Building the foundations for improvement

Building the foundations for improvement @DrAmarShah Amar.Shah@elft.nhs.uk

Mental health services Newham, Tower Hamlets, City & Hackney, Luton & Bedfordshire Forensic services All above & Waltham Forest, Redbridge, Barking, Dagenham, Havering Child & Adolescent services, including tier 4 inpatient service Regional Mother & Baby unit Community health services Newham & Tower Hamlets IAPT Newham, Richmond and Luton Speech & Language Barnet

The old way (Quality Assurance) Requirement, Specification or Threshold No action taken here Reject defectives Better Quality Worse

Performing well?

@ELFT_QI The strategic case for change Make quality our absolute priority National drivers Enable our staff to lead change The economic climate 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 The need to focus on a more compassionate, caring service with patients first and foremost More structured and bottom-up approach to improvement The desire to engage, free and support our staff to innovate and drive change Engaged and motivated staff leads to improved patient outcomes The need to do more with less improving quality whilst reducing cost

@ELFT_QI Building the case for change Sentinel event Visits to other organisations Trust board bespoke learning sessions Early small scale tests Developing the strategy through engagement Long-term business case approved Identify strategic partner Assess readiness for change

Use of data to guide decisionmaking Executive WalkRounds Stop solving problems at the top Change in Executive behaviours Give people time and space to solve complex problems Paying personal attention Manage the expectations

Make it feel meaningful Make it feel possible Make it feel valued and permanent Provide skills and support

Engaging, encouraging & inspiring 1. Targeting / segmenting communication for different groups (community- based staff, Bedfordshire & Luton staff) 2. Sharing stories newsletters, microsite, presenting internally 3. Celebration awards, conferences, publications, internal presentations 4. Share externally social media, Open mornings, visits, microsite 5. Work upstream trainees, regional partners, key national and international influencers AIM To provide the highest quality mental health and community care in England by 2020 Developing improvement skills Embedding into daily work 1. Pocket QI for anyone interested, extended to Beds & Luton 2. Refresher training for all ISIA graduates 3. Improvement Science in Action waves 4. Online learning options 5. Develop cohort and pipeline of improvement coaches 6. Leadership and scale-up workshops for sponsors 7. Bespoke learning, including Board sessions & commissioners 1. Learning system: QI Life, quality dashboards, microsite 2. Standard work as part of a holistic quality system 3. Job descriptions, recruitment process, appraisal process 4. Annual cycle of improvement: planning, prioritising, design and resourcing projects 5. Support staff to find time and space to improve things 6. Support deeper service user and carer involvement QI Projects Directorate-level priorities - Defined through annual cycle of planning - Most local projects aligned to directorate priorities Trust-wide strategic priorities 1. Reducing inpatient physical violence 2. Improving access to community services 3. Enjoying work 4. Shaping recover in the community 5. Value for money

qi.elft.nhs.uk

Working upstream Psychology trainees Pocket QI, embedded into QI project teams with 4 bespoke learning sessions Nursing students Intro to QI delivered within undergraduate and postgrad syllabus, embedded into QI project teams during student placements 477 completed Pocket QI so far. All staff receive intro to QI at induction 690 graduated from ISIA in 6 waves. Wave 7 in 2017-18. Refresher training for ISIA grads. 53 QI coaches trained so far, with 35 currently active. Third cohort of 20 to be trained in 2017 58 current sponsors. All completed ISIA. Leadership, scaleup & refresher QI training in 2017 Currently have 6 improvement advisors, with 3 further QI leads in training Estimated number needed to train = 4000 Needs = introduction to QI & systems thinking, identifying problems, how to get involved Estimated number needed to train = 1000 Needs = Model for improvement, PDSA, measurement and using data, leading teams Estimated number needed = 50 Needs = deep understanding of method & tools, understanding variation, coaching teams Needs = Model for improvement, PDSA, measurement & variation, scale-up and spread, leadership for improvement Estimated number needed to train = 10 Needs = deep statistical process control, deep improvement methods, effective plans for implementation & spread Experts by experience All staff Staff involved in or leading QI projects QI coaches Sponsors Internal experts (QI leads) Board All Executives have completed ISIA. Annual Board session with IHI & regular Board development Needs = setting direction and big goals, executive leadership, oversight of improvement, understanding variation Bespoke QI learning sessions for service users and carers. Over 95 attended so far. Build into recovery college syllabus Needs = introduction to QI, how to get involved in improving a service, practical skills in confidence-building, presentation, contributing ideas

Improvement Science in Action

Developing Improvement Coaches

Intro to QI for Service Users & Carers

Support around every team Project Sponsor QI Coach QI Team QI Forums Service User Input QI Resources

Use of data to guide decisionmaking Go see Gemba Executive WalkRounds Stop solving problems at the top Change in leadership behaviours Paying personal attention Give people time and space to solve complex problems Manage the expectations

Changing the way we use data to guide decision-making Safety trust wide excluding Beds and Luton(London) Clinical Effectiveness trust wide excluding Beds and Luton Patient Experience trust wide excluding Beds and Luton Our Staff trust wide excluding Beds and Luton Complaints June and July 2016. Reasons given by staff leaving June to July 2016

Identify the needs of the customer/ population Develop service models to meet the needs Put in place structures and processes to deliver high quality Identify clear measures of quality for the service, and monitor these over time Take corrective action when appropriate Internal vigilance to hold gains made through improvement Identify what matters most Design project and bring together a diverse team Discover solutions through involving those closest to the work, test ideas, implement and then scale up Periodic checks to ensure the service is meeting the needs of the customer/population Actions to address gaps identified

Make it feel meaningful Make it feel possible Make it feel valued and permanent Provide skills and support

Number of active projects Our QI Projects 250 200 150 100 50 0 Month

Is it making a difference?

QI Projects

No. of Incidents No. of Incidents Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 jan.17 feb.17 No. of Incidents 220 200 180 160 140 120 100 80 60 UCL 175,462 LCL Incidents resulting in physical violence (ELFT excluding Luton and Bedfordshire) - C Chart 102,625 42% Physical violence to patients (per 100,000 occupied bed days) Physical violence to staff (per 100,000 occupied bed days) 850 850 750 750 650 650 550 550 450 450 350 350 250 250 150 2013 2014 2015 2016 150 2013 2014 2015 2016

jan.14 feb.14 mar.14 apr.14 mai.14 jun.14 jul.14 aug.14 sep.14 okt.14 nov.14 des.14 jan.15 feb.15 mar.15 apr.15 mai.15 jun.15 jul.15 aug.15 sep.15 okt.15 nov.15 des.15 jan.16 feb.16 mar.16 apr.16 mai.16 jun.16 jul.16 aug.16 sep.16 okt.16 nov.16 des.16 jan.17 jan.14 feb.14 mar.14 apr.14 mai.14 jun.14 jul.14 aug.14 sep.14 okt.14 nov.14 des.14 jan.15 feb.15 mar.15 apr.15 mai.15 jun.15 jul.15 aug.15 sep.15 okt.15 nov.15 des.15 jan.16 feb.16 mar.16 apr.16 mai.16 jun.16 jul.16 aug.16 sep.16 okt.16 nov.16 des.16 jan.17 No. of Referrals DNA % Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Average Waiting Time / Days Access to Services Collaborative 70 Average waiting time from referral to 1st face to face appointment (10/13 teams) - X-bar Chart 65 UCL 60,66 19% 60 55 50 LCL 53,17 49,42 45 40 44,51 35 1700 1600 1500 No. of referrals received (10/13 teams) - I Chart 26% 39% 37% 35% UCL 1st face to face appointments non-attendance (10/13 teams) - P Chart 36% 1400 33% 1300 1200 1100 1000 900 800 700 UCL 1 021,71 LCL 1 213,13 1 284,57 31% 29% 27% 25% 23% 21% 19% 17% 15% 31,73% LCL 24,38% 23,52% 20,32% Legend - Testing begins - 3 teams leave the collaborative - 2 new teams join the collaborative - New DNA operational definition

Waiting Times from First appointment non-attendance No. of referrals received Tower Hamlets City & Hackney Tower Hamlets City & Hackney Tower Hamlets Newham City & Hackney Tower Hamlets Newham Enchanced Primary Care Liason Team Clinic MSK Physio Specialist Health Visiting Sexual and Reproductive Health Clinic CAMHS Community Mental Health Teams (CMHTs) Psychological Therapy Service (PTS) Mental Health Care for Older People (MHCOP) Memory Service Other * * referral to 1 st appointment 37% 52% 50% 23% 63% 18% 32% 52% 60% * - - - - - - - - - - 129% 25% 25% 18% 27% * 62% 16% - - - - 44% 36% 18% 35% 49% 34% 43% 22% 21%

Score Score Score (%) Score 85 Staff experience and engagement Staff able to contribute towards improvements at work 4,2 Staff Motivation to Work 80 75 70 65 4,1 4,0 3,9 3,8 3,7 60 ELFT Score 3,6 ELFT Score 55 2010 2011 2012 2013 2014 2015 2016 3,5 2010 2011 2012 2013 2014 2015 2016 Staff job satisfaction Overall Engagement Score 4,1 4,1 4,0 4,0 3,9 3,9 3,8 3,7 3,6 3,5 3,4 ELFT Score 3,8 3,7 3,6 3,5 ELFT Score National Median 3,3 2010 2011 2012 2013 2014 2015 2016 3,4 2010 2011 2012 2013 2014 2015 2016

qi.elft.nhs.uk qi@elft.nhs.uk @ELFT_QI