15 November 2021

The QI Fellow Blog

By Craig Donohoe, QI Fellow, QI coach, expert by experience and carer

This is my blog as the first Quality Improvement (QI) Fellow – Expert by Experience in the ELFT QI department. I am Craig Donohoe, an expert by experience, carer, and service user from Luton, Bedfordshire. In this 15-minute read I will share my story about being a QI Fellow, service user and carer leadership within QI, and how QI can be meaningful tool for healing, empowerment and creativity for service users, carers and staff together.

The QI Fellow role was created to learn from service users and carers about how QI can be developed and delivered and how we can improve authentic co-production. The fellowship is a unique role for an NHS Trust. It encourages service user and carer leadership within Quality Improvement in ELFT, so I have had the experience of leading the Introduction to QI for Service Users and Carers course and the Authentic Experience QI project.

QI is Healing

When I initially joined People Participation, my levels of anxiety, hoarding, and perfectionism left me with the realisation that my career was over and I would not get to use my MA, BA, work qualifications, and international work experiences. The pressure of having to choose a perfect career since I first graduated was an expectation that led me to mainly withdraw from the working world through decades of procrastination, hoarding and checking.

Figure 1: Craig and Michelle chairing the QI Forum

At my first Bedfordshire Community Mental Health QI forum I failed to understand what the purpose of the QI forum was, and what we were being asked to contribute to the meeting. At the end of the meeting, the group asked who wanted to chair the next one and I volunteered because I am a trained and experienced voluntary community chair. Although at the time I did not realise it,  a service user had never chaired a QI forum before.

The feedback on my chairing was really positive and I managed to give everyone a voice. In retrospect it began a turning point in my life. Michelle Rigozzi, Improvement Advisor (pictured in Figure 1) and I went on to develop a guide for chairing meetings that can make them more accessible, democratic, and co-produced (Figure 2). We have shared this story at trust-wide quality improvement conferences and national forums including the Scottish government and NHS England.

Figure 2: Craig’s tips for chairing meetings

Chairing these meetings, training other service users and carers to chair and sharing this story gave my life a new found meaning; it felt like my lost career had restarted. Using a forgotten talent to make a positive difference to local services gave me a purpose that was incredibly healing.

I began to relate my healing experience to the transformative power of QI. With Obsessive Compulsive Disorder, perfectionism, and procrastination I experienced a brain lock where I repeated rituals to ensure I never made a mistake. The rituals are extremely time consuming and evolved until I was carrying a great deal of paper with me to check. This meant I was often late for important appointments and failed to respond in time for many important opportunities that came my way. This contributed to a cycle of failure where I would compensate by trying to make it even more perfect next time, so I did not make a mistake. This kept me locked in to repeating the cycle again and again. This is graphically illustrated in the vicious cycle of perfectionism in Figure 3.

Figure 3: the Cycle of Perfectionism

The beauty of QI is that when, for example, I tried to improve the chairing and agenda structure of my local QI forum, I no longer focused on the crippling effects of initial mistakes I may have made. Instead, I learned from the feedback from forums, seeing if we had achieved the individual vision each participant set for that forum. Using the Plan, Do, Study, Act cycle (Figure 4) for this set me on a trans-formative cycle of improvement. Mistakes became opportunities for learning. To put it simply, QI was breaking me out of my brain lock! That was and is life changing or even life-reviving. My realisation then was that QI was not only a tool for service and project improvement, but an unanticipated tool for meaningful personal recovery not just for me, but for other service users, carers and patients. Making a difference to local services and using our skills gives us a feeling of purpose. Ultimately, my own QI journey has not been perfect but it has been enough to allow me to fully participate in life.

Figure 4: the Plan, Do, Study, Act Cycle

As I progressed in my QI journey, I attended ELFT QI conferences led by keynote speakers including Don Berwick from the Institute for Healthcare Improvement in the USA. I asked if QI was a way of being and I was told that it was, confirming for me that it is a whole way of thinking, creating and feeling that can be applied to all our work and does not exist exclusively in QI project meetings.

The challenge has been for me as QI fellow to communicate QI as an accessible way of being for service users, carers, patients, and staff. Learning from our own experience of using the services to contribute to improvements can help us make sense of  often traumatic mental health challenges like my own. A heart felt  journey in improvement can mean that others do not go through what we went through. This allows us to make sense of those mental health challenges so they no longer feel senseless but are opportunities to tell powerful, transformative stories of our journeys to positively impact others.

How do we Create the Space for Service User and Carer I Leaders to come Forward?

Figure 5: illustration of Louis Braille

When Louis Braille created his Braille system, he would have been considered in modern day terms a child patient. Using what now would be considered a PDSA cycle, he improved on the previous system that had been developed by a fully sighted soldier for the trenches. Would our QI processes and structures allow a modern-day Louis Braille to come forward? Would they inhibit or liberate such a person?  How do we create a space for service users, carers, patients, and experts by experience to influence which QI projects are started in order to directly exercise our experience of services and improve them?

In co-production with other service users and carers, I led the teaching of the Introduction to QI for Service Users and Carers. We have started to develop the first Introduction to QI for young people. We have influenced the QI culture with our leadership of the “Authentic Involvement” QI project. Developing the authentic involvement co-creators charter (Figure 6) into a mnemonic, poem and song was so transformative that the words were performed as a musical song at national QI and People Participation conferences.


Figure 6: the Authentic Involvement Co-creators’ Charter


The Power and Flexibility of  QI Work Outside of Projects

Figure 7: ELFT’s Sequence of Improvement

By sharing QI tools widely, such as the graphic in Figure 7, we not only encourage QI as a way of being and thinking outside of formal QI project meetings, we also engage more  potential QI leaders from all staff , patient, service user, and carer groups to meritocratically solve the problems ELFT and the NHS in general currently face.

The Power of QI as a Meritocratic and Democratic Tool for all those who Use and Deliver Services

QI is not only a meritocratic method, but a democratic method that is based on the ability of anyone who experiences, receives, or delivers services having the potential to solve problems and create solutions. In QI, we listen to everyone, regardless of  their staff position or status within their organisation, just like the Japanese principle of Kaizen (illustrated in Figure 8) where any employee is empowered to continuously improve their workplace organization.


Figure 8: Kaizen and Kairyo

Conclusion: How I have Found Meaning and Healing as the QI Fellow

Making a positive difference through QI has shown me my own life means something. It has dissolved the power of so many mental health conditions, the assumption that my life did not have meaning and that I had to be perfect to survive. My experience of being the QI Fellow in the QI dept has been a life-changing process of Kaizen (continuous self-development) and Kairyo (continuous improvement). I have realised I can participate fully in life as a professional and be brave enough to lead in QI to create things that did not exist before. This is particularly healing because our QI work can directly or indirectly improve or save lives through improving services. Like the lifeboat rescue service staff, that experience of being needed by others in QI gives me meaning each day.

The QI Fellowship has not been the perfect job for me but I have learned now that it has been ‘enough’ for me. As together we create more pathways for service user, patient, and carer leadership within QI we continue to evolve and surpass the definitional limits of what QI can be and view it as a service wide healing tool. We are moving beyond just little I and big I involvement to leadership involvement!

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