The Atlas of Shared Learning

Case study

Quality improvement using the principles of the Leading Change, Adding Value framework

Leading change

The Senior Development Nurse at South West London and St George’s Mental Health NHS Trust (SWLSTG) undertook a programme of quality improvement, by supporting staff across the Trust, to embed principles of the Leading Change, Adding Value framework into practice. This programme has supported the continued professional development of nursing staff to carry out a series of improvement projects, all targeting quality improvement and leadership.

Where to look

A key focus for NHS organisations is the provision of high quality services, which are annually assessed by NHS Improvement and the Care Quality Commission. They focus on the quality and impact of the services provided to ensure they can be sustained whilst always striving to improve (NHS Employers). The senior development nurse at SWLSTG identified unwarranted variation in the approach(es) to quality improvement across the Trust. There was no standardised approach or methodology and some staff reported that at times they did not feel confident as practitioners of behaviour change. The Nursing and Midwifery Council (NMC) standards of proficiency for registered nurses highlight that nursing staff must practice effectively, promoting the safety and wellbeing of their patients by ensuring their work is evidence-based.

The senior development nurse recognised an opportunity to embed a framework around quality improvement initiatives to address unwarranted variations seen in practice.

What to change

The senior development nurse, with colleagues from across SWLSTG, worked collectively to identify principles of the Leading Change, Adding Value framework (LCAV) which could be embedded in practice. LCAV is for all nursing, midwifery and care staff, no matter what your role is or where you work, and how staff can lead the changes needed to improve services, experiences and outcomes for patients, individuals and populations. The framework specifically looks at reducing ‘unwarranted variation’; by seeing where care is not equal and taking steps to address that variation, everyone can receive the same highest standards of better outcomes, better experiences and better use of resources. The senior development nurse supported colleagues to be aware of and understand these principles, as well as aligning quality improvement projects with the ten aspirational commitments embedded in LCAV.

A programme of roll out and engagement was developed for nursing, midwifery and care staff at SWLSTG. The programme highlighted how the recommendations for evidence-based practice and leadership at all levels could be utilised locally, whatever your role and wherever you work. The senior development nurse also undertook a piece of work with the Deputy and Director of Nursing to align the LCAV Framework to the Trust’s own nursing strategy. This aimed to support and encourage nursing colleagues to measure the outcomes of their work.

How to change

A nursing development conference was hosted by the Trust to launch the programme including 70 key stakeholder nursing colleagues from across the Trust. The event supported an understanding of the framework and a coordinated approach to planning how this could be implemented. The aim was to support colleagues to identify a project that they could implement to improve clinical practice.

Quality improvement support resources such as the summary document of the LCAV framework, the e-learning tool and resources that supported staff to identify and address unwarranted variation in practice. Existing systems such as staff induction and mandatory training were developed to include the framework, including examples of how the framework was or could be used within the Trust. A bi-monthly bulletin was developed, which advocated and showcased good practice sharing when the quality improvement projects were implemented and evaluated.

The senior development nurse helped to create a culture shift in approach to quality improvement through empowering staff at all levels to lead change and add value. Reflective learning sets have been developed within preceptorship to support staff and culture change, with a supportive forum to debrief and discuss challenges they have faced, including change resistance. Coaching skills are then utilised to enable effective problem-solving.

Adding value

Better outcomes – Across the Trust, nursing staff have transformed practice through service improvement, targeting the triple aim outcomes. Examples include:

  • Senior nursing staff at the Lotus Assessment Suite developed resources to improve carer/family experience as well as the experience of their vulnerable loved ones. To understand the impact of, and overall enhancement of carers’ experience, senior nursing staff obtained qualitative and quantitative feedback. Internal data showed an increase in the volume of feedback received from carers, suggesting that this demographic have been better engaged by staff. Feedback from clients on the unit was uniformly positive and they reported that improved integration of their carers removed some of the worry that their loved ones are not being supported, and assisted shared knowledge and experience regarding the treatment pathways and options available under secondary services.
  • The implementation of the ‘Green Light Toolkit’ to improve mental health services for individuals with learning disabilities and autism has shown significant improvements in the SWLSTG audit results. In January 2018, SWLSTG achieved 8 out of 9 standards compared to June 2018 where all 9 standards were successfully met for the Basic Audit. This is a significant improvement from 2017 when only 4 out of 9 standards were achieved in the Basic Audit. There was also an increase in the better and best audit showing a steady and clear improvement across the Trust. Scores indicated that only 2 standards were met in Better and Best Audit in 2017 compared to 7 standards in the Better Audit and 4 standards met in the Best Audit in June 2018.
  • A project for physical health monitoring and compliance in forensic services; with the overarching aim to increase staff confidence, clinical competence and importantly promote early detection and treatment of long-term physical health conditions. This has led to an increase in compliance rates as indicated in the audits completed by the Physical Health Lead. Feedback was received in the form of questionnaires from both staff and service users. Particularly, staff expressed they felt more confident using the equipment, undertaking the monitoring and recording the readings. Most service users also expressed that selecting the times they wanted their vital signs taken worked better for them and increased their willingness to engage with physical health interventions.

Better experience – Several recent projects have focused on improving service user care and incorporating carer support within clinical pathways. Verbal feedback received from service users and carers has suggested that they feel more involved within care pathways. Additionally, they appreciate being listened to and agree that they would like to be consulted prior to any changes being made. Personal accounts by carers reflected the feedback received so far; “My daughter felt safe and understood”, “The only place that has taken my son’s situation seriously”, staff have shown such “understanding towards him”.

Better use of resources – These different workstreams / projects have seen nurses apply specific focus to ensuring they apply high value care and work in partnership with individuals, families and carers. This includes care planning, crisis intervention strategies and recovery pathways. This is a move away from a ‘one size fits all approach’ and further aids collaborative two-way processes, which incorporate individual choice and diversity.

Challenges and lessons learnt for implementation

Practitioners need to be actively encouraged to reflect and make sense of experiences for continued learning and development in practice.

Nurses undertaking quality improvement projects at SWLSTG recognised that although they faced resistance at times, with perseverance they could make positive changes. They achieved this by ensuring the service user was involved at each stage in the quality improvement process and by empowering service users to voice their opinions and concerns.

Nursing staff at SWLSTG would recommend to other nurses to devote time to the areas of clinical practice they find most interesting and rewarding. For a project to be successful, to be able to motivate yourself to keep pushing for its implementation and to engage the staff around you, it is important that practitioners are genuinely passionate about the change they want to implement – but if they have that, nurses can create incredible outcomes both for the people they are caring for and the colleagues they work with.

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