Quality Improvement In Mental Health - King's Fund

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Qualityimprovement inmental healthAuthorsShilpa RossChris NaylorJuly 2017

Quality improvement in mental health12345678Contents1234Key messages3Introduction5Improving quality and quality improvement5The purpose of this report7Our approach7The structure of this report8Why does quality improvement matter?9The potential of quality improvement in mental health10Case studies12Tees, Esk and Wear Valleys NHS Foundation Trust12East London NHS Foundation Trust16Institute of Mental Health, Singapore20Summary22Leading quality improvement25Building board-level support for quality improvement25Quality improvement means leading in a different way27Summary31Contents 1

Quality improvement in mental health12345678Sustaining quality improvement32Building an infrastructure for quality improvement32Building capability and capacity in the workforce34Partnering for quality improvement in mental health356Challenges and opportunities377Reframing relationships with regulators408Key lessons42Quality improvement can make a difference42Quality improvement takes time42Quality improvement means leading in a different way43Quality improvement requires fidelity to the chosen method43Quality improvement in mental health is broadly similarto quality improvement in other health care settings43Appendix 1: Quality improvement methods44Appendix 2: Quality improvement resources47References49About the authors54Acknowledgements555Contents 2

Quality improvement in mental health12345678Key messages Quality improvement is a systematic approach to improving health servicesbased on iterative change, continuous testing and measurement, andempowerment of frontline teams. There is a pressing need to improve the quality of mental health care, andquality improvement approaches have an important role to play in this. A growing number of mental health providers in the UK and internationallyare making efforts to embed quality improvement approaches across theirorganisation, with some reporting promising results in terms of benefits forservice users and staff. Our research found that there are no fundamental differences between mentalhealth and other areas of health care in terms of how quality improvementapproaches can be used. Tools and approaches increasingly being used in theacute hospital sector can be adapted for use in mental health care, including incommunity settings. Building an organisation-wide commitment to quality improvement requirescourageous leadership, a sustained focus over time, and efforts to promotetransparency, evaluation and shared learning across the organisation and beyond. The strong emphasis on co-production and service user involvement in mentalhealth can be harnessed as a powerful asset in quality improvement work. Thisis one aspect of quality improvement where there is considerable potential formental health providers to innovate and to share learning with others acrossthe health system. Leaders play a key role in creating the right conditions for qualityimprovement. Mental health leaders seeking to adopt a quality improvementapproach in their organisation should consider the following lessons.–– From the outset, it is vital to build board-level commitment to theprinciples of quality improvement and support for the rationale to shiftthe emphasis from assurance to improvement.Key messages 3

Quality improvement in mental health12345678–– Quality improvement requires leaders to engage directly and regularlywith staff and, critically, to empower frontline teams to develop solutionsrather than imposing them from the top.–– Doing quality improvement at scale requires building an appropriateinfrastructure, including a robust support structure for frontline teamsand mechanisms to spread learning across the organisation.–– Fidelity to a chosen methodology helps to sustain and embed qualityimprovement in ways of working and in the organisation’s culture. Fundamentally, quality improvement rests on an understanding that thosedirectly involved in giving and receiving a service are best placed to improve it,provided they are given the right tools and authority to do so.Key messages 4

Quality improvement in mental health112345678IntroductionImproving quality and quality improvementAll health care organisations in the NHS are required to improve their qualityof care. For example, one of the key lines of enquiry used by the Care QualityCommission (CQC) to establish if an organisation is well led is whether robustprocesses are in place to support learning, continuous improvement and innovation(see box, below).What is quality in the NHS?Improving the quality of care for NHS patients was the central theme in the NHS next stagereview (Department of Health 2008), which defined quality based on the three criteriabelow. This definition has since been adopted throughout the NHS and was used as the basisof the NHS Outcomes Framework. Safety – doing no harm to patients. Experience of care – this should be characterised by compassion, dignity and respect. Effectiveness of care – including preventing people from dying prematurely,enhancing quality of life, and helping people to recover following episodes of ill health.Elements of this definition of quality were subsequently incorporated into the NHS regulatoryframework developed by the CQC in 2013. Thus, assessments of the quality of NHS servicesare based on the following questions, which are more wide-ranging and take into account thegovernance and leadership of care providers. Are services safe? Are they effective? Are they caring? Are they responsive to people’s needs? Are they well led?Introduction 5

Quality improvement in mental health12345678The term ‘quality improvement’, as used in this report, has a specific meaning andis not synonymous with improving quality. Quality improvement in health careis based on a principle of organisations and staff continuously striving to improvehow they work. There is no single definition, but it is generally understood tobe a systematic approach based on specific methodologies for improving care –enhancing patients’ safety, outcomes and experiences (see Appendix 1). It putssignificant emphasis on the role of frontline teams in consistently applying an agreedset of tools and techniques to test, measure and learn (Health Foundation 2013).Quality improvement is sometimes distinguished from quality assurance, whichrefers to the ongoing monitoring of the quality of care against agreed standards.Quality improvement is a concept that has its roots in industries such as carmanufacturing (Health Foundation 2013; Young et al 2004). Quality improvementmethodologies such as Lean have been highly influential in health care too (seeAppendix 1 for an overview of the main methodologies used in the health sector).Outside the UK, examples of successful improvement in health care settings can befound in organisations such as Jönköping County Council in Sweden (Alderwick et al2015), Intermountain Healthcare in the United States, Canterbury District HealthBoard in New Zealand (Timmins and Ham 2013) and the Virginia Mason MedicalCenter (VMMC), also in the United States (Ham 2014).The use of quality improvement is not new to the NHS. In England, qualityimprovement has been supported in the past by the NHS Modernisation Agencyand then the NHS Institute for Innovation and Improvement. Both organisationssaw quality improvement as key to tackling the challenges facing the NHS.While the use of quality improvement has become increasingly common in acutehospitals (Care Quality Commission 2017a), until recently the approach has receivedless attention in organisations focusing on mental health or community services.This now appears to be changing, with organisations such as NHS Improvement,the Institute for Healthcare Improvement (IHI), the VMMC and others workingincreasingly with mental health care providers internationally and in England.Introduction 6

Quality improvement in mental health12345678The purpose of this reportThis report explores the potential opportunities arising from the applicationof quality improvement approaches in the mental health sector and identifiesrelevant learning from organisations that have already adopted these approaches.We are specifically interested in understanding how and why some mental healthorganisations have embraced quality improvement strategies and what has enabledthem to do so. In particular, we explore what changes are needed from seniorleaders to cultivate a quality improvement ethos within their organisation.We have deliberately focused on examples where there have been concertedattempts to embed a culture of quality improvement across whole organisations.Our justification for this is the argument, made by several authors, that theimpact of quality improvement work is often greatest when it forms part of acoherent, organisation-wide approach as opposed to discrete, time-limited projects(Dixon‑Woods and Martin 2016). In the organisations we studied, the goal hasbeen that quality improvement should become routine practice in all areas,supported by a process of cultural transformation.While our primary focus is on mental health, several of the organisations studiedalso provide community health services for general physical health needs. Webelieve that many of the lessons described will be pertinent to organisationsproviding any form of care in hospitals or the community.Our approachOur aim was to capture the narratives and practical lessons from organisationsthat are attempting to embed quality improvement as a routine way of working.Therefore, we interviewed board members and senior leaders across NHS mentalhealth and combined mental health and community health trusts. Through initialscoping work we identified organisation-wide quality improvement initiativestaking place at East London NHS Foundation Trust and Tees, Esk and Wear ValleysNHS Foundation Trust. We also studied the work done by the Devon PartnershipNHS Trust, South London and Maudsley NHS Foundation Trust and the Institute ofMental Health in Singapore, to elicit further insights. In addition, we interviewedsix experts in the field of health care quality improvement (from the HealthFoundation, the IHI, the West of England Academic Health Science Network andthe Scottish Patient Safety Programme). In total, we conducted 20 interviews.Introduction 7

Quality improvement in mental health12345678To capture wider views from within the mental health sector, we also convened ahalf-day seminar at The King’s Fund in January 2017 attended by approximately90 senior leaders to understand their roles in driving quality improvement. We alsoreviewed policies, literature and online resources relating to quality improvementin mental health.The structure of this reportIn section 2, we explore the rationale for embracing quality improvementapproaches in the NHS in general and in mental health organisations in particular.We then present case studies of mental health organisations that have embeddedquality improvement as a fundamental way of working and describe the benefitsthese approaches have led to (Section 3). Sections 4 and 5 focus on what can belearnt from the case studies about how mental health services can embed aculture of continuous improvement. Sections 6 and 7 consider the challenges andopportunities for improvement in the mental health care sector, as a whole, and howrelationships with regulators could be reframed to enable mental health providersto focus on improvement. Section 8 concludes by summarising the key lessonsfrom this research.Introduction 8

Quality improvement in mental health12345678Why does qualityimprovement matter?2The NHS faces great challenges in delivering high-quality care at a time of severefinancial constraints and workforce shortages (Dunn et al 2016; Addicott et al 2015).The King’s Fund and others have argued that the solutions will not come solelyfrom large-scale reforms or from the ‘top-down’ imposition of targets, or evenfrom external forces such as inspection and regulation (Ham 2014). These leverscan only be effective if used in combination with a focus on ‘reform from within’,based on an understanding that those closest to complex quality problems (frontlineteams, patients and carers) are often best placed to find the solutions. This is a coreprinciple of quality improvement.Transforming the NHS depends much less on bold strokes and big gestures bypoliticians than on engaging doctors, nurses and other staff in improvementprogrammes.(Ham 2014, p 3)The scale of the financial and workforce challenges across all parts of the NHSmeans it is more important than ever to find ways of improving the quality of carewhile tackling unwarranted variation and waste. This is not to suggest that qualityimprovement offers a quick solution to the pressures the system is under or that itpresents an alternative to ensuring that adequate resources reach frontline services– sufficient funding and effective approaches to improvement are both needed.Quality improvement is not a quick fix but rather a continuous process and, as wewill describe in the subsequent sections, it is a long-term commitment that requiresa cultural shift in ways of thinking, leading and working. In this section, we considerthe rationale for quality improvement and argue that it is time for mental healthorganisations to embrace it.Studies have shown that quality improvement approaches can be adopted in healthcare to improve processes of care. For example, a review of studies where Leanthinking had been applied in health care settings found positive results for patientWhy does quality improvement matter? 9

Quality improvement in mental health12345678care (Mazzocato et al 2010), and another systematic review found that most studiesreported improvements in different aspects of surgical care (such as decreasingoperative complications or length of stay in hospital) following the application ofLean, Six Sigma (see Appendix 1) or a combination of both (Mason et al 2015).Many NHS organisations have started to explore quality improvement throughdiscrete projects and using a range of methods. A smaller but growing numberhave developed more systematic, organisation-wide programmes to ensure thatcontinuous improvement happens at scale and as part of their standard way ofworking. For example, the Royal Devon and Exeter NHS Foundation Trust has along history of quality improvement, beginning in 2003 when, together with otherlocal health and social care providers, it took part in the IHI’s Pursuing Perfectioninitiative. It subsequently took part in a number of other programmes, includingLeading Improvement in Patient Safety and the Productive Ward (Jones andWoodhead 2015).The potential of quality improvement in mental healthThere is a pressing need to improve quality in mental health care, in response toboth longstanding problems and more recent pressures (Care Quality Commission2015a; Gilburt 2015). For example, the recent independent review of the provision ofacute psychiatric care for adults commissioned by the Royal College of Psychiatrists(and chaired by Lord Crisp) found ‘a long list of problems’, including inadequateavailability of inpatient care (or alternatives) when needed, wide variation in accessto evidence-based therapies across the acute care pathway, a lack of clarity as to theoutcomes expected, and significant differences in the quality of leadership and inorganisational culture (Crisp et al 2016). One of the review’s key recommendationswas that expanding the use of improvement methodologies in mental health couldplay an important role in addressing some of the quality problems identified.The examples described in this report lend further support to this recommendation.Some of the reported benefits of quality improvement are illustrated in the followingsection. Several recent studies have also indicated that there is potential to enhanceservice users’ experience and improve outcomes by using a quality improvementapproach in mental health care (Abdallah et al 2016; Poots et al 2014). For example, arecent evaluation of a quality improvement project to reduce the number of violentincidents on older people’s mental health wards found that not only did the numberWhy does quality improvement matter? 10

Quality improvement in mental health12345678of incidents decrease over one year but there was also a reduction in rates of injuryamong staff and an increase in the average number of days between incidents (Brownet al 2015).It is important to note that it is relatively early days for evidence in this field andmost impact data is self-reported. The data we have presented is not taken fromindependent evaluations and therefore we cannot say to what extent the reportedoutcomes can be attributed specifically to a particular quality improvement approach.Nevertheless, the examples indicate that quality improvement has something to offerin relation to a broad range of quality issues in mental health care.We note that the evidence about the impact of quality improvement in health caresuggests that in order to maximise success, a number of factors are important,including how rigorously the method is applied (Holt et al 2017; Fulop and Robert2015; Kaplan et al 2012; Health Foundation 2011; Walshe and Freeman 2002). Thechallenges involved in doing quality improvement successfully have been reviewedin a recent article by Dixon-Woods and Martin (2016). The authors argue that littlebenefit will be gained if quality improvement methodologies are used in the absenceof several enabling conditions, including: an ongoing organisational commitment as opposed to multiple, small-scaleprojects that are time-limited fidelity to the chosen quality improvement method devolution of decision-making responsibilities so that frontline staff are trustedand supported to make changes rigorous evaluation and sharing of learning across the organisation and beyond.In the following sections, we explore in greater depth the conditions needed to makea success of quality improvement.Why does quality improvement matter? 11

Quality improvement in mental health132345678Case studiesThe potential of quality improvement – and the challenges involved – are bestarticulated by describing the stories of organisations that have embarked on thisapproach. In this section, we outline three examples of mental health organisations(two in England and one in Singapore) that have adopted quality improvement astheir routine way of working: Tees, Esk and Wear Valleys NHS Foundation Trust East London NHS Foundation Trust Institute of Mental Health, Singapore.We describe the initial impetus for taking an improvement approach, organisationalchanges that have been required in order to put the ethos of improvement into practice,and some of the ways in which the impact of quality improvement has been felt.Tees, Esk and Wear Valleys NHS Foundation TrustTees, Esk and Wear Valleys NHS Foundation Trust (TEWV), in the north east ofEngland, provides mental health and learning disabilities services in inpatient andcommunity settings. The trust was rated ‘good’ overall by the CQC following acomprehensive inspection in 2015, maintaining that rating in a follow-up inspectionin early 2017 (Care Quality Commission 2017b; Care Quality Commission 2015b).Conversations about quality improvement at the trust began in 2007 between thechief executive and clinical directors, and were influenced by improvement workthat was taking place across the NHS in the north east at that time (through apartnership with Virginia Mason in the United States). At the same time, the trustwas going through a period of organisational change following a merger withanother trust. This also created momentum for developing a new strategy toimprove care quality and reduce waste (and therefore costs).Case studies 12

Quality improvement in mental health12345678The

Quality improvement in mental health is broadly similar to quality improvement in other health care settings 43 Appendix 1: Quality improvement methods 44 . organisations have embraced quality improvement strategies and what has enabled them to do so. In parti

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