20 August 2020

City and Hackney: Nurturing the roots of change using projects and daily improvement tools during the pandemic

By Francisco Frasquilho, Senior Improvement Advisor

2021 update: The Mother and Baby Unity (MBU) project team have continued to trial out a new electronic recording system for referrals, seeing a shift downwards in the time taken to process new referrals (an 85% reduction) in September 2020. The team were also planning to test out a new ward welcome pack and exploring service user satisfaction at ward community meetings.

The pandemic crisis has led to urgent and rapid changes to healthcare. How does Quality Improvement fit in with an ever changing environment, especially during an era of unprecedented stress on an already burdened system? What does QI look like in the time of the pandemic, and how can grass root ideas continue to be nurtured?

A vast majority of QI activity at ELFT has been populated by the concept of ‘QI projects’ as the mainstay of improvement work. In City and Hackney there continues to be some great examples of grass roots improvement, using both projects and daily improvement tools. The QI project provides a time limited format as an ideal way to support training, learning, and change, especially around high priority areas of work. However, during COVID 19 previously viable projects have been suspended or closed due to a need for urgent actions to the developing situation. Alongside this, a massive reduction in face to face contact in some areas has also given way to increased virtual working, quite new territory to explore for directorates and QI. The traditional in-person tools of the QI coach are no longer as feasible, gone are the readily accessible stack of different coloured sticky notes and pens. QI therefore needs to adapt to support these new ways of working. The QI project is by no means gone, but this is a timely reminder that improvement isn’t only located in project work. Like any keen gardener will tell you, a plan and good tools can help weather storms, but knowing how to use the right tool and at the right time is essential.

Continuing QI project work in City and Hackney: Mother and Baby Unit (MBU) Project

City and Hackney Centre for Mental Health

The MBU is an inpatient mental health ward supporting mothers and their babies, it is one of the few national centres that provide this care. The MBU team wanted to look at improving the satisfaction of service users with the admission process onto the ward, often the first experience a mother will have of such care. The MBU team wanted to use QI after attending one of the ELFT’s virtual pocket QI trainings. They designed their own driver diagram, a visual knowledge building tool that helps unpack and understand complex issues that contribute to the improvement issue (figure 1). For more information on driver diagrams please access the link https://qi.elft.nhs.uk/resource/driver-diagrams/. They are now collecting information from staff and service users around measures of satisfaction relating to admission and what needs to change to increase their satisfaction.

Fig 1. Initial draft of Driver Diagram with project SMART Aim and primary drivers.

The team has since met virtually using MS teams and used the QI development platform, ‘Life QI’, to look at their ideas and data. As part of their PDSA cycle (Plan, do, study, act – a means to test changes) they have tested a holistic referral screening process involving multiple team members such as doctors, nurses, and nursery staff. They are also looking at new ways to process referrals electronically. They wanted to see how to ‘grow the garden’ of improvement, to nurture changes by trying out ideas, based on the theory within their driver diagram.

The MBU project lead learnt that using the range of experience of staff, at this early stage, can support mothers and their babies, not only during their stay, but potentially after discharge from the ward. Staff who had deeper familiarity with social care aspects brought their experience to discussions of support. The team didn’t need a QI project to start this work, but are now using a project framework to guide their learning.

Projects aren’t the only approach: Tools for daily improvement

The MBU QI project is an example of our traditional approach to QI at ELFT fitting in a new world of pandemic work, but there have been other examples of improvement tools and conversations that sit outside of a project framework. Tools such as process mapping and driver diagrams have been used to support reflections on the local neighbourhood and community transformation work, as well as looking at crisis pathways in the borough. These are all ongoing pieces of improvement work that are not within the traditional ELFT QI project approach, but nonetheless make use of the principles of improvement outside of a project framework.  QI, at its essence, is an approach to developing helpful conversations and encourage actions based on these, building on the will and creativity already within a system.

The ongoing challenge: Nurturing growth and learning in improvement

There’s a clear need to bring more fluid and immediate ways to use a QI framework to support change, however, the role of QI projects is also key to addressing complex issues that go beyond one tool or meeting.  Like any keen gardener knows, it’s never enough to just have good ground to nurture growth – but it very much helps! Appropriate use of tools, timed and focused work, can all make a difference in how we understand our system and the way improvement can support key changes. Specific project plans and work can really help develop key parts of the landscape that need more time, consideration, and further support to work.

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