Test submission 1

MFI questions Aims Q1 What am I trying to accomplish?

I have over heard my colleagues complain carrying out an additional role called a Community Triage Practitioner. I became interested in what this role was supposed to achieve. I asked my colleagues what they have to do; I noticed that there did not appear to be unity in how the role is conducted. I think the role does appear to have a place, however, what it should like does not appear to be resolved and people are carrying out this role with little focus and no clear boundaries.

With the comments that my colleagues have made, I aim to make the CTP role more efficient with a clear role description, in order that the practitioners are following the same procedures. This would be of benefit to the team and the client group.

Measures: Q2 How will you know that a change is an improvement? Once the role has been designed incorporating the feedback from my colleagues, I would then disseminate to the redesign. The redesigned role could be monitored over a 3 month time scale and then reviewed, potentially by using another focus group.

Changes: Q3 What changes can be made that will result in improvement? The change that could be made could be to redesign the CTP role with the input of my colleagues who currently perform the function.

3a) Whats wrong? From speaking to my colleagues that carry out the CTP role, I found that that doing it a week at a time is not therapeutic for the client group -Its too loose, not structured enough -Its not managed well -Some CTP practitioners dont grasp the role -the role includes some duplication of what is done by the discharge coordinator on the ward The role of the Community Triage Practitioner is not as effective as it could be

3b) What might work? To assist me with exploring this question, I intend to research the broader problems with practice when it comes to discharging patients from the hospital to the community. Looking at where it goes wrong and examples of good practice. Reviewing professional guidelines will be useful as they stem from national policies, that practitioners have a duty to follow.

Boolean search

Concepts Psychiatric hospital Or Psychiatric unit And Discharge coordinator Or Triage practitioner And Or 7 Day Follow Up Assessment of need

Test submission 2

Safeguarding Vulnerable Adults in Richmond Community Mental Health Team: working towards improving NHS Staff confidence in recording and processing referrals and investigations for vulnerable clients. Safeguarding Vulnerable Adults is very high on every Social Care Teams agenda and most social work trained staff are fairly comfortable in resolving Safeguarding issues; responding promptly and appropriately to the Safeguarding referrals using available systems. The situation among NHS Staff in the Community Mental Health Team (CMHT) remains challenging, partially because of the complex operational systems, and partially due to recent changes in approaches towards Safeguarding referrals/investigations. NHS Staff work primarily on what is called the RIO System, and although this system is able to record Safeguarding, the Local Authority is unable to collect all the data to evaluate and audit the quality of the work; this was previously managed (until end of 2012/beginning of 2013) by the administrator who inputted all of the data gathered from the NHS Staff to a different system called Framework I, so this was available for the Local Authority to review, evaluate and measure. In previous years Safeguarding Adult issues were mainly dealt with by Social Workers in an integrated Community Mental Health Team; Nursing or other Allied Health Professionals (OTs) were not involved in leading or conducting any active Safeguarding Investigations. What has changed more recently (mid 2013) is the fact that all NHS Staff in the CMHTs are now required to take an active part in referring and conducting Safeguarding Investigations as a part of their duties as Care Coordinators, and all Safeguarding data is now to be recorded directly to Framework I System (Local Authority System, not previously used by NHS Staff). As a result of that there are recurrent difficulties around Safeguarding in CMHTs; there is an apparent staff reluctance to attend to Safeguarding issues resulting in delays around recording in Framework I System, retrospective recording, staff unable to meet deadlines for strict timelines for various reasons, which all causes concern in general for the CMHTs performance when it comes to Safeguarding, but more over concerns regarding the most vulnerable clients safety and wellbeing. I used The Model for Improvement (Langley et al. 2009 in Bournemouth University 2014) which helped me to explore the subject of my interest and to start identifying clearer ideas on aims, measures and changes I would like to consider for this Service Improvement Project. In my role within the CMHT I face exactly the same difficulties around operational systems used in recording Safeguarding. I admit that this is not something I will be able to change within the short period of time allocated for Service Improvement Project as well as due to the complexity of the topic (involvement of IT/other Operational Systems). However, the lack of NHS Staffs confidence reflected in their reluctance to attend the mandatory training and later use of knowledge gained during separate training sessions made me think about more personalised approach to improve NHS Staffs beliefs on their skills and abilities when it comes to tackling Safeguarding. Having detailed knowledge of both training sessions available to staff, direct staff observation and an informal discussions with staff around their difficulties with Safeguarding Investigations helped me to find the answer to the first Model for Improvement Question (Langley et al.2009 in Bournemouth University 2014), What am I trying to accomplish?. I deducted that by improving staffs confidenc e and improving their skills in identifying and conducting Safeguarding Investigations I will see an overall positive difference in Teams Safeguarding Performance with more positive and prompt interventions for Service Users. This leads me to the second question linked to the measures: How will I know that a change is an improvement (Langley et al. 2009 in Bournemouth University 2014)? I am planning on creating a very brief staff questionnaire two/three questions around their confidence and skills around Safeguarding

and question around training they may find useful to improve their confidence in skills they have as Safeguarding Investigators. This will hopefully aid my preparation for the intervention I would like to arrange for CMHT Staff. Similar, but more complex, a questionnaire will be provided to staff at the end of Service Improvement Project to evaluate their general feeling of confidence in tackling Safeguarding issues. This will be further analysed with the addition of the data gathered from Safeguarding Adult Coordinators (Performance Management). I hope to complete and gather results of this questionnaire by the end of June 2014 which will hopefully; alongside the literature review will allow me for further planning of the intervention. Question three focuses on changes which can be made in order to provide improvement (Langley et al. 2009 in Bournemouth University 2014). Two sub questions: what is wrong, and what might work? has been partially explored above. I looked at two angles of the training currently provided to all staff, IT Framework I and Safeguarding Investigator Training, two very different training sessions, not linked with one another and often conducted with a significant time gap between one and another. When staff are ready to undertake the Investigative role they have already forgotten all about Framework I and how to start recording their work in a different IT system. This causes significant anxiety (also linked to the strict guidance around safeguarding and pressure from management to attend to the Safeguarding tasks promptly) and have a negative impact on their confidence to continue their overall Safeguarding duties.

References: Langley et al., 2009.The Model for Improvement in: Bournemouth University, March 2014, Unit Guide: Preparing for your Service Improvement Project (PSIP4).

Test submission 3

Plan: to implement a redesigned partogram across Hampshire Hospital Foundation Trust. A partogram is a tool used to document the progress of the labour and the health and wellbeing of the mother and fetus.

Much work has already been done on researching and evaluating a partogram for use, therefore my project will be intervention led to implement the document. There may be some small focus/ surveys groups prior to implementation to confirm the final design. The main research element will be within the evaluation stage, however at this point I am unsure what methods I will use for this.

Test submission 4

Section 1: Context, rationale & personal approach The NHS currently faces the need to reduce costs and improve the quality of patient care. Evidence gathered through effective and appropriate measurement and evaluation, is essential to achieving this (Russell et al, 2011). This concept is inherent to service development which when applied to public services is essentially making changes that will lead to measured improved quality of outputs (e.g speed and reliability of services) and outcomes (e.g patients treated successfully) and better professional development (learning) (Boyne, 2003, Batalden & Davidoff, 2014). The goal of service improvement is to achieve a higher quality experience for patients than the NHS is currently achieving (Maher and Penny 2005).

Improving quality is about making healthcare more safe (the health foundation, 201?)(definition of safe=avoiding harm to patients from care that is intended to help them - HF). The importance of quality and safety in the NHS has been highlighted since the publication of the Department of health (DH) Quality for all document (DH, 2008) & the Francis report of the Mid Staffordshire trust (2010). As part of the arrhythmia nurse specialist team I manage and perform various treatments & procedures for patients with heart rhythm abnormalities. I also determine post procedure management for those Part of the role is managing and performing the More

procedures that are nurse-led.

cardioversion list (a shock treatment to return the heart to a normal rhythm).

recently, this now incorporates defibrillation testing (DFT) of Implantable Cardioverter Defibrillators (ICDs) for those patients where this has not been able to be performed at the time of implant. This involves putting the patient into a life threatening rhythm under general anaesthetic (GA) and ensuring the device performs a successful shock to return them back to normal rhythm. It is therefore essential that as a team we maintain patient safety throughout.

This is an area that requires urgent service improvement following two recent Adverse Incident Reports (AIRs) which highlighted problems that could have potentially caused harm to the patient. Various models of service improvement are available to prepare for this service improvement project. As I have limited knowledge in this area, the Plan, Do, Study, Act (PDSA, Langley et al, 2009) model appears to be one of the more simplistic tools to use and therefore I feel suits my learning requirements???. This model has also

been advocated by both the health foundation (201?) and NHS improvement (2012). Langley et al (2009, p xiii) share their premise that the three questions (what are we trying to accomplish?, how will we know that a change is an improvement? and what change can we make that will result in an improvement?) linked to learning through testing - the PDSA cycle - embed a significant proportion of the pragmatic designs that can link system knowledge to effective redesign. Fundamental to the success of any

improvement effort is the understanding that improvement requires that change occur (Langley et al, 2009, p15). Using Lewins force field analysis (cited Bellman 2003 p22), driving forces and identification of present state have been discussed within the arrhythmia nurse team relating to the need for service change with DFTs. These include: AIRs, different staff pre-assessing patients compared to those performing the procedure - potential for errors/miscommunication, need for update of integrated care pathway (ICP), currently no protocol in place for nurses undertaking this procedure, lack of understanding of those staff who do not routinely perform procedure, inconsistency in what is written on consent form, the Francis & Darzi reports. With respect to the Francis report, although fortunately there has been no patient casualty, potential risks have been identified by the AIRs, therefore a change in service/practice is required.

Therefore, the aim of this SIP is to improve the safety of the patients undergoing DFT on a nurse-led list with a specific focus on improving paperwork to ensure no essential preprocedure checks are missed and that all the appropriate information is available to the nurse undertaking the procedure. I will therefore need to perform research to firstly examine current practice to address the present state, implement an appropriate intervention and then evaluate post implementation. The model for improvement will be used to guide development of the intervention and how to measure its effectiveness in improving the service and nursing practice.

When looking at research there is a known dichotomy in quantitative versus qualitative research. The positivist paradigm is one that has its roots in physical science. It uses a systematic, scientific approach to research and favours the quantitative approach to research. qualitative paradigm is based on interpretivism?????? need

references/quotes ???

My personal preference is a leaning towards quantitative research, partly because of the difficulties in interpreting qualitative data but also because I prefer numerical data to show

change/improvement. I do however acknowledge that potentially a mixed methodology may be advocated depending on what answers I aim to seek once I have finalised my plans for research and intervention for service development.

Further discussion for service development will now incorporate the model for improvement:

what are we trying to accomplish?

1. improved patient safety 2. accurate/relevant information available at time of procedure (inc imaging/anaesthetic
risks - need to research best practice)

3. consistency in documentation 4. increased knowledge relating to procedure????? (?to inc???)

how will we know that a change is an improvement?

1. Audit of paperwork prior to intervention - is necessary information on it for procedure? 2. Audit of paperwork post intervention - any changes in information yield? 3. ????questionnaire for staff pre & post???? 4. no further AIRs forms generated as a result of lack of information at time of procedure
what changes can we make that will result in the improvements that we seek?

1. change paperwork (ICP) to incorporate prompts for information 2. protocol to cover nurses performing DFTs - disseminate to group with teaching
session - ?questionnaire pre & post?????

3. pre-printed consent forms to ensure consistency in patient information given.

A literature search will be undertaken ..........

REFERENCES Bellman, L (2003) Nurse-led change and development in clinical practice. London: Whurr publishers.

Boyne, G (2003) Sources of public service improvement: a critical review and research agenda. Journal of Public Administration Research and Theory. 13 (3), 367-394

Maher, L and Penny, J (2005) Service Improvement, in Peck, E Organisational Development in Healthcare: approaches, innovations and achievement, Oxford: Radcliffe publishing.

The health foundation (201?) Quality improvement made simple. Available at: http://www.health.org.uk/public/cms/75/76/313/594/Quality_improvement_made_simple.p df?realName=uDCzzh.pdf [accessed 20/4/14]

DH

(2008)

High

quality

care

for

all.

Available

at:

http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/healthcare/highqualitycare forall/index.htm [accessed 24/4/14]

Francis, R (2010) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry Executive summary. Available at: http://www.midstaffspublicinquiry.com/report

[accessed 24/4/14]

NHS improvement (2012) First steps towards quality improvement: A simple guide to improving services www.changemodel.nhs.uk/dl/cv_content/29728 [accessed 21/4/14]

Test submission 5 Section 1: Context, rationale and personal approach.

Current role as an Occupational Therapist working with parents who have learning disabilities. Key drivers: increasing occurrence and referral to adult learning disability services. Services have been found to be deficient in meeting the needs of this client group, partly due to poor communication between different services potentially involved: these include:

1. Adult learning disability teams 2. Children and family social work teams 3. Midwifery 4. Health visitors 5. GPs
I have worked with many families who fall into this category and have witnessed the poor services on offer; this has included lack of knowledge, poor communication and some prejudice from different organisations. Knowing what is wrong, a recurring discussion I have had with colleagues in my service is how we can improve service provision.

Section 2: Literature review.

SIP topic: Occupational therapy and working with parents with learning disabilities.

Sources of information:

BU library and Athens Websites: learning disability specific, parents with disabilities, law and civil rights, College of Occupational Therapy, SCIE, Department of Health, local and national services, Norah Fry research centre.

Identify main concepts:

Parents with learning disabilities/intellectual disabilities/learning difficulties Learning disabilities and parenting Occupational therapy and parents with learning disabilities Statutory services and parents with learning disabilities

Section 3: Action plan/strategy summary

Model of improvement: aims to produce a local pathway to improve communication between relevant services, supporting parents with learning disabilities. This will involve regular meetings bringing key services together. The measure of change will be to interview local workers before and after the development of the pathway, to assess ability and confidence to:

1. Screen parents, who might have learning disabilities 2. Know how and when to make specific referrals for the involvement of learning disability services 3. Know the key considerations, working with parents with learning disabilities 4. Have effective communication between relevant services at local levels.

The interviews may be individual or in a focus group. This will be an Intervention-led strategy. The research method will be qualitative, to gather workers stories and experiences, but also quantitative methods will be used, in the form of a scale of knowledge, before and after the pathway is developed.

Test submission 6

(Aims)

What are you trying to accomplish?

A person receiving support and services from our Community Mental Health Team for Older Adults, is likely to be reviewed by both a Memory Clinic Nurse or Community Psychiatric Nurse , employed by the Trust (NHS), as well as a Social Worker or Reviewing Officer, employed by the Local Authority. At present these reviews are undertaken independently, at different times and more often than not the information is not shared as both parties record into different IT Systems. The aim of my service improvement project is to stop this duplication of resource and to streamline and develop a process of review that will meet both health and social care requirements in respect of statutory review and shared care protocols. These reviews can then be recorded in both IT systems, possibly in a newly developed format. Hopefully, there will be improvements for our service users who will not need to be seen to repeat the same information to different professionals at different times. (Measures) How will you know that a change is an improvement? Reduction in the number of 'overdue' reviews for both Trust and LA Through audit of 'reviews' recorded in IT Systems Through feedback from professionals Through feedback from service users? (Changes) What changes can be made that will result in improvement?

Deciding on an intervention 3a) What is wrong? 'Silo' working

Only recording in one IT System

3b) What might work? Better management, co-ordination and administration of review process A standard template for reviews to meet both health and social care requirements Agreed protocol for recording reviews

Next step and by when? By Mid-May latest - Use basic method to establish what is wrong - speak to colleagues / Manager / Admin Team through informal discussions, possibly using a short questionnaire.