Photo by Richard Dykes | Unsplash
The first time Renarta Rowe, MBChB, MSc, MRCPsych, saw a run chart that indicated her organization’s improvement efforts were starting to have an impact, she nearly cried. For four years before she had ever heard of the Model for Improvement, Rowe, a psychiatrist at Birmingham & Solihull Mental Health NHS Foundation Trust (BSMHFT) in England, had been part of a group developing clinical practice guidance that was making limited progress.
“Churning out documents and saying what your recommendations are doesn’t necessarily lead to improvement,” Rowe remarks.
BSMHFT then started a quality improvement (QI) collaborative with support from the Institute for Healthcare Improvement (IHI). “I’d never heard of quality improvement formally before,” Rowe recalls, “but I knew we needed some kind of understanding of what it was we were going to change in order to then know whether it changed or not.” The more she learned about improvement science, the more she felt she had been “intuitively aligned” with QI methods without realizing it.
Rowe is one of the leaders of a 12-month initiative that aims to reduce restrictive practices across the inpatient services within BSMHFT. For a person admitted with a serious mental health diagnosis, the use of restrictive practices — including physical restraints, seclusion, or rapid tranquilization — may become necessary to reduce the possibility of harm to themselves or others during, for example, a psychotic episode. While sometimes needed, these methods are not without disadvantages. Consequently, decreasing the use of restrictive practices can reduce trauma and the risk of physical harm (to both patients and staff), improve overall outcomes, and reduce length of stay.
The Advantages of a Collective Effort
While fully acknowledging that there is much work to be done, Rowe has observed that bringing teams together to take part in QI collaborative has led to the following:
- Clarity and productivity — The collaborative infrastructure — including the support of a coach, improvement advisor, and senior sponsor for each team — means “everybody is focused like a laser” on their improvement efforts, according to Rowe. “It's helped everybody use their time more productively,” Rowe explains. “We’re much more able now to just get on with the job.”
- Validation — Prior to the collaborative, Rowe’s practice group had difficulty making progress because they were not the local decision makers. Good data, however, has helped build credibility for their change ideas. “The use of run charts and the signals in the run charts means it’s solid data,” Rowe notes.
- Solidarity and meaning — Every three months, the 14 project teams from around the Trust come together to exchange lessons learned. The shared learning and mutual support that are hallmarks of the collaborative approach to QI have been especially meaningful this year. “In the dark days of the pandemic, and all of the stresses that we have,” Rowe notes, “sharing experiences about the projects — the challenges, yes, but also the exciting positive experiences — has been phenomenal. We’ve got a common purpose.”
- Promising results — About halfway through their year-long effort, Rowe says their data is showing “fantastic downward shifts.” Though careful not to prematurely declare the collaborative a success, she sees in the preliminary data “glimmers of what could be” and appreciates how this early progress is keeping participants motivated.
They have, of course, also faced difficulties. The slow pace of progress and the impact of the pandemic (including personnel shortages) have been frustrating. “Trying to help staff have time out for training, team meetings, and just head space to think about the work have probably been our biggest challenges,” Rowe observes.
Overall, however, participating in the QI collaborative has been gratifying, especially for Rowe and others who have been working on reducing restrictive practices for years. “We feel so excited. It was very frustrating before to see what could potentially help, but we couldn’t make it work,” she explains. “The work we did [before the collaborative] didn’t go to waste, but what we’ve got now is a clear, consistent, scientific method of turning what we want to do into what we are doing.”
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