Photo by Allie Smith | Unsplash
The COVID-19 pandemic has forced an astounding pace of change in health care. In the face of what can feel like insurmountable challenges, we are seeing amazing stories of innovation and community spirit across the world. It’s at times like this that we need, more than ever, to hold on to what we have learned about tackling complexity while embracing the very best principles of quality improvement (QI).
In just a few weeks, the primary care psychology services at East London NHS Foundation Trust have moved to an entirely virtual delivery model. We are still offering the same care — indeed, an enhanced service in some ways — but in a new way.
How has this happened so quickly? We could have consolidated power and decision-making at the top of the organization and issued directives. Given the context of the pandemic, this would have been easy to do, and perhaps even forgivable.
Instead, our four primary care psychology services ran through a series of intentional PDSAs to learn and scale. They built on their assets — as all good improvement work does — and involved patient representatives at every stage.
Week 1 — Testing remote working. In this first PDSA, all four services moved to working entirely from home. Many of the several hundred staff members occasionally worked remotely, so much of the infrastructure existed. However, this first PDSA involved planning to ensure all had sufficiently robust technology, planning how to record notes and schedule consultations, and thinking about how best to support clinicians through remote supervision.
Week 2 — Offering scheduled consultations by telephone. Some telephone consultations had always been part of the service model, but not at this scale. However, having tested and learned how to use telephone consultations, it was easier to implement at full scale as some of the groundwork had been put in place, e.g., ensuring all patient telephone numbers were available and all clinicians had practiced how to deliver therapy over the phone.
Week 3 — Testing video consultations instead of telephone. The plan for this test involved creating guides for staff and conducting training webinars to ensure staff were familiar with using the technology. Although in other circumstances it might have been preferable to start small and adapt, the pace of change needed meant that this was tested at full scale. Every clinician ran a series of PDSAs as they learned and adapted their technical and clinical skills to the videoconferencing medium.
Week 4 — Offering group therapy by videoconference. This was entirely new. For this test, the service ran one group therapy session virtually to learn and adapt. The feedback from service users was positive, and some people commented that it felt easier to speak and contribute when in a group video call rather than in a face-to-face group. This is a service delivery model that offers great opportunities for the future to enable greater access and efficiency.
All through this series of PDSAs, the staff and services have paid close attention to data. They captured quantitative and qualitative information from patients about their experience and attendance to inform adaptations to the service model.
Staff have been closely involved in the planning, running, and learning from these PDSA cycles, and so have felt part of the improvement process. The service has also continued to involve patient and service users throughout the improvement process.
More Ways to Use Improvement Methods
In addition to using QI methods to transition to virtual care delivery, we have used our quality improvement department to support organizational learning and applied a systematic approach when responding to the enormous challenges of the coronavirus.
For example, we have integrated our improvement capacity into our incident response structure. Each decision-making and oversight body has access to skilled improvers to support teams. We are also beginning to see the use of QI to help standardize processes. Teams are using tools like flowcharts, and driver diagrams to develop a theory of change.
Here’s the driver diagram one part of our organization, our community health services in Bedfordshire, is using to help structure their response and learning from this current challenge:
The Role of Leaders
For our teams that are learning to work together while being physically remote, we are realizing the value of having shorter, but more frequent check-ins, clear and transparent goals, and shorter sprints of work.
The current crisis might seem like the perfect time to stick to a “command and control” style of leadership, but holding onto our core leadership for improvement behaviors is also critical at this time. Leaders need to stay curious, pay attention, be available and accessible, and truly listen to those we serve. This includes continuing to pay close attention to the potential inequalities and disparities that the pandemic may accentuate within our communities.
At this time of unprecedented challenge, when the very nature of health care is likely to change forever, it’s crucial that we hold onto the core principles of quality improvement. We encourage all our services to systematically capture the changes they have made, develop theories about both positive and negative likely impact, intentionally capture data to identify whether these impacts occur, and to start thinking now about the improvements they want to maintain once the pandemic is over. By continuing to support our staff and people in our communities and maintaining our dedication to improvement, we hope to emerge from COVID-19 stronger than ever.
Amar Shah, MD, is Consultant Forensic Psychiatrist and Chief Quality Officer at the East London NHS Foundation Trust, an IHI Strategic Partner.
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