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Quality champions drive improvements that benefit patients and save millions

An NHS trust has used US-style improvement techniques to train hundreds of clinical and non-clinical staff to become quality champions. Nurses have responded to the initiative with enthusiasm

An NHS trust has used US-style improvement techniques to train hundreds of clinical and non-clinical staff to become quality champions. Nurses have responded to the initiative with enthusiasm


Picture: iStock

Getting grassroots staff involved in quality improvement brings benefits for patients and helps the workforce feel they are delivering the best services. That’s the experience of Wrightington, Wigan and Leigh NHS Foundation Trust (WWL), which has trained 380 staff as quality champions, who lead on and implement improvement schemes across its hospitals.

The quality champions scheme started when the trust looked at its mortality rates in the wake of the Mid Staffordshire NHS Foundation Trust care scandal. They were relatively high, says the head of quality improvement at the trust, Caroline Greenhalgh. The trust’s chief executive Andrew Foster was familiar with the techniques used at the US-based Institute for Healthcare Improvement (IHI), and thought they could benefit his organisation. An action plan was devised to train 30 members of staff in improvement techniques and support them in making improvements in their own area.

Skills and knowledge

‘We had a lot of people who wanted to be involved in quality improvement but did not necessarily have the skills,' says Ms Greenhalgh, who trained as a nurse. 'The Advancing Quality Alliance helped devise a bespoke programme and because it was in 2012, the Olympics year, we decided to call them quality champions.’ 

Staff are all volunteers and can choose any project as long as they can show how it promotes the wider strategy of improving patient care. ‘We give them the skills and knowledge they need,’ she says.

The initial training is three days, spread over a week, and staff then go back to their day jobs, hopefully with skills that will help them initiate change. 

‘Part of the uniqueness of what we do is that we get together different disciplines. We had a team consisting of the head porter, the patient engagement lead and the outpatient sister, who all worked on outpatient letters,’ she says.

'We instinctively knew that if we were getting it right it would save us money. The work so far has saved around £12 million'

Caroline Greenhalgh

While that may seem an odd team, she points out that the porters were often approached by patients who were lost. Looking into the problem, the team found that there were issues with the letters, such as a header giving the address of one of the hospitals in the group while inviting patients to attend another. Adjusting how the information was presented in the letters helped solve the problem.

Projects rewarded

The IHI methodology focuses on data collection and showing that changes have made a difference. Improvements sustained for six months are recognised with a silver award for staff, and if they are adopted outside their own area, the staff who worked on them receive the gold award. ‘The measurement must be quantitative, qualitative or both,’ Ms Greenhalgh adds. If projects are successful, they are adopted – potentially more widely – and become "the way we do it from now on".'

There is high level buy-in and support. A monthly committee that looks at the projects is chaired by the chief executive, with other executives attending. ‘It’s an opportunity for quality champions to share their work and what they have been able to achieve, or not achieve,’ says Ms Greenhalgh. ‘If they have come up against a blockage then the executives may be able to unblock that for them.’

She adds that the trust has started to analyse the financial benefits from this staff-led work: ‘We instinctively knew that if we were getting it right it would save us money.’ Research suggests that it has saved around £12 million to date. Examples of improvements that have delivered real cost savings for the trust, as well as improved care and outcomes for patients, include reductions in the length of stay for inpatients and moving arthroplasty injections (to improve joint function) out of a costly operating theatre environment.   

Enthusiastic nurses

Nurses are one of the most active groups when it comes to training as quality champions and implementing changes, she says, while bands one to four are difficult to reach. Junior doctors – who are often keen but find it hard to free time up for improvement – had a special programme this year where each of the teams was mentored by a consultant.

‘Nurses tend to be more senior and we get many specialist nurses involved – possibly because they are able to control their diaries,’ says Ms Greenhalgh. Nurses involved with community services have been particularly enthusiastic, she adds. 

There is no guarantee staff will be able to get protected time off to work on their projects but often this is arranged through discussions with line managers. ‘It should be a win win situation,’ she says. ‘Everything we are doing should make it better. You can have a better patient experience and staff experience.’

 

Gold quality champion improves care for patients with acute kidney injury

Acute kidney injury (AKI) is recognised as a dangerous, even life-threatening, condition that mainly affects older people who may already have other health issues.

This can present challenges for hospitals caring for such patients, who may be spread around different wards and being treated for different primary presentations. A hospital may have ten or more patients with AKI stage three and knowing what is happening with all of them – and making sure their AKI has been recognised – is not easy.

Educating staff

Guidance on AKI management issued by the National Institute for Health and Care Excellence in 2013 was a spur for many trusts to examine their practices. At WWL there was concern that a baseline study showed AKI was associated with a high mortality rate so AKI nurse Suzanne Wilson was appointed to make improvements. She is now a gold quality champion, having demonstrated a sustained impact on mortality.  Her work has also influenced other trusts. 

An early focus of her work was getting on to wards, educating staff and raising awareness of AKI. To do this, she organised regular one hour drop-in sessions where she would take staff through a presentation explaining what AKI was, which patients were at risk and who would need early referral to intensive care units or to a tertiary centre.

She also arranged sessions involving other speakers to demonstrate the multidisciplinary working needed. This included a patient speaker who worked alongside staff addressing topics such as pain, radiology and dehydration. The sessions attracted 70 to 80 people each time. Ms Wilson also offered telephone advice for staff at other hospitals in the group and is involved at an early stage when a patient with AKI arrives at the emergency department.

Pragmatic solutions

Overall, mortality from stage three AKI has reduced from 44% to 19% since Ms Wilson started at the trust. Length of stage of patients with AKI stage three has reduced from 15 days to nine, and patients are in AKI stage three for a shorter duration.

Early intervention also seems to have an effect. When Ms Wilson started, the trust had about 70 AKI stage three patients a month, but this has now reduced to between 45 and 50. 

One aspect of her improvement work focuses on patients with both heart failure and AKI. This can create issues around medication. Fluid balance, for example, is important for both conditions but the optimal point may be different for each. By working with other staff, Ms Wilson has found pragmatic solutions to some of these issues and develop guidance on how to manage this group of patients.

If a patient has fluid overload, extra fluids may need to be given orally rather than intravenously. Medications are also managed to take account of both conditions.


Alison Moore is a freelance journalist

 

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