Quality planning

Approach to quality improvement, leadership and governance

The Executive lead for quality improvement is our Medical Director.

Trust-wide improvement approach: We have a robust governance structure and an open, honest ‘just and learning culture’. We firmly believe that quality is everyone’s responsibility: in 2019/20 all staff will have a quality improvement objective. Regular reporting and our desire for continuous improvement mean that our approach to quality is both planned and responsive. This dynamic practice enables us to re-prioritise and focus on what matters most. Quality is led by our expert clinical staff, informed by the experience of our patients and their loved ones and lived by our staff.

In 2019/20 we will continue to facilitate a series of internal quality, safety and leadership peer reviews across all clinical service areas to share learning, improve CQC standards and bolster good practice. Senior leaders and staff are encouraged to carry out ‘Working with’ days as part of both continuous improvement and personal development aims. People report back to their teams to share learning.

Quality Improvement governance system: A monthly Integrated Quality Performance Report (IQPR) is presented to Board by the Chief Executive – this is publically available on the KMPT website. Underpinning the IQPR is a series of executive chaired meetings. They bring together KMPT experts in their field in order to understand the data at a granular level and test that actions in hand to resolve concerns are strong enough and delivering improvements in a timely way.

Supporting the work of the Board are its sub-committees, each of which considers, in detail, aspects of the IQPR. This report enables the Board to operate at a strategic level, confident in the work of the sub-committees in testing assurance and understanding further detail provided by the executive and their teams.

Building Quality improvement capacity and capability: A Quality Improvement team is in place to facilitate learning, sharing of best practice and conduct in-depth reviews such as our Rapid Process Improvement Workshop in a ward for older adults, which we facilitated in March. This work is underpinned by LEAN improvement methodology and particular attention is being paid to ensure that learning is shared and embedded, not just in this particular ward, but for all wards for older people, with local health and care partners and with the wide pool of staff who are participating in the review. There will be report outs at 30 days, 60 days, 90 days and quarterly from there to our Quality Committee to ensure that outcomes are actioned to support improvement to quality to be achieved and sustained within the specific ward and also rolled out across all Older Adults wards. We are investing in Quality, Service Improvement & Redesign (QSIR), college approach, to support us to build improvement capabilities and capacity in our organisation. We are participating in the national NHSI program and have supported 7 senior leaders drawn from our multi-disciplinary workforce to be develop as QSIR facilitators in order to roll out further training across the Trust. Once the initial cohort complete QSIR Practitioner training in May, we will review and agree our approach with the intention of commencing local training program in the Autumn that will drive delivery of our quality strategy.

There are a number of quality groups and forums within Care Groups; we have invested additional capacity in creating a Senior Quality Lead role for our operational service. During 2019/20 we will develop a more holistic approach and ensure that learning and best practice from all teams involved in quality improvement is captured and shared. In addition as part of the annual appraisal cycle, all staff will have an agreed objective focused around quality improvement.

Evidencing impact of quality improvement investment: All quality improvement projects, national clinical audits, service evaluations, and accreditations are tracked, assessed and evidenced to ensure we achieve the intended impact of quality improvement. Impact and learning is shared and constructively critiqued at monthly Clinical Audit and Effectiveness Group and Quality Performance Reviews.

As we develop further improvement capacity and capability in our organisation we will also give focus to key areas such as project management, tools to support measurement of improvement and sustainability of improvement.

Summary of the quality improvement plan (including compliance with national quality priorities)

The 2019/20 quality improvement priorities have been developed by the Trust’s Quality Committee through a broader engagement workshop In February 2019. The workshop is attended by Quality Committee members, Care Group clinical and quality leads and representatives from the three Trust wide groups. All three Trust wide groups have discussed and contributed suggestions for 2019/20 priorities as have the Patient and Carer Consultative Committees.

Quality Priorities 2019-20

The quality priorities address the three priority areas of Patient Safety, Patient Experience and Clinical Effectiveness.

Patient Safety

• To enhance 7 day follow up by implementing plans for Samaritans 24/48 hour contact. This priority was proposed to ensure the collaborative work in 2018-19 is consolidated into practice. It also aligns with national Suicide Prevention initiatives.
• To increase the incident reporting of low harm incidents, and associated learning. The Trust has been aware that its benchmarked position on incident reporting is low and CQC also noted the Trust performance on low harm incident reporting. Opportunities for learning and quality improvement are missed by not routinely reporting all incidents.

Patient Experience

• To improve experience of KMPT care for BAME service users. This priority aims to improve Equality and Diversity from a patient and carer perspective and will be Expert by Experience led.
• To increase carer and service user attendance at, involvement in and satisfaction with CPA reviews. Carer and service user involvement is fundamental to the effectiveness of CPA reviews.
• To improve service user experience of Discharge planning and process. This priority was proposed by our Carer and Service User forums and reinforced by the Trust thematic complaints reviews. The evidence of successful improvement would be a reduction in complaints that relate to discharge.

Clinical Effectiveness

• To improve the use of HoNoS as the Trust’s primary Clinical Outcomes recording and monitoring (CROM)
• To improve the quality of Clinical Supervision for nurses – year 2. This is a continuation of the 2018-19 priority focussing on evidencing the effectiveness of the revised Supervision policy developed and agreed in year 1.
• To submit 3 research project bids (oriented to service delivery) which have been proposed and initiated by KMPT staff.

The Quality Priorities will be approved by the Trust Board and published in KMPT’s Quality Account.

CQC headlines: Our CQC inspection in November 2018 has confirmed that we have made significant improvements in the overall safety and quality of the community mental health teams for working age adults, improving our rating for these services from Requires Improvement to Good. We are pleased that community staff now have manageable caseloads which are reviewed regularly. Patient care and staff morale has significantly improved in these teams. However we know that our acute wards for working age adults and psychiatric intensive care units Require Improvement. The CQC found that these wards are still not sufficiently safe, effective or well led. We will address these concerns along with the seven ‘Must do’ and 31 ‘should do’ actions in our CQC Quality Improvement Plan. This will inform our quality priorities for 2019/20. In addition we will share the learning and best practice from our Outstanding services with the aim of adapting and applying this within our acute wards, community mental health teams and our crisis teams, as we work towards achieving outstanding ratings.

Quality: areas for improvement

Of significant importance, is the enormous difference between the target average length of stay (LoS) for older adults. The target is 52 days, and our performance in December 2018 was over double, at 107.3. Clearly, this is not what we want for our patients and being able to discharge people when they no longer need to be in hospital is a priority. Our most senior clinical staff are leading work to address this unsatisfactory situation, and a focused Rapid Process Improvement Workshop (RPIW) quality improvement initiative commenced on Orchards Ward in March 2019. We know that if our average LoS was at the right level, our patients would receive the right care in the right place, and we would have significant numbers of spare beds on our wards for older adults. We aim to reduce length of stay by 26% during 2019/20. This will be monitored through the 30, 60 and 90 day reports outs from the RPIW and care group monthly QPR meetings.

Our increased LoS for adults, which should be around 25 days, is now at 30 days. Our analysis shows that there were 7 discharges whose LoS was in excess of 200 days. Further analysis will help us understand why these patients were inpatients for such a long time, and importantly, to identify the barriers to discharge. Enhancing our Patient Flow Team will provide additional capacity for us to constructively challenge LoS over 50 days.

The Trust has a strong track record of eliminating out of area bed use for general admissions. The remaining area of use is female psychiatric intensive care (PICU). Working with commissoners we plan to eliminate use of out of area beds for this group by 2021. An improvement project will be scoped to evaluate alternative options. First steps will be to agree with commissioners appropriate response for women requiring an intensive care option and develop an outline delivery plan with commissioning colleagues.

Extra Care community response to be implemented in February 2019 to reduce number of women with a primary diagnosis of Personality Disorder admitted to PICU. Ongoing discussions with CCGs to achieve zero inappropriate out of area placements by 2021

Top three risks to quality and how we are mitigating them:

1. There is a risk of continued financial overspend which will impact the ability of KMPT to deliver long term financial sustainability. This is following four consecutiveyears of reported deficit which have depleted cash reserves and resulted in the need for a revenue support loan, due for repayment in 2020. To mitigate, delivery of recurrent savings is required which will be generated from benchmarking, pathway redesign and externally identified opportunities through engaging proactively with Model Hospital and the STP.Consistently delivering outstanding quality of care: There is a risk that community mental health team demand and capacity will be impacted following KMPT/KCC partnership changes. To mitigate this the following actions have been taken: implementing ‘active review’ to ensure that patients who are waiting or not yet allocated a care co-ordinator have appropriate care; daily red board meetings; safety huddles to agree actions for patients; caseload realignment, ongoing recruitment and retention initiatives. For new patients a new operating model assesses people’s primary need for either mental health or social care, and a relevant professional lead is then allocated.
2. There are a number of significant mitigations KMPT have in place to ensure effective use of available resource, increase the capacity to operate safely (likely to be required temporarily), on-going review with KCC to ensure clarity of role and function across the two organisational requirements.

Key Mitigations

Actively recruiting agency staff to work in the teams that have severe staffing shortages. The Workforce Business Partner updates the Chief Operating Officer two weekly

• Reduction in bureaucracy - A review of clinical record keeping requirements for non CPA patients with a potential to significantly decrease the amount of documentation required without impacting on required data
• Developing of the clinical care pathways and rolling out across the CMHTs in the next 12 months. Initial Interventions and Personality Disorder Change Programme are both in test phase. Roll out to begin May 2019.
• Compliance and review of Active Review process to ensure fit for purpose – May 2019
• Delivery of a clarified Social Care Standard Operating Procedure (KCC responsibility)
• Teams given clarity on areas of required focus led by the Chief Operating Officer, Medical Director and Director of Nursing

Recruit retain and develop the best staff making KMPT a great place to work: In line with the health and social care sector, recruitment and retention are high risks. To mitigate:

• Recruitment – we have implemented new initiatives such as centralised recruitment, fast tracked all newly registered nurses into posts within KMPT, introduced rotational posts for Band 5 nurses, a career pipeline for support worker/healthcare assistants which includes nursing associates; piloted new roles to reduce the need for consultant time such as non- medical prescribers and advanced clinical practitioners.
• Retention –we have implemented a new managers induction; improved our training and recruitment offer; introduced i-learning; increased our staff survey response rate in line with the best performing mental health trusts to ensure we have every opportunity to gain feedback from staff; invested in Freedom to Speak up Guardian and ambassadors; created Health and Wellbeing champions; invested in staff MOT health checks and wellbeing sessions. In addition we have taken specific actions in services with particular retention issues.

Learning from national investigations such as Gosport Independent Panel: We want to increase the reporting of incidents. We have actively encouraged staff to report incidents however the number of reported incidents at KMPT remain low compared to other mental health trusts. Our learning from national investigations such as the Gosport Independent Panel has driven our work on encouraging people to speak up, report incidents and to ensure that we apply a just learning culture when investigating incidents. What matters is that we learn and share that learning. But to do that, we first need to know something has gone wrong. We have invested in recruiting a dedicated Freedom to Speak up guardian and also have a network of Freedom to Speak up ambassadors. Posters and intranet articles mean that staff know who the ambassadors are and how to contact them if they have concerns. We also have a ‘green button’ facility for staff to report concerns online. This means they can keep anonymity if they wish. All issues are addressed and individuals supported accordingly.

Learning from deaths: We have used our established Serious Incident and Mortality review meetings that take place three times a week (Monday, Wednesday, and Friday) to review the deaths that have been reported. The membership of this group includes a patient safety representative from each of the Care Groups, the Deputy Director Quality and Safety, the Head of Patient Safety, the Patient Safety and Complaints Facilitator, a member of the Datix team, to present the data, and once a week a doctor is present on the group to provide medical input.

The important themes on lessons learnt following investigation of a mortality report are:

• The need for discharge summaries to be obtained in every case
• Full, complete and current care plans improve quality of care
• Risk assessments should be formally completed and recorded.
• Delays in allocation of care-coordinators can increase risks and must be minimised
• Complex cases should be presented and discussed at Risk Forums/MDT meetings to ensure cross professional contribution to risk assessments. formulation and management and review

These themes inform our quality improvement and clinical audit work to drive improvements.

Reducing Gram-negative bloodstream infections: the Trust continues to promote infection prevention and control as the heart of good management and clinical practice. In this regard, emphasis is given to the prevention of healthcare associated infection (HCAI), including Gram- negative bacterial infections, and the improvement of cleanliness in all our in-patient wards and community settings. Although our cases of Gram-negative infections are minimal, we still proactively take steps to minimise the risk. Antimicrobial stewardship is an initiative to reduce Gram-negative bacterial infections and is maintained through our Antimicrobial prescribing and management policy. All suspected or confirmed infections are reported to the infection control team.

Summary of the quality impact assessment process and oversight of implementation

CIP Governance structure: KMPT has a robust CIP governance process in place which has oversight of the full programme and ensures that there is a focus on recurrent CIP delivery. The governance process incorporates both the 4% CIP target that has been set and the high level programmes that have been identified as areas of focus to close the financial gap and ensure delivery of the control total.

Ideas for CIPs are generated both from front line staff and wider organisational or STP related changes. All ideas are subject to a Quality Impact Assessment which is completed by the lead for the CIP and evaluated by the QIA panel, comprising the Executive Director of Nursing and the Executive Medical Director. Any schemes that are deemed detrimental are not approved and are not enacted.

The newly established Transformation team supports Care Groups with collating detailed plans for delivery. Monthly programme reports are provided to support the Trust-wide delivery programme. Transformation programme and Care Group CIP reports are provided to the Executive Team prior to the Quality Performance Reviews (QPRs).

How CIP governance structure operates: Depending on the nature of schemes, the Trust has a range of internal governance frameworks to support service change, whether this is for efficiency reasons, in response to risk, necessary demand changes or research opportunities. The Quality Improvement process is embedded in the organisation and sits under the Medical Director. All projects are logged with the QI team, and major changes are discussed and reviewed by the Quality 1Committee (for example the most recent St Martins programme and clinical care pathway work). New schemes found will be signed off by clinical and operational leads within the Care Groups and Support Services and reviewed by the QIA panel.Fortnightly CIP meetings are held as part of CIP governance process to ensure regular monitoring. This is supplemented by:

• Deep dive approach (Oct 18 –Mar 19)
• Annual planning for 2019/20
• Exec led six hats CIP meeting to be held in February 2019

Consideration of CIP risks

All CIP plans are risk rated for likelihood of delivery. Financial RAG rating is applied based on an assessment of deliverability. This is adjusted during the lifetime of the scheme, with green anticipated as 100% of the value, amber as 50% and red as 0%. Tolerances are applied and gap analysis conducted and monitored so that proportionate actions can be taken to bring delivery back on track. Due to the robust governance process all schemes are constructively challenged from a range of clinical and management perspectives so that risks are understood from the outset and then regularly reassessed. This ensures that impacts on quality, finances and ability to deliver are all triangulated.

Monitoring CIPs and quality of care

Care Group progress reports are produced, highlighting key risks and issues, deviation from agreed milestone delivery, any impact to financial opportunities and high-level visibility of new ideas and opportunities. These also include KPIs and metrics to provide early warning of any adverse impact on the quality of care. Monthly Quality Performance Review meetings discuss progress and areas of concern, with reports presented aligned to CQC key standards. This ensures focus on outcomes, including patient experience. The IQPR is then presented to Board each month, and published on the KMPT website to ensure openness and transparency.

Triangulating intelligence: Our newly launched IQPR, and monthly Quality Performance Review meetings enable care groups and the Executive Team to review all aspects of quality, workforce, activity and financial indicators in one forum. The report highlights key areas of success or concern and their impact on CQC standards, patients, and Trust-wide performance: the Board and managers actively use this information to improve quality of care and enhance productivity, and we have received positive feedback from the CQC and NHSI on the impact of this triangulated report.

The QIA process

Quality is assessed against the four core quality domains:

1. Patient safety: ensuring that care is safe, working to achieve zero harm within a patient safety focussed culture
2. Clinical effectiveness: ensuring that service interventions and activities are evidence based and provided in the most effective way that produces positive outcomes for patients with a focus on recovery and the instillation of hope
3. Patient experience: ensuring that the patient is at the centre of all that we do and that all our patients have a person-centred care plan.
4. Staff experience: ensuring there are no negative impacts on staff morale and effectiveness

The QIA Group is jointly chaired by the Executive Medical Director and Executive Director of Nursing and Quality. The notes of the meetings capture the outcome. Approved QIAs are signed by the Executive Medical Director and Executive Director of Nursing and Quality.

The purpose of the Quality Impact Assessment (QIA) Group is to support the Trust’s governance processes by assessing and monitoring the quality impact of service change. The QIA Group provide support and advice to owners of proposed service change from the early design stage through to post implementation. This includes supporting owners in understanding and assessing the risk to patient safety, clinical effectiveness; patient experience and staff experience and in developing mitigating actions as required.

QIA Sign-off

Following approval at the QIA Group, approved QIAs are submitted to Executive Assistants so that they can add electronic signatures for the Executive Medical Director and Executive Director of Nursing and Quality.

Board oversight process for CIP QIAs

• The QIA Group oversee QIAs for all service change. This includes all business cases, commercial and/or service changes/developments and cost improvement programme (CIP) initiatives. In line with the Business Case Production Procedure, business cases will not be considered for approval by the Executive AssuranceCommittee (EAC) without a supporting QIA either approved by or open to consideration by the QIA Group.
• QIA’s include baseline metrics which are monitored and reviewed by the QIA group quarterly post-implementation for a period of 12 months, or at a frequency and duration as defined by the QIA Group. In some cases it may also be appropriate for quality metrics to be monitored during implementation.
• The QIA Group report monthly to the Quality Committee, and thus into Board. This enables Board to have oversight, and also ensures that timely action can be taken to address any deterioration in the quality of care.