Building a culture of improvement takes years of careful nurturing

In our Building the foundations for improvement report, published last year, we featured a case study of East London NHS Foundation Trust and the work it had been carrying out to improve quality.

The trust was one year into a quality improvement (QI) programme, which it set up in February 2014, with the ambitious goal of providing the highest quality mental health and community care in England by 2020. The two aims for its QI work were to reduce harm by 30% each year and ‘provide the right care at the right time in the right place’.

Supported by the Institute for Healthcare Improvement (IHI), the trust’s QI programme is designed to embed continuous improvement at every level of the organisation, by engaging teams of people to set up projects tackling quality issues.

A six-month training programme has also been an important way to build improvement skills and knowledge within the trust, supported by a central quality improvement team.

One year on from our report, we spoke to Amar Shah, Associate Medical Director of QI at the trust, about how the work has progressed and the results they are starting to see.

Amar says: ‘The programme has made great progress. We’ve moved faster than we anticipated and that’s because there’s been a lot of appetite internally. We have trained 650 staff members in two years and we now have 160 improvement projects running across the organisation.’

Promising results

The trust is now just over two years into the QI programme, and it’s seeing some very promising results. Most notably there’s been a 25% reduction in violence across all inpatient wards. Comparing the trust's levels of violence with other mental health providers, it has gone from being at the upper end of levels of violence two years ago to now being in the bottom 25%.

The organisation began its work on violence reduction on one ward in Tower Hamlets, which had the highest frequency of violence across the whole trust. It then scaled this work up to all six acute mental health wards in Tower Hamlets leading to a 57% reduction in violence across all inpatient wards in the borough.

‘We're now scaling up the work in Tower Hamlets to the 16 wards across Newham and Hackney. It's a phased scale up and spread approach with a good structure of support around it,’ adds Amar.

Understanding the wider impact of the programme

The finance team is now undertaking economic evaluation of some of the QI projects, to help understand the cost impact alongside service improvements.

Amar explains: ‘If we reduce violence, this will result in fewer incidents of staff injury and less time off. We're now able to model what the direct and indirect cost savings are from preventing violence on wards.’

The trust’s staff survey results have also improved as the QI work has grown, showing the additional impact the programme is having. The 2014 scores for engagement, satisfaction, motivation at work, and staff feeling able to contribute to improvements at work were the highest across all providers in England. Scores for 2015 are a little lower, as the trust took over Bedfordshire and Luton services, which have not yet been exposed to quality improvement. But excluding these services, Amar says the trust's score continues to remain extremely high.

Working closely with commissioners

As well as preparing the organisation internally for improvement, the trust has spent time delivering training to commissioners and other key stakeholders to build their understanding of QI. In January this year it ran a session, with the IHI, for mental health commissioners across London.

But its work to engage external stakeholders goes back much further than the last 12 months. Ahead of implementing the programme, the trust engaged widely with commissioners to develop its strategy and aims.

Amar says: ‘A number of local commissioners have been on the journey with us. They’ve been supportive of our work and learnt about QI. The last training wave included local commissioners, local authority leads and a team from the Department of Health. In the long term this will help to influence commissioning and the planning of service delivery.’

Putting QI at the heart of the organisation

Over the last year, the organisation has been working to integrate QI into its day-to-day operations to ensure the programme underpins the way it leads and manages its services.

Meanwhile, the trust has developed a group of local QI coaches - with strong skills in improvement and coaching teams - who have ring-fenced time to support a portfolio of projects. It has also aligned projects with four priority areas (violence reduction, reducing harm from pressure ulcers, improving access to services, and improving the physical health of people with severe mental illness), to ensure all of the teams are heading in a common direction.

Even with this success more work is needed to firmly embed QI into the organisation. Amar says the trust is aware that it takes years of careful nurturing and attention from senior leaders to develop a culture of continuous improvement and learning.