative working with the service users on the wards, building a real sense of community whereby staff and service users are taking ownership in tackling violence together. Before the improvement project, violence was not openly discussed, blame and shame were often associated with violence, and only senior management held the responsibility for tackling violence.

Staff and service user representatives from the collaborative wards also shared what they are proud of as a result of the violence reduction work, and why they felt it is important to make Forensics a safer environment. Hear it directly from them in the video recorded during the celebration event.

Hear it from other staff and service users when we asked if they are feeling safer:

What were the key ingredients for enabling the work?

As with all QI projects at ELFT, there is a QI sponsor. Their main role is to champion improvement projects, and help the project teams to unblock challenges. Hear it from Day Njovana, QI Sponsor for the violence reduction work in Forensics. He reflects on his role as the QI sponsor, the challenges in getting the work started and top tips for overcoming the barriers.

Having a regular monthly collaborative also helped bring people together to stop, think and to go faster with the violence reduction work. It allowed wards that are implementing and testing the change package to connect, learn together and from each other, challenge the perceptions of violence, and build a collective understanding of why it occurs. For example, Bow ward found the value by recording each of their safety huddles as it helped to bring clarity on the agreed plan.  It also improved communication to staff coming on the next shift to know what has been discussed in the previous huddle, for example who is feeling unsafe and which service user will be dissatisfied with their care today. As a result, Bow ward created a safety huddle book. This best practice was shared at the collaborative, and it was adopted by five other wards.

Service users are invited to join in the conversation at every collaborative. They add the richness into the discussion by providing expert insight into why violence and aggression matters and how it occurs on wards. Having service users at the collaborative also gives staff the confidence to involve and work more collaboratively with them on a ward level. One service user on West Ferry ward, which is a Psychiatric Intensive Care unit, described the impact of being involved as part of the safety discussion in their weekly community meetings as follows:

“When you guys first brought it to community meetings it felt like we were being blamed especially when you looked at all those orange and red dots on the map. You found that we ended up arguing amongst us and others would even walk away from the meeting.

Over time, continuing to talk about it made us realise that we were also a part of the issue and we needed to understand how to support each other and live safely as a community.

Talking about violence also made us feel listened to as the whole team was there and we could reflect and how staff or us could work or treat each other to make sure the ward was safe.” – Service user, West Ferry ward

Celebrating success frequently along the way also helped with sustaining momentum with the work. For example, wards took the initiative to celebrate three consecutive green days (incident-free days) with their service users. It created a community approach to make this a priority. It was also a more meaningful and relatable outcome than a 30% reduction in violence and aggression incidents for the service users. This also helps to motivate both staff and service users and building the degree of belief that safer wards are possible with the change package.

Looking forward

As captured nicely by one of the collaborative wards (Ludgate), the violence reduction journey to date has been a bit like “weathering the storm and sailing into the sunset”.

We feel this analogy applies to the overall collaborative journey as well. Sometimes we have to pause and look back on how far we have sailed past the storm. There is still some distance to go, for example focusing on the next strand of the violence reduction work on sexual violence and aggression. It may get stormy again on the way as that is life, but we are better equipped this time round.  So with our heads up, we will continue our journey sailing into the sunset to a much safer work, and therapeutic environment for recovery for both service users and staff.

Project story: Improving satisfaction of staff and stakeholders in forensic receptions

Reception staff at John Howard Centre, a specialist forensic psychiatric services provider in East London, have been working on improving satisfaction levels for service users, visitors and staff. Below is an overview of their journey so far. Read more about this project here >>

Celebrating a 28% reduction in physical violence in Newham

Emma Binley – Improvement Advisor

Newham celebrated a 28% reduction in physical violence incidents as a result of the violence reduction collaborative. The service is now moving to Quality Control. Read more about their journey in this blog by Improvement Advisor Emma Binley.

Newham’s violence reduction collaborative began in June 2016, when all the wards came together to discuss the change bundle that had been tested in Tower Hamlets. Each ward selected the combination of change ideas they initially wanted to focus on:

• Safety Discussion in Community Meetings
• Safety Huddles
• Broset Violence Checklist

Each ward measured the number of incidents of physical violence (red dot) and non-physical violence (orange dot) using the safety cross, which different to the other directorates was displayed in the ward office. Between June 2016 -April 2018 the teams came together for collaborative learning sets every six weeks.

Over the two years of continuous hard work and dedication, Newham achieved some incredible results; a 28% reduction in physical violent incidents across the whole unit with even greater reductions on individual wards.

As the work began to focus on developing quality control systems, Newham decided to run a celebration event to mark the completion of the violence reduction work in its current form and  to thank the staff and service users for all their hard work and commitment over the past two years. In April 2018, staff and service users came together and shared their experience of being part of this learning system and each ward told their story in their own unique way including, a role-play from Topaz ward, poem from Ivory ward and a Rap from Ruby Triage ward.

Each of the wards were asked to share their experience of being part of the violence reduction collaborative and describe the impact of the work on their wards, below is a summary of  some of the comments that were shared. Click on the images to zoom in:

At the end of the event the group were asked if they had any advice for anyone else thinking of working on reducing violence and here is an example from one of the groups:

Similarly to Tower Hamlets and City and Hackney, Newham are now working on refining their quality control board and quality control systems. Their unit-wide safety huddle takes place on a daily basis around their quality control board and they have also developed an audit template, which they share and discuss on a monthly basis at the Senior Nurse’s meeting, with the aim to ensure that the change bundle continues to be used reliably. The collaborative learning sets have now transitioned into Time to Think meetings which also focuses on reducing restrictive practices.

Celebrating Violence Reduction in Forensic Services

A celebration event took place in Forensics on 16 July to mark two years of successful work on Violence Reduction within the service. Watch this space for more details about this work! Words by Michelle Rigozzi, Improvement Advisor.

Michelle Rigozzi – Improvement Advisor

Over sixty people attended the Violence Reduction celebration event on 16th July, including ward staff, service users, executive team members and external partners such as NELFT and CNWL.  As a collaborative, Forensics saw an 8% in physical violence and a 16.6% reduction in non-physical violence incidents by week per 1000 occupied bed days.

Change in Culture

What really stood out was the culture shift towards collaborative working with our service users, building a real sense of community and staff and service users taking ownership in tackling violence.  It was a fantastic opportunity to hear the personal stories and impact shared by staff and service users from each ward as a result of the violence reduction work, and seeing their individual reductions.

Day Njovana, Head of  Nursing for Forensics. presenting at the celebration event.

A service user rightly summarised it in her own words: “It is very important to reduce violence because it is not tolerated. We want to be respected.  Staff respect us and we respect staff, so we don’t discriminate.” More details on this work, including a short film of these stories, will be available at the Forensics Quality Improvement page soon, stay tuned!

Whilst Forensics have successfully moved to talking openly about risk and physical violence and how they can manage it, for various reasons sexual aggression and violence incidents are still rarely talked about in the services.  This is a very real and prevalent issue for staff as sexual violence and unwanted sexual attention can be demeaning and a source of stress and fear. This is going to be the next step for Forensics.

A Rash of Purple Dots

At the event, many dressed in purple to represent a key innovation in Forensics: putting purple dots on the safety cross to record incidents of sexual aggression and violence.  This is a way to encourage frank discussions about this very real and challenging subject.  The use of the purple dots has spread across Forensic wards.  Reports of further innovation across the wards was inspiring, including successful service user-led safety huddles and collaborative care plans.  Artworks representing what the violence work had meant to each ward were displayed around the room during the event.

Keeping Momentum Going

The project teams are now looking at how to keep gains in the long term, that are resilient to changes such as different staff on the ward.  A new wave of work is also considering how violence can be reduced through reducing restrictive practices.

The day had the buzz of real achievement and investment from the participating staff and service users.  A staff member said: “We are proud of the safe space that has been created on the ward, where everyone can be supported and feel comfortable to talk about their distress after the incident”

Another said: “We are proud that it is a collective, MDT- owned response…and the future is great because we have decided as a team that this must continue”.

Forensic services forms part of the scale up and spread of violence reduction work started in Tower Hamlets in 2014-15.

Service user ownership: lifestyle improvement project on Woodberry Ward

Learn more about how service users take the lead in this lifestyle improvement project in the video below. introduction by Courtenay Gilchriest, Support Staff.

Read more about it here.

QI Project story: Introducing genetic testing into routine psychiatric practice

Dr Ian Hall

In the Q&A below, you can learn more about the project and access Dr Ian Hall’s presentation

Dr Ian Hall, Consultant Psychiatrist, East London NHS Foundation Trust and Associate Dean, RCPsych, presented some results of the QI project on Introducing genetic testing into routine psychiatric practice during the RCPsych International Congress in June 2018. In his presentation, he reviewed what recent developments in genetic testing can offer to psychiatric patients and explained how  the team used Quality Improvement methodology to introduce genetic testing into routine practice, in collaboration with the clinical genetic service at Great Ormond Street Hospital.

The project team is also composed of Dr James Smith (Specialty Registrar), Drs Faisal Faruque, George Bruce and Christopher Chung (Foundation Doctors), Dr Kate Adlington (Core Trainee), Niah Gaynair (Lead Speech and Language Therapist) and Vivienne Smith (Clinical Psychologist in training).

What motivated the creation of this QI project and who is involved in it?

We wanted to make sure that people with learning disability had access to the latest developments in genetic testing, as this can help explain why they have a disability, and also help with identifying any health screening they need, and also develop intervention strategies for any mental health problems they may have.

Which change ideas were tested?

We developed a screening tool for staff to use to identify people for genetic testing, and introduced a bespoke training for staff in the community learning disability service.  We developed and tested accessible materials to help explain genetic testing to people with learning disability.  We integrated the offer of genetic testing into our initial multidisciplinary assessment.

What were the main difficulties?

Staff were enthusiastic but had limited knowledge of genetic testing.  We hadn’t anticipated the complexities of explaining results to patients and their families, so have developed protocols to assist with this.

What were the main results/achievements so far?

We now routinely offer genetic testing at assessment for people with learning disability.  Results take time to come through, but patients and their families have found the results helpful, and it had helped us devise specific management plans in some cases.  We have developed excellent working relationships with the Clinical Genetics Service at Great Ormond Street Hospital.

How will this project ultimately improve the quality of life of the populations we serve?

Patients and their families will have a better understanding of their disability, and access bespoke health screening and interventions for their condition. Families can make better informed decisions about having children.

What is next?

We aim to roll out the genetic testing to other learning disability services in the Trust, and work further with people with learning disability and their families to refine the way we offer and explain genetic testing.

You can access his presentation slides in this page.

This project’s Life QI code is 108051. 

Bedfordshire & Luton QI Celebration

On Tuesday 22 May our Bedfordshire and Luton Directorates held their annual QI celebration event at Kings House.

The event brought together 120 staff, service users, carers and external partners to share learning and achievement in quality improvement over the last year.

Presentations included an overview of QI in the Directorates and plans for the coming year, where we premiered the QI in Bedfordshire and Luton collections on the QI microsite, along with their interactive training dashboards.

Our service user led QI project ‘Bridging the Bedford Gap’ shared their work on raising awareness of the Bedfordshire Recovery College, and all delegates worked on a Force Field Analysis to help us think about more ways to get our service users and carers involved in QI.

We heard about Inpatient Innovations from ward staff in Luton and Bedfordshire. Psychology teams shared their work on reducing waiting times for first appointments, and reducing referral to assessment times in Luton and Bedford Community Mental Health teams.

Following a video message from our Chief Executive Dr Navina Evans, our keynote speaker Dr Helen Bevan, Chief Transformation Officer at NHS England, gave an inspiring presentation on ‘Rocking the boat and staying in it: Bringing change to health and healthcare’, followed by a panel discussion with Helen and local leaders.

One of the highlights of the day was a performance of ‘Change is gonna come’ by Marie Miller, who brought the house down singing an adapted version of the song with QI lyrics (thanks to Charmaine Elliot), check it out on Twitter!

You can find access all slides on the QI microsite and see highlights from the event in the short video below. We look forward to more great QI work coming out of Bedfordshire and Luton in 2018!

Click image to find more photos from the day

Co-producing Quality Improvement with Service Users in Tower Hamlets

Learn about the benefits of service user involvement in this blog written by service users and staff working at the Isle of Dogs QI team, with the supervision of Francisco Frasquilho (Coach and Improvement Advisor supporting Reshaping Community Services) and Emma Binley (Improvement Advisor supporting Reshaping Community Services).

“If you look at history, innovation doesn’t come just from giving people incentives; it comes from creating environments where their ideas can connect.” – Steven Johnson

Without service users being part of quality improvement work, even with all the best will in the world, work risks losing direction and purpose as other system pressures impinge and take over. Working collaboratively with service users has been vital to the progression of the Reshaping Community Services QI priority area. This particular journey began with two people who have personal experience of mental health services and wanted to share their learning and knowledge. They are both intent on helping others understand their experiences and keen to build relationships both within the team and with other partners, such as the local recovery college. This has now grown to involve more services users and staff over the last few months.

We have been working together with the Isle of Dogs and South Poplar Community Mental Health Teams (CMHT) on the Reshaping Community services QI project and the team was keen to share their experiences with others. The stories of their journeys are illustrated below in their own words*.

What has it been like working together on the QI project?

 “My Care Coordinator spoke to me about this opportunity. Because I had attended Recovery College and other courses in the past, I thought that I would come along.  Initially I thought that all I would do is presentations about my illness; but it’s more than that. My opinion is important and the workshops have shown me that I am important and that I can make a difference. We work as a team of equals. We have built a relationship based on respect and shared ideas.  I liked how the team’s Operational lead explained our ‘being equal i.e. everybody is a service user because we all use our GPs, Dentists’. Our experiences of using different services make us equals. I like how our workshops are structured. We have a lot of questions but we don’t necessarily have answers. The good thing is that we think about how, where and what kind of answers we are looking for including the possibility of not getting an answer. The workshops are supportive because we have a say on how the service can be improved. I hope that this experience will help others; both staff and service users and will hopefully lead me to future employment.”

“My Care coordinator talked to me about this project and encouraged me to attend. He told me that the project would be about how we can improve the service. We were asked about our experiences and how we felt. We were also asked about ideas, what small changes can be done quickly to make amendments and big changes to make the service better. The timing of the workshops was perfect for me. I was experiencing isolation and motivating me to get out of the house was a challenge.  The meetings gave me something to look forward to, they gave me a sense of value, of purpose. That’s the way it makes me feel and that’s why I also feel emotional. It has happened at the right time for me. Things are falling into place.  I’m just so happy. Every time I’m coming out, I’m learning new things, learning importance of coming out of the house, of having a focus. The meetings have helped me develop; I’m gaining and building my confidence. I really like the questions we ask ourselves as it makes us think. I am changing and I am positive that we are going forward.”

“In my current role, I have little face to face interaction. The project has given me the opportunity to understand our team’s role in the wellbeing in the life of service users. For me it has been enlightening and brought me a sense of purpose. I can see the direct results of working with service users and it has been a unique experience. This work has allowed me to focus my attention on the service user primarily; much of this stems from the idea that we are all service users. Therefore we should provide services that we would be happy to use ourselves and this helps shift the focus of how we would like to provide services. Working with service users has facilitated to understand the needs of those who use our service which motivates us to improve everything that we do.”

“Participating in this project has been a really good opportunity for me. At the start, I recognised that I was anxious working with service users as face to face contact is limited in my daily role. As I got to know everyone in our team, I also related to how our service users felt.  I thought at times that I didn’t know enough and that I myself was not confident. Working together has made me realise that our confidence and learning is not limited by how we identify ourselves, i.e. as a staff or as a service user. I am really looking forward to our continued learning.”

Why is this collaboration between service users and staff useful?

1. The way you [as a staff member] relate to us – make us feel comfortable, saying that you are a service user yourself. Sharing your experience with us – revealing that you have diabetes, for example. This is part of our change idea of how to make people relax.
2. Genuinely asking us what we think …. Prompting question in a non-judgemental way
3. Willingness to meet either as part of the project or outside like the Recovery College.
4. Showed us that we are important and we can make a change
5. Talking about possibilities and hope
6. Trusting us
7. Respecting each of us and listening to our views. Everything is discussed in the room and not in third parties.
8. Making us feel valued and important.

It is this sense of working alongside, and with others, that has amplified this work. The inspiration has been powerful and energising. This work continues to grow. If we are serious about improvement work then we must have service users at the core of it.

* Names were removed to respect wishes to remain anonymous.

Improving Support to Informal Carers in Community Health Newham

Thana Narashiman, QI Communications Assistant interviewed Anthony Edwards, an Occupational Therapist (OT) working at ELFT and also a full-time carer to his late wife. The interview is based on Anthony’s incisive report which exposed the gaps in provision of care and support provided by various services. This resulted in a QI project in the Community Neurology Team.

What was the genesis for this project?

During my role as a full-time carer for my late wife, who battled a brain tumour from 2012-2014, I identified a number of gaps in the provision of services by Acute, Community, Hospice and Social Care staff. All of the staff were very caring and dedicated, however the effectiveness of the hands-on care I provided was compromised mainly due to lack of guidance and hands-on training for the health related care tasks I carried out; and also because it was difficult to navigate a complex Health and social care system. It was the family’s wish for my wife to be cared for at home. My experience as a both an Occupational Therapist and a full time carer led me to compile this report; and it laid the framework for a Quality Improvement (QI) project.

Joanne Raphael, John Kauzeni, Rozi Hamilton, Charan Saduera and Maloles Munoz-Cobo

What was the impact on you personally as an Informal Carer?

Due to the gaps in services, my own physical and mental health was affected and that of our young children. More importantly it had some impact on the comfort and dignity of my wife. I felt that the care I was providing as an informal carer could have been safer, more effective and more dignified had the gaps in services been identified earlier.

What were the identified service gaps?

No signposting of emotional/psychological advice/input during diagnosis to both patient and family; No guidance to carer regarding medication, preventing pressure sores and managing falls or managing seizures; The absence of a key worker or co-ordinator for carer or patient which manifested in perceived disjointed care and advice; No advice regarding self-referral for Local Authority Carers Assessment / Financial Advice (Benefits and Pensions) which would have assisted on social aspects.

Was it easy to navigate the patient pathways?

I have many years’ experience as a professional health worker, which enabled me to self-advocate and navigate the myriad health and social care systems. However, I feel that most patients, carers and families would be unable to navigate the current complex health and social care pathway systems, and advocate and co-ordinate care well for their loved one.

What was your QI proposal?

I decided to form a multi-disciplinary QI Project group and also managed to secure the participation of another “expert by experience” carer who had personal experiences of caring for an adult son with complex mental health needs. The aim of the project was mapped as listed below.

Who was your QI Project Group?

Our multi-disciplinary group comprised of , The Community Neurology Team, Physiotherapist, Health and Social Care Navigator, our local People Participation Lead (PPL) , Community Matron, Palliative Care Occupational Therapist ; and member of a Governance Team. And of course other carers as part of the philosophy of engagement with both service users and carers though our Working Together Groups. The experiences collated from within the group and with working with service users and families resulted in our main change idea for this project: “Support Informal Carers (unpaid/family carers) through improved assessment of their needs so they are better equipped to care for their loved one.”

Could you please expand more about improving “needs” assessments?

In physical health for family carers there are very few standardised holistic assessments forms to assess needs.  There is one example with UK Palliative Care-The Carers Support Needs Assessment , although within mental health and dementia services greater strides have been made.

How did you improve on the assessment of carers in physical health areas?

In order to better assess Informal carers’ Support Needs we have devised an Informal Carers’ Checklist to meet the needs of informal Carers of patients in Community Health Newham. We have drawn on project member’s professional experience, and their experience of being family carers; and good practice which is now clearly stipulated in policy document from: The NHS England Commitment to Carers Document (2016).  This requires CCGs (Clinical Commissioning Groups) to commission services that address and improve the emotional, physical, and educational, employment, leisure needs of Informal Carers.

Why is this assessment important for carers?

This is important as many Carers experience high levels of isolation; depression; stress, physical ill health; injury; and some find it hard to maintain or resume social networks, employment and leisure activities. Our discussion with informal carers via a confidential survey suggested that there are additional issues that needed to be considered like accessing services like Community Dentists and Opticians.  Moreover, access to leisure and social activities and employment were equally important, but were currently not fully addressed. The report’s recommendations were provision of good quality access to practical and emotional support with professionals sharing information and decision making with carers.

How did you further enhance the checklist?

The involvement and input of carer members in our project group has greatly enhanced the scope of our checklist in potentially meeting Carers Needs notably with the addition of a number of extra checks/questions to ascertain carers support needs:

“Would the carer benefit from an assessment for respite care for their loved one?”

“Access support and guidance for accessing other services such as Community Dentists, and Community Opticians?”

“Advice on managing and attending medical appointments for your relative/loved one?”

“Advice and support related to leisure and social activities; and /or employment?”

Our draft Informal Carers Checklist is currently being piloted over a two month period with 10-15  informal carers of stroke patients in our Community Stroke Team with baseline measurements recorded for satisfaction before and after the pilot. We are also measuring the confidence levels of the multi professional staff within the Team (EPCT) to support the holistic needs of informal carers.

You can learn more about this project here

This project’s Life QI code is 100791. It was also presented at the 2018 annual Quality Conference. Find out more here.

If you are part of ELFT, you can also access the Community Health Newham, Adult Services Carers Handbook here

QI Project Story: Improving the disciplinary process at ELFT

ELFT’s human resources department has already seen a reduction from 107 days to 52 days in the time taken from start to completion of the process, but other challenges lie ahead. Read this blog by the HR team on how this Quality Improvement project is developing.

The specific aim of the project was to reduce the length of time taken to conclude 80% of disciplinary processes in 115 days or less.

There has been an increasing focus on the application of systematic methods for quality improvement in healthcare, with a growing body of evidence suggesting benefits across clinical settings. The approach adopted by East London NHS Foundation Trust (ELFT) incorporates extensive efforts to engage and involve staff and service users, build improvement capability at scale and embed continuous improvement efforts into daily work.

ELFT has been using quality improvement to tackle complex quality issues such as violence on in-patient wards, patient waiting times and community-acquired pressure ulcers. We chose to focus on Disciplinary Processes as there was a wealth of data available to us and a real desire in the Trust to improve the process and reduce the amount of time taken in resolving disciplinary issues and also the over representation of BME staff in the process.

The team used quality improvement to guide their work through not only the design and implementation phases of their project, but also to ensure sustained levels of engagement from all of those who were involved. The specific aim of the project was to reduce the length of time taken to conclude 80% of disciplinary processes in 115 days or less.

To achieve this, a number of change ideas were tested including reducing the preliminary report to a one page document, introducing a meeting between the commissioning manager, line manager and HR, pairing experienced investigation officers with non-experienced investigation officers, among others. The combination of a number of change ideas including offering a hearing date at the outset of the process culminated in a reduction of time it takes to conclude a case from 107 days to 52 days.

In the year prior to the project, the average number of days that staff were suspended was 104 with an average cost of £296 per day. By reducing the length of time that a case took to be heard by 50 days resulted in a saving of £429,200 in a year based on a case rate of 29 per year.

In the three year period up to November 2015, 16% of cases that progressed to a hearing resulted in no case to answer. Between January 2016 and January 2018, only 2% of cases resulted in no case to answer, which shows improvement.

We have introduced an agreed outcome process where staff admits the alleged misconduct; they can agree to accept a written warning without the need to go to a formal disciplinary process.

Agreed outcome represents 19% of the disciplinary cases. Whilst there is a significant increase in the number of disciplinary cases overall, we can say that there has been a shift in the organisation’s culture in terms of taking formal disciplinary action against medical and dental staff. We can also conclude that the number of cases that result in no case to answer has reduced significantly from 16% to 2%. Also, 19% of cases avoided going to a formal hearing as a result of the agreed outcomes process.

However, there is still a disproportionate effect of disciplinary processes for black staff which has increased, whilst the proportion of white staff has remained the same. In terms of the internal processes, we have centralised employee relations activity to improve the consistency of disciplinary sanctions. We are also in the process of rolling out a fair treatment process to triage disciplinary cases before they progress to formal investigation. The Trust are moving towards a performance culture by implementing performance rating for agenda-for-change staff, as part of the appraisal forms to enable managers to have performance conversations.

We have also reviewed and re-launched the Trust Disciplinary Policy and Procedure, significantly reduced the number of suspensions and, where practicable, assigned staff to have alternative duties. Previously we had 89 suspensions and now we are reporting 51 suspensions. Additionally, we have seen a reduction in the number of cases reaching an employment tribunal. At the last report there were 13 live employment tribunal cases compared to 5 currently.

Ethnicity and disparity

Whilst ELFT has a culture of inclusion supported by a highly diverse board, including BME female CEO and Chair, it also faces similar challenges to other London Trusts across a range of Workforce Race Equality Standard (WRES) indicators.

A review of all employee relations cases in the past three years was undertaken alongside the project with the aim of reducing the number of BME staff over represented in Disciplinary processes.

Lessons Learned

We learned through analysis of 3 years’ worth of employee relations data that it was black or black British nurses in band 5/6 positions who had been with the organisation for over 3 years that were more likely to be disciplined than other staff. This helped us learn about the importance of deep analysis of data to understand the differences between types of staff who are being disciplined.

We have also learned that the project team and change team set up are crucial to the success of the project, ensuring the right people are in the team and that they have some ground work as a team about how they will work together as well as what they will be doing.

The project team trialled changes to see if they worked before incorporating them into policy, by trialling changes that were outside of policy which had implications for further process so had to be clearly identified and communicated, particularly to staff side colleagues.

Another valuable lesson is that you don’t always get what you expect – it was anticipated that a reduction in overall cases would impact positively on the number of BME staff being disciplined. However, whilst cases have reduced, the ratio has not shifted in the way we would expect. Therefore, a more targeted aim statement will be developed in the next iteration of the QI work on disciplinary and a new driver diagram developed to support this.

Finally, we learned that it is important to support staff by giving them time and space to focus on QI work.

Luton Wellbeing Service: achieving enjoyment at work through engagement and communication

In this blog, the Enjoying Work QI team at Luton Wellbeing Service share their journey towards increasing the percentage of staff having a good day at work from 55% to 75% in four months. Words by Kelly Gale (Improvement Advisor) and Sharon Gugerly (Project Lead).

Luton Wellbeing Service was one of services at East London NHS Foundation Trust that volunteered to be an early prototype team for Enjoying Work, which is aimed at helping increase staff experience of work using quality improvement methods.  The team comprised of Sharon Gugerly (Project Lead), Douglas Hiscock (Coach), Brian Toye (Sponsor), Jen Taylor-Watt (Improvement Advisor), Giap Huynh, Sandra Brown, Syed Ali Naqvi, Faz Parker (Team Members) and  Shefa Begum (Business Partner – Human Resources).

The project was launched in June 2017 and the first task was to gather baseline data using the online survey tool Survey Monkey.  The survey asked all staff to rate their day using the Likert Scale:

To what extent do you agree with the following statement?:

Did you have a good day at work yesterday?

The answers on the Likert Scale were:  “Strongly Disagree”, “Disagree”, “Agree”, “Strongly Agree”.

All staff members were asked to complete this daily for the month of June and 185 responses were collected. Of those, only 55% said they “Agreed” or “Strongly Agreed” that they had had a good day. Using that baseline as starting point, the team created their driver diagram and identified which factors they needed to work on.

The team used a board to communicate with staff.

From the responses to the survey and from engagement sessions with the whole staff team, four themes emerged which were contributing to people not have a good day.  They were: Stress, Work Environment, Management Communication and IT.

The staff engagement session had developed many change ideas, so all staff were invited to rank them in order of importance, so that the project team could start on identifying change ideas that meant the most to most staff.

Some ideas were tasks, things they could just get done without the need to test first. Staff were also asked to rank these in order of importance to them. The results from the staff ranking were acted upon and a communications board was placed in the main staff area so that everyone could be informed and kept updated as to what was happening.

Changing the way the whole team meeting was used and executed was ranked as the number one change idea, so the team started a PDSA (Plan, Do, Study, Act) cycle on how they were going to do this.

Changing the time of the meeting was the first thing that they tried; this was quite successful with the team. The next change they agreed on was to add a lunch break in the meeting as it was conducted over the whole of the lunch period.  Their third cycle was to have a much more structured meeting with an agenda and a way of providing feedback about the meetings.

The team created a Kanban board, the board was a great success as the staff team were able to see what had been completed, what was in the process of being done and what was lined up to do next.

Kanban board

The whole team were asked to continue completing the survey throughout the project to see whether the changes and improvements being made were having the desired affect and whether this would be reflected in the data.

The percentage of staff members who responded with “Strongly agree” or “Agree” that they had had a good day increased from the baseline of 55% to 75% and this was being maintained.

Towards the end of 2017, the service was commissioned to a different provider, which meant that it would be transferred from ELFT. Staff enjoyment at work was subsequently affected and the project team decided it was not viable to continue with the project in its current format.

Although they were not able to run the project in its entirety as they intended to, they used the learning and structures they had developed to refocus the work on supporting staff during this period of change. They also took time to capture and share some of the outstanding work and valuable learning from their original project.

The lessons from the project are:

Complete the small tasks first – this shows that things will be done and encourages others to become involved and builds the momentum for the others to join in.

Involve the whole team:  the project was designed to help everyone in the team and the more of the team involved, the better the ideas generated and the outcomes will be.

Clear communication:  Let everyone know what is going on, get everyone involved and keep them updated.

If you are part of ELFT and are interested in taking part in an Enjoying Work project please click here to know more.

—–

Learn more about this project on Life QI – Project Code #103865

East London NHS Foundation Trust (ELFT) has been using the Life QI platform since June 2015 to manage our Quality Improvement (QI) portfolio. Projects are proposed, approved and worked on through the platform. Learn more about how important this platform is in this blog by our Data Manager Forid Alom. 

Pursuing enjoyment at work within the ELFT Quality Improvement team

In this blog, Deeksha Mehta, QI Principle Information Analyst and Project Lead, shares her experience with the Enjoying Work project.

Deeksha Mehta

We began thinking about improving our enjoyment at work when we kicked of a whole team project in June 2017. Initially we undertook an appreciative inquiry and began to gather some baseline data about whether or not people were having a good day. At first people were keen to share what was holding them back and we were able to quickly build a driver diagram and develop some change ideas.

However, over time we found that interest in the work from the wider team was mixed and people were less forthcoming about providing feedback and contributing to measuring our enjoyment at work. On reflection this made sense; people had provided feedback but as a project team we had struggled to be responsive to this, get to testing ideas and being transparent.

As part of the wider trust learning set on enjoying work we had an opportunity to learn from the other 6 pilot teams around the trust doing this work. One great idea we learnt about was the Kanban board that Luton IAPT had developed as part of this work.

The team used a board to communicate with staff.

A Kanban board is a visual management tool that lets people know what tests of change are planned in progress and completed. We’ve recently introduced one of these to help develop team engagement more and develop transparency around the work.

An important part of the work we have done recently was developing our anonymous We Care survey. This was an opportunity for the wider team to give some more feedback about things that were still affecting them and provide some ideas about how to change it. In addition to this, it also provided an opportunity to see if our original driver diagram still reflected what was going on within our system.

We would like wrap up my story with a quote “If you focus on results nothing changes , if you focus on change you will see the result”.

If you are part of ELFT and are interested in taking part in an Enjoying Work project please click here to know more.

Learn more about this project on Life QI – Project Code #105547 .

East London NHS Foundation Trust (ELFT) has been using the Life QI platform since June 2015 to manage our Quality Improvement (QI) portfolio. Projects are proposed, approved and worked on through the platform. Learn more about how important this platform is in this blog by our Data Manager Forid Alom. 

QI Project Story: City and Hackney Home Treatment Team

In this video, Florence Agyemang reflects on her team’s journey in the process of reducing the rate of undocumented medication doses in the City & Hackney Home Treatment Team.

Florence Agyemang, a Clinical Lead in the City and Hackney Home Treatment Team, is taking part in Wave 7 of the Improvement Leaders’ Programme, which is about to graduate. She is part of a Quality Improvement project that is aimed at reducing the rate of undocumented medication doses in the service to 5% by the end of April 2018.

An audit carried out in February 2017 showed that 36% of medication doses due to be signed for in the previous week were undocumented on the medication chart and this was what instigated the team to take action.

Since then, they have implemented several PDSA cycles with strategies that helped them reduce the number of undocumented missed doses and waste so far.

Learn more about this project on Life QI – Project Code 100895.

East London NHS Foundation Trust (ELFT) has been using the Life QI platform since June 2015 to manage our Quality Improvement (QI) portfolio. Projects are proposed, approved and worked on through the platform. Learn more about how important this platform is in this blog by our Data Manager Forid Alom.  

QI Project Story: Bridging the Bedford Gap

Read about how the team overcame challenges and are celebrating achievements in this blog by Felicity Stocker, Satwinder Kaur, James Patrick, Kamila Naseova, Kay Sookun and Evri Anagnostara.

Left to right: Satwinder Kaur, James Patrick, Kamila Naseova and Felicity Stocker.

The Bridging the Bedford Gap project aims to raise awareness of the Bedfordshire (and Luton) Recovery College (RC), and improving access to it. It aims to encourage diversity, promoting People Participation and learning about Quality Improvement. The team is also committed to being together and having fun, and to look after each other.

The team consists of a Recovery College manager, Ward managers, people participation lead and three service users: Felicity Stocker (Project Lead), Satwinder Kaur (Tea Party Poetry workshop facilitator) and James Patrick. The whole project is very much service user led.

The project started by inviting a number of service users and carers to an initial meeting in the summer of 2017, where we introduced the QI concept and asked all those that attended what we should focus on. We did a brainstorming session in which everyone put one idea on a post-it note and we then scored this according to our priorities.

The project that got the highest rating was the Recovery College. We all felt strongly that patients who are on the wards, which are located in Luton, can feel they are far away. The project then would work on ways to link them back to the Bedford community and the fantastic RC.

We decided to start on Oakley Court, which is formed of two wards: Ash and Willow. They both offer care for male patients from Bedford Borough and Central Bedfordshire, and are based in Luton. We had a fantastic response from the staff who gave great encouragement to the patients who wanted to take part in the initial project.

Before delivering workshops we gathered initial data for four weeks to gauge the knowledge of Recovery College by patients and staff. Then we started the first PDSA (Plan, Do, Study, Act) cycle: a Tea Party Poetry Workshop led by Satwinder Kaur. We plan to offer other sessions on People Participation, Recovery College Brochure walkthrough or work on discharge packs.

Since the beginning of the project we have faced several challenges, such as getting initial approval for the project and communication between team members. Travel to Oakley Court from Bedford takes time both by car and public transport. Also, patients are admitted and discharged, so the continuity is not as good as we would like.

On the other hand, we have certainly seen some achievements. We have had excellent feedback from ward patients following the Tea Party Poetry sessions, and also buy-in from ward staff. Satwinder Kaur, the facilitator said: “It has been a long journey from losing my identity to mental illness to finding my voice through my passion of Tea Party Poetry. Service users look forward to future sessions”.

In the light of all this, we can now say that being familiarised with the ELFT QI methodology has enabled us to learn about how to communicate within the team and with the outside world, to meet new people and to overcome anxiety. We have also been supported by our QI coach, Anna Smith. She is creative and encourages us to test our ideas. We are certainly feeling much more confident now.

We are now keen to see how our PDSA cycles are influencing the initial data and want to see how we can share our findings across the Trust.

Learn more about this project on Life QI – Project Code 106961

East London NHS Foundation Trust (ELFT) has been using the Life QI platform since June 2015 to manage our Quality Improvement (QI) portfolio. Projects are proposed, approved and worked on through the platform. Learn more about how important this platform is in this blog by our Data Manager Forid Alom.

Becoming an improvement leader: Wave 7 project stories

Discover how people have evolved through their QI training journey and practical learning.

Those taking part in the Improvement Leaders’ Programme spend eight months immersed in practical Quality Improvement learning. The course covers the basics of QI, useful tools, measurement and data analysis, driver diagrams, PDSA, reliability, implementing and spreading results, and learning from other projects.

We have spoken to Carlos Santos, Community Psychiatric Nurse, and Edward Lander, Operational Team Lead, both part of the Wave 7 of the Improvement Leaders’ Programme, about their journey. They are part of the Recovery Team South service (Newham Adult Mental Health), which is currently working on a Quality Improvement project to increase satisfaction and efficiency through the Recovery Pathway.

The problem that instigated the team to launch this project was high outpatient clinic caseloads. The team is committed to improving service user and staff satisfaction levels and the aim is that 90% of staff and service users report satisfaction with care by December 2018.

In this video, they reflect on their journey so far and how training and development helped them with their journey within QI.

Lisa Clarkson, Head of Quality at Newham Clinical Commissioning Group (CCG), is also part of the Wave 7 Improvement Leader’s Programme. Due to her role, she had already been exposed to QI methodology. She was later invited to a QI Forum and to take part in the Improvement Leaders’ Programme.

Here are Lisa’s thoughts on her QI learning journey.

For more information on the ELFT QI method please click here. For details on our training options for staff, service users and carers, please visit this page. If you are not part of ELFT and want to know more about how we work, please follow us on Twitter of join our next open event.

Connection and involvement towards violence reduction in City & Hackney

Find out how collaborative work helped City & Hackney achieve an outstanding 57% reduction in violence across all adult mental health wards. Words by Kelly Gale, Improvement Advisor.

Kelly Gale, Improvement Advisor

City & Hackney Adult Mental Health Service began a project on Violence Reduction in the summer of 2016. Violence was an issue in varying degrees across all six wards in the unit, so an improvement collaborative was formed to work on reducing violence together.

Each ward started testing change ideas such as safety huddles and safety crosses and recording the data. The wards would also regularly meet to compare their findings and results. This collaborative working enabled the ward managers and staff teams to learn from each other on what is working well in each area and work out ways in which the improvements made could be increased.  It also created some healthy competition between the ward teams, which made them strive for improvements.

Through this joint working, the ward’s safety huddles also became unit-wide huddles. This gave the ward managers a way of knowing exactly what is going on in the other wards and gave them ways of helping out their colleagues if they were in difficulty that day – a true collaborative working.

Results were presented to staff, carers and service users at the end of 2017.

The wards achieved the phenomenal results of reducing violence and aggression across the wards by 57%. This level has been maintained and the project is now going into quality control. This means that it has ceased to be a standalone project and the changes have now been adapted into the normal working style of the wards.

To ensure that these levels are maintained going forward, the violence and aggression data is still being collected daily as part of their usual routine and the ward managers meet regularly with the Borough Lead Nurse/Associate Clinical Director to review the results, which are also then being reported to the Directorate Management Team (DMT).  It is only through a joint, all levels approach that we can ensure the levels of reduced violence are continually on everyone’s radar and that there are systems for it to be maintained long term.

If you want to know more about the City & Hackney Violence Reduction collaborative please access The City & Hackney Violence Reduction Collaborative page.

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.

Successful QI project achieves waiting times reduction

The Improving Access to Learning Disability OT Service established a QI project with the aim of reducing waiting times for all referrals to 18 weeks. Click on the image to read more details.

A successful Quality Improvement (QI) project has achieved a sharp drop in times Learning Disability (LD) service users wait to access a Bedfordshire and Luton service. The Improving Access to Learning Disability OT Service established a QI project with the aim of reducing waiting times for all referrals to 18 weeks. The average wait at the start of the project was 27.05 weeks. The average wait now is 15.45 weeks.

Access the details by clicking on the image

The team had been working with a large waiting time from referral to start of intervention. Service users requiring Sensory Integration (SI) intervention were waiting up to 70 weeks. The SI patients were waiting longer because other patients with higher priority/risk needed more prompt intervention and would be prioritised.

The team used QI to re-think how the system operated and try to make the change from a reactive system to proactive. The need for change was also highlighted by the CQC during the service inspection in August 2016. The longest wait for SI referrals at the beginning of the project was more than 70 weeks. It has dropped to 21 weeks.

A driver diagram which became the team’s framework for change was designed following a brainstorming session. Change ideas that were tested included establishing telephone triage, use of smartphones for wifi and establishing a standard for the number of sessions expected for different interventions.

Project lead Debbie Alaluf, Senior Specialist Occupational Therapist and Sensory Integration Practitioner, said: “We are delighted with the results. The QI project has enabled us to review our total way of working.” QI coach Sarah Stilwell provided support throughout the project. “QI provided the tools needed and the team provided the energy, expertise and desire to drive positive change,” she said. “They were fantastic.” The QI project poster and more details are available here.

Trust Board QI Story: reducing waiting times at Luton CMHT Psychology service

Dr Timothy Sporle, Consultant Clinical Psychologist, presented some results from the QI project aimed at reducing wait times for 1st appointments in Luton in the latest ELFT Trust Board meeting. The presentation is available below.

The Luton Community Mental Health Team (CMHT) Psychology service has seen a 50% drop in first contact wait times over the past few months, as a result of change ideas put into practice as part of a QI project. Dr Timothy Sporle, Consultant Clinical Psychologist, presented results from the Reducing Wait Time for 1^st appointment QI project in the ELFT Trust Board meeting, which took place on 14 December 2017.

Service user waiting times to first face to face contact was between 11-13 weeks before July 2014. There was also evidence of lack of service user knowledge about the psychology assessment, whilst staff also felt that receiving more information before an assessment could be more effective.

In an attempt to tackle those problems, the team then implemented a Psychology Awareness Programme (PAP) as a change idea. The programme is comprised of three group sessions and allows service users to gain more understanding about the service. Also as a result of the programme, service users are receiving wellbeing advice more quickly and are encouraged to think about their goals early on.

“By the time they reached their first assessment, service users were better informed about the process”, said Dr Timothy Sporle. The team is now focusing on processing staff and service user feedback in order to refine the PAP programme. The project will also concentrate on assessing whether the introduction of the PAP could also have led to a drop in DNA rates for first assessments.

The slides prepared by Dr Timothy Sporle and Assistant Psychologist Ros Humphreys are available below:

Celebrating 65% reduction in violence and the impact on staff and service users through the City & Hackney Violence Reduction Collaborative

Jane Kelly, Associate Director for Inpatient Services & Lead for the City & Hackney Violence Reduction Collaborative, supported by Jen Taylor-Watt, Improvement Advisor for City & Hackney

In early 2016, a person was injured every 3.7 days on our inpatient unit from incidents of physical violence. Some staff reassured themselves about the threat of violence when they came to work with the idea that “A&E is only next door”.

As the Associate Clinical Director for Inpatient Services & Borough Lead Nurse, on hearing this, I felt devastated. Things were getting worse and worse, and I felt I was failing my ward teams and communities, by not being able to stop them experiencing such very high levels of violence and aggression.

I knew that something needed to change, and with the support of Jen Taylor-Watt, Andy Cruickshank and the QI team, in February 2016 launched the City & Hackney Violence Reduction Collaborative, using a package of change ideas that had been proven to help reduce violence on the Tower Hamlets inpatient unit.

Fast forward 22 months, and we have just spent 2 wonderful afternoons with inpatient staff, reflecting together – and with friends from the broader system – on the achievements of this work within Hackney. Our inpatient wards have succeeded in reducing violence across the unit by 65%, using data over time and this has had a huge impact on us as a unit.

Changing course

Gardner Ward and Joshua Ward were our 2 acute admissions wards with the most violence 2 years ago. Staff talk about running from the door to the office on the Gardner Ward because they were so scared to be on the floor. Some of our new starters on Joshua Ward were so frightened when they were on the ward they needed to be escorted by other staff members. Gardner and Joshua have now both reduced violence by over 70%.

Rebecca Finnegan, Ward Manager on Bevan, our intensive care unit, which cares for our male service users who are most unwell, describes sitting in her office and hearing the pinpoint alarms going off 2-3 times an hour; levels of violence which meant the dominant mentality was “how am I going to get through the next 12 hours before I go home, rather than having a sense of fulfilment in the job”. Bevan has now reduced violence by 39% as a straight count of incidents, or 61% if you take into account changes in occupancy on the wards (as a rate per 1000 occupied bed days). In August-September 2016 there were 61 incidents of violence on Bevan. In the same period in 2017 that’s down to 14 (see image).

So what impact have these reductions had on our wards? What is the meaning behind the numbers?

Staff and service users spent time reflecting on this and bringing their feelings to life on artwork that we shared at the afternoon events. See the journey of each ward here:

As you can see, each ward has represented their experiences differently, but there are movements from darkness to light, from division to togetherness, from fear to calm, etc. We have also created a film, on which staff and patient representatives shared their perspectives on the impact of violence and aggression and the difference this project has made. View it here.

Journey

Brett Ward’s second canvas makes clear that they are still in transition. They’ve come a long way and the present state is much better than where they were 2 years ago, but staff and service users can see a future where things can be even better.

This is true for all of us on the unit in Hackney. This package of change ideas has had an incredible effect on the culture and functioning of the unit; such simple ideas like having proactive conversations about safety and violence in community meetings and bringing the team together to manage risks in safety huddles have really changed the dynamic of the care environment… but we can go further.

It’s a bit like we are a sail boat, which 2 years ago made some adjustments to slightly change the angle of our course. At the time, these felt like small changes; almost imperceptible initially, but after a bit of time we began to notice that we were going in quite a different direction and the sea around us began to look different. Less choppy, more calm.

That change in angle means that, nearly 2 years on, we now really are in a completely different part of the ocean from where we would have been. Rebecca Finnegan talks about how the changes on Bevan Ward mean staff and service users can now spend time on creative projects together, like making jewellery and bookmarks to sell at events and raise money for a bilingual ward library. This really was unimaginable 2 years ago; in terms of where the staff team were at, how service users felt on the ward and the dynamics and culture of everyone together. She comments,

“when you take away the violence, the fire-fighting, that stress of constantly feeling like you’re battling against your patients, you open your service up to doing so much more”

Experiences and expectations have changed.

Staying the Course

The key, of course, is that we ensure we carry on with this new trajectory. It’s so easy, when you do work like this, to get buffeted back to where you were before. The demanding nature of what we do unfortunately contributes to this, as well as the fact that continuing these new ways of working requires continued leadership and energy – the whole crew of the boat committing to continue working in the same direction, if you like. Hear about the leadership this work has already involved here.

Our recent events were partly celebration, but also a time to reflect together on where this work has taken us and to renew our commitments to each other to continue to chart our different course. As well as reflecting on what we found most inspiring about the sessions, we made commitments to each other – as ward teams, clinicians and other partners in the broader system and our Trust and Directorate Management Team – about how we could support each other to hold the gains. See these in the slideshow below.

We also needed to acknowledge as a unit the incredible support and commitment we received from Jen, without whom we would not have achieved the results we did. Her input enabled the ward teams to be creative and fun, as well as achieving and maintaining great results. Jen has certainly been the first mate on our boat and we will miss her leadership and guidance!

So finally, I’d like to renew this call – to everyone in Hackney – to support this work. To encourage your team to do your safety huddles, to make sure you are recording your incidents on your safety cross and to continue to talk openly as a ward community – staff and service users – about your experiences and learning from violence and aggression. Service users and relatives, please discuss and challenge your ward teams to keep up with this work. People from beyond the wards in the broader system, please show interest and support when you are working with us. All of your leadership and interest will make a difference.

ELFT Memory Clinic wins RCPsych Team of the Year award for Quality Improvement

The award was presented to representatives of the team at the Royal College of Psychiatrists’ head office in Prescot Street on 6 November 2017.

East London NHS Foundation Trust’s Memory Clinic was the winner of the prestigious Psychiatric Team of the Year award, promoted by Royal College of Psychiatrists (RCPsych). The annual awards mark the highest level of achievement within the field of psychiatry. The panel recognised the clinics’ achievement in cultural change and interventions using QI methodology.

The clinics was also praised by its commitment to Quality Improvement in relation to dementia diagnosis.

Lesley Smith, ELFT Community Matron, was involved in the project as a service manager. She said that the project helped the team understand how different each area works within the memory service. “Although we all worked differently we could put systems in place that worked across the memory services. The QI process helped us to get a better understanding of the service issues and get an in depth idea of where changes were needed”, she said. “Receiving the award was fantastic and a great tribute to the work that was done by everyone. We feel very proud of our achievements”.

ELFT Chief Executive Dr. Navina Evans said: “I am thrilled to hear that our Memory Clinic teams have won an award. Their work to reduce waiting times from referral to diagnosis has had a significant impact on individuals and their families. This is a very positive change for people with memory problems as it will allow them to get the help they need faster than before”.

Other professionals involved in the project were Andrew Whipp, Jana Mikova, Michael Henderson, Dr Gabrielle Faire, Marco Aurelio, and Mahmood Dilloo.

Click on the image to see details

Forensics: an honest conversation about failure and what we’ve learnt as a directorate

The Forensic Service has an active and diverse QI Programme, which has enjoyed many notable successes. Some projects don’t succeed though. We recently spent some time thinking about the learning we could take from those, and how to keep enthusiasm and momentum within the group of people who have invested their time and energy.

Learn more about overcoming obstacles in this blog written by the Forensics QI Sponsors, QI Coaches and Improvement Advisor.

“Project team disengaged”

“Project has lost momentum”

These are the two most common forms of feedback we hear during the Projects’ Progress Update in the Forensics monthly QI Business Meeting and Breakfast QI Forum. At least half of the projects in the Directorate’s portfolio are in a similar state, month-on-month. Undoubtedly, it is frustrating to see a once great idea and an enthused project team with a promising improvement project grinding to a halt. It is not the outcome that had been envisioned, especially after witnessing how some excellent QI projects have flourished, and bought about significant improvements to our service such as the Self-Catering by Service-Users and The Bridge Club to name a few.

We have plenty of goodwill as the local QI team (QI Sponsors, QI Coaches and Improvement Advisor) to help re-energise these inactive projects. Unfortunately, the actual uptake of this help by project teams has been low. As a result, we felt stuck with forging ahead constructively to help restart these inactive projects. An instinctive outcome would be to instruct closure but instead, we saw this as an opportunity for us, as the local QI team to better understand what was failing these project teams, and share some honest reflections on project viability and their importance.

Our analysis started with an honest conversation on ‘why do viable QI projects struggle or become a non-starter?’ We structured our reflection and thinking by using the Cause and Effect Diagram. What was immediately evident was that current culture of the workplace interconnected with many other causes identified. For example, ‘lack of personal sense of agency’, ‘no shared belief’, ‘doing QI is not part of job plan, it is outside of staff’s day-to-day work’, and ‘QI is held by the project team ’.  Therefore, culture is one of the biggest barriers towards the chances of a project succeeding.

On the other hand, the leading enabling force for carrying out a QI project is ‘reliance on goodwill’ and special interest of the Forensic Staff. It was clear to us that the starting point and change formula would be to effectively manage and support the goodwill and passion from staff to lead on change, and foster a shared vision that all staff have a role to play in QI to deliver continuous improvements for the directorate.

We had a timely visit from the Institute for Healthcare Improvements (IHI) to Forensics, where we had the pleasure of obtaining guidance from Executive Director Pedro Delgado. He suggested we could champion the importance of all QI projects to the service as this can help to create the shared vision cascading down to the front line staff. Also, “Where we succeed, we celebrate. Where it doesn’t work, we learn”. We need to be open and transparent with unsuccessful projects. There is valuable new knowledge in each of them that we can all learn from. We should also take time to thank our project team for their time and energy for running a QI project even if it was an unsuccessful attempt.

Since the discussion with Pedro, we have taken on these valuable lessons to refine our processes for project closure. We have refined the forums on how we can share the learnings from unsuccessful projects. Systems have also been developed to manage the closure process to ensure project teams are recognised for their efforts and contributions to continuous improvements for the service. We will certainly be running our Plan, Do, Study, Act (PDSA) cycles to ensure the processes are building into the culture.

It took Thomas A. Edison 1000 attempts to create the lightbulb but he recognised that he had not failed but just found 1000 ways that don’t work. We feel that we are on a similar journey of discovery. We have not failed, but we have certainly learnt what structures and processes are needed in order for QI to be sustainable in Forensics in the long run. We were able to persevere and do so because we stayed connected to our core intention that is we truly believe in our staff, their QI projects, and the benefits it can bring to the service and our service users. As Dr Paul Gilluley summarised in his tweet:

“@NHS_ELFT sometimes you need to look back and recognise how far you have come before you look up push on with the climb #forensic #QI”

This is the start of our climb, and we look forward to the coming months learning as a service how best to deliver, enable, and better support staff in doing QI.

Read some of our QI Sponsors and QI Coaches personal reflections on what helped them to stay connected:

“QI could have been another failed NHS change that would soon fizzle out with time. It takes time to grow on you, once bought into the idea and seen the scope for continuous change and challenging the norm (this is how we do things here), you realise that the gift is in our hands to improve the quality of service for staff and patients. I am particularly pleased by the adoption of QI as a way of working rather than an added extra to the role. The changes have been slow, at times painful, disheartening, tiring and you realise early on that this is a long haul flight.”  – Day Njovana, QI Sponsor for Forensics

“I’m all for change and improvement, that’s why I got into coaching. It’s not a good feeling when projects don’t go as far as you envision. In the beginning you get a feel of a project and can project a potential outcome, especially when there are people who are invested. So to see a project halt or teams become disengaged, is not an expected outcome. I don’t like to give up. I look at the reasons behind why a project or idea was suggested in the first place and see whether it could have brought about a change. This is a driving factor for me wanting to continue and forging on. My hope and vision is to see the project do what it was created to do and hopefully more.” – Kimalee Foster, QI Coach for Forensics

“I felt very frustrated for the team that the project was not starting up. I wanted the team to feel the benefits of starting something worthwhile, a project that hopefully would improve their working days and their customers’ experiences. I didn’t want to give up on them or the project. Previously there hadn’t been clear and coherent acknowledgment on the part of the service of this project’s importance, now there was. This helped the team to really believe that their project was worthwhile on a wider scale than they’d maybe realised before. They now began and quickly the project came to life. On reflection, this has been the case with many of the successful projects, and I now realise a key factor to look out for in a project’s early days is the explicit support of the service the project takes place in.” – Charles Kennedy-Scott, QI Coach for Forensics

How to keep going with QI when pressures mount

Francisco Frasquilho – Improvement Advisor and QI Project Coach

Francisco Frasquilho, Improvement Advisor and QI Project Coach at Tower Hamlets, reflects on persistence and Quality Improvement, in collaboration with Project Leads Tamsin Black and Helen Healy

The psychotherapy service (PTS) in Tower Hamlets began their Quality Improvement (QI) project on reducing therapy wait times in early 2016. With a new team operational lead and a keen desire to improve the experience of their service the PTS team set up regular weekly meetings to look at how their systems and processes related to service user wait times. Such work is challenging in its own right, given the complexity of factors that impact on demand and capacity, but this team also faced significant external and internal challenges. As a QI coach and Improvement Advisor with this team since October 2016 I’ve experienced some of the ups and downs of this journey. This is their story, so far. It is a testimony and reflection on their hard work, especially their persistence in managing the challenges that face many teams working in the NHS while keeping a focus on QI.

An essential part of any QI framework is the space to learn, to test out ideas, and to study change. Success is not always guaranteed, but in QI the outcome is only as good as the journey taken. The risk of uncertainty is an ever present companion in this work; in fact this is often one of the main reasons for engaging in QI work in the first place. Uncertainty and unplanned change became a very real challenge for the Tower Hamlets PTS. Midway through the project there was an urgent need to achieve assessment wait time targets of fewer than 11 weeks. Achieving these targets became the over-arching focus for a period of months and drew much of the thinking in the project, whereas previously the focus had been on the wider PTS system. Under such circumstances any project team risks moving from “Plan – Do – Study – Act”, the classic PDSA engine that powers QI work, to “Must Do”, and often multiple simultaneous “Must Do’s”, in order to reach targets. Maintaining a rigorous QI approach under such circumstances can be very difficult unless there is protected space to meet, review data, and plan. Tamsin Black and Helen Healy, the project leads, supported by the wider PTS QI team, insured that consistent time and space to meet was secured. Those meetings formed the basis for balancing real life urgency with the reflection and learning a QI framework encourages.

Tamsin Black – Project lead, Consultant Clinical Psychologist

As if such an environment was already not challenging enough, the natural ebb and flow of talented and motivated staff members leaving or joining the team can also impact the rhythm of improvement. The PTS team’s openness in making use and learning from a wide range of views, experience, and skills was essential in helping them manage the impact of staff changes. These ultimately included skilled administrators, people participation, clinical psychology trainees, and staff with diverse therapy backgrounds. Looking at ways to keep a focus on testing changes in such a rich flow of ideas and experiences depended again on the team’s capacity to continue to meet regularly, to test changes, and ultimately to collect and use data. Techniques such as the “7 step meeting process” also brought the wide range of skills and interests in the group into a coherent ongoing structure, especially when key members of the team left or others joined. The team were also very willing to talk more and learn about QI, and this curiosity was often backed up with further contact with the core QI and Improvement Advisor team. The Head of Department, Tamsin Black, also made use of her own reading around QI, looking at developing ways to support staff to become “leader-leaders” supporting them to take ownership of changes based on the work of David Marquet (2013).

The capacity to keep going, persist, and stay focused, especially given multiple demands and staffing changes, was demonstrated in the outcomes. One of PTS’ key change ideas involved introducing a telephone booking process for assessments, immediately shaving off two weeks from prior waits, while subsequently seeing an increase in assessment slots booked. These changes bore fuller fruit in December 2016, with the team achieving their goal of reducing service users’ wait for assessment to less than 11 weeks. Further improvements culminated in a total reduction in wait times of 65% from date of referral received to assessment through 2017. This substantial improvement was maintained over a period of 6 months. A subsequent increase in wait times was seen from June 2017 and has been attributed to further staffing changes impacting from May 2017. Since then the call and book system has been implemented as “business as usual” and the team are continuing to keep an eye on assessing wait times.

Click on the image to enlarge chart

The team are now part of the new Access Collaborative, focusing on managing flow and wait times across the whole PTS system, from referral received to end of therapy. They hope that the same desire to improve the experience of their service users and lessons learned from this project will ensure that success will be seen in their new venture.

Authors:

Francisco Frasquilho (Tower Hamlets Improvement Advisor and QI Project Coach)

Helen Healy (Project lead: Clinical Psychologist and CBT Lead)

Members of PT QI Project Team:

Tamsin Black, Helen Healy, Maria Papastegiou, David Beecraft, Rowena Russell, Nicola Godwin, Anna W., Sue Goulding, and Francisco Frasquilho.

References:

Marquet, D. L. (2013). Turn the ship around!:A true story of building leaders and breaking the rules. Penguin Portfolio: London

A Carers’ Perspective on Quality Improvement: A personal story

Thana, QI Communications Assistant, interviewed Zhenreenah; a carer and expert by experience client in August 2017, about her abundant passion and energy for engaging with QI Projects at the Trust. She shared her expert advice in this personal story.

Zhenreenah

Carer | Expert by Experience

(Pictured with ELFT CEO Dr Navina Evans at the People Participation Awards)

Are you involved in any QI (Quality Improvement) projects currently? If yes, please could you share your story.

I am very passionate about Carers and based on my personal experience, I am committed to sharing my expertise to improving the service and Quality Improvement is the way forward.

One of the key issues for me was that Carers were not aware of what was happening in both the Trust and with Social Services in Newham. As carers we access services from both organisations. Services were in transitions and it was very challenging and we carers felt that there was a need to keep people/carers updated.  There was a gap and we tried to address it.

One of the concerns was that previously integrated services were fragmented, as for example when social services were “disconnected” from East London Foundation Trust services (ELFT) without any communication with clients like us Carers. It was very confusing when it all suddenly disappeared including engagement with us carers’ group as we worked closely with both organisations.

Therefore, one of the early QI projects was the compilation of a carers’ pack which started as a mini project with a small group of passionate carers to address the confusion.

What was the project aiming to do?

Following suggestion from former ELFT staff, the need for a QI carer’s group was discussed and this led us to come together as carers to collect and share information about local services which we felt would be useful in our role caring for our families.

The key aim of the project was to collate the information about services which spanned various stakeholders so in essence we wanted to bridge the gaps in services so information was easily accessible.

We wanted to compile a reference document which clearly stated what carers were seeking and how best to access services. This led to the creation of the Carers’ Information Pack and quarterly Newsletters related to Mental Health in Newham.

What was your motivation to be part of the project?

I have a passion for carers. Many carers like myself are sometimes left in the dark and they need a voice to share their opinions. I now share my enthusiasm with others carers during the ELFT monthly induction sessions for new staff members joining the Trust.

This Carers’ Information Pack can provide information and help find carers who we don’t currently reach and also identify “hidden” carers who are not registered in the system as such. Many are just too busy caring, for their loved ones and have no clue that they’re Carers and in need of a statutory Carers assessment to acknowledge this.

It is estimated that there are currently approximately 24,000 carers. (Editor’s Note : This is not a definitive audited figure as we don’t have the authorised data) in the local community in Newham but we don’t have the number of carers who manage mental health within family members. I have tried many times to collect the information but have yet to succeed.

I am very grateful that previous ELFT staff member and Carers UK (an independent charity) guided us in forming this group. However the newsletter only goes out to 10 Carers who are member of the Carers Group and that is a low circulation considering there are over 24,000 carers in Newham.  It would be good to get the newsletter to more Carers, the mental wards in Newham and for Carers who are “hidden” (not registered as Carers) and busy working.

How would you describe your experience of being involved in this QI project?

The project progressed well initially with a couple of meetings. However, as time progressed I found it more difficult to attend meetings at ELFT’s Head Office alongside my other carers’ commitments which can arise suddenly and unexpectedly.

Because of hospital appointments and other issues going on, the enthusiasm started to fizzle out and I was emotionally drained and the meetings were impacted. I tried my best to keep asking how the project is going and for me to attend, but found the project was almost finalised.

I feel Carers should be given more freedom to shape their projects within the group and then come together and meet staff for brainstorming at agreed schedules. One of my recommendations would be to encourage carers to find time when they can catch-up to access project developments outside of formal meeting times designated by ELFT staff and whether meetings can be localised in their own areas and then to rotate venues.

This will allow carers to decide what works best for them in view of their own commitments.

What are your thoughts on the value and importance of QI work within ELFT?

Based on my experience, I feel it is very valuable as I like to see positive changes.

I have many ideas (Editorial note : Zhenreenah has compiled over 51 QI ideas for this interview) and with my abundant positive energy, I want to see services develop for the benefit of service users and carers, as well as staff. My aim is to help people get better and recover and move on.  For us carers, emotional wellbeing is also very important.

To me, it is good that service users engage with their treatment and use opportunities within the Trust to access training, prevent isolation and help people to move on; understand their own mental health, and see what the trust has to offer, e.g. voluntary jobs, training, etc. etc. I see this as gentle nudges to help vulnerable people regain confidence.

My experience of the Service User & Carer QI training is that it generated energy and ideas amongst participants, but we felt that guidance as to what to do next was not obvious and we felt slightly unsupported.

Service Users & Carers like me have many ideas to improve services but following the training it would be helpful to be directed towards people providing local designated QI support who can help us develop our QI ideas. We need more guidance as to what the process is or I worry that people will lose the motivation.

What advice would give to other project teams on how to engage service users/carers effectively in QI projects?

I would strongly urge that we need to be very diligent when we engage with vulnerable people who we are asking to engage and contribute. Let’s not forget the 6 “C” for compassionate care. (Editorial Note : https://www.england.nhs.uk/6cs/wp-content/uploads/sites/25/2015/03/introducing-the-6cs.pdf)

We need proper support system in place and be mindful not to treat service users/carers as “numbers” but to listen well and provide the necessary support so that they feel comfortable to engage. To me, it is very important to be aware that service users/carers can be on medication and so we need to be mindful of this and for us to treat people with respect and dignity.

Equally, when we encourage service users/carers to apply for opportunities/positions, we need to consider providing post interview feedback and coaching if for example they are not successful as it can have a detrimental impact on their emotional wellbeing.

We must develop the procedures to encourage, engage and prompt people to progress. If service users/carers don’t feel confident, they will lose the trust in staff and in the system. This will be sad loss for QI projects when you are trying to engage our experts by experience, service users and carers.

Is there anything else you would like to share with others across ELFT about your experiences that haven’t yet been mentioned?

Once Service Users & Carers have engaged and are contributing towards improvement projects I feel it’s important to provide them with access to the resources needed to do the job. I am ready to start a project and would like to know how to start one up please.

For example, myself and other carers have invested our time in compiling and editing our Newham Mental Health Carers Newsletter. However, we were not initially provided with access to computers and resources related to printing and distribution but some ELFT staff kindly volunteered to assist us and distribute our first edition.

I would like to use my concerns about the needs of people in supported housing. I’ve also recognised that we need to do more for people with mental health issues during their stay in physical health hospital environments. I would like to use my energy and expertise to help people make improvements in these areas but need guidance. I would like to know how  are people supported when starting a project and it fell on the way side? What is the procedure to get them back on board?

I would also like to thank all staff that has helped me and other carers since joining the trust. The training, the awards, the services, and all of the other engagements.

Editorial Note

I have always been very impressed with Zhenreenah’s energy and passion to suggest improvements to services.

As a carer myself, I can resonate with many of the issues articulated in this article and I hope it gives you an insight into the invaluable and compassionate work of Carers.

The opportunities to engage both within QI Team and People Participation offers many opportunities like that provided to me to assist the QI team with my expertise. By sharing the unique stories we can collaboratively improve the services by exposing the gaps and integrating the various pathways to improve the client journey.

As Zhenreenah mentioned, we need to be mindful always to treat service users/carers with compassion and to provide the support to guide then forward at their own pace as it is easy to be myopic and focus too much on statistics and charts.

The human element – the person – should always remain at the core and form the epicentre of the 6 “C” Quality of Care mantra.

Service User Perspective: Barriers to Engagement with QI Projects

Tony Fulham

Thana Narashiman , QI Communications Assistant, interviewed Tony Fulham; service user in July 2017, about his personal journey and barriers to engaging with QI Projects at the Trust and offered his advice.

Please share with us some barriers you faced to getting involved in Quality Improvement (QI) Projects?

I believe the biggest barrier to engaging was myself. I had ‘false pride’ and was not able to manage change well. The change of personal status – from being employed full time to becoming the victim of a serious crime which caused me severe trauma.

As a result of this incident, I was medically diagnosed with Post Traumatic Stress Disorder (PTSD) arising from the trauma. I was referred to my local mental health services at East London Foundation Trust (ELFT).

My engagement with the services caused me confusion as I wasn’t sure what it was all about. I was not aware of what resources were available to me to access and meeting the criteria for treatment was itself quite confusing and alien to me as I was functioning under adverse shock.

What other personal barriers were you facing?

I felt that my identity totally changed. It was also those environmental changes – I wasn’t aware of my local community and my neighbours and became increasingly isolated, that led to change.

Once I accessed Mental Health Services there was a lot to learn and I found it hard to take it all in.

I also lived with survivor’s guilt and had to come to terms with my personal circumstances through understanding what was back then PTSD and how it had impacted me with those changes within myself for my self-understanding.

I struggled for self-awareness of me with coming to terms with my personal change of circumstance(s) once I was discharged from local Community Mental Health Team (CMHT) services.  I was left confused about state entitlements like entitlement to Department Work and Pensions (DWP) benefit allowances, housing needs etc. and to accessing these services were very fragmented I feel at the time looking back now.

What experiences did you gain from confronting the challenges?

I stumbled across the ELFT Working Together Group and became involved through tenacity as I was approached to be the new chair of a local HealthWatch Mental Health Task Group.

From all of this, I wanted to learn more about recourse to the state benefits system in order to help other people like myself. I successfully trained as a generalist  advice worker within a local advice centre. I truly enjoyed this engagement as I got to meet people in my community which helped addressed my isolation and trepidation within society.

I also learnt how to use a computer & discovered new soft skills within me which were invaluable. All this helped me to build upon my confidence.

What were your experiences of attending other ELFT meetings?

My first Tower Hamlets Working Together Group was very new – and sadly it was not a warm welcome. The group’s focus is on reintegrating people who’ve been discharged from the service. From my observation, it seemed to be very much “the old guard”, people had been in the group for years and years. It put a lot of people off from attending, I felt I was alone again.

I had a basic experience of chairing meetings with the NHS and so volunteered to become the new Chair of the Tower Hamlets Working Together as I thought it would help my recovery. I also wanted to influence positive change and felt the group needed a fresh approach.

What can you share with us regarding any other barriers that we can change?

A simple matter : meeting rooms not being very welcoming with no windows and not a dark room and also no windows can be opened due to Heating and Ventilation (H&V) system.

Since meetings were alien to me, I really did not know the “rules” of a meeting so simply felt I couldn’t leave the room when needed to.

I didn’t have any personal reference or the training to know how to behave and I felt like an actor, not truly being myself. So any training would be useful for all.

What are the opportunities moving forward?

As part of my engagement here and with the People Participation Team in general, I am now involved with the monthly ELFT QI steering group and I am going to be co-chairing the meeting with the current chair, Erayna soon.

I have also been engaged wider as part of local Metropolitan Police Safer Neighbourhoods meetings and Community Safety Board – as I wanted to give back to the community when I was within my local CHMT.

What is your passion?

“I want to make a big impression” : “6 foot manhole imprint” and “something that’s long lasting.”

I would like to witness improvements to the Mental Health service for people entering the service in the future and to use my lived expert experience to a better use.

Prior to being a victim of a serious crime where I nearly lost my life, I was a more of a taker and now I want to be a giver. It has really changed my life seeing life more positively now.

I don’t want to be a passenger anymore –  I wish to be involved in QI to acquire new skills and training and be a driver of change for both carer, service users and staff members to share back.

Tony Fulham

Service User

21 August 2017

Service User and Carer Involvement in QI Projects

Clinical Psychology Trainees tell us about how they have involved service users & carers in their quality improvement projects.

Improving the triaging process

Creating a new triage tool leading to better risk management…

This clip was shown to delegates attending the 2017 Annual QI Conference in Bedfordshire & Luton

Safety Huddle Implementation

Being part of the violence reduction collaborative at ELFT has seen a significant reduction in violence and aggression on the ward…

This clip was shown to delegates attending the 2017 Annual QI Conference in London

Violence Reduction Collaborative Stories

Being part of the violence reduction collaborative at ELFT has seen a significant reduction in violence and aggression on the ward…

This clip was shown to delegates attending the 2017 Annual QI Conference in London

First Impressions of being involved in a QI project

Ugne talks about her first impressions of quality improvement at ELFT

This clip was shown to delegates attending the 2017 Annual QI Conference in London

The Violence Reduction Collaborative

Being part of the violence reduction collaborative at ELFT has seen a significant reduction in violence and aggression on the ward…

This clip was shown to delegates attending the 2017 Annual QI Conference in London

Improving Quality of Referrals

Improving quality of referrals – The challenges of a Quality Improvement Project

This clip was shown to delegates attending the 2017 Annual QI Conference in London

A People Participation Lead’s view of QI

A People Participation Lead’s view of QI

This clip was shown to delegates attending the 2017 Annual QI Conference in London

Safety Huddles

Implementing Safety Huddles on a Ward

This clip was shown to delegates attending the 2017 Annual QI Conference in London

Woodberry Ward Lifestyle Improvement Project

A summary of the Lifestyle Improvement Project on Woodberry ward

This clip was shown to delegates attending the 2017 Annual QI Conference in London

Are You Listening?

This is a summary of the Improving complaints QI project

This clip was shown to delegates attending the 2017 Annual QI Conference in London

Getting Involved

Hugh speaks about his experience of People Participation and Quality Improvement.

This clip was shown to delegates attending the 2017 Annual QI Conference in London

Violence reduction on older adult mental health wards

The Safer Wards project aimed to increase the safety of patients with mental health needs, specifically tackling the level of violence and aggression on older adult wards in Newham and Hackney, sites covered by our East London mental health trust. We developed a strategy to tackle this issue based on Quality Improvement methods, to better understand the issues underlying the problem, and plan a service improvement that would be feasible within financial and resource constraints. The specific aim of the work was a 20% decrease in violent incidents on the 3 wards in City and Hackney, and Newham

Quality Improvement (QI): What drives this?

Thana, an ELFT Expert by Experience writes about his experiences at the International Forum on Quality and Safety in Healthcare and of getting involved with quality improvement at East London Foundation Trust

Many of us are engaged in improving our lives to make it easier for both ourselves and for other people. The challenge in Health and Social Care is how to engage with clients (service users and carers) AND collaborate with medical professionals and support staff to radically improve, advance the status quo and measure service excellence. It is about working symbiotically.

I was privileged to attend the International Forum, an IHI (Institute for Healthcare Improvement) and BMJ show at London EXCEL Conference Centre (kind courtesy of Tim and Marco) on the 26-28 April 2017, where over 3000 international delegates were in attendance. At times, it felt like I was at the United Nations. On the second opening day, there was an Amazon drum music incantation – dare I say without the rain dance – performed by our talented multi-disciplinary staff!

It was exciting to listen to the opening presentation from Lord Ara Darzi who was being interviewed by two “experts by experiences” members. Many people found this talk inspiring as it enshrined the ethos of the NHS Constitution… – “Nothing about us without us” manifested by tangible actions. This principle of engagement should always underpin all QI projects. The words of wisdom from Lord Darzi regarding the role of “experts” to enact real change are revolutionary.

The first hand stories shared by experts at the initial ELFT experience day event held at the Mile End Park Ecology Pavillion on the 26 April were fascinating with follow-up site visits to various venues. The presentation by the “experts by experiences” team at the Mile End Ecology Pavilion to over 150 International delegates were truly inspiring – which documented the various personal journeys and QI outcomes. The role-playing by fellow team members showcasing both “good and bad” practices in QI staff engagement was enlightening to the delegates. Ugly practices have virtually been eliminated at the East London Foundation Trust (ELFT) due to constant auditing of services.

Delegates at the conference who also shared their personal experiences were awe-inspiring as they advanced forward with innovative solutions.  The reality is that we have a global team of experts with diverse experiences who are constructively challenging the status quo and advancing lateral thinking to quality improvements.

I had an encounter at the conference with an ELFT staff member, Mr Farouk, who imparted very inspiring words, which have sparked me to pursue this onward journey of self-improvement and share experiences within QI engagement to humanize the process.

By real example, I can share good practices being enacted locally by the Psychological Therapies Unit led by Dr Amra Rao and their team. We are brainstorming innovative system redesign to tackle service demand with resource challenges and exploring innovative consulting models with clients.

This blueprint diagram showcases the transformational pathways while the QI metrics are being formulated with assistance from QI expert lead, Emma.

This proactive approach initiated by Dr Amra’s team resonates with the core message shared by other “experts by experiences” at the conference which followed two core strands:  “we are not waiting” and “we are patients who are impatient” for tangible advancement to improve services.

Moreover, we are reviewing holistically the “whole person” social resilience issues focused towards integrated health and social care recovery pathways as depicted below by Dr Amra Rao’s team.

Whole Person Model diagram developed by Mental Health Wales

This international conference ended with a former NASA astronaut, Chris Hadfield, showcasing the ability of humans to work cooperatively to design innovative propulsion transport capsule systems which can land astronauts on the Moon, spacewalk in deep space and construct and co-exist in an international space station.

This IHI event may be construed as a small step for us but it is a giant step for clients to radically change the ecosystem of health and social care improvements. This is the ultimate challenge for QI and for us all to be pioneers and working symbiotically as one team to constantly adapt to change.

I end with another case example: My parents get visited daily by an exceptional District Nurse called Mary (employed by the Trust) to administer insulin at home but the positive emotional wellbeing imparted during each of her visit is awe inspiring. What drives this ELFT staff member to deliver consistent exceptional care each morning, which is always positive and inspiring?  Can we truly measure this quality of care or this “driver” encoded within the psychology of this person to confer compassionate care? 

If you wish to discuss any matters raised in this blog please contact me via the QI team else engage DIRECTLY with the QI team if I have inspired you to spark new projects within your domain. Engaging with QI has assisted me to inspire and improve the quality of human lives by Leading by Example.  So to conclude, QI is indeed driven by ALL people.

Thana

Expert by Experience

(This blog was drafted in a personal INDEPENDENT capacity and is unedited and may not represent the views of the TRUST. )

Spotlight on the Bridge Club

QI Lead, Naomi Nowlan chatted to Kemarr Salmon, Bridge Club project team member and Forensic Directorate employee of the month December 2016.

The Bridge Club was nominated as team of the year at the 2016 EFT Staff Awards

What is your day to day role?

Working as an OT assistant at the John Howard Centre – facilitating groups and interventions, leading cooking sessions and helping service users to overcome barriers.

How did you get involved in QI?

The Bridge Club project started in early 2015, when Sian (project lead) wanted to set up football sessions in the local park. I was working for Wolfson House security team at the time and also playing Semi-Pro (non-league) football so wanted to get involved. Every time a service user went through reception, I asked were they interested in taking part in football sessions. There wasn’t much interest at first, but that turned around when we changed the proposed venue from Finsbury Park to the artificial grass pitch Sobell Leisure Centre.

What is the Bridge Club? Why was it set up?

The idea of the Bridge Club is to “bridge the gap” between hospital and the community. It acts as a social club for both service users and those in community, providing activities outside normal working hours and as a focal point to meet friends.

It started out with 15 patients on escorted leave and a number of others on unescorted leave. However, now there are very few service users who are escorted – as all have become either unescorted or have moved into community setting. Those service users that are now based in the community bring their friends along and the club continues to expand through word of mouth.

It’s not just service users that attend the Bridge Club, staff can and do attend. At a football match, you might see MDT staff, the QI team, or the management team making cameo appearances!

So you mentioned football, what other activities does the Bridge Club do?

The Bridge Club has three regular activities; boxing takes place at Pedro Boxing Club each week and football sessions at Sobell Leisure Centre alternate with a Café event at the Redmond centre in Woodbury Downs every other week.

The football team also plays matches; with a recent friendly against Tower Hamlets Tigers unfortunately ending in defeat, but a Wolfson House vs. John Howard Centre game attracted 36 staff and service users on a Friday night (JHC won!)

Recently the club has started going to live football matches, the first one – Haringey vs. Hornchurch at Haringey enabled a service user to see his local team play for the first time in 20 years. We then took it to another level by attending a League 2 match with 12 people on unescorted leave from Wolfson House in December, to see Leyton Orient defeat Accrington Stanley 1-0 at home.

The club also organises special events such as a Christmas lunch, white water rafting and outings to free concerts and fireworks displays. Upcoming events include ice skating, rock climbing and a trip to The Ultimate Cycling Experience at The VeloStudio.

Why is the Bridge Club different?

I think football breaks down barriers, as staff and service users are equal on the pitch. It has also become a bit like a family, as Wolfson House is always the meeting point, even for those based in the community. In some ways, it has become its own community, targeting social isolation, by enabling people to meet new friends and linking service users to those in community on discharge, whilst also giving those who have been discharged a link back to their friends at Wolfson House.

I have also seen the services users I work with gain more confidence as they are exposed to real experiences; going to cafes, crowds at the matches etc.

What has been your favourite moment with the Bridge Club?

There are so many, but I think it has to be the service user seeing his home team play for the first time in 20 years, meeting the manager and getting a signed program from the team.

What’s next for the Bridge Club?

For football, I’d like to travel a bit further to see teams in greater London play. Maybe even to have a guest player to attend or lead one of the sessions. The café and boxing will also continue in the New Year with some extra events like a theatre trip in the pipeline too.

Self catering on Woodberry Ward

Learn more about this QI project that introduced self-catering to Woodberry Ward in our Forensic Mental Health service.

Read an interview with the Project Lead Alison O’Reilly here

Mental Health Tariff – Completion and Accuracy

Peter Macrae, Bailey Mitchell and Auz Chitewe share the improvements this City & Hackney QI project has made to care clustering allocation.

This project involved the North 2 Recovery Team, South 1 Recovery Team, Gardner Ward, Conolly Ward teams. To find out more and see some data from the project view the project poster below

Stacey Hemmings QI project interview

Stacy Hemmings, Clinical Phycologist trainee, discusses her research and participation on the project for how to reduce DNA testing in first appointments in the City and Hackney Therapeutic Community using SMS text messaging.