Using quality improvement to enhance mental healthcare
Intended for healthcare professionals
CPD    

Using quality improvement to enhance mental healthcare

Sarah Galloway Quality improvement and innovation project manager and improvement advisor, South West London and St George’s Mental Health NHS Trust, London, England
Justin Earl Associate medical director for quality improvement and innovation, South West London and St George’s Mental Health NHS Trust, London, England

Why you should read this article:
  • To increase your understanding of the methods, tools and techniques used in quality improvement

  • To inspire you to use a quality improvement approach to enhance the care of mental health service users

  • To contribute towards revalidation as part of your 35 hours of CPD (UK readers)

  • To contribute towards your professional development and local registration renewal requirements (non-UK readers)

Enhancing the quality of care in healthcare organisations is a constant requirement. Quality is not a static concept and requires continual improvement activities and staff equipped with the skills to undertake the necessary changes. Quality improvement is a systematic approach to enhancing patient care and outcomes that uses iterative tests of change and continuous measurement.

This article explains the methods, tools and techniques used in quality improvement and explores its link to other approaches to improving quality, such as audit, research and service evaluation. The article also details a case study demonstrating how nurses on an inpatient mental health ward used quality improvement to address the low completion rate of weekly named-nurse key work sessions.

Mental Health Practice. doi: 10.7748/mhp.2022.e1618

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@SWLSTG_Qii

Correspondence

Sarah.Galloway@swlstg.nhs.uk

Conflict of interest

None declared

Galloway S, Earl J (2022) Using quality improvement to enhance mental healthcare. Mental Health Practice. doi: 10.7748/mhp.2022.e1618

Published online: 05 July 2022

Aims and intended learning outcomes

This article aims to provide an overview of quality improvement and explain how it can enhance patient care and outcomes, including when used in combination with other approaches to improving quality, such as audit, research and service evaluation. The article further aims to enhance mental health nurses’ understanding of the role they can have in quality improvement, individually and within their team. After reading this article and completing the time out activities you should be able to:

  • Recognise the important role of mental health nurses in improving patient care and outcomes.

  • Describe quality improvement and its relationships with other methods of improving quality.

  • Understand the importance of measuring improvements and the role of measurement in evaluating change.

  • Recognise the important contribution that service users and carers can make to quality improvement.

  • Identify areas in your clinical practice that could benefit from improvement.

Key points

  • Quality improvement is one approach to improving quality in healthcare, other approaches being audit, research and service evaluation

  • Quality improvement is a systematic approach that uses iterative tests of change and continuous measurement

  • In quality improvement, staff are directly involved in making changes and service users have an important role as ‘experts by experience’

  • A structured approach to quality improvement can be described as having five stages: outlining the issue, defining the aim, selecting improvement measures, exploring change ideas and undertaking testing

  • Quality improvement often involves testing change ideas through plan, do, study, act (PDSA) cycles

  • Choosing appropriate measures is crucial in determining whether change ideas are resulting in an improvement

Introduction

Improving the quality of care in the NHS is a constant requirement, particularly in a challenging context of low staffing and financial constraints that adversely affects the quality and safety of patient care (NHS Improvement 2016). Quality is not a static concept, but an activity that requires continual improvement activities and staff equipped with the skills to undertake the necessary changes. Quality in healthcare does not have a single agreed definition (The Health Foundation 2021), but there is an expectation from service providers and service users that the care delivered will be safe, caring, respectful and personalised. In addition, the care delivered should be well led, sustainable and equitable, although this is challenging to achieve in a complex system such as healthcare. In England, standards of care are set by the Care Quality Commission (CQC) (2022), which regularly conducts inspections to ensure that services meet these standards.

Some healthcare organisations adopt a ‘top-down’ approach to quality improvement in which the agenda is set by the organisation’s board, while others prefer a ‘bottom-up’ approach in which the impulse for quality improvement comes from staff. The authors of this article suggest that this polarisation between top-down and bottom-up is unhelpful and that collaborative working – whereby healthcare organisations set strategic priorities collaboratively and the improvement activities are undertaken by locally run teams – is more likely to be successful.

Quality improvement is not a ‘quick fix’ and can be seen as a way of supporting staff, service users and carers to be directly involved in making changes and obtain the tools, skills and empowerment to make decisions (Jabbal 2017). Dixon-Woods and Martin (2016) reported concerns that quality improvement is primarily being undertaken by experts and early adopters, including healthcare leaders and quality improvement teams, which can contribute to a divide between them and front-line staff. It is therefore important not to see quality improvement as a separate ‘department’ tasked with fixing issues, but as an organisational responsibility involving, at all levels, staff with the skills and knowledge to enhance quality and address safety concerns (Berwick 2013).

TIME OUT 1

Write down the research, audit, service evaluation and quality improvement work you have been involved in so far in your career. Can you identify any training or development needs for yourself and your team?

Defining quality improvement

Although there is no single definition of quality improvement, the simplest way to describe it is as follows: a change for the better (that is, an improvement) driven by a methodology (the tools and techniques used to implement the change). The Health Foundation (2021) described quality improvement as follows:

‘Quality improvement is about giving the people closest to the issues affecting care quality the time, permission, skills and resources they need to solve them. It involves a systematic and coordinated approach to solving a problem using specific methods and tools with the aim of bringing about a measurable improvement.’

This description identifies one of the fundamental principles of quality improvement, which is that those who are closest to the quality issues – namely the staff who deliver services and the service users and carers who receive them – are optimally placed to determine what the issues are and find solutions to them.

Quality improvement is a systematic approach that uses iterative tests of change and continuous measurement (Jones et al 2019). It is important to clarify the difference between ‘improving quality’ and ‘quality improvement’, since these terms are not interchangeable. Improving quality in healthcare services can be achieved through a variety of methodologies and approaches, which include audit, research, service evaluation, service redesign, implementation of clinical guidance and learning from serious incidents. Quality improvement is one of the many different methodologies that can be used to improve quality. Table 1 provides a brief description of three of the other methods – audit, research and service evaluation – and their relationships with quality improvement.

Table 1.

Audit, research and service evaluation and their relationships with quality improvement

Approach Goal Link to quality improvement
AuditDetermine whether services meet established standards and identify areas where improvements are needed
  • Quality improvement can be used to improve the areas that have been determined by an audit as not meeting the established standards

  • Audit can be a useful measurement tool in a quality improvement project

ResearchGenerate new, generalisable knowledge through the application of a rigorous scientific method
  • Quality improvement uses small tests of change to understand what works in a given context. It can assist teams to determine how to implement research findings in their specific environment

  • Research findings take 17 years on average to be implemented in practice, if at all (Morris et al 2011). Quality improvement could be a valuable means of transforming research findings into evidence-based practice more quickly

Service evaluationEstablish whether a service is fit for purpose and delivers the required outcomes for service usersA service evaluation can be used to identify areas which a quality improvement project could then improve

(Adapted from Backhouse and Ogunlayi 2020)

TIME OUT 2

A nursing student approaches you about the time service users have to wait for cognitive behavioural therapy and how that waiting time could be reduced. You think a quality improvement approach would be helpful. How would you describe quality improvement to the student? How would you explain why it could be helpful?

Quality improvement approaches

There are a range of quality improvement approaches, for example Lean Six Sigma (Juran 1989), experience-based co-design (Bate and Robert 2006) and the Model for Improvement (Institute for Healthcare Improvement 2022a). These approaches share the following features (MINDSetQI 2018):

  • The concept of a cycle of improvement which involves defining and diagnosing an issue, testing ideas for change, collecting and analysing data, implementing the improvements and evaluating them.

  • A set of tools and techniques that support people to implement the changes.

  • A recognition of the importance of engaging stakeholders, including service users and carers.

  • A recognition of the importance of workplace culture and the need for clinical and managerial leadership.

A systematic review by Knudsen et al (2019) found that only a minority of the quality improvement projects they had examined had the key features of a quality improvement project. The authors of this article concur with Knudsen et al’s (2019) conclusion that quality improvement projects should be conducted and documented with rigour to reduce any methodological issues.

The Model for Improvement

There is no clear evidence that one quality improvement approach is superior to another. However, one approach that has been used across healthcare settings is the Model for Improvement (Institute for Healthcare Improvement 2022a), which is valuable because it is simple and can support improvement efforts that range from informal to highly complex. The Model for Improvement consists of three questions and of the plan, do, study, act (PDSA) cycle.

The three questions of the Model for Improvement are (Institute for Healthcare Improvement 2022a):

  • What are we trying to accomplish? This question focuses on establishing a clear aim that is SMART (specific, measurable, achievable, relevant and time-bound).

  • How will we know that a change is an improvement? This question focuses on determining whether the changes being tested are resulting in an improvement.

  • What changes can we make that will result in an improvement? This question focuses on generating change ideas which can then be tested using PDSA cycles.

Generating change ideas can be facilitated by approaches such as brainstorming, ‘fresh eyes’ and Six Thinking Hats (NHS England 2022), which work best when used in a group. The Model for Improvement (Institute for Healthcare Improvement 2022a) is based on the principle of small-scale testing of change ideas over time, with a process of quality improvement driven by PDSA cycles. It is important to move through each of the four stages of the PDSA cycle sequentially. These four stages are:

  • Plan – plan the change idea to be tested, plan the data collection and predict the expected outcomes.

  • Do – carry out the testing and collect data.

  • Study – analyse the data, compare the outcomes to what had been predicted and summarise what has been learned.

  • Act – act on what has been learned and plan another PDSA cycle if necessary. Determine whether the change idea should be adopted, adapted and tested again, or discarded.

It will usually take several PDSA cycles to refine change ideas before they are ready to be implemented.

TIME OUT 3

How could your organisation support you to undertake a quality improvement project? What quality improvement approach does it use? What training might be available to you? Do you know what your organisation’s priorities are in terms of care quality?

Stages of a quality improvement project

When managing a quality improvement project it is important to use a structured approach. Depending on the size and complexity of the project, different project management approaches can be used. The following five-step approach, which was developed by the authors of this article and is aligned with the Model for Improvement (Institute for Healthcare Improvement 2022a), delineates five stages of a quality improvement project:

  • Step 1 – clearly outline the issue. Involve colleagues who can assist you with this, examine different sources of data and seek input from service users and carers where possible. At this stage it is also important to secure senior leadership support for the project. The colleagues involved can become your project team, in which each person’s role will need to be defined.

  • Step 2 – define the aim. This step links to the first Model for Improvement question (‘What are we trying to accomplish?’).

  • Step 3 – select improvement measures. It is often beneficial to use a balance of quantitative and qualitative measures if possible. This step links to the second Model for Improvement question (‘How will we know that a change is an improvement?’).

  • Step 4 – explore change ideas. This step links to the third Model for Improvement question (‘What changes can we make that will result in an improvement?’).

  • Step 5 – undertake testing and learn from it. Use PDSA cycles to test the change ideas. Note the predicted outcomes and the learning from each cycle.

Once the necessary changes leading to improvements have been made, it is important to continue to use data to monitor whether the improvements are being sustained before considering introducing the changes in other teams and services.

Role of mental health nurses

Mental health nurses have an important role in improving the quality of patient care and consequently patient outcomes. Nurses constitute the largest staff group within the NHS in England (NHS Digital 2019), so ensuring they have the skills to engage in and lead quality improvement work is crucial. The closeness of the nurse-patient relationship is unique and places nurses in an optimal position to collaborate with service users and carers to identify areas that require improvement and make changes. Additionally, nurses’ involvement in quality improvement has benefits beyond improved quality of patient care, such as financial gains, reduced sickness and increased job satisfaction (Robinson and Gelling 2019).

The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council (NMC) 2018a) emphasises the importance for nurses to maintain their skills and knowledge, and this would include their skills and knowledge in quality improvement. The NMC (2018b) Standards of Proficiency for Registered Nurses recognise the need for nurses to understand improvement methodologies, quality improvement strategies and how to use improvement tools. The Leading Change, Adding Value nursing strategy (NHS England 2016) advocates for nurses to lead change irrespective of setting or banding, key skills being demonstrating curiosity and developing innovative solutions. However, these policy documents and strategies do not include an implementation plan, which may lead to variation between and within healthcare organisations in terms of how they are applied.

Involving service users and carers

Service user and carer involvement in healthcare services is considered particularly important following the events at Mid Staffordshire NHS Foundation Trust, where the concerns of service users and carers had neither been listened to nor acted on (Francis 2013). The Berwick (2013) report recommended that service users and carers should be ‘present, powerful and involved at all levels of healthcare organisations’.

Service users and carers have an important role in quality improvement because they can offer first-hand knowledge as ‘experts by experience’. An expert by experience is ‘someone who has personal, lived experience of using health, mental health and/or social care services, or of caring for someone who uses those services’ (NHS Improvement 2018). The term has been challenged by McLaughlin (2009) and Scourfield (2010), who argued that having such personal, lived experience does not necessarily qualify someone as an expert. However, the authors of this article suggest that while healthcare professionals and experts by experience may have differing perspectives and make different choices, the aim should always be to ensure service users and carers have an essential role in monitoring the quality and safety of care.

Changes to processes, pathways or care delivery should consider the views of service users and carers, and it is important to collaborate with them in quality improvement work, since they are uniquely placed to describe positive and negative experiences of care. There is growing literature on service user involvement, its importance and strategies. For example, Bombard et al’s (2018) systematic review found that the level of service user engagement could influence the outcomes of service redesign. However, it also identified that while most service users had positive experiences, some felt that their involvement was ‘tokenistic’, particularly when their requests were denied or decisions had already been made (Tritter and McCallum 2006, Bombard et al 2018).

Chambers et al (2017) emphasised the need for service evaluations and interventions to incorporate the service user perspective. Gillard et al (2010) identified that, when conducting research, considering a range of perspectives can provide different – and potentially richer – ways of understanding an issue and developing change ideas. This is equally applicable to quality improvement.

A widely used and well recognised conceptual framework for service user involvement is the ‘ladder of participation’ (Arnstein 1969), shown in Figure 1. The ladder of participation can be useful for organisations to determine the level of involvement of experts by experience and for experts by experience to decide how involved they want to be in quality improvement. It is important to recognise that not everyone will want to contribute to quality improvement projects.

Figure 1.

Ladder of participation

mhp.2022.e1618_0001.jpg

Measuring improvement

While all changes do not necessarily lead to improvement, all improvement requires changes (Institute for Healthcare Improvement 2022b). When undertaking quality improvement work, it is crucial to ask oneself: ‘How will we know that a change is an improvement?’. The answer is: through measurement. There are three main reasons why healthcare professionals need to measure: for research, for judgement and for improvement (NHS Institute for Innovation and Improvement 2017). Measuring for research or judgement will not necessarily enable nurses to determine whether there have been improvements at a local level.

It is essential that healthcare professionals, including nurses, are able to measure improvement in a complex healthcare system. Some nurses may perceive measuring improvement as intimidating, but in reality, with appropriate knowledge and understanding, it can be straightforward. Many nurses have reported that while they value statistics, they do not use them in their everyday practice and therefore feel uncomfortable handling them (Gaudet et al 2014). In the context of a quality improvement project, the aim of measuring improvement is to identify how to make an intervention effective, rather than to prove that it is effective, so while the data need to be useful they do not need to be perfect (Jones et al 2019).

Measuring improvement can be helpful to understand (NHS Institute for Innovation and Improvement 2017):

  • Whether the aim of the project has been achieved.

  • How much variation there is in the system.

  • What results have been seen with the small tests of change.

  • Whether the change has resulted in an improvement.

  • Whether the change has been sustained.

As described above, quality improvement focuses on small tests of change. Continuous measurement enables healthcare professionals to decide whether the change idea being tested is making a difference and contributing towards the aim of the quality improvement project. If the testing shows that there is no change or that there is change for the worse, then the change idea should be discarded and a different one tested instead.

Choosing the appropriate improvement measures is crucial in determining whether the change ideas being tested are resulting in an improvement. Table 2 shows the three main types of improvement measures (Burton 2016).

Table 2.

The three main types of improvement measures

Type Description Examples
Outcome measuresThe high-level clinical or financial outcomes that the quality improvement project is designed to produce
  • A reduction in the time taken for medicine rounds

  • A reduction in the number of instances of seclusion

Balance measuresMetrics that need to be monitored to ensure that improvements made in one area do not have unintentional effects on another area
  • The number of service users readmitted to mental health inpatient care after having been discharged

  • The number of cases of assault on staff and service users

Process measuresSpecific steps in the process under review that can positively or negatively affect the outcome measures
  • The time taken for pharmacy to organise service users’ medicines once they are discharged from the ward

  • Patient feedback scores on discharge

(Adapted from Burton 2016)

TIME OUT 4

With your team or some of your team, discuss the following questions:

Have any quality improvement projects taken place in which the team was involved?

What approach was used and what were the outcomes?

How did you identify areas for improvement and what were these areas?

How did you involve service users and carers?

How could you enhance service user and carer involvement?

Case study

This case study details a quality improvement project undertaken in 2020-21 in a mental health ward to address the low completion rate of weekly named-nurse key work sessions and the lack of documentation of these sessions in patient records.

Ward B (a pseudonym) is a specialist mixed inpatient mental health ward with a maximum bed occupancy of 18 service users, many of whom present with behaviour that challenges and significant physical health issues. Ward B experienced significant nursing staff shortages and relied on agency and bank staff. As a result of the staff shortages, there were challenges in fully supporting and developing the existing staff. Permanent staff often had to spend time inducting agency and bank staff, which contributed to a suboptimal quality of patient care because it took them away from direct care activities. It also became apparent that there was no system for organising named-nurse key work sessions, which relied on the ward being sufficiently staffed and experiencing no incidents. The senior leadership and the CQC had raised concerns, since performance measures were below the expected standards and service users reported dissatisfaction with their care.

The nursing team decided to undertake a quality improvement project with the aim of enhancing front-line staff’s understanding of the issues and determine what changes were needed, including in terms of staff training. In addition, staff needed to review their processes and be reminded of the importance of named-nurse key work sessions. Service users were asked to provide input into the project by discussing the issues and suggesting solutions during community meetings. One suggestion from service users was that nursing staff could book time in their diary for upcoming named-nurse key work sessions and that service users could remind their named nurse when a session was due.

Table 3 outlines the quality improvement project for Ward B.

Table 3.

Quality improvement project for Ward B

IssueAll service users on Ward B should receive a one-hour weekly key work session with their named nurse and the sessions need to be appropriately documented. However, as identified by an initial audit, in October 2020 only 27% of service users received this
AimTo improve the frequency and quality of named-nurse key work sessions on Ward B. The target was set at 80% of service users receiving a weekly named-nurse key work session, and the sessions being appropriately documented, by the end of June 2021
Data collection tools
  • Weekly audits were conducted to determine the percentage of service users receiving a weekly named-nurse key work session

  • Staff and service users questionnaires were used to understand the barriers to completing key work sessions and to determine staff’s knowledge of the 80% target. Staff and service users could suggest change ideas

Outcomes of data collection The main barriers to staff completing key work sessions were:
  • Not having enough time during their shifts

  • A lack of knowledge and confidence in conducting key work sessions

The change ideas tested were:
  • Including named-nurse key work sessions on the staff allocation plan

  • Ensuring that staff document instances when a service user declines a key work session

  • Including training on named-nurse key work in the three-day new starter course

  • Providing an ad hoc named-nurse key work refresher training to permanent staff

  • Nurses sharing best-practice advice on named-nurse key work sessions

  • Appointing a key work champion to support staff

Improvement measures The improvement measures chosen for the project were:
  • Outcome measures: the number of named-nurse key work sessions taking place and the number of sessions documented in patient records

  • Balance measures: service user feedback, complaints and compliments

  • Process measures: the number of named-nurse key work sessions scheduled during each shift and the number of bank and/or agency staff working during each shift

Table 4 shows the percentage of service users who received a weekly named-nurse key work session each month between November 2020 and September 2021. The percentage was 26% in November 2020 and reached a maximum of 73% in July and August 2021.

Table 4.

Percentage of service users who received a weekly named-nurse key work session (November 2020-September 2021)

Month Percentage of service users
November 202026%
December 202042%
January 202156%
February 202150%
March 202152%
April 202166%
May 202168%
June 202169%
July 202173%
August 202173%
September 202167%

PDSA cycles were conducted for each change idea. Table 5 shows, as an example, the PDSA cycles conducted about the change idea of sharing best-practice advice. The PDSA cycles also enabled the team to determine that:

Table 5.

Plan, do, study, act (PDSA) cycles about the change idea of sharing best-practice advice

Stage Cycle 1 Cycle 2
Plan Best-practice advice on named-nurse key work sessions will be shared at the end of each shift during handover. The nurse in charge will ask one nurse on the shift to share some best-practice adviceBest-practice advice on named-nurse key work sessions will be shared at the end of each shift during handover. The nurse in charge will ask one nurse on the shift to share some best-practice advice and write it on the staff noticeboard. Every week nursing students will collate the advice and disseminate it via the ward’s newsletter
Do The plan outlined above was implementedThe plan outlined above was implemented
Study On some shifts there were high numbers of bank or agency staff who may never work on Ward B again, while permanent staff often missed the best-practice adviceStaff felt that the best-practice advice served as a reminder or prompt for their named-nurse key work sessions with service users
Act The success of the change idea was limited because it depended on who was present at handovers. Best-practice advice needs to be shared more widely. The change idea needs to be adapted and tested againThe change idea will be adopted. Nursing students will continue to collate best-practice advice and disseminate it in the ward’s newsletter
  • The percentage of service users who received a weekly named-nurse key work session decreased when the ward was understaffed or permanent staff were on leave.

  • The strategies used would not enable the team to achieve its target of 80% of service users receiving a weekly named-nurse key work session.

As part of the quality improvement work, feedback from service users was sought more frequently. Service users were encouraged to remind staff when their named-nurse key work session was due or alert them if their session was late, but this depended in part on the confidence of each service user. Any issues, such as a missed session or a service user’s dissatisfaction with their care, were discussed in supervision between the named nurse and their supervisor, but the need for this significantly decreased. Ongoing monitoring revealed increasing compliments from service users about their care and a decrease in complaints.

TIME OUT 5

Identify one area of your practice that you feel could be improved and consider the following questions:

How would you define the issue?

Who would you need in the project group?

What change ideas do you already have?

How would you measure improvement?

How would you engage experts by experience?

Conclusion

Quality improvement can encourage staff to embrace change and enhance patient care. It could also be a valuable means of transforming research findings into evidence-based practice in a timely manner. Collaborating with service users and carers provides a unique perspective on their lived experiences and is crucial to ensure that any improvements made are relevant to them. As shown by the quality improvement project detailed in this article, change driven by mental health nurses can lead to significant improvements in patient care and outcomes. However, achieving this requires organisational investments in staff training, including their understanding of the methodologies and measures used, and dedicated time.

TIME OUT 6

Identify how using quality improvement to enhance mental healthcare applies to your practice and the requirements of your regulatory body

TIME OUT 7

Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account: rcni.com/reflective-account

References

  1. Arnstein S (1969) A ladder of citizen participation. Journal of the American Institute of Planners. 35, 4, 216-224. doi: 10.1080/01944366908977225
  2. Backhouse A, Ogunlayi F (2020) Quality improvement into practice. BMJ. 368, m865. doi: 10.1136/bmj.m865
  3. Bate P, Robert G (2006) Experience-based design: from redesigning the system around the patient to co-designing services with the patient. Quality & Safety in Health Care. 15, 5, 307-310. doi: 10.1136/qshc.2005.016527
  4. Berwick D (2013) A Promise to Learn – A Commitment to Act: Improving the Safety of Patients in England. http://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf (Last accessed: 24 May 2022.)
  5. Bombard Y, Baker GR, Orlando E et al (2018) Engaging patients to improve the quality of care: a systematic review. Implementation Science. 13, 1, 98. doi: 10.1186/s13012-018-0784-z
  6. Burton T (2016) Why Process Measures are Often More Important than Outcome Measures in Healthcare. http://healthcatalyst.com/insights/process-vs-outcome-measures-healthcare (Last accessed: 24 May 2022.)
  7. Care Quality Commission ( 2022) What We Do. http://cqc.org.uk/what-we-do (Last accessed: 24 May 2022.)
  8. Chambers M, McAndrew S, Nolan F et al (2017) Service user involvement in the coproduction of a mental health nursing metric: The Therapeutic Engagement Questionnaire. Health Expectations. 20, 5, 871-877. doi: 10.1111/hex.12526
  9. Dixon-Woods M, Martin GP (2016) Does quality improvement improve quality? Future Hospital Journal. 3, 3, 191-194. doi: 10.7861/futurehosp.3-3-191
  10. Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: Executive Summary. http://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/279124/0947.pdf (Last accessed: 24 May 2022.)
  11. Gaudet J, Singh MD, Epstein I et al (2014) Learn the game but don’t play it: nurses’ perspectives on learning and applying statistics in practice. Nurse Education Today. 34, 7, 1080-1086. doi: 10.1016/j.nedt.2013.05.009
  12. Gillard S, Borschmann R, Turner K et al (2010) ‘What difference does it make?’ Finding evidence of the impact of mental health service user researchers on research into the experiences of detained psychiatric patients. Health Expectations. 13, 2, 185-194. doi: 10.1111/j.1369-7625.2010.00596.x
  13. Institute for Healthcare Improvement (2022a) How to Improve. http://ihi.org/resources/Pages/HowtoImprove/default.aspx (Last accessed: 24 May 2022.)
  14. Institute for Healthcare Improvement (2022b) Using Change Concepts for Improvement. http://ihi.org/resources/Pages/Changes/UsingChangeConceptsforImprovement.aspx (Last accessed: 24 May 2022.)
  15. Jabbal J (2017) Embedding a Culture of Quality Improvement. http://kingsfund.org.uk/sites/default/files/2017-11/Embedding-culture-QI-Kings-Fund-November-2017.pdf (Last accessed: 24 May 2022.)
  16. Jones B, Vaux M, Olsson-Brown A (2019) How to get started in quality improvement. BMJ. 364, k5408. doi: 10.1136/bmj.k5437
  17. Juran JM (1989) Juran on Leadership for Quality: An Executive Handbook. The Free Press, New York NY.
  18. Knudsen SV, Laursen HV, Johnsen SP et al (2019) Can quality improvement improve the quality of care? a systematic review of reported effects and methodological rigor in plan-do-study-act projects. BMC Health Services Research. 19, 683. doi: 10.1186/s12913-019-4482-6
  19. McLaughlin H (2009) What’s in a name: ‘client’, ‘patient’, ‘customer’, ‘consumer’, ‘expert by experience’, ‘service user’ – what’s next? British Journal of Social Work. 39, 6, 1101-1117. doi: 10.1093/bjsw/bcm155
  20. MINDSetQI (2018) MINDSET Introduction to Quality Improvement in Mental Health. http://mindsetqi.net/wp-content/uploads/2018/02/MINDSet-A5-Brochure-updated-Jan-2018-WEB.pdf (Last accessed: 24 May 2022.)
  21. Morris ZS, Wooding S, Grant J (2011) The answer is 17 years, what is the question: understanding time lags in translational research. Journal of the Royal Society of Medicine. 104, 12, 510-520. doi: 10.1258/jrsm.2011.110180
  22. NHS Digital (2019) NHS Workforce Statistics – December 2018. NHS Digital, Leeds.
  23. NHS England (2016) Leading Change, Adding Value: A Framework for Nursing, Midwifery and Care Staff. http://england.nhs.uk/wp-content/uploads/2016/05/nursing-framework.pdf (Last accessed: 24 May 2022.)
  24. NHS England (2022) Quality, Service Improvement and Redesign (QSIR) Tools. http://england.nhs.uk/sustainableimprovement/qsir-programme/qsir-tools (Last accessed: 24 May 2022.)
  25. NHS Improvement (2016) Evidence from NHS Improvement on Clinical Staff Shortages: A Workforce Analysis. http://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/500288/Clinical_workforce_report.pdf (Last accessed: 24 May 2022.)
  26. NHS Improvement (2018) Valued Care in Mental Health: Improving for Excellence. A National Mental Health Improvement Model. http://mygovcentral.com/wp-content/uploads/2020/10/Valued-care-in-mental-health-Improving-for-excellence.pdf (Last accessed: 24 May 2022.)
  27. NHS Institute for Innovation and Improvement (2017) The How-to Guide for Measurement for Improvement. http://england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/How-to-Guide-for-Measurement-for-Improvement.pdf (Last accessed: 24 May 2022.)
  28. Nursing and Midwifery Council (2018a) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. NMC, London.
  29. Nursing and Midwifery Council (2018b) Future Nurse: Standards of Proficiency for Registered Nurses. NMC, London.
  30. Robinson J, Gelling L (2019) Nurses+QI=better hospital performance? A critical review of the literature. Nursing Management. doi: 10.7748/nm.2019.e1858
  31. Scourfield P (2010) A critical reflection on the involvement of ‘experts by experience’ in inspections. British Journal of Social Work. 40, 6, 1890-1907. doi: 10.1093/bjsw/bcp119
  32. The Health Foundation (2021) Quality Improvement Made Simple: What Everyone Should Know About Health Care Quality Improvement. http://health.org.uk/publications/quality-improvement-made-simple (Last accessed: 24 May 2022.)
  33. Tritter JQ, McCallum A (2006) The snakes and ladders of user involvement: moving beyond Arnstein. Health Policy. 76, 2, 156-168. doi: 10.1016/j.healthpol.2005.05.008

Share this page

Related articles

Developing a clinic to meet patients’ pre-operative needs
This article describes a practice development project at a...

An assessment of the value of music therapy for haemato-oncology patients
The aim of this service evaluation was to assess the value...

Identifying and meeting survivorship needs
This article reports on the development and delivery of a...

Assessing the benefits of social prescribing
Social prescribing provides GPs and other healthcare...

Management of patients with low-risk febrile neutropenia
The National Institute for Health and Care Excellence in the...