Are patients active participants in your organization’s quality improvement (QI) efforts? Does your housekeeping staff know how to run PDSA cycles to test changes for improvement?
The answer to both these questions is “yes” at the East London NHS Foundation Trust (ELFT) because — like most health care organizations — we are trying to improve the quality of our care while reducing costs. The key way we do this is by developing the QI skills of staff throughout our organization and engaging our service users to help us rethink and redesign care. During my 14 years at ELFT, I’ve seen how that investment can pay off. We’ve made dramatic progress by giving people throughout our organization the skills, tools, and confidence that they can contribute to continuous improvement.
I’m a senior QI lead at ELFT, with a background in mental health nursing. I’m one of the many people at my organization — including nurses, doctors, social workers, administrators, domestic (housekeeping) staff and patients (who we call service users) — who have been trained in QI. We provide award-winning mental health and community services to one of the most culturally diverse parts of the UK.
Our QI initiatives have resulted in significant reductions in inpatient violence, medication errors, and waiting times for treatment in the community. Also, a recent survey conducted by the NHS last year rated ELFT as the top Trust in the country for staff engagement — out of the 57 mental health and community trusts in England. In addition, between 2014 and 2016, ELFT realized a £181,296 (US $233,965) reduction in costs related to violence.
Embedding QI into our culture has helped us feel that we all have the power to contribute to change. When I first started at ELFT, it was common practice to think that only service leads or senior leaders could work on improvement. Whenever you had a problem, you had to work it up to someone senior who would decide whether or not it was worthy of attention.
Now, instead of just complaining or thinking it’s someone else’s responsibility, staff now identify problems in their day-to-day work and ask, “Can I do something about this? Can I use QI to help solve the problem?” They draw people together to work on common problems, share lessons they’ve learned, and celebrate successes.
Broadening the Impact of Improvement
In the past, we had no infrastructure for sharing improvement work outside a team. We now have a learning system, a platform to share an improvement or an innovation.
This means that if I start a new QI project, I probably don’t have to reinvent the wheel. Someone somewhere within our organization of 5,000 staff has probably done something similar, and I can start from where they left off and improve on it.
For example, I supported a project team that reduced the bed occupancy and length of stay on their ward. A year later, another team decided to work on the same issues. It was great to go to the nurses, doctors, and social workers on the original team and say, “Hey, listen, there are some people trying to solve the same problems. Can they have a conversation with you?”
We created communication between people who typically wouldn’t have had much interaction. The first team is not only sharing what they learned, but they’re saying, “If you’re going to improve on what we did, we’d love to know about it, because we think we can do even better.” That kind of generosity, humility, and willingness to continuously learn is what I see all around ELFT.
Everyone Can Contribute to Improvement
Without necessarily following a handbook on disseminated leadership, we’ve done it using QI. For example, the ward manager of one of the directorates I support on our inpatient ward, assembled, printed, and bound Plan-Do-Study-Act (PDSA) booklets for every member of his team so they could record their ideas and plans for tests of change. This included clinical staff, but also the contracted domestic staff.
When he meets with his staff he often asks, “What’s in your PDSA booklet?” He encourages people who interact with service users, but aren’t involved in clinical care, to run rapid cycle changes as part of their day-to-day work. The domestic staff now approach the staff and share their observations and suggestions for improvements.
Service users also participate in QI efforts. One of the directorates I work with has a strategic team that includes sponsors, coaches, a QI lead, service users, and caregivers as core members. Each person has an equal voice.
At one meeting, one of the service users, Gavin (not his real name), raised an issue that he said bothered him as a taxpayer. “Every time I get admitted to hospital,” Gavin explained, “they ask me to bring my medicines with me.” They don’t, however, let him use the medications he brings from home. Instead, the hospital staff disposes of them.
Even if a hospital admits Gavin for only one day, and he gets discharged the next, he’s prescribed more medicines. If the hospital readmits him, the same process happens again. “I can’t see how we justify this type of waste,” he said. I asked Gavin what he wanted to do, and he responded, “We should start a QI project about it!” A pharmacist joined his efforts.
I saw Gavin a month later, and he eagerly told me about the ideas he was developing with the pharmacist. He said he’d talked about this problem repeatedly for the past two or three years, and was excited to finally have the chance to help work on it.
The Importance of Celebrating Success
In the UK, when there’s something in the media about health care or the National Health Service (NHS), it’s often something negative. Before ELFT built celebrating success into our work, we rarely shared stories about improvement. But with all of health care going through a transformation right now, I think improvement stories are important to inspire us, ground us, and help us see there’s a different way of doing things.
A lot of professionals have probably experienced suggesting a change that wasn’t taken forward. Sharing a different paradigm in which people who see the problems are involved in the solution helps people engage in improving services.
As ELFT Medical Director Kevin Cleary sometimes notes, when we started our QI journey in 2012, we had no way of predicting how much improvement we were going to make, but we knew prioritizing QI was the right thing to do. Our results demonstrate how our commitment, hard work, and integration of QI methodology and training into every level of our organization have paid off.
Auzewell Chitewe is Senior Quality Improvement Lead at the East London NHS Foundation Trust.
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Building a Culture of Improvement at East London NHS Foundation Trust