At Northwick Park Hospital an educational programme has been in place for those who care for patients with symptoms of alcohol dependency and recovery . Too often dependent patients being treated for other physical conditions are released with limited understanding and awareness of the support that is available to them. During the soft launch of the improvement project alcohol dependent patients were referred to an alcohol nurse specialist, who was better equipped to support transition into a detox care bundle.
The overall aim has been to improve the care experience, as well as the long-term well-being of alcohol dependent patients. Training and education of triage nurses and doctors has been paramount because they are the first point of contact with them. Refferal to specialist hospital based staff can offer detox and psychological treatment for dependency related moods and behaviours, which this can make all the difference to the outcome for the patient and the efficacy of clinicians.
The project aims to avoid premature discharge from hospital services and to shape a well-planned and thought through discharge leading to referral to community-based support. Over time this should reduce both physical and dependency related hospital admissions and improve the standard of care for patients that require this kind of treatment and support.
Protocols follow existing NICE guidelines and utilise existing treatment and support programmes, but provide liaison and cross referenced services between them that can make all the difference to patient success and well-being.
Cherelle Augustine is a CLAHRC NWL Improvement Leader Fellow, cohort 2015. Cherelle is a Patient Ambassador for sickle cell disease. In 2005 Cherelle, at the age of 19, co-founded a charitable organisation called Broken Silence in loving memory of a friend who passed away due to complications of sickle cell. Broken Silence was founded by young people, champions young people and targets awareness towards young people.
March 13th 2017 was the first time the Master of Public Health (MPH) course at Imperial College had a patient teach their students on the ‘Improving Health Services’ module. It was a privilege to be invited by Rachel Matthews, Patient and Public Engagement and Involvement Theme Lead at NIHR CLAHRC NWL, to co-facilitate her session at Imperial. Being part of a milestone of an institution of such a magnitude can be daunting and although I have yet to complete a masters course myself, I knew I had a lot to offer these students.
Service users such as myself can spend half their life or more in and out of hospitals or primary care services. I was diagnosed with sickle cell disease, the UKs most common genetic condition, at six weeks old. I have grown up with immense pain, had a near death experience at seven and lived with the after effects of childhood strokes, of which I currently have had six, and as a teen have watched a friend pass away from complications of the same illness. Going through this and more, I became self-aware and was raised to self-manage my condition. Even as a child, I have always been at the centre of making big decisions. My self-awareness has countless times saved my life.
Unfortunately, this independence and understanding of my needs has not always been well received by healthcare professionals. I shared this truth with the students. I was able to share not only my stories and values as a patient, but skills I had learnt through running a charitable organisation, being involved with an All Party Parliamentary Group, MPs, Lords, NHS England, the Improvement Leader Fellowship, co-producing and being on both sides of research.
It was an honour to be able to speak to the MPH students and I am hopeful that I was able to change the mindset and self-awareness of at least one individual going into healthcare. I hope I inspired the students to think about patients as not just somebody to fix, but as an individual with the understanding and skills to work together with to impact positive change in their care and the health service. Change starts with the individual and an individual can change the world.
A range of Frontiers of Improvement Science have been developed through a series of meetings between UK and Swedish improvement science fellows in conjunction with international improvement scientists from Europe and North America. Dr Julie Reed and Dr Tom Woodcock, Health Foundation Improvement Science Fellows based at the NIHR CLAHRC Northwest London, have been pivotal in the organisation of the event and helping to define some of these frontiers. The event will see a range of presentations and discussions that hope to build on many of the perspectives that are in development and provide an opportunity to elaborate on them further.
Julie Reed provides a general introduction to Improvement Science and makes the case for the need to define the current boundaries of the field, using examples from other fields in the history of science. Julie goes on to outline the unique role and perspectives different disciplines bring to improvement science using the example of the Anamorphic cube, which represents different images or figures, depending on the angle which the viewer takes. The cube offers an analogy to the way that perspectives in improvement science might be viewed to explore their different facets.
Tom Woodcock expands on one of the frontiers related to measurement in quality improvement in his talk ‘Translating Measurement Theory into Improvement Practice: Planning to Avoid the Pitfall’. Tom draws on his vast experience of working directly with quality improvement projects and programmes both in the UK and internationally, as well as his post-doctoral research in developing measurement systems. Tom elaborates on the development of the Measurement Plan Assessment Tool (MPAT), which aims to provide a structured way to support the creation of measurement plans in QI programmes. You can find out more about the work that was undertaken to develop MPAT here.
A number of Imperial College London researchers based with CLAHRC Northwest London also contribute to discussions on the day, after recently presenting their work at our April Research Partners Meeting.
Laura Lennox, Associate lead for Improvement Science and Quality Improvement, presents on her doctoral work that includes a systematic review of sustainability methods used in healthcare Improvement and their impact on supporting long term success. The work highlighted a range of constructs consistently seen across the studies, which included:
The Initiative Design and Delivery;
Negotiating Initiative processes;
The People Involved;
The Organisational Setting;
The External Environment
Stirman SW, et al. The sustainability of new programs and innovations : a review of the empirical literature and recommendations for future research. Implement Sci . BioMed Central Ltd; 2012;7(1):17.
Williams L, et al. A cluster-randomised quality improvement study to improve two inpatient stroke quality indicators. BMJ Qual Saf.2015;(August).
Schouten LMT, et al. Evidence for the impact of quality improvement collaboratives: systematic review. BMJ. 2008 ;336(7659):1491–4.
Alan Poots, Principal Information Analyst, introduces the challenges in selecting appropriate interventions for use in quality improvement initiatives. Alan uses the Bradford Hill criteria to outline how quality improvement initiatives themselves may generate types of knowledge that may support attribution of causality.
Grazia Antonacci, Research Associate at Imperial College Business School, presents her empirical work undertaken as part of her PhD. Interviews of healthcare and quality improvement staff across eight QI initiatives revealed details about the success and utility of process mapping as a quality improvement method. This included 26 factors that were identified as important in supporting process mapping, at the level of the activity itself, the project and the wider organisational context.
Richardson, W. C., Berwick, D. M., Bisgard, J., Bristow, L. R., Buck, C. R., & Cassel, C. K. (2001). Crossing the quality chasm: a new health system for the 21st century.
Edwards, N. “Can quality improvement be used to change the wider healthcare system?.” Quality and Safety in Health Care 14, no. 2 (2005): 75-75.
Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). Systematic review of the application of the plan–do–study–act method to improve quality in healthcare. BMJ quality & safety, 23(4), 290-298.
Kaplan, H. C., Provost, L. P., Froehle, C. M., & Margolis, P. A. (2012). The Model for Understanding Success in Quality (MUSIQ): building a theory of context in healthcare quality improvement. BMJ quality & safety, 21(1), 13-20.
Bandara, W., Gable, G. G., & Rosemann, M. (2005). Factors and measures of business process modelling: model building through a multiple case study. European Journal of Information Systems, 14(4), 347-360.
Trebble, T. M., Hansi, N., Hydes, T., Smith, M. A., & Baker, M. (2010). Process mapping the patient journey through health care: an introduction. BMJ, 341(7769), 394-397.
Jackson, T. L. (2013). Mapping clinical value streams. CRC Press.
Glaser, B. G., & Strauss, A. L. (2009). The discovery of grounded theory: Strategies for qualitative research. Transaction publishers.
Bate, P., Mendel, P., & Robert, G. (2008). Organizing for quality: the improvement journeys of leading hospitals in Europe and the United States. Radcliffe publishing.
Repenning, N. P., & Sterman, J. D. (2001). Nobody ever gets credit for fixing problems that never happened: creating and sustaining process improvement. California management review, 43(4), 64-88.
In her presentation Sophie Spitters, a PhD student, explores how innovations are spread between organisations, focussing on the influence of context on both the intervention and the process of implementation. Sophie draws on a case study of a community paediatric allergy service that was developed in one area of northwest London and subsequently spread to two other areas. Sophie has traced that intervention modifications and implementation process in the new sites and compared this to the original site.
Craig,P., Dieppe,P., Macintyre,S., Michie,S., Nazareth,I., & Petticrew,M.(2008). Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ, 337(September), 979–983. http://doi.org/10.1136/bmj.a1655
Damschroder,L.J., Aron,D.C., Keith,R.E., Kirsh,S.R., Alexander,J.A., & Lowery,J.C.(2009). Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science, 4(1), 50. http://doi.org/10.1186/1748-5908-4-50
Warner,J.O.,& Lloyd,K.(2011). Shared learning for chronic conditions: a methodology for developing the Royal College of Paediatrics and Child Health (RCPCH) care pathways for children with allergies. Archives of Disease in Childhood, 96(Supplement 2), i1–i5. http://doi.org/10.1136/adc.2011.212654
Although the debate about what exactly constitutes Improvement Science research continues, The Health Foundation, a leading funder, proposed three distinct categories, providing a helpful way of understanding Improvement Science and the research that is being undertaken in this emerging field:
Research about improvement science – the study of how improvement work is undertaken;
Research using improvement science methods – studies that assess the use of specific quality improvement methods or approaches;
Research to create frameworks, models and concepts related to improvement science – the development and exploration of concepts in Improvement Science.
At CLAHRC Northwest London, quality improvement (QI) projects within the local NHS are our vehicles for testing and exploring the use of QI methods and approaches. Data generated from these projects offers CLAHRC Northwest London the unique opportunity to undertaken research across all three areas. Research provides valuable insights into how improvement work is undertaken, the roles of different QI tools, methods and approaches and also the development conceptual frameworks and models to support future improvement endeavours.
At our February research partners meeting we heard from two researchers about Improvement Science research that had been undertaken at CLAHRC Northwest London.
Planning Measurement for Improvement: Getting the most out of your data
Yewande Adeleke, from the Public Health and Information Intelligence team, reported on a Health Foundation funded study led by Dr Tom Woodcock. The study aims to create a web-based tool to help healthcare quality improvement teams to effectively plan measurement strategies, which are crucial in supporting and evaluating improvement endeavours. As part of the development of this tool, the team undertook a two-round modified Delphi survey to establish consensus on the content of the tool by engaging experts in the field.
The survey enabled the team to scale back the number of items that were initially identified for inclusion in the tool by one third and identified 5 overarching concepts:
The design of measures;
Data collection and management;
Like with many tools designed for use by practitioners, not just researchers, the development of the new tool needs to be carefully balanced, to ensure it is comprehensive but also pragmatic to support use in the field. This tool aims to offer an important contribution to QI planning, especially in supporting improvement teams to develop good measurement plans.
Although the next step for the team is the creation of the web-based tool, this has also provided an opportunity to reflect on the rigorous measurement planning approach CLAHRC Northwest London has developed over the last 8 years. The CLAHRC approach to working with NHS staff to support them to engage with improvement data, especially through the use of the Web Improvement Support for Healthcare (WISH), could provide some real insight that may be useful in developing the tool.
Future plans include testing the tool with current improvement projects that CLAHRC Northwest London support, introducing a further level of rigour to data collection and analysis and providing an opportunity to gather feedback about its utility.
Exploring the use of Process Mapping in practice in the healthcare sector
Dr Grazia Antonacci, from the Quality Improvement and Improvement Science team, presented on the work she recently undertook at CLAHRC Northwest London for her PhD that was supervised by Dr Julie Reed and Professor James Barlow in collaboration with the University of Rome Tor Vergata. Dr Antonacci’s work explored the role of process mapping in healthcare, first through a systematic review, then followed by a qualitative study of QI project in the NHS that are supported by CLAHRC Northwest London.
Process mapping can be defined as a methodology to analyse and better understand the systems and processes in which improvement interventions may be introduced. The origins of process mapping can be ascribed to Frank Gilbreth (American Society of Mechanical Engineers – 1921). The use of mapping techniques then rapidly increased in the manufacturing field as well as in service industries and included application in many domains (quality improvement, business engineering, development of information technologies etc.). The popularity of the use of process mapping in healthcare is undoubtedly linked to the need for an approach to share knowledge and experience of processes across a wide range of stakeholders, especially in increasingly complex healthcare systems. Despite the widespread use of process mapping there are no systematic reviews of its use in healthcare, as such Dr Antonacci identified and reviewed more than 60 empirical studies that used process mapping in healthcare, of which nearly two thirds were published since 2010. This review offers a novel contribution to the literature on process mapping and identified several deficiencies, especially related to the poor involvement of stakeholders (particularly patients) and poor training in process mapping techniques.
The findings of the systematic review were subsequently used to inform a qualitative study to explore the use of process mapping by QI projects supported by CLAHRC Northwest London. Interviews were undertaken with NHS staff and identified that process mapping was undertaken in a wide variety of settings for numerous reasons, with a particular emphasis on the need to:
Improve communication between different professional groups or organisations;
Develop consensus and a shared understanding of how processes actually occur in complex systems;
Promote patient-centred care by supporting dialogue between healthcare professionals, patients, and their families.
As this study outlines, whilst there is no single consistent approach to process mapping, the need to involve stakeholders across professional and organisational boundaries are crucial and often require leadership to achieve this. So despite the potential benefits of using process mapping, a more structured and informed approach is required.
Both researchers eloquently outlined the need for Improvement Science research. CLAHRC Northwest London recognises that despite the wide use of many QI methods and approaches, such as process mapping and measurement strategies, there are still gaps in our understanding of how these methods are currently used and what contribution they make to improvements. Furthermore, it is necessary to identify ways in which the methods and tools can be enhanced to be more effective whilst remaining practical.
Many of the improvement programmes at CLAHRC Northwest London centre around the principles of preventative medicine and care. As we all know the most basic preventative care is to maintain a healthy eating and exercise regime.
Current projects that make this goal measurably easier include iHydrate, which ensures the adequate water intake and hydration of care home residents. Dehydration is a significant problem among older people, which has adverse effects on their health and can result in admission to hospital. I-Hydrate aims to optimise the hydration of residents and increase the number of residents consuming their daily target fluid intake.
Another project which emphasizes the maintenance of healthy habits is SHINE, now in its second round, which promotes both physical and mental wellbeing. Most people will have a range of health needs spanning both mental and physical wellbeing. Unfortunately, health services are often provided in a way that does not recognise the inter relationships between physical and mental health.
NIHRCLAHRC NWL has also funded My Medication Passport (MMP), a patient-held record of medicines, designed by patients, for patients. It is available as a pocket-sized booklet and as a smartphone app originally designed to help patients to make a record of their own medicines list and any medication changes in order to improve communication about medicines between patients, carers and healthcare professionals. While nutrition and exercise should always be the cornerstones of a healthy lifestyle, some long-term conditions require more medical influence and it is important to keep the facts and details of that care in one easily accessed location.
Improvement programmes like these, and more in our latest round of funding, make it easy and manageable to make good choices regarding daily food and exercise choices. Even when we all do our best sometimes we need a helping hand.
While it has always been important to spend allotments for health services wisely, maintaining an awareness and record of efficiency is now both effective and beneficial for the improvement of the quality of services and care.
In the last year NIHR CLAHRC NWL have developed an independent eLearning resource called QI4U as part of an effort to build capacity in a systematic approach to quality improvement for front-line NHS staff and service users. QI4U is available for anybody who has an interest in effective quality improvement of healthcare services for the benefit of patients. QI4U is targeted towards but not limited to front-line clinicians, academics, patients and service users.
QI4U plays a big part in CLAHRC NWL’s ambition to empower and build capacity within Northwest London in the systematic approach to quality improvement
As part of the National Institute for Health Research, CLAHRC NWL have been front runners in developing, collaborating and delivering high quality research projects to find new ways of improving healthcare. CLAHRC NWL utilises the skills, knowledge and expertise of researchers, health and social care professionals, managers, commissioners and patients with the aim to ensure the results of the research are translated quickly and effectively into benefits for patients, the wider NHS and social care.
QI4U has proven to be a transparent and easy way to accomplish this goal.
The Central and North West London (CNWL) Annual Gem and Long Service Awards took place on Thursday 26 January 2017. SHINE, a CLAHRC NWL funded research driven improvement project, won the Project of The Year award.
“As a member of the SHINE Project Team since its beginning in 2014, I have seen many changes in the way the team members interact with each other and also with the Danube ward team. As a service user I found that working with ‘professionals’ as an equal valid member of the team has benefited the project as a whole and has been a real learning curve for all. To win the CNWL Project of the Year has for me been an affirmation of how everyone works together in a very important project dealing with physical health needs for people with severe mental health problems.” – Jenny Trite, Project Team Member and Service User.
“This award is hugely important for the team as we reflect on what we have achieved so far and roll out our work more widely. It is great to have this recognition and appreciation of what we have done – or started to do – to improve our patient’s physical health, which has become a huge passion for me since I have been working on the project. I am so glad to work with all the members of the SHINE team, although I particular want to thank Bill Tiplady who first asked me to be involved, our service user colleagues – without whose constant hard work none of our interventions would have been helpful or meaningful – and the Danube ward team who are so committed to quality of care despite working in an acute, busy environment”. – Ed Beveridge, Project Clinical Lead and Consultant Psychiatrist at CNWL NHS Foundation Trust.
In 2016, Barry Jubraj and Nina Barnett were guest editors for the EJHP BMJ ‘most read’ themed journal issue devoted to ‘deprescribing‘.
“Our themed issue provides an introduction to the deprescribing debate, with articles ranging from reviews by international experts on the current problems surrounding deprescribing, to a description of practical tools to support the process.”