Posted on: 8 March 2021
Spring is in the Air
As we put together our March newsletter, many of us are looking forward with cautious hope that Spring will bring some regained freedom of movement; even with the need to maintain essential social distancing and hygiene practices.
For this issue, we have tried to continue our theme of thinking about how we use the principles of improvement in our daily work, sometimes without even consciously thinking about it. We hope that the examples provided this month will inspire you and perhaps allow you to bring improvement testing onto your work patterns as a more deliberate act of improvement. The examples show that it can be as simple as asking ‘how did that go?’ regularly and reflecting on how that can change what you do as a result.
Also in this issue we welcome a new member of the QI Team, Sarah McAllister, who has joined CNWL as an Improvement Coach.
We have our regular reminder of available QI training dates. March dates for the Rapid Tests of Change training workshop are now available and we are glad to say that the February dates have proven popular and generated some thoughtful and useful discussion. Do visit LDZ and book if you are interested!
We welcome your feedback and if there is anything you would like to see in future editions of the newsletter, do please get in touch by e-mailing firstname.lastname@example.org.
Applying QI thinking/methodology in practice
Last month we featured some of the theory and an example of how the principles of improvement can be applied in practice to make rapid improvements by testing changes in a service. So, this month, we thought that it would be useful to bring you some further examples of where tests of change are currently being used across CNWL services.
Housebound Vaccination Programme, Milton Keynes – how PDSA cycles helped us to get our kit just right!
Community Health Services in Milton Keynes (MK) were asked if they could support to primary care colleagues, and provide a number of teams to deliver covid vaccines to housebound patients across the city. Within 3 weeks, the CHS had managed to recruit, train and equip teams and start first vaccinations in partnership with the MK Primary Care Networks.
CHS were aware that the speed of creating the teams meant that they had not road tested any of the processes associated with the service. This included the provision of kit for the teams who were out on the road each day.
CHS needed to provide kit that:
- Protected staff and patients at all times in line with IPC guidance on use of PPE
- Minimised the amount of items brought into each home to reduce risk of contamination
- Was easy to access for each patient visit
- Allowed them to stay out on the road to finish each vial of vaccine at a time
- Minimised waste of equipment and PPE
Each time we made a change, we made sure we spoke to the team that evening about their experience of using the kit during the day.
- Was it easy to access what they needed?
- Did they have everything they needed?
- Did they have suggestions for improvement?
CHS used PDSA cycles to help test out different ways of providing kit to vaccination teams. This is summarised in the diagram below. This PDSA ramp shows how, over 2 and a half weeks, the team carried out 5 complete PDSA cycles to move from a prototype kit, to the kit that is now agreed to be used by the teams for all future vaccination.
CHS moved from a really time-consuming process to pack individual kit boxes, which were wasteful and very bulky to transport, to a more efficient, sustainable way of providing kit which allows staff to pick kit for each patient as they need. As well as being less labour intensive to prepare, this has reduced waste and made the kit easier to transport. CHS have now written up the kit list and included this in all packs of information for teams. This is the first step in a new set of PDSA cycles – making it easy for teams to access, replenish and return their kit.
Key to our success – communication and feedback!!
- We explained what we were doing, we asked for feedback as soon as possible to keep it fresh, and we acted on it as soon as feasible.
- We kept staff informed at all times about why the kit might look different from day to day.
New kit - stacked and ready to go to vaccinate up to 22 patients
New kit - unstacked
Vaccine delivery in Camden
Over the past two weeks, new Improvement Coach Sarah McAllister (see Meet the QI Team below), has been redeployed into the Camden community vaccination team, working alongside both local and redeployed staff to vaccinate community patients around Camden. The work is fast paced, having to ensure the vaccine is stored at the correct temperature, and bringing all the right equiptment to vaccinate people in their homes. This can feel chaotic for some staff.
In the first week, Sarah noticed that she was working with colleagues from a variety of backgrounds; new and existing bank staff, staff returning to a nursing role and staff who had not administered vaccines to patients in a long while. Sarah described having to train up several new people as more staff became involved in the vaccine rollout.
Sarah quickly recognised the need for some documentation or checklist to make sure everyone knew what needed to be done for each shift; from doing a lateral flow test to recording delivery of the vaccine jab on Pinnacle, the National Vaccination Database. So Sarah devised a process checklist (pictured, right) and put it up on the wall to provide a prompt to all staff. The process was being standardised!
Listening to staff working in the team, Sarah gained feedback about an issue that needed improvement; that staff did not all know what the Organisation Data Service (ODS) code was for entering on Pinnacle. This was vital to ensure accurate recording of where the vaccines were being delivered. So the checklist was altered to include the code and as it is in red, it is difficult to miss it. We have removed the code for publication in the example.
In effect, Sarah was using improvement principles; identifying a problem that needed improving, testing whether a change idea worked by gaining direct feedback and adapting it to refine the process.
Covid staff testing
The COVID staff testing team (in operation since March 2020) has taken many opportunities to apply QI theories and principals. The team has had to adapt quickly to a constantly changing work environment as they respond to the challenges arising from the pandemic.
One particular component of the QI model for improvement, Plan Do Study Act (better known PDSA) has informed pretty much every change and innovation within the staff testing team. PDSAs have enabled the team to plan and implement new systems and processes quickly, collectively testing and refining processes until the team can agree they are good enough to be standardised and added to Standard Operating Procedures (SOP). These processes have included co-ordinating priority symptomatic testing for CNWL staff; asymptomatic tests for staff, patients, and partner agencies; reporting to commissioners and Public Health England (PHE), and most recently, managing patient and staff positive COVID19 results.
PDSA cycles (as with all things QI) require a team approach, whereby everybody contributes their ideas and where every stakeholder involved in the system or process is consulted either before or after implementation.
A good example of this was when the team needed to deliver an antibody drop-in site at Argo House. By including everyone involved in delivering the service at the planning stage, the team were able to open this facility within a week. The service started on 11 June 2020 and about a half dozen sessions were delivered by the end of July.
The team then refined and continually improved the drop-in facility at Argo House by listening to and acting on feedback from staff using the service.
The SOP for COVID+ staff and patient testing has been constantly reviewed and revised using the principles of applying PDSA cycles and feedback from users.
Covid-19 Redeployment Process
Our colleagues in Human Resources have been working on the process of redeploying staff around CNWL to support services as they respond to the Covid pandemic since March 2020. During the first Covid wave, many services were temporarily changed or even closed down. This meant that there were a good many staff available to redeploy into Covid hotspots.
However, more recently, the second wave has placed some severe strain on resources as services cope with increased demand and the affects of more staff needing time off or shielding due to Covid. The importance of the Redeployment Team has once again become critical to coping with these demands.
With the help of the QI Team, a number of improvement change ideas have been introduced to help maximise the effectiveness of the Redeployment process:
- Redeployment Web pages – taking the approach of asking ‘what do I need?’ and ‘what do I want to do?’, the web pages were redesigned to help staff quickly find what they need. And we employed user feedback to make sure the content was right. The correct information is now less than ‘three clicks away’.
- Process Mapping – using a process map to understand your process is a detailed way of identifying parts of the process that can be improved.
- User feedback survey – setting up a short questionnaire on survey monkey to gain feedback about how staff and managers experience the process is invaluable to knowing what is working and what is not; allowing informed decisions about what to adopt, adapt or abandon.
- Data – gathering data about the numbers of requests for redeployment and successful redeployments and then plotting the data over time allows you to see what is changing and if you have improvement in your system.
- Communications – targeting communications for specific reasons, for example to encourage staff and managers to identify themselves as available for redeployment, has a great impact on the way the process performs.
- Standard Operating Procedures (SOP) – one of the steps that you can take at the end of some improvement work is to ‘write up’ your process into a SOP document. Being able to write down and describe how your system works does two very important things: it confirms that you understand your system and it standardises they way people work within the system. Effectively a SOP document can become the ‘manual’ for how you are making your process work, so that if new staff come in to the team, they have a set of guidance to work to. A SOP for the Covid-19 redeployment process is being developed as we go to press!
Meet the QI Team - Sarah McAllister
This month we welcome a new member of the QI Team, Sarah McAllister, who has joined the CNWL family as an Improvement Coach.
Sarah is a mental health nurse by background having predominantly worked in acute inpatient settings. Her passion for improving healthcare services began when she embarked on a local QI project using the Model for Improvement to increase the completion of smoking cessation care plans from 30% to 100% over four months. This led to further improvement work that focused on improving the therapeutic activities that were offered to service users on acute wards.
Sarah is a strong advocate for service user involvement within research and QI work. Recently she worked alongside a group of service users, carers and clinicians to co-design an intervention toolkit to improve nurse-patient interactions on acute mental health wards. She has also co-designed and delivered an extensive range of teaching and training sessions related to this and other work.
Sarah holds a master’s in clinical research and is working towards gaining her PhD in Health Services Research, with further skills and expertise in behaviour change, qualitative and quantitative research methods and grant writing. She also has an extensive publication record and can support teams or individuals who may like to write up and present their QI projects at conferences or in peer reviewed publications.
Sarah started work at CNWL in February and immediately went on redeployment to help the community vaccination programme in Camden. An unusual start to her new employment, but Sarah has already been busy bringing improvement thinking to the vaccination effort, as well as injecting vaccines.
Sarah said recently, “In a mental healthcare setting, injections were rarely welcome, but in my redeployment as a vaccinator, I have never seen so many people who are happy to see me and receive an injection!”
Upcoming Training Dates
Rapid Tests of Change
Many CNWL staff are working through a rapidly changing environment as a result of Covid-19.
This short 1.5-hour reflective training session is based on using the five principles of improvement and testing of change using Plan Do Study Act (PDSA) cycles. As well as providing theory, the course gives some real practical examples of how theory has been applied and lots of time to ask questions and discuss this topic.
Rapid test of change QI training is bookable on LDZ at: https://cnwllearning.org/login/index.php
Search for ‘rapid tests of change’ to find the course.
- Wednesday 10 March 2021 09:30 am – 11:00 am
- Tuesday 23 March 2021 09:30 am – 11:00 am
Contact information for Improvement Advisors:
- Diggory Division, Michele Dowling: email@example.com
- Goodall Division, Peter Smith: firstname.lastname@example.org
- Jameson Division, Marcus Maguire: email@example.com
- CNWL QI Microsite: www.cnwl.nhs.uk/qi
- Life QI: www.lifeqisystem.com/
- IHI Open School: www.qi.cnwl.nhs.uk/training-and-events/online-qi-training
If you want to get in touch please contact us here: firstname.lastname@example.org