Annual QI Conference Slide Set

Quality improvement
annual conference
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Marie Gabriel (Chair) and

Mary Elford (Vice-Chair)
Woodberry Ward Self-Catering
Project team: Alison OReilly, Dr Sian Llewellyn-Jones, Ali

Kilic, Jon McCartan, AA
Genevieve Holt, John Wilson
Background
Challenges and objectives
No
flavour
Complaints about the food

Poor physical health and dietary intake
To enable Service Users to take control of
their environment
Develop skills for discharge
Increase structured activity / meaningful
occupation
Food
Ward environment
smells
Spaghettis
too short
No
nutrition
Project aim For 60% of

Service Users to be
participating in delivery of a
daily meal at least once a
week
Sequence of PDSAs for one change idea or

secondary driver
A P
S D
Cycle 5: Expand across the

service
Cycle 4: Long term implementation
Cycle 3: Monthly Pilot

AP
S D
Cycle 2: Research / visits / planning

Cycle 1: : Lunch Group
Strengths
People keen to be
involved
Good food
Well supported by staff
once begun
Time of day
Variety within menu
Challenges
Washing up
Rota people dropping
out
Limited meal options
New systems
ordering, quantities,
deliveries
Gathering data
Initial anxieties
Data
Service Users involved in Woodberry Ward Catering - P Chart
80%
UCL
60%
50%
40%
30%
20%
10%
0%
Across the month over 90% total participation
23-Feb-15
16-Feb-15
09-Feb-15
02-Feb-15
26-Jan-15
19-Jan-15
12-Jan-15
05-Jan-15
29-Dec-14
22-Dec-14
15-Dec-14
08-Dec-14
01-Dec-14
24-Nov-14
17-Nov-14
10-Nov-14
03-Nov-14
LCL
27-Oct-14
No. of SU's involved / %
70%
Number of Service Users participating in meal

preparation
Data
Service User Survey
Meal Satisfaction
Ward Environment
Use of time
Self-esteem
Confidence to do things for myself
Data
Possible measures for future:

MOHOST Functional ADL skills
Nutrition / physical health
Incidents
What next?
Long term implementation

Expanding across the service
Focus on physical health
Incorporating other areas of the service e.g.
cleaning / domestic tasks
Obtain more data to recognise change
A look back at our first year of QI

with Dr Kevin Cleary
(Medical Director)
Professor Jonathan Warren

(Director of Nursing)
Mason Fitzgerald
(Director of Corporate Affairs)
and Steven Course

(Acting Director of Finance)
Some thoughts and guidance from

our strategic partner, the IHI
Derek Feeley
Pedro Delgado
Executive Vice President at IHI

and previous Chief Executive of
the NHS in Scotland
Executive Director at IHI for

Europe and Latin America
Now lets hear about some of the

QI work taking place
Now lets hear about some of the

QI work taking place
Rapid
fire
7
minutes
each
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Violence reduction on older adult wards

is it worth it?
Dr Waleed Fawzi, Carmel Stevenson, Cathy McCarthy, Jenny
Dusoye, Peter Daby & the rest of the QI project team
web
qi.eastlondon.nhs.uk
email
qi@eastlondon.nhs.uk
@ELFT_QI
Why violence?
The view from the shop floor
Reduce harm to patients & staff
Reduce sick leave
Create a better environment on the ward
A platform for many initiatives
Where?
Sally Sherman
Cedar Lodge & Larch Lodge
Reducing harm from inpatient violence

AIM
PRIMARY DRIVERS
SECONDARY DRIVERS
CHANGE IDEAS
Provide adequate
staffing levels
Supportive staff
Support for staff
affected by violence
Reduce the number of
incidents of physical
violence on elderly
inpatient wards by
20% by 1 August
2014
Reduce staff sickness
due to physical
violence on elderly
inpatient wards by
25% by 1 August
2014
Systematic ways of
identifying and
meeting patient needs
Ensuring patient
needs are met
Creating a safe and

therapeutic
environment
Dynamic risk
assessment tool
Hourly rounding
Discussion with
patients about violent
incidents
Regular access to
meaningful activities
Staff training and

education in violence
reduction tools
Increased staff
awareness
Awareness sessions for

staff about violence
reduction
Ensure accurate
reporting of violence
Safety Cross
Understanding the
causes and variation
Analysis of incidents to
identify variation and
target interventions
The Team
Multidisciplinary
Matron, OT, nurses, HCAs
Enthusiastic
Motivated
Creative
The initiatives
Anticipate and preempt:
Approach patients every 2 hours (intentional rounding)
Act before it happens
Sensory room
Pet therapy
Activities during the week
Activities during the weekend
Noise reduction
Our PDSA ramps
Test: Pet therapy
Test: Use of befrienders for

pts with no relatives
Implement: Sensory
stimulation on both wards
Implementation: Embed
rota for using multisensory
room on the ward
Test: Use of the multisensory
stimulation room
Test: Exercise to music in the
daily community meeting
Implementation: Structured
activity 4 mornings a week
and 2 afternoons a week
Implement:
Run
awareness
sessions on all
wards
Develop:
develop an
awareness
session on
violence
reduction for
ward staff
Across all older

adult wards
Test: Structured activity 5

mornings a week and 2
afternoons a week
Test: Provide drinks in patient
room to reduce wandering
and repeated requests to staff
Test: flexible leave offered on
a daily basis to targeted
patients
Test: structured leave three
times a week for targeted
patients
Unit 1 Sally Sherman
Test: Further develop and

test sensory room
Test: Sensory stimulation on
both wards
Test: Sensory stimulation on
1 ward
Implement: Intentional
rounding across both wards
Test: Test for two weeks

with checking form
Test: Try intentional

rounding over 4 days
Test: Try intentional

rounding on one shift
Unit 2 The Lodge (2 wards)
0
10/07/13
10/07/13
11/07/13
20/07/13
21/07/13
22/07/13
31/07/13
17/08/13
18/08/13
27/08/13
09/09/13
24/09/13
24/09/13
15/10/13
18/10/13
22/10/13
24/10/13
01/11/13
04/11/13
06/11/13
11/11/13
15/11/13
29/11/13
26/12/13
13/01/14
20/01/14
11/02/14
25/02/14
25/03/14
27/03/14
04/04/14
10/05/14
25/05/14
04/06/14
17/06/14
26/06/14
08/07/14
12/07/14
19/07/14
22/08/14
18/10/14
18/11/14
24/12/14
14/01/15
28/01/15
30/01/15
Days since last incident of physical violence
Days between incidents of physical violence, 3 wards

combined T chart
50
40
30
Average 2.9 days
Date of physical violence
Average 6.4 days
20
10
Jan 15
Dec 14
Nov 14
Average 177 days
Oct 14
Sep 14
Aug 14
200
150
Desired
direction
03/11/12
04/11/12
26/11/12
28/11/12
10/12/12
03/01/13
04/01/13
12/01/13
12/01/13
24/01/13
29/01/13
30/01/13
01/02/13
18/02/13
28/02/13
14/03/13
05/04/13
05/04/13
19/04/13
23/05/13
13/06/13
16/07/13
22/08/13
08/09/13
24/09/13
15/10/13
15/10/13
15/10/13
22/10/13
24/12/13
03/02/14
21/02/14
07/03/14
22/03/14
30/04/14
11/06/14
28/06/14
05/08/14
01/11/14
18/11/14
22/01/15
28/01/15
30/01/15
Days since last injury to staff

60
40
Desired
direction
Average 8 days
Jul 14
Jun 14
May 14
Apr 14
Mar 14
Feb 14
Jan 14
Dec 13
Nov 13
Oct 13
Sep 13
Aug 13
50
Jul 13
300
Jun 13
May 13
100
Apr 13
250
Mar 13
Feb 13
Days of staff sickness each month

120
Days between staff injury due to violence T chart
100
80
Average 24 days
20
Days of staff sickness on 3 testing wards I chart
UCL
LCL
Average 115 days
Impact on Costs
3 step approach to analysis
Clinicians, Nursing, Finance and Admin teams identified
the key cost drivers
(Staff Sickness + Patient Treatment + Legal + Damage + Admin + QI)
Cost of all violent incidents over 21 months was reviewed
Data compared Before - During - After QI implemented
Apr13Sep13 Oct13Mar14 Apr14-Dec14
Cost Identification Map
Cost of Violence Lodges & Sally Sherman Apr 13 to Dec 14
Economic evaluation
Reduction in number of incidents by 36% led to
Reduction in Cost of Violence by 49%
Data sourced by Finance, Human Resources, Legal, Estates & Facilities,

Governance, Clinicians & Nursing and the QI Team.
Assumptions used in the Cost of Violence calculation
Cost of 50% of sickness absences plus associated bank and agency cover
Actual damage costs were used, excludes capital investment for major works
Actual legal costs were used, no calculations, excludes impact on insurance
Impact on ongoing patient treatment costs were not considered
Violence Collaborative
A strategy for reducing physical

violence on all adult inpatient mental
health wards in Tower Hamlets
Lea Ward
Bricklane Ward
Roman Ward
Milharbour Ward
Rosebank Ward
Globe Ward
Why is this important?
Globe ward
Dates of incidents
04/08/2014
26/06/2014
19/06/2014
05/04/2014
26/02/2014
11/01/2014
11/01/2014
10/01/2014
11/10/2013
08/10/2013
02/07/2013
17/05/2013
20/04/2013
09/01/2013
07/11/2012
10/10/2012
Re-launch of
BVC following
review and
implementation
21/09/2012
17/09/2012
11/09/2012
28/08/2012
30/07/2012
17/07/2012
22/06/2012
100
17/06/2012
Initial
implementation of
BVC
04/06/2012
09/05/2012
19/04/2012
17/04/2012
31/03/2012
30/03/2012
23/03/2012
07/03/2012
1000
25/02/2012
18/02/2012
04/01/2012
Time between events
Time between incidents on Globe ward

plotted on T Chart
Following implementation of the
BVC time between incidences of
10
11 days
5.5
days
Quicker access to PICU
5 days
between
violence
Safety huddle
Violence standing agenda on
community meeting
Flattened
hierarchy
11 days between
violence
Partial success with spread of Globe ward

package of care
Tower Hamlets Centre for Mental Health

Violence Collaborative
Build the
will
Launch
AIM: To
reduce
inpatient
physical
violence at
Tower
Hamlets
Centre for
Mental
Health by
30% by Dec
2015
Engagement
Build
improvement
capability
Globe
TH QI Forum
Violence Group
Roman
Lea
Brick lane
Bespoke QI learning events for staff,

service users, carers, police
Millharbour
Rosebank
Violence Collaborative Learning Set 1
Nurses
Doctors
Pharmacist
Social therapist
Police
Patient
Carer
OT
Different wards working in Parallel on

Multiple Change Ideas or Drivers
S
A
P
D
P
A
LEA
GLOBE
ROSEBANK
Section 17 leave
NEWS training
Patient property
BRICKLANE
ROMAN
Ward round
Mindfulness & NEWS
D
S
MILLHARBOUR
Personal support plan
A
P
Where are we in our violence

reduction programme:
November 2014
QI Forum and
experts agree
strategy (driver
diagram) and
select high
priority areas and
change ideas to
be tested
Further
learning sets
and action
periods as
required
November /
December 2014
Early January
2015
Mid to Late
January
Team members
recruited for
each ward and
initial projects
assigned
Teams
supported to try
initial change
ideas prior to
first learning set
LEARNING SET 1 Full Day
May/June
2015
Action period
3 (6/52)
May 2015
LEARNING SET
3-Half Day
March/April
2015
Action period 2
(6/52)
February 2015
Action period 1
(4/52)
March 2015
LEARNING SET
2-Half Day
0
03-Feb-15
23-Jan-15
18-Jan-15
22-Dec-14
20-Dec-14
09-Dec-14
23-Nov-14
21-Nov-14
09-Nov-14
11-Oct-14
07-Oct-14
28-Sep-14
19-Sep-14
15-Sep-14
08-Sep-14
05-Sep-14
13-Aug-14
07-Aug-14
04-Aug-14
29-Jul-14
22-Jul-14
16-Jul-14
11-Jul-14
02-Jul-14
29-Jun-14
27-Jun-14
24-Jun-14
20-Jun-14
12-Jun-14
03-Jun-14
20-May-14
01-May-14
30-Apr-14
24-Apr-14
19-Apr-14
11-Apr-14
05-Apr-14
30-Mar-14
29-Mar-14
27-Mar-14
20
16-Mar-14
10-Mar-14
05-Mar-14
27-Feb-14
17-Feb-14
12-Feb-14
10-Feb-14
29-Jan-14
18-Jan-14
16 Feb 15
02 Feb 15
19 Jan 15
05 Jan 15
22 Dec 14
08 Dec 14
24 Nov 14
10 Nov 14
27 Oct 14
13 Oct 14
29 Sep 14
15 Sep 14
01 Sep 14
18 Aug 14
04 Aug 14
21 Jul 14
07 Jul 14
23 Jun 14
09 Jun 14
26 May 14
12 May 14
28 Apr 14
14 Apr 14
31 Mar 14
17 Mar 14
03 Mar 14
17 Feb 14
03 Feb 14
20 Jan 14
06 Jan 14
Number of incidents every fortnight

0
11-Jan-14
11-Jan-14
09-Jan-14
03-Jan-14
Days since last incident of violence

25
No. of incidents resulting in Physical Violence (Rosebank Ward) - C Chart
20
UCL
15
10
LCL
Tower Hamlets Violence and Aggression (Acute Wards) - T Chart
18
16
14
12
10
AIM
PRIMARY DRIVERS
SECONDARY DRIVERS
OT programme
Fitness activities
available for
inpatients
CHANGE IDEAS
Participation documented electronically and
utilised by nursing/medical staff
Publicise and promote through ward staff and
up-to-date information boards
Community facilities
Purchase new weighing scales for each ward

Staff training in consistent measurement of
weight
Reduce mean
weight gain by
30% on acute
wards by April
2015
Identify patients
who are obese or
are at risk of
obesity on
admission
Support healthy
eating whilst in
hospital
Measure and document

weight on admission to
ward
System of regular documentation

Integrate into medical care through ward
round
Share information about

weight with appropriate
professionals
Availability of
information and support
for inpatients
Referral pathway to dietician support

Ward staff to receive training to work with
patients who seek or require health lifestyle
support
Weekly programme of group learning sessions
covering areas of lifestyle change for patients
Food diaries for high risk patients
Canteen food options to

meet healthy lifestyle
requirements
Canteen staff to receive education about food

groups and portion sizes
Canteen environment to feature heathy eating
information for staff
AIM
PRIMARY DRIVERS
SECONDARY DRIVERS
OT programme
Fitness activities
available for
inpatients
CHANGE IDEAS

weight
Reduce mean
weight gain by
30% on acute
wards by April
2015
Identify patients
who are obese or
are at risk of
obesity on
admission
Support healthy
eating whilst in
hospital

ward

round

professionals
Availability of
for inpatients

support

requirements

AIM
PRIMARY DRIVERS
SECONDARY DRIVERS
OT programme
Fitness activities
available for
inpatients
CHANGE IDEAS

weight
Reduce mean
weight gain by
30% on acute
wards by April
2015
Identify patients
who are obese or
are at risk of
obesity on
admission
Support healthy
eating whilst in
hospital

ward

round

professionals
Availability of
for inpatients

support

requirements

PUBLICISE AND PROMOTE THROUGH WARD

STAFF AND UP-TO-DATE INFORMATION BOARDS
PUBLICISE AND PROMOTE THROUGH WARD

STAFF AND UP-TO-DATE INFORMATION BOARDS
AIM
PRIMARY DRIVERS
SECONDARY DRIVERS
OT programme
Fitness activities
available for
inpatients
CHANGE IDEAS

weight
Reduce mean
weight gain by
30% on acute
wards by April
2015
Identify patients
who are obese or
are at risk of
obesity on
admission
Support healthy
eating whilst in
hospital

ward

round

professionals
Availability of
for inpatients

support

requirements

MEASURE & DOCUMENT WEIGHT ON

ADMISSION TO WARD
A P
S D
Cycle 5: Use inline form on all wards

Cycle 4: Test inline form on triage ward
Cycle 3: Development of inline form to allow

physical health data (incl. weight) to be collected
and extracted from RiO.
AP
S D
Cycle 2: Staff to be trained in weight measurements to reduce

inaccuracies.
Cycle 1: Audit weight data for accuracy.
12-Jan-15
5-Jan-15
29-Dec-14
22-Dec-14
15-Dec-14
8-Dec-14
1-Dec-14
24-Nov-14
17-Nov-14
10-Nov-14
3-Nov-14
27-Oct-14
20-Oct-14
13-Oct-14
6-Oct-14
29-Sep-14
22-Sep-14
15-Sep-14
8-Sep-14
1-Sep-14
25-Aug-14
23-Aug-14
18-Aug-14
11-Aug-14
4-Aug-14
28-Jul-14
21-Jul-14
14-Jul-14
7-Jul-14
30-Jun-14
23-Jun-14
16-Jun-14
Weight Change / Kg
OUTCOME MEASURE:
AVERAGE WEIGHT GAIN: ADMISSION TO DISCHARGE
12.00
Average weight change at point of discharge (I chart)
10.00
UCL
8.00
6.00
4.00
2.00
0.00
-2.00
-4.00
LCL
OUTCOME MEASURE:
AVERAGE WEIGHT GAIN: ADMISSION TO DISCHARGE
Average weight change at point of discharge (I chart)
One long stay

patient had gained
>20kg which
distorted the weekly
average weight gain
12.00
1. Audit of weight
2. Staff BMI data training
10.00
UCL
6.00
4. Inline
physical
health
form used
4.00
2.00
0.00
-2.00
LCL
12-Jan-15
5-Jan-15
29-Dec-14
22-Dec-14
15-Dec-14
8-Dec-14
1-Dec-14
24-Nov-14
17-Nov-14
10-Nov-14
3-Nov-14
27-Oct-14
20-Oct-14
13-Oct-14
6-Oct-14
29-Sep-14
22-Sep-14
15-Sep-14
8-Sep-14
1-Sep-14
25-Aug-14
23-Aug-14
18-Aug-14
11-Aug-14
4-Aug-14
28-Jul-14
21-Jul-14
14-Jul-14
7-Jul-14
30-Jun-14
23-Jun-14
-4.00
16-Jun-14
Weight Change / Kg
8.00
AIM
PRIMARY DRIVERS
SECONDARY DRIVERS
OT programme
Fitness activities
available for
inpatients
CHANGE IDEAS

weight
Reduce mean
weight gain by
30% on acute
wards by April
2015
Identify patients
who are obese or
are at risk of
obesity on
admission
Support healthy
eating whilst in
hospital

ward

round

professionals
Availability of
for inpatients

support

requirements

CATERING INTERVENTIONS
A P
S D
Cycle 4:Use of photographs to monitor

meal nutritional quality rating scale
Nursing staff to check portions weekly.
Cycle 3: New oven in place. Regular
feedback data from SUs re proposed
changes.
AP
S D
Cycle 2: Dietitian & catering to develop lower-calorie menu

options. DP restructuring menu forms. Post-meal snacks at
lunch, balancing healthy/unhealthy options on wards
(removing takeaway leaflets, evening toast, fruit availability).
Cycle 1: Education of canteen staff re: food portions and groups, use
of posters in canteen to guide staff.
CATERING INTERVENTIONS DATA
CATERING INTERVENTIONS DATA
Please rate this meal using the scoring chart
Rate this meal using the scoring chart

Text a CODE to 020 3322 5822
5 = Ideal plate
28203
28205
28216
30155
1 = Unacceptable
30401
NEWHAM WEIGHT GAIN QI PROJECT

o Sponsor: Dr Zelpha Kittler
o Project Leads: Steve Yarnold & Simon Tulloch

o QI support: Genevieve Holt
o Service User support: Hyat Ali & Laura Couldrey
o Dietetic support: Patience Dlamini & Emma Burnikell
o Clinical support: All staff at NCfMH
Thank you
Reducing Pressure Ulcers in the Extended Primary Care

Service
Eirlys Evans, Deputy Director of Nursing

Dr Kate Corlett, Associate Medical Director-Primary Care
Community Health Newham
Background
Pressure ulcers can cause serious harm and severe pain to
patients
Particular challenge for community services compared to
inpatient services
Between Feb 2014 and Jan 2015 there were 174 grade 2-4
pressure ulcers acquired in the Trusts care. This equates to a
minimum cost of 1.4 million to the NHS.
AIM:
To reduce grade 3-4 pressure ulcers acquired and attributable in the EPCS by 25%
by December 2015
To reduce grade 2 pressure ulcer acquired and attributable in the EPCS by 25% by
December 2015
Waterlow Assessment
Currently testing change ideas in two teams (NE and NW) to
improve reliability of this process
Mean reliability has increased from 57% to 72% for the entire
EPCT
Further improvements expected as new ideas spread to entire
service
NE team tests new

documentation pack
NW team tests
documentation pack
NW team tests B6
coordination of
assessments
Clinical Management of Pressure

Ulcers
Testing RAG rating clinical management meeting as a way of
improving management of those with pressure ulcers.
Some signals that this may be having a beneficial effect.
Currently testing this in other teams in the EPCS
Clinical
management
meeting fully
embedded
Caseload Management
Remains one of the largest underlying problems that may be
impacting on pressure ulcers
Wide body of work to cleanse caseload underway. Caseload
has dropped from 6,037 open cases in June 2014 to 4,239 in
January 2015
Change ideas and tests now been developed to ensure
caseload is better controlled
Our Progress
Grade 3-4 Pressure Ulcers Acquired in EPCT
Grade 2 Pressure Ulcers Acquired in EPCT
No overall change
in the mean
number of grade
3-4 acquired
pressure ulcers
50% reduction in
the mean
number of grade
2 acquired
pressure ulcers
Next Steps
More accurate baseline and improved reporting
Whole systems approach to prevention of pressure ulcers
across Newham
Implementing new PDSAs e.g. case management
Benchmarking partners
Revise QI aim for 2015
AIM:
To reduce grade 3-4 pressure ulcers acquired and attributable in the EPCS by 25%
by December 2015
To reduce grade 2 pressure ulcers acquired and attributable in the EPCS by 25% by
December 2015
Missed Doses
Project Leads: Maureen Brown &
Zahra Khaki
Project Team: Dr Nodira Nasritdinova, Patrick Watson,
Gordon Mackenzie, Madanha Mwaramba, Wolowiec
Teresa, Steve Skinner
Background
A systematic literature review reported dose omissions are a common administration

error (Keers, 2013) and omitted and delayed doses are one of the most frequent causes
of medication incidents reported to the National Patient Safety Agency (NPSA) (Cousins
et al., 2011). The NPSA proposes a staged approach to defining locally agreed critical
medicines and developing systems to improve and audit the timeliness of
administration (NPSA 2010).
Many patients on Butterfield Ward have chronic physical health conditions as well as
severe and enduring mental health problems. In order to improve the patients
opportunity for recovery and improve physical health we need to ensure that the
treatment plan is followed and can be robustly evaluated.
Individuals with severe and enduring mental health problems have a reduced life span
of about 20 years (Newman & Bland 1991, Brown et al. 2010) compared to the general
population; ensuring they receive the right treatment could aid in bridging health
inequalities.
Project Aim
Reduce missed doses of medication to

meet the Trust standard of less than
4% for non-critical medicines and 0%
for critical medicines by April 2015.
Driver diagram
AIM
PRIMARY DRIVERS
Reduce unnecessary harm

resulting from medication
errors
SECONDARY DRIVERS
CHANGE IDEAS
Improvement patient
experience
Nurse self auditing

dose omissions daily
analysing trends to
identify factors
contributing to errors
Reduced inpatient stay
To ensure that
patients receive
the right
medication at the
right time by
reducing omitted
doses of
medication to less
than 4% for noncritical medicines
and 0% for critical
medicines by the
end of April 2015.
Decreased
morbidity/mortality
Improve patients physical
health
Reduction in polypharmacy
Improved staff well being

Support nurses in the
administration process
Patient Involvement with

their medication /patient
education/empowerment
Fewer incidents from the

administration process
Patient
concordance/adherence
reduced readmission
Promote recovery
Increased Staff Vigilance in

the administration process
Better informed staff,

greater awareness of
medicines management
Nurse survey assessing

attitudes to medication
rounds & identifying &
addressing barriers
Medicines
rationalisation, review
drugs and timings
Allocate a medication
support role
Implement a no Q
policy during
administration
Audit presented at UIG
& community meetings
Visual cues for nursing

staff at patients in the
treatment room
Audit presented at
ward away days &
posters displayed
Sequence of PDSAs
Cycle 5:
Introduced new policy of not

disturbing administering nurses during
administration (Jul 2014)
A P
S D
Cycle 4:
Introduced role of medication support

in the nursing team (Jul 2014)
AP
S D
Cycle 3: Service user meeting to discuss no Q system

Cycle 2:
New missed doses audit tool developed and audit

completed (Jun 2014)
Cycle 1: Pharmacy Audit for missed doses at Wolfson House (Apr 2014)
Sequence of PDSAs
Cycle 8:
Use of questionnaire to ascertain the

cause of missed dose running in parallel with the
night Registered Nurses completing Datix for missed
doses
AP
S D
Cycle 7:
Project audit tool aligned with pharmacy audit tool

to ensure consistent measurement of missed doses
Cycle 6: All Registered Nurses will now contribute to data collection

for project (Oct 2014)
Week Commencing
31-Dec-14
07-Dec-14
06-Dec-14
03-Dec-14
30
02-Dec-14
19-Jan-15
12-Jan-15
05-Jan-15
29-Dec-14
22-Dec-14
15-Dec-14
08-Dec-14
01-Dec-14
24-Nov-14
17-Nov-14
10-Nov-14
03-Nov-14
27-Oct-14
20-Oct-14
13-Oct-14
5%
28-Nov-14
19-Nov-14
18-Nov-14
17-Nov-14
16-Nov-14
15-Nov-14
11-Nov-14
07-Nov-14
06-Nov-14
17-Oct-14
15-Oct-14
13-Oct-14
07-Oct-14
06-Oct-14
0%
06-Oct-14
29-Sep-14
No. of Non-Critical Doses Missed / %

2%
04-Oct-14
02-Oct-14
Time Between Events / Days
Data
Non-Critical Doses Missed - P Chart
4%
3%
UCL
1%
LCL
Week Commencing
Critical Doses Missed - T Chart
25
20
15
10
Week Commencing
19-Jan-15
12-Jan-15
05-Jan-15
29-Dec-14
22-Dec-14
5%
15-Dec-14
08-Dec-14
01-Dec-14
24-Nov-14
17-Nov-14
10-Nov-14
03-Nov-14
27-Oct-14
20-Oct-14
0%
13-Oct-14
2%
06-Oct-14
3%
29-Sep-14
No. of Doses missed / %
Data
Total Doses Missed (Non-Critical and Critical) - P Chart
4%
All RNs began data

collection (1st Oct 14)
UCL
1%
LCL
Spot the data outlier?

Missed Doses
Week
Date
Wk 1
Wk 2
Wk 3
Wk 4
Wk 5
Wk 6
Wk 7
Wk 8
Wk 9
Wk 10
Wk 11
Wk 12
Wk 13
Wk 14
Wk 15
Wk 16
Wk 17
29 Sept - 05 Oct 14
06 - 12 Oct 14
13 - 19 Oct 14
20 - 26 Oct 14
27 Oct - 02 Nov 14
03 - 09 Nov 14
10 - 16 Nov 14
17 - 23 Nov 14
24 - 30 Nov 14
01 - 07 Dec 14
08 - 14 Dec 14
15 - 21 Dec 14
22 - 28 Dec 14
29 Dec 14 - 04 Jan 15
05 - 11 Jan 15
12 - 18 Jan 15
19 - 25 Jan 15
Date of 1st Non critical doses Non critical

day of week
prescribed
doses missed
29-Sep-14
6-Oct-14
13-Oct-14
20-Oct-14
27-Oct-14
3-Nov-14
10-Nov-14
17-Nov-14
24-Nov-14
1-Dec-14
8-Dec-14
15-Dec-14
22-Dec-14
29-Dec-14
5-Jan-15
12-Jan-15
19-Jan-15
650
940
969
1040
1050
1104
1113
1293
919
864
1030
943
957
969
1010
449
119
2
7
13
10
4
17
15
1
7
37
0
12
11
4
0
1
0
Percentage of non
Critical Percentage of
Percentages
Critical doses
Total doses Total doses
critical doses
doses critical doses
of missed
prescribed
prescribed
missed
missed
missed
missed
doses
0.31%
165
2
1.21%
815
4
0.49%
0.74%
247
2
0.81%
1187
9
0.76%
1.34%
287
6
2.09%
1256
19
1.51%
0.96%
268
0
0.00%
1308
10
0.76%
0.38%
254
0
0.00%
1304
4
0.31%
1.54%
238
3
1.26%
1342
20
1.49%
1.35%
238
3
1.26%
1351
18
1.33%
0.08%
329
3
0.91%
1622
4
0.25%
0.76%
257
2
0.78%
1176
9
0.77%
4.28%
335
19
5.67%
1199
56
4.67%
0.00%
217
0
0.00%
1247
0
0.00%
1.27%
224
0
0.00%
1167
12
1.03%
1.15%
225
0
0.00%
1182
11
0.93%
0.41%
231
4
1.73%
1200
8
0.67%
0.00%
251
0
0.00%
1261
0
0.00%
0.22%
111
0
0.00%
560
1
0.18%
0.00%
33
0
0.00%
152
0
0.00%
Learning
The project has raised the profile of
medication errors (missed doses) among
staff and service users on the ward. This
has resulted in improved quality of care,
through reduced error rates as evidenced
by the data we have collected over the
past few months.
QI Tips from Butterfield Ward

Planning clinicians are keen to get doing but careful planning of how is
crucial to a successful project, as well as what to measure and actually
measuring it.
Change ideas these are exciting but must be aligned with measures to
establish if they result in real change
Communication the project team require regular meetings to ensure work
is being co-ordinated, and data can be scrutinised so the team respond in
real time
Engagement project work needs to become business as usual, so staff need
to believe it is meaningful if it is going to be a priority in practice: QI ideas
that come from frontline staff are the ones that will be embraced most easily
Improvement has been demonstrated easily, with very little financial
investment from the service. Improving the quality of care provided and
reducing harm has proved an extremely rewarding experience for ward staff
and patients!
THANK YOU FOR

LISTENING!
Any questions?
Improving Young Peoples Experience Of

Feeling Listened To and Understood At
The Coborn Centre For Adolescent
Mental Health
Project lead:
Rachel Trimmer
Project team:
Laura Fialko (Lead Psychologist)

Claire McKenna (Service Manager)
Project sponsor: Rafik Refaat
Why we chose this project:
% of Young People Responding As Happy

or Very Happy To CAMHS Satisfaction Survey Questions
The kinds of service offered
to you
The confidentiality and

respect for your rights
100%
90%
The service you received in

a general sense
80%
71.43%
70%
71.43%
64.29%
69.05%
64.29%
59.52%
60%
54.76%
53.13%
54.76%
57.14%
54.76% 54.76%
54.76%
52.38%
50.00%
50%
45.24%
45.24%
40%
30%
20%
10%
0%
1
10
11
CAMHS Satisfaction Survey Questions

How the professionals
listened to and understood
your problems
12
13
14
15
16
17
Our Aim
To improve the experience among young
people on a CAMHS Adolescent Inpatient
Unit of feeling their problems are listened to
and understood,
by achieving 80% of young people
responding as happy or very happy in
response to this question,
by March 31st 2015.
% of Young People Responding As Happy

or Very Happy
100%
90%
80%
71.43%
70%
71.43%
64.29%
69.05%
64.29%
59.52%
60%
54.76%
53.13%
54.76%
57.14%
54.76% 54.76%
54.76%
52.38%
50.00%
50%
45.24%
45.24%
40%
30%
20%
10%
0%
1
10
11
CAMHS Satisfaction Survey Questions
12
13
14
15
16
17
Areas for Improvement
Ward Round
I am given the opportunity to raise issues that matter
to me in ward round: Average response = 5/10
I can influence the decisions made about my care in
ward round: Average response = 4/10
I am happy with how often I see my consultant:
Average response = 3/10
Care Planning
I understand my care plan: Average response = 6/10
My care plan reflects my needs: Average response = 5/10
My care plan is helpful as a plan for my recovery: Average
response = 5/10
Change Idea 1
Consultant Clinics
A weekly opportunity for young people to

meet with their consultant once per week
prior to ward round and raise any issues
they would like to be heard by the team.
Sequence of PDSAs Consultant Clinics
A P
S D
AP
S D
Cycle 1: : Is it possible to fit weekly Consultant Clinics
into consultants diaries?
A P
S D
AP
S D
into consultants diaries? Yes. Each consultant was able to
fit 2 weekly clinics each into their diaries.
A P
S D
AP
S D
Cycle 2: Will the consultant clinic make a difference to how

young people feel listened to and understood?
A P
S D
AP
S D

young people feel listened to and understood? Initial feedback
looks positive. Process measures need to be repeated regularly.

I love it! It feels like the way things should be done.

I find it a better way to see the young people, I have more
time. The young people are less pressured than when seen
in front of the ward round group. The only problem of
course, is making sure I am free every Monday and
Wednesday morning to do the clinic.
It is less intimidating
A P
S D
AP
S D
Cycle 3: Can the advocate continue to

support the young people with their ward
rounds using this new format?


A P
S D
AP
S D

rounds using this new format? Yes.


Cycle 4: Will young people
A P
S D
AP
S D
continue to receive structured

ward round feedback with this
new format?

rounds using this new format? Yes.


Change Idea 2
Recovery Star
Sequence of PDSAs Recovery Star
A P
S D
AP
S D
Cycle 1: : Can a recovery star be created using outcome
measure data?
A P
S D
AP
S D
measure data? Yes.
Recovery Star
Template
A P
S D
AP
S D
Cycle 2: Will young people find the recovery star a

useful and meaningful tool for care planning?

measure data? Yes.
A P
S D
AP
S D

useful and meaningful tool for care planning? Initial
feedback from the pilot has been positive. Process
measures need to be repeated regularly.

measure data? Yes.
Staff feedback
It provided a helpful
structure.
The young person clearly
enjoyed being in control of
the pen and colouring in the
dots.
The scoring system could go

the other way e.g. 5 = no
difficulties, 1 = severe
difficulties.
Young person
feedback
I liked it
A P
S D
AP
S D
Cycle 3: How can we use the recovery

star with all young people?

useful and meaningful tool for care planning? Initial
feedback from the pilot has been positive. Process
measures need to be repeated regularly.

measure data? Yes.
Challenges:
Is feeling misunderstood an unavoidable part of
adolescence?!
Admission to an inpatient unit may in itself make
young people feel they have not been listened to or
understood.
Discharge biases
It is difficult to meet regularly and gather momentum
with staff working on shift patterns and on wards that
are hard to leave for meetings.
Learning
Data is a good way to evidence the need for change,
especially when trying to get other team members involved.
It takes time to gather meaningful levels of data.
Recording data on a database is key!
The challenges associated with a QI team made up of
different disciplines on different work schedules are
outweighed by the benefits of having experience, input and a
task force covering the breadth and depth of your service.
Supporting an Improvement Culture at

The Coborn
Peak team interest
Away day projects

Talking about QI in different forums
Play with ideas and process
Getting it wrong
Positive drive from senior management group (SMG)
Training commitment
SMG 5 out of 7 have attended QI training
Next focus is nurse leaders
True commitment
Protected time for leaders
Different way of allocating time
Challenges Involved in Supporting

Improvement Culture at The Coborn
Following through of QI projects to
completion
Agreeing the priority of QI projects
What not to QI
Ensuring clozapine trial in all

Treatment Resistant Schizophrenia
NATASHA PATEL, JENNIFER MELVILLE

TOBY BALDWIN, HAN LIM, SUSHAM GUPTA
& THE CITY & HACKNEY ASSERTIVE
OUTREACH SERVICE
Drivers for change

High level of psychiatric and physical morbidity of patients
with psychosis under the care of AOTs

Clozapine is the treatment of choice for TRS
- Maudsley Guidelines
- NICE guidelines on Schizophrenia
The National Audit for Schizophrenia (NAS) report shows
lower levels of use of clozapine in ELFT compared to the

national average*
* high levels of high dose and polypharmacy and many
cases without documented rationales
Barriers Patient & Clinician factors

Patient Factors:
Complex group of patients difficult to diagnose actual TRS

High level of substance misuse
Poor insight
Poor compliance and engagement
Problems associated with blood monitoring
Ethnicity-related issues incl. Benign Ethnic Neutropenia
Clinician factors:
High risk medication

Need for ensuring blood monitoring
Risks of repeated re-titration if non-compliant
Problems with titration in the community
Limited experience with use of clozapine esp. during training years
concerns about poor side-effect profile esp. metabolic syndrome disorders etc
Improving access to clozapine for treatment resistant schizophrenia in specialist teams

AIM
Ensure correct
diagnosis of
TRS of
AOS/Rehab
patients in C&H
directorate by
01.02.2015
Identify whether
trail of clozapine
has been
considered for
100% of TRS
patients
Reduce the
number of
patients on high
dose
antipsychotics
and
polypharmacy
PRIMARY DRIVERS
SECONDARY DRIVERS
Appropriate
diagnosis of TRS
and patients on high
dose/polyphramacy
Review diagnosis at each clinical and CPA reviews by

AOS/Rehab responsible clinicians or senior colleagues
(of in-patient/community patients as well as those in higher
supported placements)
Identify whether
patient is on
clozapine or has
been prescribed in
the past
Impact on supported
accommodations
Impact on clozapine
clinic
Impact on In-patient
(Ruth Seifert Ward)
Review case noted esp. those on high dose/polypharmacy

Request information from pharmacist colleagues
Offer clozapine to appropriate candidate
Rehab and high supported placement manager to audit

number of placement during this period
Clozapine clinic audit- by senior clozapine clinic

nurse/manager to Identification, number of new patients
on clozapine
Audit any admissions related to initiation or retitration of

clozapine during this period- by senior nurse
Sequence of PDSAs to show steps of

change
Cycle 5: Understanding
the barriers to prescribing
A P
S D
Cycle 4: Monitor progress and

embed TRS form into practice
Cycle 3: developing database in AOS
and Rehab which included diagnosis,
high dose poly pharmacy plan
AP
S D
Cycle 2: Refining TRS form and clarified clinical

variations of TRS
Cycle 1: :Developing TRS assessment form
Outcomes
Percentage of caseload with a diagnosis of schizophrenia or

schizoaffective disorder who have been diagnosed with TRS
90
80
14
70
Increase
in number of patients
taking clozapine during
improvement project
Percentage
60
Median
50
40
30
20
10
100
09/01/2015
02/01/2015
26/12/2014
19/12/2014
12/12/2014
05/12/2014
28/11/2014
80
60
Median
50
40
30
20
10
09/01/2015
02/01/2015
26/12/2014
19/12/2014
12/12/2014
05/12/2014
28/11/2014
21/11/2014
14/11/2014
Percentage
70
07/11/2014
Run Chart showing % of caseload of patients with a diagnosis of

treatment resistant schizophrenia who are on clozapine or have had a
trial of clozapine
90
8
Reduction
in number of patients on
high dose antipsychotic
therapy and polypharmacy
during improvement project
21/11/2014
16
14/11/2014
07/11/2014
Learning points
QI is a very useful tool to bring about changes if owned
by the team
In this case it improved quality of care significantly
Provided thinking and learning space
Need for perseverance and commitment
Meeting regularly (if possible weekly, however difficult)
IS THE KEY
We struggled with admin-related things and actual
regular in-putting data electronically in the QI-website
Enjoying the process and getting the whole team to be
enthusiastic about it!
Thats just a flavour of the QI work

happening

happening
120
Active
QI
projects

happening
120
Active
QI
projects
Another 35 projects
presenting their work on
posters
Meet the projects

Look at the posters
Vote for your
favourite
One vote allowed. Vote
by SMS or Tweeting.
Details of codes in your
conference guide
Vote for your favourite poster

Text a CODE to 020 3322 5822
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Title
Code
No
Title
Code
1
2
3
83696
83746
83966
20
21
22
83968
23
83979
84397
24
25
Weight management
84398
26
8
9
10
11
12
84399
84457
85734
86507
86508
27
28
29
30
31
86509
32
14
Self-catering
Co-ordinator caseload
Specialist addictions unit
Front Door project
Missed doses
Improving care in the last
years of life
Procurement compliance
86510
33
15
Reducing falls
87887
34
16
Reducing omitted doses
87888
35
Corporate induction
Reducing background noise
QI microsite
Communication between
governors
The Bridge club
Medicines reconciliation
Reducing non-attendance in
CMHTs
Interpreting Service
Clozapine trial in TRS
Womens health
This is my ward round
MH Tariff Clustering
Reducing physical violence
on Globe ward
Reducing bed occupancy
Improving physical health
monitoring
Access to psychology
services
88249
89112
89114
5
6
Pressure Ulcers
Podiatry services
Coborn Centre
Domestic abuse and
sexual violence
Capacity management
Internal communications
88232
36
Dementia care team
96302
88233
37
Effective psychological
therapies
96415
13
17
18
19
Reducing violence on
older adult wards
Advance care planning in
memory services
Physically deteriorating
patients
88238
89115
90142
90725
95757
95982
95985
96167
96296
96297
96298
96299
96300
96301
Professor Martin Marshall

Professor of Healthcare Improvement, UCL
What works to improve the quality

of patient care?
Martin Marshall
Professor of Healthcare Improvement, University College London
Lead, Improvement Science London
East London NHS Foundation Trust QI Conference

10th March 2015
Most of the
people who work
in the NHS are
only half-trained
What works?
Getting the strategy right

Planning carefully
Creating a conducive environment
Delivery, delivery, delivery
Recognising that there are many

different ways to improve quality
Health system
Clinical teams
Education and training
Clinical audit
Peer review/ collaboration
Guidelines
Performance management
Regulation
Incentives/sanctions
Competition
Commissioning
Organisations
Org. development
TQM/CQI, BPR,
PDSA, Lean, 6 sigma
Aligning change strategies to the nature

of the task
Stacey, 2012
Aspiring to create the characteristics of

high performing organisations
1.
2.
3.
4.
Specification and planning

Infrastructure design
Measurement and oversight
Self study
Avoiding the temptation to focus on

structural change
BMJ, 2002
What works?
Planning carefully
Putting in a lot of effort at the planning stage

Convincing people that there
is a problem
Demonstrating to them that
the problem is actionable and
engaging them in finding
workable solutions
Helping them to see that
addressing the problem
should be a priority
Aiming for a balance between internal

and external facilitators of change
Quality improvement collaborative
in Newham general practice:
Internal
External
Professional desire to improve

patient care
Professional desire to develop
new knowledge and skills
Creation of a conducive learning
environment
Link to contractual obligations

Align to CPD imperatives
Financial incentives
Thinking about embedding, spreading and

sustaining improvement from an early stage
Linked into existing health and social care services

Used established staff to provide services and provided training for them
Achieved PCT/CCG support from early stage
Incorporated into commissioning strategy
Remembering that all efforts to improve

have unintended consequences
What works?
Planning carefully
Creating a conducive
environment
Remembering that improvement requires

more than just an effective intervention
Intervention
Implementation
Context
Recognising that culture is important and

changing it is difficult
Working with general practices in
East London:
Minimal infrastructure to support QI
activities
High level of autonomy and
independent working practices
Time is precious
Strong small business ethic
Regular weekly meetings of most
practices
Pride in achieving targets
Adopting a whole systems approach to

change
Sources of behaviour
Intervention functions
Policy categories
Behaviours
Psychological
Physical
What works?
Planning carefully
Using multiple interventions which combine

technical and social elements
Outer North East London COPD
improvement project
Marshall, Mountford, Gamet et al., BJGP, 2014
Social elements
4 half day master classes for practice staff
Mentorship and practice-based supervision
for practice nurses
Technical elements
1 day certified course in spirometry training
Provision of template to aid data collection
Provision of care plans
Data feedback using benchmarking
Choosing interventions which are known

to be effective
Improving Patient Care
Richard Grol, Michel Wensing, Martin Eccles,
David Davis, 2013
1.
2.
3.
4.
Aligned to established values and norms

Relative advantage
Simple
Testable and reversible
Being a little bit sceptical about the

quality of the data that we have available
Milbank Quarterly, 2012
1. Develop a strategy
2. A MIRACLE OCCURS
3. Quality of health care

improves
perhaps we could be a little more explicit here at step two
Our quality
improvement programme
The strategic case for change

Make quality our
absolute priority
Improving
quality of care
is our core
purpose
Of greatest
importance to
all our
stakeholders
Build on the
excellent work
already
happening to
improve quality
National drivers
The need to
focus on a
more
compassionate,
caring service
with patients
first and
foremost
More
structured and
bottom-up
approach to
improvement
Enable our staff

to lead change
The desire to
engage, free
and support
our staff to
innovate and
drive change
Engaged and
motivated staff
leads to
improved
patient
outcomes
The economic
climate
The need to do
more with less
improving
quality whilst
reducing cost
The culture we want to nurture

A listening and learning
organisation
Empowering staff to
drive improvement
Patients, carers
and families at
the heart of all
we do
Increasing transparency
and openness
Re-balancing quality
control, assurance and
improvement
Build the
will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Build
improvement
capability
Alignment
1.
2.
3.
4.
5.
6.
Launch event & roadshows

Microsite
Using the power of narrative
Celebrate successes
Network of champions / ambassadors
Learning events
1.
2.
3.
4.
5.
6.
Initial assessment of alignment & capability

Recruiting central QI team
Online training
Face-to-face training
Follow-up coaching on projects
Develop in-house training for 2016 onwards
1.
2.
3.
4.
Align all projects with improvement aims

Align team / service goals with improvement aims
Align all corporate and support systems
Patient and carer involvement in all improvement
work
5. Embed improvement within management structures
Reducing Harm by 30% every year
1. Reduce harm from inpatient violence
2. Reduce harm from falls
3. Reduce harm from pressure ulcers
4. Reduce harm from medication errors
5. Reduce harm from restraints
QI Projects
Right care, right place, right time

1. Improving patient and carer experience
2. Reliable delivery of evidence-based care
3. Reducing delays and inefficiencies in the system
4. Improving access to care at the right location
Build
the will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
35,000
Build
the will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
35,000
page views of the QI microsite in the last year
Build
the will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
our one-stop shop for QI

built and managed by
the QI team, total cost
300
35,000
our one-stop shop for QI
Build
the will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
built and managed by

the QI team, total cost
300
35,000
Build
the will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Introducing microsite 2.0
Build
the will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Introducing microsite 2.0
Build
the will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
1,000
Build
the will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
1,000
Staff, service users, carers, Governors,

commissioners engaged in the first 4 months of
the programme
Build
the will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Bespoke learning sessions
Build
the will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Psychology
trainees
Trainee
doctors
External
partners
Health visitors
Nursing
students
Band 3 nursing
staff
Specialist
services
leadership
Service users
and carers
Finance team
Bespoke learning sessions
Build
the will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
4,000
Build
the will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
4,000
staff receiving the monthly QI e-newsletter
Build
the will
Percentage of staff opening the e-newsletter
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Build
the will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
550
Build
the will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
550
local services receiving the quarterly paper

newsletter, including GP practices and voluntary
sector organisations
Build
the will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
projects shortlisted
for regional or
national awards
Build
the will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
for regional or
national awards
regional award
Build
the will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
6 6
for regional or
national awards
regional award
teams presenting
their work to the Trust
board each year
Build
the will
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
6 6
for regional or
national awards
teams presenting
their work to the Trust
board each year
1 7
regional award
projects being
written up for
publication with BMJ
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Build
improvement
capability
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
1,000
Build
improvement
capability
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
1,000
Open School lessons completed
Build
improvement
capability
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Recruited a central QI team
Build
improvement
capability
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Developed 3
improvement advisors
Build
improvement
capability
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Developed 3
improvement advisors
Board sessions
Build
improvement
capability
Improvement Science in Action

- 6 month learning path
Prework
Workshop
Workshop
9/29-10/1
(3 days)
Webex #1
Webex
1
10/14
AP-1
Project
Planning
AP-2
Learning
Webex
2
11/21
set
AP-3
Reliability
Webex
Webex#23
11/30
Sustaining
Gains
Learning Set
2&
graduation
Supports:
Faculty consults
Listserve
The two learning
sets will be focused
sharing the
onWebex
callsparticipants work on their
projects and learning
from each other.
These sessions
Assignments
Coaching
callsalso will reinforce the
AP-4
Webex #3
AP-5
content from the Webex calls and the ISIA workshop.
Improvement Science
in Action wave 1
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Build
improvement
capability
Improvement Science
in Action wave 1
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Build
improvement
capability
Improvement Science
in Action wave 1
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Wave 2
Build
improvement
capability
Improvement Science
in Action wave 1
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Wave 2
Build
improvement
capability
Insert training video
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Waves 3 & 4
of
Improvement
Science in
Action
Build
improvement
capability
2015 training opportunities
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Waves 3 & 4
of
Improvement
Science in
Action
Developing 5
more
improvement
advisors
Build
improvement
capability
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Waves 3 & 4
of
Improvement
Science in
Action
Developing 5
more
improvement
advisors
Build
improvement
capability
Developing 30
improvement
coaches within
directorates
Alignment
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Alignment
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Alignment
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Alignment
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Alignment
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Project Sponsor
QI Team
QI Forums
QI Resources
How have our

projects developed
over time?
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
QI Projects
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
QI Projects
September 2014
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
QI Projects
October 2014
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
QI Projects
November 2014
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
QI Projects
December 2014
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
QI Projects
January 2015
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
QI Projects
February 2015
Reduce harm by
30% every year
AIM:
To provide
the highest
quality
mental
health and
community
care in
England by
2020
Violence
Reduction
Tower Hamlets
Collaborative
Pressure
Ulcers
Extended primary
care teams
MULTIPLE I/P WARDS
MHCOP
MULTIPLE WARDS
Older adult
inpatient wards
Right Care, Right

Place, Right Time
Physical
Health
Access to
services
City & Hackney
Newham
REHAB
AOS
CONNOLLY
BEVAN
PSYCHOLOGY
Newham
MULTIPLE WARDS
MHCOP
TRAINING LODGE
Childrens
CDC x2
CAMHS x3
MHCOP
MEMORY SERVICE
NEWHAM
City & Hackney

ALL CMHTS
QI Projects
Is it making a difference?
Datix incident reporting

Month
Feb 15
Jan 15
Dec 14
Nov 14
Oct 14
Sep 14
Aug 14
Jul 14
Jun 14
May 14
Apr 14
Mar 14
Feb 14
Jan 14
Dec 13
Nov 13
Oct 13
Sep 13
Aug 13
Jul 13
Jun 13
May 13
Apr 13
Mar 13
Feb 13
Jan 13
Dec 12
Incidents each month
Incidents of physical violence across the Trust (C Chart)
230
UCL
210
190
170
150
LCL
130
110
90
70
50
Datix incident reporting

Feb 15
Jan 15
Dec 14
Nov 14
Oct 14
Sep 14
Aug 14
179 per
month
Jul 14
Jun 14
May 14
Apr 14
Mar 14
Feb 14
Jan 14
Dec 13
Nov 13
Oct 13
Sep 13
Aug 13
Jul 13
Jun 13
70
May 13
90
Apr 13
Mar 13
Feb 13
Jan 13
Dec 12
Incidents each month
Incidents of physical violence across the Trust (C Chart)
230
UCL
210
190
170
150
LCL
130
110
145 per
month
50
Month
19% reduction across the Trust
Physical violence to staff (per

100,000 occupied bed days)
550
Incidents per 100,000 bed days
Incidents per 100,000 bed days
Physical violence to patients (per

100,000 occupied bed days)
500
450
400
350
300
250
200
150
2013
2014
850
750
650
550
450
350
250
2013
2014
ELFT Score
NHS benchmarking club mental health services
Staff experiencing physical violence from

patients, relatives or the public in last 12 months
50
Score (%)
40
30
20
10
0
2010
NHS staff survey
2011
2012
2013
2014
Jan-15
Dec-14
Nov-14
Oct-14
Sep-14
Aug-14
Jul-14
Jun-14
May-14
Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
70
Mar-12
130
Feb-12
Jan-12
No. of Incidents
Jan-15
Dec-14
Nov-14
Oct-14
Sep-14
Aug-14
Jul-14
Jun-14
May-14
Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
No. of Restraints
100
Episodes of Restraint in Prone Position - C Chart
90
80
70
60
UCL
50
40
30
20
LCL
10
Incidents resulting in the use of Restraint (C Chart)
170
150
UCL
110
90
LCL
50
Jan-15
Dec-14
Nov-14
Oct-14
Sep-14
Aug-14
134 per month
Jul-14
Jan-15
Dec-14
Nov-14
Oct-14
Sep-14
Aug-14
Jul-14
60
Jun-14
80
Jun-14
May-14
Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
68 per month
May-14
Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Incidents resulting in the use of Restraint (C Chart)

Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
No. of Restraints
90
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
70
Mar-12
130
Feb-12
Jan-12
No. of Incidents
100
Episodes of Restraint in Prone Position - C Chart
56% reduction
70
UCL
30 per month
50
40
30
20
LCL
10
16% reduction
170
150
112 per month
UCL
110
90
LCL
50
Restraints per 100,000 bed days
Use of restraint (per 100,000

occupied bed days)
1450
1250
1050
850
650
450
250
2013
2014
0
RES043
RES035
RES072
RES041
RES004
RES071
RES042
RES073
RES003
RES045
RES040
RES008
RES009
RES016
RES052
RES067
RES079
RES001
RES028
RES002
RES058
RES022
RES015
RES006
RES019
RES066
RES065
RES076
RES020
RES075
RES047
RES054
RES069
RES029
RES030
RES064
RES078
RES023
RES038
RES056
RES018
RES050
RES007
RES063
RES051
RES048
RES077
RES062
RES027
RES025
RES046
RES034
RES014
RES049
RES036
RES024
RES060
RES017
RES055
RES053
RES068
RES005
RES080
RES057
RES021
RES061
RES074
RES059
RES039
RES010
RES031
RES037
RES044
RES026
RES011
RES012
RES013
RES033
Incidences of Restraint per 10 beds (August 2014)
35
30
25
20
15
10
Instances of Prone Restraint per 10 beds (August 2014)
Pressure Ulcers
Grade 3-4 Pressure Ulcers Acquired in EPCT
14
UCL
12
No change in the
grade 3-4 acquired
pressure ulcers
10
8
6
4
2
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
LCL
Feb
Grade 2 Pressure Ulcers Acquired in EPCT
50% reduction in
grade 2 acquired
pressure ulcers
Serious incidents per 100,000 occupied bed

days in adult mental health
165
145
125
105
85
65
45
25
5
2013
2014
Prescribing errors
230
Errors per 100,000 occupied bed days
Errors per 100,000 occupied bed days
Drug administration errors

210
190
170
150
130
110
90
70
50
2013
2014
90
80
70
60
50
40
30
20
10
2013
2014
Staff feeling satisfied with the quality of work and patient

care they are able to deliver
90
Score (%)
85
80
75
70
65
60
55
2010
NHS staff survey
2011
2012
2013
2014
Staff able to contribute towards improvements at work

85
Score (%)
80
75
70
65
60
55
2010
NHS staff survey
2011
2012
2013
2014
Staff job satisfaction

4
3.9
Score
3.8
3.7
3.6
3.5
3.4
2010
NHS staff survey
2011
2012
2013
2014
Staff Motivation at Work

4.1
Score
3.9
3.8
3.7
3.6
3.5
2010
NHS staff survey
2011
2012
2013
2014
Staff recommendation of the Trust as a place to work or

receive treatment
4.2
Score
3.8
3.6
3.4
3.2
2010
NHS staff survey
2011
2012
2013
2014
Overall Staff Engagement score

4.05
4
3.95
Score
3.9
ELFT Score
3.85
National Average
3.8
3.75
3.7
3.65
3.6
2010
NHS staff survey
2011
2012
2013
2014
So, what will it take to

sustain this?
And finally
The winner of our poster competition!
Summary and close
Dr Kevin Cleary
qi@eastlondon.nhs.uk
@ELFT_QI

Annual QI Conference Slide Set

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Quality improvement

Marie Gabriel (Chair) and

Woodberry Ward Self-Catering

Project team: Alison OReilly, Dr Sian Llewellyn-Jones, Ali

Complaints about the food

Project aim For 60% of

Sequence of PDSAs for one change idea or

Cycle 5: Expand across the

Cycle 3: Monthly Pilot

Cycle 2: Research / visits / planning

Across the month over 90% total participation

No. of SU's involved / %

Number of Service Users participating in meal

Service User Survey

Possible measures for future:

Long term implementation

A look back at our first year of QI

Professor Jonathan Warren

and Steven Course

Some thoughts and guidance from

Executive Vice President at IHI

Executive Director at IHI for

Now lets hear about some of the

Now lets hear about some of the

Use your phone or tablet to ask a

Text a CODE to 020 3322 5822

Tweet @poll and a CODE

Ask a question about these QI projects

Tweet @poll 178756 then your message

Violence reduction on older adult wards

Reducing harm from inpatient violence

Creating a safe and

Staff training and

Awareness sessions for

Our PDSA ramps

Test: Pet therapy

Test: Use of befrienders for

Across all older

Test: Structured activity 5

Unit 1 Sally Sherman

Test: Further develop and

Test: Test for two weeks

Test: Try intentional

Test: Try intentional

Unit 2 The Lodge (2 wards)

Days since last incident of physical violence

Days between incidents of physical violence, 3 wards

Average 2.9 days

Date of physical violence

Average 6.4 days

Average 177 days

Days since last injury to staff

Days of staff sickness each month

Days between staff injury due to violence T chart

Days of staff sickness on 3 testing wards I chart

Average 115 days

Cost Identification Map

Cost of Violence Lodges & Sally Sherman Apr 13 to Dec 14

Data sourced by Finance, Human Resources, Legal, Estates & Facilities,

A strategy for reducing physical

Why is this important?

Time between events

Time between incidents on Globe ward

Quicker access to PICU