Deliver and improve: A board members’ guide to trust- wide improvement

NHS Confederation | February 2022 | Deliver and improve: A board members’ guide to trust- wide improvement

NHS Providers trust-wide improvement programme, supported by the Health Foundation, aims to support NHS trust leaders to develop their understanding of organisation-wide approaches to improvement and develop the skills and confidence they need to support their organisation to take the next step on its improvement journey.

As part of this, the programme offers opportunities to reflect on the implications for improvement from COVID-19 and support trusts to sustain the beneficial changes made in response to the pandemic. The programme provides opportunities for board-level peer learning through webinars, workshops and action learning sets, and online resources to support their improvement journey. Our strategic partnership with the Health Foundation enables us to draw on its extensive work on this topic, and existing communities of improvement leads across the sector through the Q Community.

 This resource seeks to help you navigate these by bringing together a selection of useful articles, reports, videos and podcasts to support conversations at board and quality committee level, to support you in decision-making and taking action.

The content aligns with the factors required to drive and embed improvements in a health care organisation or system, as highlighted by the Health Foundation in their guide Quality improvement made simple, recently updated. We also signpost to the current range of learning support available to boards.

See also:

NHS Providers’ online hub

Deliver and improve: A board members’ guide to trust-wide improvement

Improving delivery of low tidal volume ventilation in 10 ICUs

Donadee, C. et al.(2022). Improving delivery of low tidal volume ventilation in 10 ICUs. BMJ Open Quality. 11. e001343. doi:10.1136/ bmjoq-2021-001343

Low tidal volume ventilation (LTVV) improves mortality in patients with ARDS and is associated with decreased morbidity and mortality in mechanically ventilated patients without ARDS. This QI project succeeded in improving compliance with LTVV in all ICUs that participated in the project.

Abstract
Low tidal volume ventilation (LTVV) is standard of care for mechanically ventilated patients with acute respiratory distress syndrome and has been shown to improve outcomes in the general mechanically ventilated population. Despite these improved outcomes, in clinical practice the LTVV standard of care is often not met. We aimed to increase compliance with LTVV in mechanically ventilated patients in 10 intensive care units at 3 hospitals within the University of Pittsburgh School of Medicine Department of Critical Care Medicine. Four Plan-DoStudy-Act (PDSA) cycles were implemented to improve compliance with LTVV. Initial compliance rates of 40.6 per cent–
60.1 per cent improved to 91 per cent–96 per cent by the end of the fourth PDSA cycle. The most impactful step in the intervention was providing education and giving responsibility of selecting the tidal volume to the respiratory therapist. The overall intervention resulted in improved compliance with LTVV that has been sustained.

Improving delivery of low tidal volume ventilation in 10 ICUs

Increasing oxygen prescribing during the COVID-19 pandemic

Sahota, R. & Kamieniarz, L. | 2021 | Increasing oxygen prescribing during the COVID-19 pandemic | BMJ Open Quality |

Prior to the start of this quality improvement project (QIP), it was evident that many patients at North Middlesex University Hospital (NMUH) receiving oxygen did not have a valid prescription. This became even more noticeable during the COVID-19 pandemic when almost every hospital patient was being administered oxygen as part of their treatment for COVID-19.

The aim of this QIP was to improve the proportion of hospital patients on two medical wards with a valid oxygen prescription over a 6-week period to 95%, in line with British Thoracic Society (BTS) national improvement objectives.

Unfortunately, this QIP did not achieve its aim of 95 per cent of patients having a valid oxygen prescription, in line with BTS guidelines.1 By the end of the project, 70 per cent of patients had a valid oxygen prescription, up from the baseline measurement of 0 per cent. All of the individual interventions were shown to work to a different extent, with the email sent to nursing staff proving to be the most successful. Each intervention provided incremental improvement in the process measure; at baseline 6 per cent of patients were within their target saturation range, this was 80 per cent at the end of the project, showing that the interventions were contributing towards a positive change in practice.

Abstract

Valid oxygen prescriptions for hospital inpatients have been a long-standing problem and have been described extensively in BMJ Open Quality with numerous quality improvement projects (QIPs) with the aim of improving compliance with oxygen prescribing.

The British Thoracic Society recommends that all inpatients should have oxygen target saturation set on admission: this is motivated by risks of both undertreatment and overtreatment with oxygen. The discrepancy between the recommendation and the reality produced a number of interventions studied in QIPs over the past years, all aiming at bringing the local ward teams closer to the target. This has become even more important during the COVID-19 pandemic, where non-standard oxygen saturation targets and oxygen scarcity led hospital systems to rethink their internal guidelines on the subject.

We propose three novel interventions to improve compliance: a remote, personally directed email communication to a ward pharmacist, a similar communication to ward nurses, and a remote, personally directed WhatsApp communication to junior ward doctors. We undertake a QIP which compares novel interventions developed in-house with the most successful interventions from oxygen prescribing initiatives that have previously been published by BMJ Open Quality. The main outcome measure was the proportion of patients with valid oxygen prescription on a ward.

The series of novel interventions in three plan, do study, act cycles led to improvement in the outcome measure from 0 per cent at baseline to 70 per cent at the end of the QIP. The successful interventions from previous QIPs were ran in parallel on a similar ward and achieved improvement from 17.9 per cent at baseline to 55.6 per cent at the end of the QIP.

This QIP demonstrates adapted interventions performed in context of social distancing aimed at members of multidisciplinary team which achieve superiority in increasing proportion of patients with a valid oxygen prescription, when compared with previously described methods from BMJ Open Quality.

Increasing oxygen prescribing during the COVID-19 pandemic

Listening to bereaved relatives and carers

Kent Community Health NHS Foundation Trust | nd | Listening to bereaved relatives and carers

This project is summarised on this accompanying page Listening to bereaved relatives and carers

Click to access Bereavement-Packs-Project-on-a-Page-v3.0-FINAL-1.pdf

Improving a dietetic service for care home residents

Kent Community Health NHS Foundation Trust | nd | Improving a dietetic service for care home residents

A project, which aimed to improve a dietetic service for care home residents who need nutritional support, has resulted in patients being discharged quicker and increased staff capacity.

A review by the Community Dietetic Team within Kent Community Health NHS Foundation Trust (KCHFT), indicated that some residents were staying on caseloads for a prolonged period of time. The project looked to see if things could be done differently, so that patients could be discharged sooner, while also making sure patients would still receive quality care. It also wanted to make sure dietetic staff time was being spent in the most efficient and effective way.

Two pilot studies were set up involving 30 patients each. The studies tested various changes to see what would lead to an improvement (Source: Kent Community Health NHS Foundation Trust

Full details of the quality improvement project are available from Kent Community Health NHS Foundation Trust

QI conference 2021 [video]

Kent Community Health NHS Foundation Trust | nd | QI conference 2021

Kent Community Health NHS Foundation Trust (KCHFT) recently held a QI conference ( earlier this month, 7 October) it is now available as video. The recorded sessions include a talk from guest speaker Hugh McCaughey, NHS Director of Improvement and Medical Director Sarah Phillips

The day also included presentations on QI projects underway at KCHFT, presentations by improvement organisations KCHFT work closely with and workshops.

You can also watch the video on Vimeo

One chance to get it right: improving clinical handovers for better symptom control at the end of life

Goldraij G, et al | 2021| One chance to get it right: improving clinical handovers for better symptom control at the end of life | BMJ Open Qual | Sep | 10 |3 | e001436. doi: 10.1136/bmjoq-2021-001436. PMID: 34588188; PMCID: PMC8483039.

This quality improvement (QI) project set out to improve symptom control by optimising handovers between care teams. Rather than ‘pain’ or ‘symptom control’, the experts behind the project chose ‘comfort’ as a global index of well-being in the last days of life. 

To the best of the authors’ knowledge, this study is the first to evaluate a training programme on the use of I-PASS for healthcare professionals providing care for dying patients with cancer.

The authors suggest that their study demonstrated that using education, participatory action research (PAR) and involving relatives, healthcare professionals and researchers, it was possible to obtain the successful introduction of a clinical mnemonic tool (I-PASS) and training of involved staff in its use, leading to improved patient comfort and care, as perceived by family carers. They also report that to improve learning and enhance the effectiveness of QI work, involvement and collaboration between both researchers and practitioners were required (Source: Goldraij et al, 2021).

Abstract

Poor communication contributes to morbidity and mortality, not only in general medical care but also at the end oflife. This leads to issues relating to symptom control and quality of care. As part of an international project focused on bereaved relatives’ perceptions about quality of end-of-life care, we undertook a quality improvement (QI) project in a general hospital in Córdoba city, Argentina.

By using two iterative QI cycles, we launched an educational process and introduced a clinical mnemonic tool, I-PASS, during ward handovers. The introduction of the handover tool was intended to improve out-of-hours care.

Our clinical outcome measure was ensuring comfort in at least 60 per cent of dying patients, as perceived by family carers, during night shifts in an oncology ward during the project period (March–May 2019). As process-based measures, we selected the proportion of staff completing the I-PASS course (target 60 per cent) and using I-PASS in at least 60 per cent of handovers. Participatory action research was the chosen method.

During the study period, 13/16 dying patients were included. We received 23 reports from family carers about the level of patient comfort during the previous night.

Sixty-five per cent of healthcare professionals completed the I-PASS training. The percentage of completed handovers increased from 60 per cent in the first Plan-Do-Study-Act (PDSA) cycle to 68 per cent in the second one.

The proportion of positive reports about patient comfort increased from 63 per cent (end of the first PDSA cycle) to 87 per cent (last iterative analysis after 3 months). Moreover, positive responses to ‘Did doctors and nurses do enough for the patient to be comfortable during the night?’ increased from 75 per cent to 100 per cent between the first and the second QI cycle.

In conclusion, we achieved the successful introduction and staff training for use of the I-PASS tool. This led to improved perceptions by family carers, about comfort for dying patients.

One chance to get it right: improving clinical handovers for better symptom control at the end of life

To improve quality, leverage design

Crowe, B. et al | 2021| To improve quality, leverage design| BMJ Quality & Safety|   doi: 10.1136/bmjqs-2021-013605

In this viewpoint piece in the journal BMJ Quality & Safety, the authors explain fundamental design thinking (DT) methods and how they can integrate into existing improvement efforts, providing a starting point for organisations and leaders to leverage this human-centred approach and harness the powerful emotional perspectives of ‘users’, the patients, families, caregivers and clinical team who interact with the healthcare system. In our own quality journeys, we have discovered the power of DT to elevate quality improvement (QI) work and believe the time is now to bridge these two complementary disciplines, ushering in a new era of human-centred QI using the best parts of these two powerful methodologies.

To improve quality, leverage design [paper]

Making a patient survey more user friendly

Kent Community Health | n.d | Making a patient survey more user friendly

A QI project that set out to increase the patient survey response rate, as well as make it less time consuming and easier to understand was devisedafter staff at Kent Community Health Foundation Trust learnt that the current patients feedback surveys were very time-consuming and needed to be easier to complete.

patients and their carers said some of the questions were difficult to comprehend. Most surveys are filled out with a KCHFT colleague helping the patient, although some are sent and returned by email and completed independently. To address this, Mary Stracey, a deputy clinical resource manager at the Trust, used the tried and tested quality improvement (QI) methodology and tools she’d been studying, which included a driver diagram, process mapping, fresh eyes and plan, do, study, act (PDSA) cycles. Mary put a project team together and as soon as suggested changes were made to the surveys, the new look questionnaire was tested with patients, their relatives and carers, to gather their views and comment The changes saw long, complicated questions, turned into short and simple language, with patients able to select smiley, neutral, sad and other faces as many of their answers. Questions in the survey include:

• Did our staff treat you with kindness and respect?
• Did our team have a positive impact on your current health and wellbeing?
• Did you feel listened to and communicated with effectively?

The project ran for four months, with the new look survey launched in March 2020 and used throughout the COVID-19 pandemic. It was so successful, it has replaced the former one and is to be shared with other services (Source: Kent Community Health Foundation Trust).

Full details of the project are available from Kent Community Health

QI Project: Asking patients what is important to them

Kent Community Health | n.d | Asking patients what is important to them

A quality improvement (QI) project, led by allied health professional Martyne May, Adult Speech and Language Therapy Quality Lead, aimed to improve how patients moved through the system at Kent Community Health NHS Foundation Trust (KCHFT). The project was guided by patients: asking participants what is important to them.

As part of a series of interviews and consultation with patients with language difficulties, staff provided an explanation of how the service worked and was funded. The issues facing the service at KCHFT were discussed, as well as some ideas for change that had been gathered from clinicians and administration colleagues. Everyone’s ideas were used to see how things could be done better.

Prior to the project the team prioritised referrals as high, medium or low risk, based on information gained from referral documents. They would be placed on a waiting list and seen in chronological order.  The patients could be seen by any member of the team, who would work with them until they were ready to be discharged.

In response to participants’ feedback and suggestions, the new process saw all patients receive an initial, one-off appointment where their needs could be fully assessed by a clinician, they could receive immediate advice and support and they were then added to a treatment waiting list, based on clinical needs.  For some patients, this was not appropriate and separate pathways were developed. These included those who needed rapid access, such as patients with motor neurone disease.

The pilot ran from October 2019 to February 2020. A rollout of the changes was delayed by the COVID-19 pandemic, but the new way of working was introduced across the service at the end of 2020.

The project has resulted in:

• reducing all waiting times to under 18 weeks
• reduced waiting list numbers
• clearer patient pathways through the service.

Adapted from the blog post from Kent Community Health

See also: The reducing waiting times and engaging service users project on a page

Increasing the number of patients seen project on a page

Full details are available from Kent Community Health