Improving observation practice and therapeutic engagement across inpatient wards at ELFT – The opportunity of using Quality Improvement at Scale

Providing a safe and therapeutically engaging environment is one of the core components that support service users’ recovery on inpatient mental health wards. Although observations of service users by staff are important in helping achieve this, without meaningful interaction they can be reduced to a form of surveillance which can hinder recovery. Observations should be viewed as a key opportunity for therapeutic engagement, which has been seen to have a significant impact on outcomes for service users[i].

In response to serious incidents which highlighted a need to improve observation practice on inpatient wards at ELFT, all wards across the trust have been using quality improvement to co-design work to improve observations and therapeutic engagement with service users.  Since September 2022, teams have been coming together as part of a wider learning system to share learning, and receive support from colleagues in people participation, informatics, HR and patient safety to improve practice.

This is the largest scale quality improvement programme that ELFT has ever run. However, working at scale provides both a challenge and opportunity. While there is potential to test lots of ideas quite quickly, taking ideas that work and scaling them across an organisation can prove challenging. The IHI framework for going to full scale[ii] offers a sequential approach to scaling interventions that is underpinned by small-scale testing through Plan Do Study Act cycles (PDSA). The approach consists of four main steps shown below; with the idea of the scalable unit or the microsystem in which testing of interventions or change ideas takes place key.

Following an initial set up phase for this work, teams were supported to develop and test local change ideas that they felt would make the biggest difference to improving observation completion and therapeutic engagement. Over 20 ideas were tested across the trust and are mapped to the initial driver diagram developed for this work shown below.

In September 2023, teams and service users came together to share change ideas at a trust wide learning session and decide on which ideas they would like to test for scale up across the trust under different conditions. Teams presented their top two ideas along with data around observation completion and impact on service user and staff experience to support this. These three ideas along with the theory behind them are shown below. To help with scale up, the team at the original test site produced standard guidance to assist other wards in testing which you can read here.

Each unit decided which wards would test each of these ideas, with teams designing a series of tests under different conditions. Wards are currently testing these three ideas and making modifications in their local context. You can watch a video of staff sharing their experience with testing these ideas here.

Key learning so far is that each of the three ideas might look different depending on the context. Work is now underway to understand the key concepts behind each of the three ideas.

Trustwide there have been improvements in the percentage of observations completed, and reductions in the rate of physical violence, verbal aggression, racial aggression, prone restraint, seclusion and use of rapid tranquilisation

The next phase of the work will be to support implementation of the three change concepts, with flexibility to decide how to take each one and make it meaningful within each local ward.

You can learn more about this work by visiting the following pages

[i] Farrelly, S., Brown, G., Szmukler, G., Rose, D., Birchwood, M., Marshall, M., … & Thornicroft, G. (2014). Can the therapeutic relationship predict 18 month outcomes for individuals with psychosis?. Psychiatry research, 220(1-2), 585-591.

[ii] Barker, P. M., Reid, A., & Schall, M. W. (2015). A framework for scaling up health interventions: lessons from large-scale improvement initiatives in Africa. Implementation Science, 11(1), 1-11.