Monday, March 19, 2018

Blog - Adopting Systems for Quality Improvement in Health & Care - David Fillingham

Following the recent launch our paper A Sense of Urgency, A Sense of Hope at a joint event with The King’s Fund, our Chief Executive David Fillingham takes a further look at the need for health and care organisations to adopt systems for quality improvement.
David Fillingham

It has been a long, difficult Winter for the NHS. Staff have worked incredibly hard to care for increasing numbers of patients at a time of tightening finances. Sadly, despite these great efforts, we have inevitably seen too many stories of long waiting times and a worsening experience in many places. Whilst the NHS has a marvellous ability to cope in adversity, the sense of it being in crisis is growing.

On one of the snowiest days of the year, the 1 March (allegedly the first day of Spring!) over a hundred hardy NHS folk battled their way through blizzards to a King’s Fund / AQuA event in Manchester where we launched AQuA's framework on building a system and culture of improvement, entitled A Sense of Urgency, A Sense of Hope.

By a show of hands delegates indicated that they were very familiar with the extreme pressures facing the NHS. They also recognised that the current political and economic context is such that, the sustained and large-scale investment needed in health and social care is unlikely to happen anytime soon.

The 'hope' rests in the fact that there is a strong evidence base, in other sectors and in healthcare, that the strategic application of improvement methods can improve both quality and productivity. This is not to say that more spending isn't needed, it is, but until the day it arrives there is a great deal that the NHS can do for itself to tackle the waste, delays and duplication in the system that are such a source of frustration for staff and patients alike.

The problem is that our improvement efforts are too often small-scale, piecemeal and not sustained. Organisations which have achieved transformational results, such as Jonkoping in Sweden, Virginia Mason in the US or Salford Royal and East London Foundation Trust here in the UK, have adopted a long-term approach to building their respective improvement systems.

AQuA's publication is based both on a review of the published evidence about how they have done that and on reflections on leading and supporting improvement efforts on the ground.

Our framework has five interdependent elements:
  • Vision and Strategy - developing a plan that inspires and engages everyone. It should have bold aims, measurable goals and commit the organisation to building improvement capability at every level.
  • Leadership and Culture - in an improvement culture patients and families are full partners in their care. Staff are empowered and supported to use their energy and creativity to solve problems, and leaders are positive role models who coach others in their chosen improvement approach
  • Building Capability - there is a commitment to train all staff in improvement method and to give them the time and encouragement to use those skills. Leaders and coaches will have more advanced know how and there will be a small number of genuine experts. The Board will itself commit to receiving development to carry out its own improvement leadership role effectively
  • Developing an Operating System - improvement methods will become 'hard wired' into the organisation with goals being cascaded via a process of 'catchball' and expertise focussed onto the biggest challenges. Over time an improvement approach will become "the way we do things around here" and an accepted part of daily work
  • Aligning Support Services - staff working in HR, Finance, IT/Information and Estates have a great contribution to make. They will be fully engaged and these functions redesigned to support an improvement culture.
Last year NHS Improvement, alongside other national NHS bodies, published their strategy Developing People,Improving Care. This exhorts NHS organisations to make just these kind of investments in their own improvement capability.

The newly revised CQC inspection framework asks questions as to what progress is being made on the ground. Not only do organisations need to adopt such an approach if they want to emulate the best, now they are actively being encouraged to do so by inspectors and regulators.

This kind of work takes time and is a difficult path. It's all too easy to become overwhelmed by day to day pressures. Succeeding requires courage, curiosity, persistence and optimism.
But the prize is a great one...that of seeing staff glow with the pride using their own experience, energy and ideas to transform the care that patients receive.

Feel free to share your thoughts with us via Twitter @AQuA_NHS or get in touch via to request a hard copy of our paper.

Monday, March 12, 2018

Buurtzorg Diaries - Bringing Buurtzorg Home - Wendy Lewis, Whole System Flow Lead

Early in March, several AQuA staff and members embarked on an exciting study trip to the Netherlands, to learn more about the Buurtzorg health and care system.

Throughout the week, they’ll be sharing their learning and experiences of the trip in a series of blogs. Our latest learning comes from Wendy Lewis, AQuA’s Whole System Flow Lead.

Well reflecting on a great three days where we really got under the skin of this Buurtzorg thing - it really is as good as the hype, in fact it might be better!

From the welcome we received, the honest responses and challenges to our questions to the bikes, strange contraptions for putting TED stockings on and the inspirational speakers, this has been a really stimulating and heart-warming learning experience.

As the final group discussion took place this morning, I noted the key issues we’re really wrestling with:

  1. What's the compelling narrative we need to create that will get this work across the start line? WE get it now, how do we help THEM get it?
  2. How do we create the space for self-led teams without actively seeking the obstacles and obstructors that we foresee we’ll have to overcome?
  3. Can we achieve our organisations' expectations of Buurtzorg by using a too tentative approach to testing or implementing? 
  4. Matthias van Alphen talked about how ridiculous it would be to describe someone as 'a little bit pregnant', or a little bit autonomous... Can we agree to approach this properly where self-led means self-led?
Finally, a perspective from Brendan from his experience, instead of the usual discussion if how we adapt the Buurtzorg way to our systems, we need to approach it differently:
  1. How do we change the context to fit the Buurtzorg model?
  2. Can we adopt the principles within the context we work without compromising the model?
Some questions to ponder as we return home and prepare for module three in May!

Stay tuned to our news page for more blogs where other teams will also be sharing their experiences from the trip.

Alternatively, you can follow Wendy Lewis (@ERPwend) on Twitter for the latest.

Thursday, March 8, 2018

Buurtzorg Diaries - Buurtzorg Life Poem - Jacqueline Williams, East Cheshire NHS Trust

Early in March, several AQuA staff and members embarked on an exciting study trip to the Netherlands, to learn more about the Buurtzorg health and care system.

Throughout the week, they’ll be sharing their learning and experiences of the trip in a series of blogs. Our latest learning comes as a poem from member Jacqui Williams, Associate Director for Service Transformation at East Cheshire NHS Trust.

This is our reflection of our time in the Hague,
We’ll try to give detail - and not be vague
Monday - the day our adventure began...
7 nurses let loose across Amsterdam
We’ve tried all modes of transport - car, foot, tram and bike
All thirsty for knowledge about the ‘Buurtzorg life’.

Nursing teams in neighbourhoods - where lives are laid bare
Early intervention, practice prevention and promoting self care
Really ‘knowing’ your patients - that's how it should be
Therapeutic relationships with continuity
Goals and solutions that are owned and are shared,
Everyone’s equal, with time given to care.

So, what has struck us about this philosophy?
A return to core nursing values ‘create simplicity’
Systems and support that don’t hinder or burden
A ‘no blame’ culture - and commitment to learning

Nurses self managing - committed to their job
Accountable, responsible, professional Buurtzorg!
All of this is what we can see
With a feeling that this was ‘how it used to be’

So, what next? We challenged our brains
Thinking about what, when and how we might change

Jos de Blok’s words echoing in our minds
‘Coalitions of the willing’ - we need to find
Review what we have - trade in ‘process and tools’
Reduce the bureaucracy - ‘relationships not rules’

Take the best of our past, our present practice too
There’s lots to celebrate in what we currently do

Give our nurses confidence, freedom and competency
For safe effective care that brings real quality
Nursing in different countries, different cultures, but we share the same aim

Great patient care - Buurtzorg?
The clues in the name.

Stay tuned to our news page for more blogs where other teams will also be sharing their experiences from the trip.

Alternatively, you can follow Emma Walker (@EmmaCherub) or our Whole System Flow Lead Wendy Lewis (@ERPwend) on Twitter for the latest.

Wednesday, March 7, 2018

Blog - Early Adopters & Spreading the Message - Norah Flood

In part four of our Person Centred Care blog series, Norah Flood, AQuA member and Assistant Director of Clinical Networks at North West Boroughs Healthcare NHS Foundation Trust, discusses the Trust’s implementation of Person Centred approaches and the importance of early adopters.

Noah Flood
‘We already do that’ and ‘I will not allow my patients to make a bad decision’ were the two stand out responses received when introducing the concept of Shared Decision Making (SDM) into a recently merged Community Physical Health and Mental Health organisation.

Fortunately, there were also plenty of open doors to be knocked on that welcomed the structure of tools to support the practitioner and patient to reach a decision together.

Initially, these doors belonged to the high volume services, possibly surprising, as a common concern among practitioners was the perceived extra time it would take in engaging in SDM conversations with patients. However, the case for enhanced compliance, reduced DNAs and increased patient satisfaction soon overcame those concerns.

Even better was the tangible evidence produced; demonstrating that patients did want to share in the decision, actually did know what their preferences were, and so did engage fully in their treatment plans.

Leaders in the field are essential but more crucial are the fast followers. What we found was that spread and adoption in Community Physical Health Services was both rapid and successful. Possibly because services were proactive in seeking out support to engage in SDM and adopted, or created, patient information to assist patients in determining what was best for them.

Equipment Services, Dietetics and Weight Management, Podiatry, and MSK became self-sufficient in utilising SDM and developing tools to support patients. Furthermore our Intermediate Care services introduced SDM and achieved a cultural shift in how risk was assessed and managed. This is best demonstrated by Jim's story.

An early advocate of SDM came from our Secure Care Services, who utilised this approach to support the introduction of the Trust’s smoke free policy. Tools to support service users to stop smoking were co-produced with service users, ward staff and pharmacy.

The response was both positive and immediate and the concept of Shared Decision Making was soon transferred to the unit’s multi-disciplinary team meetings; now the service user has the opportunity to fully participate if not lead their MDT.                                                                  
News travelled fast and on the back of one success came enquiries and suggestions for where else Shared Decision Making could be applied.

Another early adopter was our CAMHS services, where it was always felt that continuity of practitioner was of the upmost importance and while no-one denied that, it was realised that not all practitioners are skilled to offer the full range of interventions.

Therefore, tools were developed to assist families in deciding which therapeutic intervention they preferred to receive, and how that decision was affected if it meant moving to a different therapist.

This approach was spread to other services by the ‘share and adopt’ method, and Shared Decision Making has become something we already do across the organisation.

You can share your thoughts with Norah on Twitter via @NorahFlood1  or @AQuA_NHS, or feel free to leave a comment below.

In our next blog we hear from another of our members, Caroline Poole, Clinical Improvement Lead at Pennine Care NHS Foundation Trust; who explores a systems approach to measuring person centred care.

Stay tuned to our news page for more updates!

Buurtzorg Diaries - A Self-Led Start to our Trip – Emma Walker & Siobhan Reading

Early in March, several AQuA staff and members embarked on an exciting study trip to the Netherlands, to learn more about the Buurtzorg health and care system.

Throughout the week, they’ll be sharing their learning and experiences of the trip in a series of blogs. Starting off the series, our Strategic Portfolio Lead Emma Walker and Programme Support Officer Siobhan Reading bring us up to speed after landing in The Hague…

Emma Walker
Siobhan Reading and Emma Walker
AQuA and member colleagues excitedly arrived in The Hague for our Buurtzog study visit to see how self-led teams work in the Netherlands.

It was quickly apparent from the initial welcome meeting with our Buurtzorg hosts that we were not just going to observe self-led teams, but the programme itself for us was going to be very self-led.

Teams were given their programme for the next 3 days and then we all had to work out how to get to various points across the city - some by 7.30am the following morning!

Initially, folk talked about getting taxis, but it didn’t take long for their adventurous spirit to creep forth and you could see why these folk had been chosen as they quickly embodied self-led ‘ness’ and a can-do approach; working in small groups (with good old Google) to work out which tram, from where and when they needed to get to by when (how did we manage before the wonders of smartphones?)

So, we are off with our phones, clutching maps on bikes, trams and foot to explore the 3rd city of the Netherlands to see how Buurtzorg works in practice - not only observing nurses with patients today, but also visiting a Buurtzorg office, seeing how the very streamlined back-office function works and how social and health care provision in the community functions together.

Siobhan Reading
Today I was surprised to learn that setting up a Buurtzorg team requires an entrepreneurial streak!

You have to be prepared for the challenges of business planning, budgets and watching your overheads.  You also need to have identified if the model will work within your neighbourhood by reaching out to GPs and other community organisations.

AQuA staff and members alongside Buurtzorg colleagues

It’s not enough to just have a team of nurses. With no formal support the team has to be prepared to make all their own decisions regarding staffing and working practices.

For anyone who's had a desire to set up their own business or be free of line management maybe the Buurtzorg model can apply to more than just healthcare.

However, taking on that responsibility might not be for everyone…

Teams from localities across East Cheshire, Manchester, and Wirral will also be sharing their experiences from the trip, so stay tuned to our news page for more.

Alternatively, you can follow Emma Walker (@EmmaCherub) or our Whole System Flow Lead Wendy Lewis (@ERPwend) on Twitter for the latest.

Monday, March 5, 2018

A Sense of Urgency, A Sense of Hope – Our Latest Paper on Continuous Improvement for Health & Care

We’re delighted to announce the publication of A Sense of Urgency, A Sense of Hope; our latest paper by our Chief Executive David Fillingham CBE and Director Lesley Massey exploring how organisations can develop and support a culture and system for continuous improvement.

In the paper, David and Lesley take a look at recent best practise, changes to the health and care landscape, and distil over eight years’ experience of working with members as the North West’s quality improvement body, into five key domains where organisations can support and invest in a quality improvement system:
  • Vision
  • Leadership & Culture
  • Capability
  • Developing an Operating System
  • Aligning Support Services

Speaking on its publication, David said:

“We’re really excited to share our new paper, and hope it offers our colleagues across health and care an in-depth framework to help support their aims for continuous improvement.”

“Whilst we recognise the extreme pressure the NHS and wider care sector continues to face, we feel it’s important to still look for a light at the end of the tunnel. Therefore it is vital organisations invest in improvement, if we are to meet the demands of better, more efficient care and improved outcomes for patients.”

“We really believe this is possible and as we highlight throughout the text, there are a number of organisations we can look to for inspiration to achieve this together.”

Throughout the paper, the pair also look at case studies from our work with members, including from: Aintree Hospital NHS Foundation Trust, Manchester University NHS Foundation Trust, Mid Cheshire Hospitals NHS Foundation Trust, North West Boroughs Healthcare NHS Foundation Trust.

Other examples also point to leading improvement organisations from other industries and sectors outside of health and care.

The paper was recently launched to over 100 delegates at a joint event with The King’s Fund; exploring successful approaches to quality improvement. Following the event, co-author Lesley Massey said:

“At the event delegates gave us some fantastic feedback on the framework and each of its five domains.

“We’re now developing a self-assessment diagnostic to support the framework, and would welcome interest from colleagues across the country who would be interested in testing this.”

If you would like to request a hard copy of the paper, or are interested in testing the self-assessment diagnostic, please get in touch via AQuA@srft.nhs.ukAlternatively, feel free to share your thoughts with us via Twitter @AQuA_NHS.

Friday, February 23, 2018

Blog – From Patient to Practitioner – My Lived Experience of Working with AQuA – Carl O’Loughlin

Carl O’Loughlin has been a member of AQuA’s Lived Experience Panel since 2015. As he starts his training to become a qualified mental health nurse, he shares his experience of working with us for the past three years.

Carl O'Loughlin
I first came into contact with AQuA in June 2015, when I was working as an involvement representative on a peer support project in the Cheshire and Wirral Partnership NHS Foundation Trust (CWP). Through this project I met Paul Greenwood, AQuA’s Mental Health Improvement Advisor; who was running a Restraint Reduction initiative on one of the CWP inpatient wards.

During our meeting, I shared with him my work with CWP, together with my own lived experience of using mental health services and my professional background; where I had experience of quality improvement.

Paul also told me that AQuA was forming a Lived Experience panel and after applying to join this and an interview, I was pleased to be offered the role as one of five Lived Experience Affiliates on this panel.

At my first Panel meeting, it was evident each of us on the panel had a significant and varied range of lived experience of healthcare services. Since then, we’ve all been welcomed by AQuA staff as a fundamental and key part of the organisation.

We’ve also had quarterly meetings with either the Chief Executive or Directors, to update them on the work we do with programmes and AQuA members; which demonstrates how important AQuA value the work the panel does.

Since joining, I’ve received significant training on everything from Human Factors, Introduction to Improvement, Shared Decision Making, Dementia Awareness, Safety and Mortality and Motivational Interviewing. AQuA has also facilitated my Experience Based Design Coaches training.

My presentation and report writing skills have also improved significantly, together with my knowledge of health and social care services and how they are organised and operate.  All of this training, skills development and knowledge will prove invaluable to my nursing studies and any future nursing roles.

During this time I’ve had the privilege to work on a range of programmes, including Whole System Flow, Mental Health, Restraint Reduction, Safety, Academy and Shared Decision Making.

There’s a range of work that I’m proud of from my time with AQuA.  The most prominent of these is our work with three systems as part of the 2017/18 Whole System Flow programme. Together as a Panel, we’ve spent the last six months visiting and interviewing service users and carers from each of the three systems.

This work has given us a deep insight into what it is really like to be a service user or carer using each system, and allowed us to produce a detailed lived experience report for each system.

Each of their project teams have fed back that these ‘real’ experiences gathered by the Panel has been the most important part of each project. It’s been clear that diagnosing issues and problems in each of these systems wouldn’t have been possible without these insights.

This piece of work has been incredibly rewarding and enjoyable personally; with the patients really valuing the opportunity to share their experiences with us.

All in all, it’s been an absolute pleasure to work with AQuA as a Lived Experience Affiliate for the last three years.  I’ve found AQuA to be a highly forward-thinking organisation at all times, especially with regard to quality improvement and co-production.

Staff have really welcomed all members of the Panel, and have actively worked to co-produce and embed lived experience into their programme design and delivery. They practice ‘real’ co-production, are happy to receive challenges and feedback from panel members, and use this to actively improve their work.

I’m certainly going to miss working for AQuA and everyone that I work with there, but I’m also excited to be starting a new chapter in my life with my nursing studies about to commence.

Feel free to share your thoughts and comments with Carl, or wish him good luck with his nursing training, via Twitter @Carloloughlin1 or @AQuA_NHS