Blog: How do we intentionally develop the integrated workforce? - Elizabeth Bradbury

Elizabeth Bradbury, Director

This blog is about intentionality. We intend to improve integrated care for local people – and improvement can be anywhere on the spectrum of small local change, to radical new models of care to transform population health outcomes – and we intend to invest time, energy and resources in doing this.

But just how intentional are we about equipping our combined health and care workforce with the knowledge and skills to lead and implement transformational change? Our experience at the Advancing Quality Alliance (AQuA) is that intentionality varies across the UK, and global delegates at this year’s International Congress for Integrated Care in Barcelona had a similar view.

AQuA's Change Model for Complex Systems

In Constructive Comfort The Health Foundation emphasise the importance of investment in workforce skills including leadership, change management and quality improvement in order to accelerate and build the system-wide capability to sustain large scale change. In recent years inspirational stories have illustrated intentional skill-building as part of transformation plans in NHS Highland, South Central Foundation in Alaska, Kaiser Permanente, USA and the Canterbury system in New Zealand to name just a few. So the big question is…how do you get started?

Intentionality: getting started

If you’ve asked yourself how intentional your approach is to equipping the local workforce with the capability to drive change, and the answer is ‘not very’ or ‘there’s scope to improve’, I offer five questions to help frame your discussion:

1. What skills and knowledge do you require to implement integrated care at scale?
2. At what scale is the skill and knowledge needed and how can this be achieved locally?
3. What change models and improvement methods are suitable for your complex environment?
4. What resources are available to support implementation of the changes in the local strategic plan? This includes the role of local leadership, improvement and innovation agencies.
5. How can multiple simultaneous priority work streams be co-ordinated and the learning spread?

Ideas on how to intentionally build workforce capability to underpin integration

AQuA recently shared its intentional approach to large-scale workforce capability building in Leading in Complex Systems: 10 learning points for developing multi-agency leadership teams. We advocate a change model (see diagram) that blends approaches to make best use of staff time and resources, and underpin this with a facilitated peer learning community and team coaching.

We condensed learning from our work with local health and care systems across the UK into ten points with the aim of helping others design programmes for system leaders:

Design and Planning

• Blend theory and methodology
• Intentionally design system leadership support into transformation programmes
• Model collaboration in the provision of system leadership support delivery
• Teams learn to lead together
• Develop distributed system leadership capability
• Sustain support to leaders
• Tailor support for senior and executive leaders
  

Skills in the wider workforce

• Support relationship development at all levels
• Embed improvement expertise in leadership teams

Enablers

• Think measurement – what is feasible?

We’d really like to hear your thoughts on this topic, and invite you to share examples of how you are intentionally developing integrated workforce capability via Twitter @IFICinfo or #ICIC16.

This blog was originally published on by the International Foundation for Integrated Care IFIC. To find out more about the Foundation, please visit their website.

Elizabeth Bradbury is a Director at AQuA and Board member for IFIC from 2014-16.

AQ Listening Exercise: Share your views on the Advancing Quality (AQ) programme

Over the next three months we’re asking members to share their views on the Advancing Quality (AQ) programme; AQuAs flagship reliability of care offer.

After almost a decade of successful collaboration with North West healthcare organisations, AQ has delivered demonstrable improvements in the quality, reliability and outcomes of clinical care.

To ensure members continue to gain the most value from an effective reliability offer we would like members to help shape our 2017-18 priorities for AQ by taking part in our online survey, a short phonecall or face-to-face meeting.

Nadine Boczkowski, AQuA Programme Director for AQ & Analytics said: “Your valuable input into the listening exercise will help us to shape services and develop new offers tailored to your needs, offering support in the right areas to drive up the quality and safety of care and deliver consistently high standards.”

The Listening Exercise is open to staff across all members currently participating in AQ, as well as those who have previously taken part in the programme (please note AQuA and AQ membership are separate).

The short survey should only take approximately 10 minutes to complete, and you can take part by following the link below.

Click here to take the survey

Alternatively, if you would like to arrange a short meeting or telephone interview then please email: advancing.quality@nhs.net to arrange.

For more information about the Listening Exercise, you can download the flyer. If you would like to find out more about Advancing Quality, please visit the website.

Please note the online survey will close for feedback on Friday 30th September.

Expression of Interest: Shared Decision Making Mini Collaborative Programme

We are currently seeking expressions of interest from members to participate in a new mini collaborative programme, as part of our ongoing Shared Decision Making and Self-Management Support offers.

We will be holding an initial half-day sharing and learning event on Wednesday 9 November at our offices in Sale, and will encourage teams to continue working together throughout the programme. Applications are open to all clinical teams from across our member organisations.

Increasing collaboration between patients and practitioners forms a crucial element of the NHS Five Year Forward View, and both Shared Decision Making and Self-Management Support feature prominently in the NHS Operating Framework. This programme will provide support over a six month period to enable teams to embed these practices in their services.

Fully involving patients in the decisions about their own care and treatment has also been shown to improve outcomes, increase patient satisfaction, and make more effective use of NHS resources.

Further information about the programme can be found in the application form, or by downloading the SDM programme flyer.

The deadline for applications is 12pm Friday 9 September, and completed forms should be returned to Hannah.Towler-Lord@srft.nhs.uk.

Members will be contacted with the result of their application by Friday 16 September.

If you would like a further discussion about this opportunity, please contact either Brook Howells on Brook.Howells@srft.nhs.uk, or Rachel Bryers on Rachel.Bryers@srft.nhs.uk.

Blog: REsTRAIN YOURSELF - Implementing a restraint reduction approach in mental health - Paul Greenwood

After a fantastic final event last month for the close of The Health Foundation funded REsTRAIN YOURSELF project, I felt it was a great opportunity to share with you some of my thoughts from working on programme.

The aim of REsTRAIN YOURSELF was to reduce physical restraint in mental health inpatient settings through an evidence-based approach.

Despite only meant as a ‘last resort’, physical restraint is a coercive intervention that is commonly used in mental health services. There have been increasing serious concerns over a number of years about its overuse and significant adverse effects on patients.

Over the course of this two-year programme, I’ve had the chance to work closely with a number of teams in ward environments across the North West, to offer training and support the implementation of the restraint reduction approach.

Members who have participated in the programme include:

• 5 Boroughs Partnership NHS Foundation Trust
• Cheshire and Wirral Partnership NHS Foundation Trust
• Cumbria Partnership NHS Foundation Trust
• Lancashire Care NHS Foundation Trust
• Manchester Mental Health and Social Care NHS Trust
• Mersey Care NHS Foundation Trust
• Pennine Care Foundation Trust

Having the opportunity to work alongside staff has been such a positive fulfilling experience. Having spent a number of years as a mental health nurse myself, it wasn’t easy for me to stand back and observe things on extremely busy acute mental health wards; especially when the nurse in me wants to help and get involve

From this work over the past two years we now have a strong body of evidence on restraint reductions, and here are some of my findings:

Teams

The teams faced many challenges to enable change to occur: from juggling with staffing levels, high levels of acutely unwell patients, and always struggling to find a bed. Both staff and patients have really engaged with the project and implemented a range of approaches to dealing with violence on the wards.

Staff focus on trauma-informed care has shifted from a task-orientated ‘them and us’ dynamic, to more reflective, person-centred approach to patient care.

Having been based on wards on a weekly basis, engaging with staff during those moments of violence and aggression, and trying to help them approach situations differently has been a real challenge.

Often, the adrenaline has kicked in and it is hard for staff to pull back from rushing to restrain rather than de-escalate.

However, one of the biggest efforts by teams has been their work to improve care around self-harm, and working with patients, rather than trying to control them with restraint.

This is a very sensitive area of practice in mental health which staff do struggle with. But coaching has allowed them to be more open and stand back, take their time, and work with the patient, to see better outcomes for patients and their team.

This approach has also seen better communication in shift handovers, more formal staff and patient debriefs, more meaningful activities for patients, and the development of sensory rooms.

Patients 

Working with patients directly we also aimed to develop individual safety plans; a self-management tool that helps both staff and patients focus on what triggers violence, and strategies to help calm and de-escalate. After testing these through the Plan, Do, Study, Act (PDSA) process, these plans have been a huge positive for both parties.

To help improve communication between staff and patients, we also developed weather symbols to use in patient community meetings. This helped them to talk about violent incidents and the general mood of the ward in a safe managed environment, using language that all can connect with (Sunny, cloudy and stormy days).

Patients now comment upon their discharge about how they enjoyed the sunny days on the ward; reinforcing to the teams the importance of focusing on working with patients to make sure there are many sunny days on the ward.

A consistent theme for staff is how they now focus more on the potential impact of restraint on patients, rather than the technique, and how this can avoid trauma to both patients and their colleagues. For me, this is a big cultural shift, which I believe over time will improve team cohesiveness and ultimately lead to safer patient care.

Throughout the two years, all the wards we have worked with have made great progress 

and have seen noticeable reductions in restraint. With The Health Foundation-funded programme now at an end, we hope to continue to build on this learning as we commence the AQuA Restraint Reduction programme throughout 2016/17.

I’m really looking forward to working with many of the Trusts who participated in REsTRAIN YOURSELF, and it’s great to also welcome Greater Manchester West NHS Foundation Trust on board for our new programme.

In October we’ll also be sharing the final evaluation report for REsTRAIN YOURSELF will be published by The Health Foundation, which will be available on our website and other communications.

Paul Greenwood is AQuA’s Improvement Advisor for Mental Health. You can contact him on paul.greenwood@srft.nhs.uk, or follow him on Twitter @PaulG_AQuA.

AQuA Members Receive Parliamentary Recognition for National Malnutrition Work

Advancing Quality Alliance (AQuA) members in Salford have received the national 2016 Excellence in Public Health and Wellbeing award, in recognition of their work in combating malnutrition in older people.

Representatives from Salford Malnutrition Taskforce, which includes staff from NHS Salford Clinical Commissioning Group, Salford Royal NHS Foundation Trust and Greater Manchester West NHS Foundation Trust, received the award at a ceremony in the House of Commons earlier this month.

From left: Jean Rowlnison, Age UK, Barbara Keeley MP,
David Haynes, Age UK, Kirstine Farrer, Salford CCG

On winning the award, Kirstine Farrer, Head of Innovation and Research at Salford Clinical Commissioning Group and Consultant Dietician at Salford Royal, said:

“We are thrilled to receive this accolade from Public Health England and wish to thank Barbara Keeley MP for nominating us. We remain passionate about working in partnership to address malnutrition across the city.

“Whilst developing the Salford Together PaperWeight Armband, I never thought for one moment it would receive such an overwhelmingly positive reception nationally. Having the opportunity to work with Age UK Salford and the integrated care programme in the city just demonstrates what can be achieved when you align health care and third sector.”

Julia Wood, AQuA Affiliate for the Salford Malnutrition Taskforce, added:

“The Salford Malnutrition Taskforce is made up of representatives from numerous organisations around the city. At first individuals in the Taskforce didn’t know each other but everyone around the table was very committed to reducing the level of malnutrition in Salford. Through the determination and dedication of the Taskforce incredible achievements have been made. From a personal perspective the Salford Malnutrition Taskforce was a truly fantastic team to work with and I feel proud to have been part of the team.”

Excellence in public health and wellbeing 2016
certificate, awarded by Jane Ellison MP

The work of the team has led to the development of a number of tools to fight malnutrition across the city, including the nationally-recognised Paperweight Armband. This simple paper armband is slipped around a patient’s upper arm, and was designed as a quick, low-cost, and non-intrusive tool for identifying malnutrition.

Salford was one of five pilot sites launched by the national Malnutrition Taskforce in 2012, and has received national recognition, including a presentation to Members of Parliament earlier this year.

Notes to Editors:
For further information or to request an interview please contact, Matthew Baxter, Communications & Marketing Officer on matthew.baxter@srft.nhs.uk or 0161 206 8025.

Blog: Outlearning the Competition: The Building Blocks for Improvement - Dr Peter Chamberlain

What do highly performing organisations have in common? From Team Sky to Salford Royal, growing evidence suggests that it’s organisations’ ability to run a slick and effective ‘learning system’, providing the mechanism to sustain continual improvement. As put by Professor Steve Spear of MIT, “today’s leading organisations outrace their competition by outlearning them.”

Dr Peter Chamberlain, GP &
Commissioner at NHS South
Sefton CCG

But before we rush to think that having a super learning system guarantees success, the system itself is only one of three factors needed to maximize improvement. Also needed is the right cultural and infrastructure ingredients, such as compassionate leadership and the integration of clinical work with informatics. Organisations then need to base these essentials on the right principles, most notably in healthcare that their work is firmly person-centred.

​How organisations develop across all three areas is what’s fascinated me across my career. It’s what I’ve learnt from my time as a GP and clinical commissioner on Merseyside, as well as my time studying 15 high performing organisations as part of a fellowship at the Institute for Healthcare Improvement in Boston, Massachusetts.

What I've seen time and again is how hard it can be for organisations not at the leading edge to translate what can be quite abstract concepts into reality. What specific, pragmatic initiatives can and should an organisation be doing to bring these ideas to life?

To try and help, I devised the Quality Improvement Building Blocks Framework, shown below. The aim being simply to support organisations to think through how they need to develop in order to improve. Underpinning the 3 layers and 12 building blocks are 60 specific pragmatic development areas (not shown) which organisations can focus on.

The framework draws on interviews and iterative presentations to quality experts around the globe, as well as a range of other frameworks and training programmes in quality improvement. It’s now been tested with a range of organisations in the North West, working with the Advancing Quality Alliance (AQuA).

It’s not a silver bullet: it focusses on organisational development to facilitate continuous quality improvement and can’t negate the need for adequate funding, staffing, clinical training and due diligence procedures.

However, it’s striking how often struggling organisations will not have the middle layer of the framework (cultural and infrastructure essentials) in place. In such circumstances, regardless of best intentions, quality assurance processes (such as performance management and regulation) simply don’t achieve the intended results. As a consequence, commissioners, provider leads and staff at the point of care get increasingly frustrated and desperate.

​It’s in situations like that where the framework can be helpful to steer an organisation’s development. Through trial and error, we’ve found three different ways for organisations to use the framework, ranging from the (relatively) quick, to the long-term:

1. ‘Dialogic’ / jigsaw – framing the conversation in helping everyone understand what key concepts exist and how they fit together.
2. ‘Directive’ / explanatory guidance document – unpacking core concepts of each building block with evidence and examples of application to deepen awareness of those in responsibility eager to progress.
3. ‘Diagnostic’/ full framework – pragmatic longitudinal organisational development tool to complement coaching and a quality strategy in contributing to achieving high performing status. 

In true quality improvement fashion, the framework is still undergoing testing and support information is building. Our learning is that a number of prerequisites are required for the framework to gain full impact. These include valuing of quality improvement methodology, executive support, senior leadership capacity to address development areas, and the mechanisms throughout with the organisation to facilitate readiness for change.

Many of the concepts in the framework will be new to NHS clinicians and managers for whom such aspects never made it to part of their core training. As a result we have found quality expertise and coaching helpful and in some cases essential to guide those new to the respective concepts. However, the framework also takes organisations from where they are at and can flexibly work and walk alongside the improvement journey.

We believe the framework is fit for real world organisations that experience real world pressure and hope that with further collaboration alongside regional and national bodies that it will be scalable for use across the NHS.

Interested in knowing more? Get in touch with either myself - I'm on twitter at @drpjchamberlain, or my colleague at AQuA Liz Twelves on liz.twelves@srft.nhs.uk or @Lizzie12s.

Please feel free to send us your comments. We'd love to know if this rings true for your organisations' experience. We need to learn as much as anyone else!

This blog was originally published by the UK Improvement Alliance (UKIA). To find out more about their work please visit their website, or follow them on Twitter @theUKIA.

Blog: Enhanced Recovery in the United States - Wendy Lewis

Earlier this year I was invited to cross the Atlantic for an exciting trip to Philadelphia, USA to take part in the first annual Transatlantic Enhanced Recovery Leadership Forum.

Wendy Lewis

Alongside a team of 5 other UK healthcare professionals, including surgeons and anesthetists, we were there singing the praises of Enhanced Recovery work within the UK; with my role being to represent this from a nursing and improvement perspective.

For those who aren’t familiar with Enhanced Recovery (ER), it’s an evidence and person-centred approach to care that started in elective colorectal surgery, but has since been widely adopted for many surgical specialties, including urgent or unplanned procedures.

The four main principles of ER ensure that patients:

• Are partners in their own care 
• Are in the best possible condition before surgery 
• Have the best management during and after their operation 
• Experience the best care to enable them to return to their normal level of activity as soon as possible 

Since the national programme ended in 2012, the NHS has gone from strength to strength with ER; seeing improved clinical outcomes, experience of care and productivity for patients, their family and staff. Internationally recognised, we’re now at a stage where countries from across the globe are looking to the UK to learn how they can begin their own journeys in implementing ER.

Recognising the potential for the UK to support ER in other health care markets, the trip was also supported by UK Trade & Investment, as well as Evidenced Based Perioperative Medicine (EPBOM).

Over the two days, we met with a number of senior leaders and clinicians from across the US, who were keen to hear our views on how ER could be designed, delivered and led within their healthcare system for maximum benefit to patients. Each member of the UK team also had the chance to present to the forum, and discuss their particular area of expertise.

It was really interesting to explore how the US health system might adopt our own work on ER, and reengineer it to meet their very different structures. Throughout the discussions we had a number of themes being considered:

• How do we create the case for implementing ER in the US? 
• What are the essential clinical components of ER that create maximum benefit to the patient, staff and productivity? 
• What data is important to capture in order to support sustainable improvement? 
• How do we create person-centred, value-added care within care pathways under difficult economic conditions? 

One of the highlights of the visit was a fascinating lecture from Professor Mike Grocott, of the Xtreme Everest research group. Describing their research on the effects of hypoxia (low oxygen levels in the blood) at high altitudes, this work has since been used to improve care in intensive care facilities, and in particular around diseases of the heart and lungs and severe infections. It really was amazing to hear how lessons learnt from the summit of Mount Everest have made their way to the bedsides of intensive care units.

Interest for ER in the US is now growing rapidly. With a strong body of clinical leaders now networking and beginning to work together more and more, it’s really inspiring to see this work progressing. I’ve also had the pleasure to help support this by co-writing an ER implementation guide for the American Society for Enhanced Recovery (ASER).

Whilst they’re keen to learn from the UK’s success, it’s also interesting to see that they face many of the same challenges in implementing ER as we did in England. Difficulties in creating clinical change and stakeholder engagement are nothing new, so looks like the reaction to change are the same on both sides of the pond!

Having spent a number of years working on ER within hospitals, the Department of of Health, and NHS Improving Quality, it was amazing to take part in this trip and learn about ER from a whole new perspective.

It gives me huge pride what clinical teams in the UK are now achieving for patients, and I’m sure my colleagues in the US will see those achievements too!

Wendy Lewis is AQuA’s Portfolio Lead for Experience & Engagement and Whole System Flow. You can contact her on wendy.lewis@srft.nhs.uk or follow her on Twitter @ERPwend.