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• 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
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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 reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone 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
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.
• 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
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).
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.
Approach | Goal | Link to quality improvement |
---|---|---|
Audit | Determine whether services meet established standards and identify areas where improvements are needed | |
Research | Generate new, generalisable knowledge through the application of a rigorous scientific method |
|
Service evaluation | Establish whether a service is fit for purpose and delivers the required outcomes for service users | A service evaluation can be used to identify areas which a quality improvement project could then improve |
(Adapted from Backhouse and Ogunlayi 2020)
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?
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.
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.
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.
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.
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.
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).
(Adapted from Burton 2016)
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?
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 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.
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:
• 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.
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?
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.
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