21 November 2017

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.



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.


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

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