Monthly ArchiveFebruary 2014

Preparing for quality: East London’s transformation has begun

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 Dr Amar Shah is a consultant forensic psychiatrist and quality improvement lead at East London NHS Foundation Trust. He is also the London regional lead on quality and value for the Faculty of Medical Leadership and Management.  Contact or follow him on twitter @DrAmarShah

Dr Amar Shah

Dr Amar Shah is a consultant forensic psychiatrist and quality improvement lead at East London NHS Foundation Trust. He is also the London regional lead on quality and value for the Faculty of Medical Leadership and Management. This blog is brought to you by BMJ Quality. For more quality improvement resources go to

 Contact or follow him on twitter @DrAmarShah

At East London, the question we have been asking ourselves is, “what does it take to sustain a multi-year organisation-wide improvement programme that delivers significant improvements in quality and cost, and successfully transforms the culture of the organisation?”

Quality has been the undisputed buzzword in healthcare in 2013, with a number of seminal national reports focusing on how to improve quality of care. This blog will chronicle the journey of one provider of mental health and community services, and how we are changing our thinking and approach to quality.

At East London NHS Foundation Trust, we believe we currently deliver a good quality of care, with many ‘bright spots’ of excellent caring practice and innovation. There is also considerable inconsistency and variation, with some ‘dark spots’ of concern. This situation is not unique to East London, and most healthcare staff may be able to relate to a similar picture in their organisation. Over recent years, as with many NHS providers, our Trust has placed emphasis on quality control and quality assurance structures. This has resulted in relatively robust governance procedures, evidenced in the attainment of CQC essential standards of care for all visits and NHSLA level 3 risk management standards.

Our ambition is to deliver the best possible mental health and community care to our patients, service users, carers and families. We have made a commitment to quality of care. This is embodied in our mission to provide the highest quality mental health and community care in England by 2020. We recognise that achieving this will require a new approach to quality. The three landmark reports in 2013 on quality and safety in the NHS (Francis report, Keogh review and Berwick report) have all espoused the development of an organisational culture which prioritises patients and quality of care above all else, with clear values embedded through all aspects of organisational behaviour, and a relentless pursuit of high quality care through continuous improvement.

In addition but not unrelated, funding for the NHS is likely to remain static or possibly decline in real terms beyond the 2015 general election. Achieving year-on-year efficiency savings by focusing on rationalising inputs to the system (workforce, assets) is proving increasingly difficult and is likely to disproportionately affect staff morale and quality of care. It’s abundantly clear to anyone working in the frontline of healthcare delivery that the area of greatest inefficiency within the system lies within the clinical processes themselves, which have largely remained untouched through recent years of efficiency savings. Redesigning clinical pathways with the ambition of providing patient-centred, high value care offers the potential to realise continued savings from the health economy whilst delivering an improved quality of service to our patients. Successful redesign at this scale requires improvement expertise, dedicated resource, rigorous application of a consistent methodology and a fundamentally different approach to quality, which involves putting patients and the families at the heart of the design and improvement work.

The last year of preparation has been a steep learning curve and a great investment. We have taken time to think, talk and learn from others. Successfully embedding a new culture and achieving a step-change in quality and value of care is a huge challenge, but we now feel in a much stronger position to attempt this.

Our work began at the very top of the organisation, recognising that Board-level leadership was absolutely vital to success. Nurturing and supporting improvement to achieve better health, better care and better cost requires leaders to apply a new approach and specific set of behaviours in redesigning systems and accelerating culture change, as described in the recent IHI white paper. Our Board has invested time and energy to understand improvement, to learn from the journey of other high performing organisations, and to develop a strategy for our programme of work. Wide consultation across our clinical teams, service users, carers, Governors and commissioners has fed into the development of a strategy that we hope all can feel ownership of.

Developing the business case has been a significant challenge, with most of the evidence and experience of large scale quality improvement being in acute care. However, we believe that coordinated improvement work in mental health and community health services is just as possible, despite some additional challenges, and we are excited by the prospect of starting to work in unchartered territory.

The work before the work of improvement has been crucial in preparing the ground for applying quality improvement across a whole organisation, and eventually a whole system of care. One of our earliest decisions was that we would be more successful in this journey if we partnered with an external continuous improvement expert, to support us with strategic advice and to help us build improvement skills in our workforce at scale and at pace.

We are building a central quality improvement team in the organisation, to coordinate the programme of work and to be the internal improvement experts. Over the last few months, we have been slowly and steadily reviewing and re-aligning many of our corporate systems so that they will support our improvement work. Much of this has the potential to be transformative – for example, working towards the publication of complaints every month on our website, embedding a structure for listening at every level of the organisation, integrating quality data and making this available to every person in the organisation, reviewing all of our policies and procedures to ensure they support the development of a just culture, reviewing our clinical audit programme, refreshing our induction process, and ensuring that quality improvement is embedded within all of our internal training and development.

Alongside this, we’re developing the framework for measuring and evaluating our progress on our strategy – not an easy task, considering the lack of standardised outcome measures in mental health, and the lack of accurate tariffs and costs for patient-level activity.

We’re clear that our quality improvement programme will involve a fundamental change in the way things are done. It will seek to bring about a culture change, putting patients at the heart of all that we do and at the centre of our improvement and redesign work. We want to embed a culture of listening more to our frontline staff, service users and carers, and provide more freedom to our frontline staff to work in partnership with patients to innovate and test new ideas, whilst stopping activity of lower value. And we want to build up the skills in our workforce on improvement, and support them to use a consistent methodology to test ideas, measure their impact and then spread successful change. We’re convinced that freeing our staff to work with their patients in improving the system and pathways of care will yield the greatest improvements in quality and cost outcomes.

We’re about to open a new chapter in our organisation’s journey. It’s one that we believe could only be possible from a position of strong leadership, assurance and financial security. Our next challenge is the critical one of engaging the whole organisation in this programme, and the next blog will describe how we’re attempting to create a movement for change that is led and owned by the grassroots.


1. Dixon-Woods, M., Baker, R., Charles, K. et al. (2013) Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Quality Safety doi: 10.1136/bmjqs-2013-001947

2. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (chaired by Robert Francis QC), February 2013

3. Review into the quality of care and treatment provided by 14 hospital Trusts in England (Professor Sir Bruce Keogh), NHS England, July 2013

 4. A promise to learn – a commitment to act. Improving the safety of patients in England. National Advisory Group of the Safety of Patients in England, August 2013

5. Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2013.

Quality Improvement around the world: Top Down or Bottom Up?

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Helen Carson, Product Manager for BMJ Quality

BMJ Quality was at the Arab Health Congress in Dubai last month. This event played host to 85,000 delegates, over 2,000 exhibitors and 19 conferences, which included topics such as quality management and diabetes. Talking to delegates was a good way to learn about the myriad uses for the term “Quality”; Accreditation, safety, performance standards, risk mitigation, innovation, process improvement and patient centred care were just a few of the phrases that were regularly used by delegates to talk about quality in their organisations. This blog is brought to you by BMJ Quality. For more quality improvement resources go to

One of the contrasts to the UK was the sense that in the Middle East, “Quality” is very structured; delegates from the Middle East tended to talk about a very organised quality manager at their organisation who worked to devise and implement quality strategies and practical resources, whilst working to ensure that everyone adhered to the frameworks necessary for accreditation by the likes of Joint Commission International (JCI). These healthcare professionals saw their role as implementing quality controls to reduce risk, and to ensure that clinical practices are safe and consistent. Perhaps it was due to the nature of the events, but when I think back to the ‘quality themed’ conferences I attended in the UK in the summer, there was a contrast: Senior NHS figures were calling for frontline staff to take responsibility for quality improvement through critical appraisal and innovation. Many spoke of the redesigning of processes and services, due to the continued complexity and bureaucracy of many organisations, and the ability of those at the frontline to see a clearer path to improve services. This is of course in addition to adhering to the guidelines given by government and other healthcare bodies such as CQC and NICE.

Perhaps a sweeping generalisation but these are examples of a “top down” and “bottom up” approaches in action. Two very different approaches to the notion of Quality but, hopefully, both with patients as a central focus.

And this is where things (in the era of patients as customers) get complicated. For many patients high quality healthcare has strong links to service elements; speed at which they get to see a doctor, the manner in which they are treated.

While a healthcare professional or a hospital can appreciate the importance of these things their emphasis will likely be on clinical quality and the flow of services and processes. All of these elements need to be measured, improved and managed by empowering healthcare professionals and patients to contribute to the cycle of improvement.

So do we need to agree on a consistent meaning of the term “Quality” to move forward? Or do we need to be flexible and responsive to the needs of patients and organisations in order to give a notion of quality that is important to them?

I suspect that it is the latter.

But one thing that is for sure is that people working at the front line are unsure of their role and authority in Quality Improvement and innovation, so in this respect, clarity, support, and education are an important part in moving forward. And for all these phrases or interpretations of quality; change is essentially what is needed.

What does Quality Improvement mean to you? Want to tell us about it? We want more bloggers to add to the discussion! Contact us:

Severn Foundation School: Top Tips to facilitate quality improvement in a postgraduate medical education setting

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Clare van Hamel, Associate Postgraduate Dean and Director of Foundation School.

Severn Foundation School (FS) has embraced quality improvement (QI) as a highly effective means of achieving improvement in a wide variety of areas. Clare Van Hamel, Associate Postgraduate Dean and Director of Severn Foundation School believes QI empowers individuals, in a far more effective way than audit, helping staff to address the concerns which are directly affecting them. Here she describes ways that other Foundation Schools can follow their lead to enable foundation doctors to identify concerns and develop solutions using a multi-professional approach. This blog is brought to you by BMJ Quality. For more quality improvement resources go to

Severn FS has been fortunate in having quality Improvement leaders as part of the foundation faculty. They have really driven the enthusiasm to use QI tools supporting foundation doctors to identify concerns. Here are my top tips to facilitate quality improvement in a post-graduate medical education setting

1. Identify trainee leaders to enable near-peer championing of QI.

Severn FS have appointed Foundation School Quality Improvement Fellows. Following allocation via FPAS to the Severn Foundation School, all incoming F1s are invited to apply in open competition to be the QI Fellow for the school. The appointee is given financial support to attend an appropriate QI conference and also invited to attend relevant regional/foundation school meetings during their tenure. F1s do not have study leave but the Trusts are asked to be as supportive as possible to facilitate attendance at meetings.

The fellow is identified as a QI contact point for the other foundation trainees. The fellow is supported and mentored by the F2 QI fellow and QI faculty. There is a little more flexibility during the F2 year for the fellow to attend conferences during their study leave time supported financially by the Foundation school.

2. Identify trainer QI leads

Severn FS has been fortunate in having faculty who are committed QI champions within the region both at consultant and senior trainee level. The foundation school has recently set up a sub-group led by one of those champions to help to promote sharing of ideas and outcomes

3. Trusts need to engage and promote QI opportunities for their staff.

Many of our trusts really encourage their foundation doctors to participate in QI work as teams; with many achieving approximately 80% participation. The trusts have seen the specific benefits of the QI outcomes leading to change but also more subtly the benefits of multi-professional working leading to increased morale and respect between different professional groups. Many of the Trust’s executive teams are recognising the significance of the QI achievements and are keen to develop and endorse the work.

4. BMJ Quality subscriptions

These licences have been purchased by the Foundation school to help to facilitate sharing and publication of the QI work that has been completed by the trainees within the school.

5. Opportunities to share the QI outcomes

Severn Foundation School runs an annual regional presentation day providing opportunities for trainees to showcase their work. As a result of the positive feedback from the regional event..

6. Severn Foundation School organises the National Foundation Doctors Presentation Day

This annual event provides an opportunity for Foundation Doctors from any foundation school to present their work. The national day has attracted an increasing number of submissions >300/annum for the last two years. This year the event was supported by HEE, UKFPO, the GMC, HQIP, the BMA and others.

 7. Encourage and support your trainees to submit their work

A very large number of our trainees have presented their work at National and International meetings. We have been over-represented compared to the size of the school at meetings such as the NACT/UKFPO Sharing Best Practice Meetings. We try to provide financial support for trainees to attend to present their work when possible and encourage trusts to release trainees to present at national and international events.

 8. Highlight achievements

The trainee and faculty achievements are highlighted on our website. These are subdivided into presentations, publications and other projects.

In summary quality improvement has enabled our trainees to deliver change within their working environments, in a wide variety of fields. The work has delivered a huge number of changes including better patient care escalation policies;  improved handover; safer prescribing of drugs and fluids; induction to F1 and F2 programmes; improved access to rotas and access to protocols. Much of the work has centred on patient safety but also on efficacy and efficiency. Many of the projects have produced considerable cost saving whilst also improving patient safety. What could most concisely be described as a WIN- WIN for all involved.