Why It Matters
An organization that gets results and earns high staff engagement scores has lessons worth noting about how to build a strong quality improvement culture.
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Lessons for Building a Strong Quality Improvement Culture

By IHI Multimedia Team | Thursday, December 7, 2017
Lessons for Building a Strong Quality Improvement Culture

When an organization gets results and scores high on staff engagement surveys, it’s worth learning how they do it. The East London NHS Foundation Trust (ELFT) in the UK provides mental health and community services to a diverse and largely low-income population. They recently reported that they had seen a 42 percent reduction in incidents resulting in physical violence across their organization, a 36 percent decrease‌ in first appointment non-attendance, and a 19 percent reduction in waiting times from referral to first appointment.

In addition, in the most recent National Health Service staff survey, ELFT received the highest staff engagement score for combined mental health and community trusts in the country. When compared to similar organizations, they also had the best scores for staff satisfaction and staff recommendation of the organization as a place to work or receive treatment.

ELFT attributes much of their current success to their efforts over the last five years to build improvement capability throughout their organization. But two of their long-time clinicians describe how the organization laid the groundwork for their award-winning efforts years ago.

Dr. Karl Marlowe is the clinical director of mental health services in Tower Hamlets. Dr. Nick Bass is a general adult psychiatrist in Tower Hamlets, and director of medical education for ELFT. They both initially started at ELFT more than 20 years ago. In the following interview (that was edited for length and clarity), their descriptions of how ELFT’s improvement culture has evolved over the years offers lessons on how to lay a strong foundation for QI capability building.

Lead Improvement from the Bottom Up

Marlowe: We were doing quality improvement from the bottom up before anyone wanted us to do it. We’ve always felt a sense of ownership of the service, and the issues and problems, and, therefore, responsibility for finding solutions.

Bass: Before we took on a structured program of improvement science, we were trying to work on a set of projects to improve things we found irritating or needed to be changed. It was more of an informal network rather than a formal network of doing projects.

Marlowe: To give you an example, the violence reduction project that began on Globe Wards here in Tower Hamlets is something we instituted before we started using formal improvement methodology. It continues to be effective, and it’s spreading using a systemic improvement methodology. I think the secret is the fact that we’ve always engaged the staff. I think the PDSAs are useful, too, but it was that willingness for everybody to be involved that was key to it. Without that, it wouldn’t much matter what tools or methodology were used.

Support Your Staff

Marlowe:  We have always been very conscious of making sure that the staff are supported. When you look after the staff that feeds into patient care.

Bass:  Our nursing trainees all fight to get a placement here in Tower Hamlets because it’s seen as the best place to learn and train. It’s interesting the number of new staff — not only clinical staff, but even non-clinical staff — who say that one of the prime things that attracted them to coming here was the ability to get involved with the kind of work we do here. 

Marlowe:  We don’t use [staffing] agencies. There’s a massive nursing shortage in the UK, but we tend to fill our vacancies without having to go to external agencies because of the local staff engagement.

Celebrate Differences

Marlowe: We have to have some standardization of basic competencies, but we don’t want all the same sorts of people working on a team. We want both extroverts and introverts, for example. We want managers who understand a variety of people because they’re going to be skilled and capable of doing things differently. Let’s celebrate those differences because we’re working with complex and heterogeneous patients as well.

Bass:  Without variation in skills, experience, perspective, and general sort of psychological makeup, where’s your innovation going to come from? You need variety, even if people don’t always agree with each other. We shouldn’t sacrifice variety and variation on the altar of efficiency. 

Be Open to New Perspectives

Marlowe: About seven or eight years ago, I asked a number of our inpatient staff, “Would you want to be treated here? Would you be happy for your family to be treated here?” At the time, I put my hand firmly to my side and said, “I don’t want my family to be treated here.” I challenged every member of staff, and said, “If you don’t want to continue like this, you can make a difference.” I think the big change since then has been moving our perspective to the perspective of service users, our patients. Now when surveys ask these questions, staff not only highly recommend [ELFT] as a place to work, but also as a place to get treatment.

Bass: Many patients agree. For the last three years or so, we’ve been taking on a significant number of external patients from other services from other parts of London (or even beyond) that have been struggling with bed capacity. Patients who come and stay here — and not only the ones with good insight — tell us they really don’t want to be treated anywhere else.  

Marlowe: We haven’t got it all right. We get things wrong all the time. We’ve got a lot of changes and challenges we're facing. We're trying to look at the biases that we have. But I feel very humbled. We are incredibly lucky to be where we are at the moment.

Bass: I think we now have the opportunity to democratize our work, and do more to involve our clinical staff, non-clinical staff, and also our patients in owning and working on the problems we need to improve.


You may also be interested in:

Building a Culture of Improvement at East London NHS Foundation Trust

Rethinking Expectations: Reducing Violence in Mental Health Using QI

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