QUALITY IMPROVEMENT PLAN

2018-2021

2

CONTENTS

Introduction 3

1. Why do we need a quality improvement plan? 3

− Our quality challenges 3

2. Our approach to quality improvement 4

− Where does it fit in the big picture? 4

− How do those we serve define ‘perfect’ care? 5

− Everyone Matters 5

− The power of ZERO 5

− The Centre for Perfect Care 5

− Our Quality Improvement Model 6

− Our Quality Improvement Framework 7

− Using digital technology to improve quality 8

3. Our Key Quality Improvement Priorities for 2018-2021 9

i. Reducing Restrictive Practices 11

ii. Reduction of Community Acquired Pressure Ulcers 11

iii. Towards Zero Suicide 11

iv. Improvements in Physical Health Pathways 11

v. Just and Learning Culture 11

vi. Learning from Deaths 12

− Our Outcomes

4. Assurance 13

− Integrated Quality and Safety Framework 14

Further information 16

3

INTRODUCTION

Our quality strategy is simple: to deliver Perfect Care as defined by our service users and staff.

Our belief is that if we can channel our passion and commitment to providing the best possible care for the people we serve, we can really accelerate big improvements in our services. Supporting each other to continuously strive for Perfect Care won’t be a quick fix and won’t happen overnight, but we are clear that striving for Perfect Care is the long-term journey for our organisation.

Dr David Fearnley, Medical Director

1. WHY DO WE NEED A QUALITY IMPROVEMENT PLAN?

To deliver our vision of Perfect Care we need to ensure we deliver Safe, Timely, Effective, Efficient, Equitable, Person centred (STEEEP) care and ensure this is the standard of care we deliver every time a person is in contact with our service. To continuously improve our care it is essential we identify priorities based on the needs of our local population and analyse the risks to safety and quality within our service.

Local population challenges

• Liverpool is the fourth most deprived local authority in the country.

• Life expectancy is lower than the national average.

• The biggest cause of illness and poor wellbeing in the city is poor mental health and in Liverpool, if you have a serious mental illness, you are three-times as likely to die before the age of 75 years, on average dying 15-20 years earlier than other people.

• Hospital admissions for alcohol-specific conditions in the city are almost three times the national average.

• Drug misuse is more than twice the national rate.

• Physical and mental health outcomes are lower than the national average.

• An increasing ageing population with chronic physical health difficulties and frailty.

• Rising public expectations and an associated treatment and access gap in mental health.

• High levels of digital exclusion.

• Prevalence of health inequalities depending on socioeconomic status and health or social vulnerabilities.

Service quality challenges

To understand our key service quality issues Mersey Care entered into a joint piece of work with The Risk Authority at Stanford in the ‘Partnership for Patient Protection’. The aim of the partnership was to use long term big data relating to incidents, risks and claims and machine learning to identify our key challenges as a service. This information when combined with co-production would help us analyse and identify our key priorities for improvement work. This analysis highlighted that reducing aggression and self harm were key areas of focus. The priorities have subsequently been extended on the basis of acquisition of physical health community services to include risks and areas of improvement across their footprint.

QUALITY IMPROVEMENT

PLAN 2018-2021

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2. OUR APPROACH TO QUALITY IMPROVEMENT

Where does it fit in the big picture?

Our quality improvement plan fits within

the Trust’s existing and well recognised

strategic wheel and our Trust values, which

is an important reflection of continuity and

alignment between strategy, planning and

operations.

The overall strategy of the organisation ensures our service-users and staff have the resources to ensure the delivery of quality services that are future focused. The plan will support the organisation to achieve its goals in providing personalised, reliable, reputable and evidence-based care to the people we serve. It will ensure that compassionate values, a just and learning infrastructure and continuous clinical and organisational improvement are at the centre of our services. It will encourage engagement and alignment across and within the clinical divisions and their partners/stakeholders.

Mersey Care’s People Plan 2018-2021 is also a key enabler for the delivery of the Quality Improvement Plan. The overarching People Plan outlines our workforce priorities, along with our Trust Values and Just and Learning commitments. The intention being “to create a compelling place to work where we attract, retain and develop the best people to deliver the best care and be the best they can be”. The strategic People Plan highlights certain workforce processes, interventions and transformations which are essential in creating and sustaining a workplace culture of engaged, motivated and supported people delivering Perfect Care. It reminds all staff of their key role in achieving our priorities and improving care for the communities we serve.

How do those we serve define ‘perfect’ care?

“Recovery/Discovery to me is about helping, enabling, and supporting

others no matter what people think of us, to have a fulfilling meaningful life, understanding and supporting us with our mental health difficulties, physical

health needs or learning difficulties. We need to have our skills and talents

to be fully recognised and for us to work together and to enable each

person individually to feel happy, cared for and above all safe and recognised for our full potential.

My life is so different now because of this integrated way of caring.”

Expert by Experience

Buildings that work for us

Technology that helps us

provide better care

Improvequality

(STEEP)

Save time and

money

Great managers and teams

A productive, skilled

workforce

Side by side with service users and

carers

Effective partnerships

Researchand

innovationGrow our

service

OUR PEOPLE

OUR

SE

RVICES

OUR RESOURCES OUR FUTU

RE

EMPO

WER

ED

SERVICES USERS AND CARERS

EMPOWERED TEAMS

Striving for perfect

care and a just culture

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Perfect Care is defined by the people that use our services as:

S: Safe: “I want to know I am safe from more stress and hurt”

T: Timely: “I want to have support and help when I need it most “

E: Equitable: “I want to get the same care as any body else irrespective of who I am, where I live and what I do

E: Effective: “I want treatments which are the best and really work”

E: Efficient: “I want the care to focus on what I need in the future to live a happy life”

P: Person centred: “I want to feel cared for not processed, and to know what is going on and have a say in decisions”

EVERYONE MATTERS The equitable dimension of STEEEP is really important in our approach to Perfect Care and we are very passionate about understanding and addressing social, cultural and health inequalities, reducing stigma and reaching out to support the diverse needs of the people who use and/or work in Mersey Care and the wider community. This is a key part of delivering a person-centred and co-produced approach which drives improvement. We are committed to evaluating our outcomes in relation to peoples protected characteristics and challenging our practice to ensure that everyone is supported in the most effective way for them and all people in our diverse community are included in our aspiration for Perfect Care.

THE POWER OF ZERO Our Zero based aspirational goals are a key part of our plan as they create the mind-set for our organisation and inspire us to think differently. Zero is an important aspiration as we want to set standards high and make improvements for everyone, all of the time. Such an aspiration encourages us to ask ourselves creative and stretching questions and strive for transformational answers to our key challenges.

CENTRE FOR PERFECT CAREThe Centre for Perfect Care is the hub of quality improvement in Mersey Care. The Centre for Perfect Care was established in January 2014 and has been successful in challenging stigmatised attitudes towards suicide, reducing self harm and assaults and implementing the No Force First approach to reducing the use of restraint on our wards. Building on this success, Mersey Care is aiming for a step change in improvement, whereby everyone feels that quality improvement is their business and continuous improvement is supported at every level, and in all roles in Mersey Care. To support continuous improvement in this way, it is important to see quality improvement activity as a continuum, ranging from our ability to improve care that falls below basic standards, right through to world-leading innovation, research and development.

The Centre supports teams to co-create a listening and learning culture which engages and empowers staff and people who use services, to drive improvements in safety, experience and effectiveness outcomes. It ensures our strategy and governance promote safety and quality throughout all levels of the organisation and there is board to team commitment, leadership, accountability and inspiration to deliver and grow high quality services. The Centre is building the infrastructure to support improvement and align the organisation around our key priorities, delivery of our divisional operational plans and clinical challenges. The Centre is also focused on creating knowledge by combining research, practice and the experience of staff and service users and ensuring existing knowledge and research is shared widely and put into practice.

Evidence based Research and Development develops new standards of care for our Perfect Care priorities. The facilitation of partnerships with leading academic institutions to support research and development funding makes sure we are improving care and generating new knowledge for the benefit of our service users and across the globe.

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OUR QUALITY IMPROVEMENT MODEL Quality Improvement (QI) is a systematic approach to creating cycles of improvement in health services which involves measurement and problem definition, testing of change ideas, data collection, analysis of outcomes and implementation and review. Our model has service user co-design at it is centre and empowers frontline staff to develop programmes of improvement specific to their teams and service challenges. The aim of the improvement approach is to improve safety, experience and outcomes.

In Mersey Care we have a three step approach to improvement: the first stage is: Discovery and Analysis which is the process by which we understand the quality challenges and gaps by using rigorous data analysis, feedback from teams and the safety huddles to establish an evidence based approach. The next stage is the use of Improvement Science to co-produce change across the teams. The third stage is to deliver an Improvement Framework to increase the capacity and capability across the organisation to deliver strategic improvements at scale and embed quality improvement into the fabric of our organisation.

Our model of quality improvement is the Institute for Healthcare Improvement’s ‘Model for Improvement’ as shown below. This model, combined with using advanced digital analysis of our data, informs and strengthens our robust approach. This model is also supplemented with a Design Thinking approach. Our experience has shown that adding the design thinking element provides a more empathic approach to improvement that brings greater clarity to framing the problem and more sustainable solutions for end users, be they service users or staff. The changes we make are generated by our teams and service users using experience and data to identify themes and monitor progress. Adopted by leading organisations around the world this approach has been used successfully in Mersey Care since 2016 to bring fresh ideas, created by our service users and staff, to develop innovative solutions to address extremely difficult problems such as serious self harm, violence and more recently to redesign our commu-nity services.

THE MODEL FOR IMPROVEMENTThe Model for Improvement is an internationally recognised tool that is designed to provide a framework for developing, testing and implementing changes that lead to improvement. The Framework includes three key questions to ask before implementing a change, and is supported by a process for testing change ideas using Plan, Do, Study, Act (PDSA) cycles.

The Model for Improvement supports the process of taking the time to plan change and testing it out in small-scale cycles of change. Using this approach we can see what is working well and what it is not before we implement wholesale changes to systems.

Key questions:

Aim: What are we trying to accomplish?

• Identify a clear, bold and aspirational aim that is focused on areas of concern for patients and/or staff and is in line with Trust strategic aims and/ or national frameworks

• In the improvement cycle is there a cultural or equality characteristic which requires consideration?

Measures: How will we know if a change is an improvement?

• What data could be collected to demonstrate a change as a result of the improvement activity? Is this data already available or will we need to set up a new data collection to obtain it? An example of this could be data related to patient falls or other types of incidents

Change: What changes can we make that will result in an improvement?

• Use creative thinking techniques and/or process mapping exercises to generate change ideas. The Centre for Perfect Care can provide you with help and support to undertake process mapping or idea generation exercises.

• Link to innovation activities or current best practice (internationally, nationally and locally) to understand what others are doing

More information on the Model for Improvement can be found here: www.ihi.org/resources/Pages/ Howto-Improve/default.aspx

ACT

STUDY

PLAN

DO

AIM:What are we trying to accomplish?

MEASURES:How will we know if a change is an improvement?

CHANGE:What changes can we make that will result

in an improvement?

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OUR QUALITY IMPROVEMENT FRAMEWORK Organisations require solid foundations to improve quality at scale. In Mersey Care these foundations include the right cultural conditions for innovation and development, a supportive infrastructure which is aligned with operational plans and the skills and capacity for teams to learn and grow. We believe “As a healthcare professional you have two responsibilities, one is to provide the best care the other is to improve it” (Nelson et al 2010). Below is the framework which we will deliver within the next three years outlining our expectations as the quality improvement journey continues.

• Centre for Perfect Care will train staff at all levels of the Trust in Design Thinking and QI methodology

• Divisions will have adequate capability to facilitate QI and Leadership across their services

Output – active teams engaged in QI with engaged leaders

“200 people trained in the next 3 years”

• QI will focus on getting the basics right

• Solutions will be driven from experience and data analysis.

• Service users and staff will co-create every QI project

Output – meaningful solutions to key problems

“All staff and service users are encouraged to suggest new

ideas”

• The Model for Improvement (PDSA’s) and Design Thinking are the improvement methods across the Trust

• The CfPC will provide support and coaching for QI activity

Output – a consistent standardised approach to improvement

“Every team will have an active QI coach to support improvements”

• Clear goals and measurable outcomes for QI projects

• Projects will learn quickly from all opportunities

Output – projects will have clear, effective and experience based outcomes

“Improvement data will support decision making”

• Adequate resources for QI

• Leaders embrace change and promote sustainability

• QI success embedded in normal business

Output – QI projects succeed and spread at scale and the organisation has an infrastructure to improve

“Learning is embedded in

everyday practice”

TRAINING CO-DESIGN MODEL FOR IMPROVEMENT

EVALUATE SPREAD & SCALE

COACHING ENGAGEMENT FIDELITY MEASUREMENT ACCELERATE

QUALITY IMPROVEMENT FRAMEWORK

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USING DIGITAL TECHNOLOGY TO IMPROVE QUALITY Our new technologies will transform the way we deliver care and be a key enabler in improving the quality of our services. As a Global Digital Exemplar (GDE) organisation we were awarded extra funding to build on our digital developments and develop new ideas to address the complex challenges of delivering Mental Health Services and we are extending this to community physical health. Our GDE programme of digitisation develops world class solutions to clinical and social need and improves our efficiency, data quality and flow. Innovation is prioritised and driven by clinical need.

Our programme aims to:

a) improve access by ‘flipping the clinic model of delivery’ to one of improved access and information for people who use our services in their homes

b) grow digital skills, we are developing clinical champions in the Clinical Digital Leadership Group to ensure our strategy in this area is led by the needs of service users and frontline clinicians

c) address digital deprivation, we are focused on addressing digital exclusion particularly in our forensic services

d) improve efficiency and safety, we are looking at ways to transform basic clinical processes and engagement with our service users so that we empower clinicians and service users to make personalised, informed and safe decisions

e) develop new technology and predictive analytics to improve engagement, monitoring and prevention of some of the key challenges in mental and physical health such as our SWiM app for suicide prevention.

MINDSetQI www.mindsetqi.net is an online quality improvement toolkit for mental health services. MINDSetQI was developed in 2016 and is currently funded by NHS Improvement and it has been agreed that Mersey Care will host MINDSet QI in the Centre for Perfect Care. The purpose of MINDSetQI is to make continuous improvement in mental health easier, by sharing improvement information and case studies in a highly accessible form. By improvement information we mean information about the context and case for change in mental health, a simple description of quality improvement, case studies of service improvement and links to quality improvement tools and resources. These resources in an easily accessible digital form i.e. an online toolkit that works well on a tablet or smart phone.

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• Develop and implement a strategy on rapid tranquilisation and depot administration to reduce prone restraint by 50% by March 2019

• Reduce physical restraint associated with self harm by 20% by March 2019

• Review ligature incidents and to implement strategy to reduce the risks by March 2019

• Implement a zero segregation action plan to reduce long term segregation by 20% by March 2019

• Compile and publish good practice stories for reducing restrictive practice

I. REDUCING RESTRICTIVE PRACTICES

3 . OUR KEY QUALITY IMPROVEMENT PRIORITIES FOR 2018-2021 As an organisation we have made a commitment to improve quality in our services by focusing on key programmes of work using quality improvement i. Reducing Restrictive Practices

ii. A Reduction in Deterioration of Community Acquired Pressure Ulcers

iii. Towards Zero Suicide in Our Services

iv. Improvements in Physical Health Pathways

v. A Just and Learning Culture

vi. Learning from Deaths

The yearly objectives are described in our Quality Account and monitored by the Quality Assurance Committee, a sub-committee of the Trust Board.

• Aim for zero deterioration of grade 2 and 3 pressure ulcers whilst under our care

• Raise awareness by training for managing pressure ulcers in the mental health inpatient wards

• Reduction plan in place with a target trajectory for reduction of grade 2 and 3 pressures ulcers

• Zero grade 4 pressure ulcers in our care

II. REDUCTION OF COMMUNITY ACQUIRED PRESSURE ULCERS

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• 100% of patients in Local Services Division in-patient settings who have the capacity to engage in the process and will be offered the opportunity of completing a safety plan (ongoing)

• By March 2019 50% of patients discharged from Local Services Division in-patient settings will be discharged with a safety plan

• Targeted suicide prevention interventions to be provided to teams that have experienced a suicide or near fatal event as an ongoing intervention

• 100% Liverpool Community Health staff will complete Level 1 Suicide Awareness Training by March 2019

• 7-day follow up for those service users on care programme approach. By June 2018 we will understand the areas that need additional support. By March 2019 we will meet the national target of 95% compliance

• Centre for Perfect Care to provide an analysis of post incident reviews of suicides to identify key targeted areas for improvement by March 2019

• For clinical staff to recognise the deteriorating patient through NEWS2 to ensure prompt intervention to the treatment required

• Measures :

• 100% of inpatient wards have implemented NEWS 2

• 100% of inpatient wards have implemented the sepsis pathway

• Physical health community division implemented NEWS2

• By March 2019, the physical health pathway (Annual Health Check) for community service users supported through the care programme approach will be fully implemented

III. TOWARDS ZERO SUICIDE IV. IMPROVEMENTS IN PHYSICAL HEALTH PATHWAYS

“Being able to tell my story has meant I can make things better for other patients and this has made me feel better and valued.”Expert by Experience

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• Scope for reviewing individual community deaths will have been agreed and implemented by March 2019

• Scope for reviewing individuals in mental health care will have been reviewed and new standards adopted by March 2019

• Single action plan for monitoring completion of learning points will be developed and completion of actions monitored by March 2019

• Four thematic reviews will be conducted per year based on an analysis of mortality figures by March 2019

• Data from GPs, specifically the cause of death will be used as part of the mortality review process. The process for undertaking pathway reviews will have been developed and implemented in association with partner organisations by March 2019

VI. LEARNING FROM DEATHS

• 100% of leaders Band 7 and above and equivalent will have been assessed and have a development plan to support their teams in a Just and Learning environment by the end of March 2019

• To support colleagues’ psychological safety through the development of bullying awareness for staff based on a preventative approach to recognise bullying behaviour and development of a process to resolve issues

• To develop a standardised framework to support learning from incidents including supporting staff, how to debrief effectively, and to provide governance and validation mechanisms to improve the safety and experience of the people we serve and our colleagues so that risks are addressed and learning is maximised

• Produce a guide for colleagues and service users on Just and Learning expectations to describe the shared responsibility between individuals, teams and the organisation to create a safe and compassionate environment

V. JUST AND LEARNING CULTURE

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OUR OUTCOMES i. Reducing Restrictive Practices

• In October 2017 the Reducing Restrictive Practices Guide was launched. To date it has had the following impact when compared to baseline data:

− 23% reduction in physical restraint

− 48% reduction in prone restraint

− 21% reduction in assaults on staff

• In April 2017 the Zero Approach to Long term Segregation Strategy was launched. To date it has had the following impact:

− 14% reduction in cumulative hours

− 42% reduction in length of stay over 12 months in Long Term Segregation

− 33% reduction from patient baseline April 2018 cohort

• The Partnership for Patient Protection (P4P2) used Design Thinking methodology to develop bespoke risk management strategies to mitigate the risk of self-harm and assaults on staff. During 2017 it achieved:

− 55% reduction in incidents of self-harm on pilot wards

− 50% reduction in assaults against within the Specialist Learning Disability division

− Interventions now being scaled across phase 2 priority areas

ii. Reduction of Community Acquired Pressure Ulcers

• Supporting the drive towards Zero Pressure Ulcers the Centre for Perfect Care:

− Undertook ‘discovery’ and ‘synthesis’ work to inform future development of the Pressure Ulcer Reduction Programme

− Supported the use of technology – SEM scanner and automated grading tool – to assist with pressure ulcer reduction

− Significant reductions have been achieved in the frequency of grade 2 and 3 pressure ulcers.

iii. Towards Zero Suicide

• The Zero Suicide campaign was launched in April 2015 and to date has had the following impact:

− A 22% reduction in the suicide rate per 100,000 population

− Currently running at the lowest levels of suicide in our patient population since we started to collect data

− Over 400 safety plans completed with service users in the Local and Secure Divisions

− Current data shows a significant reduction, up to 50%, in the likelihood of readmission for those service users with a safety plan compared to those without

− 65 participants currently recruited to the SWiM, suicide prevention, app as part of the feasibility phase of a research project with The Risk Authority at Stanford and Liverpool University

− Approximately 90% of Mersey Care staff trained in Level 1 suicide awareness training

iv. Improvements in Physical Health Pathways

− The News2 policy now ratified and all divisions have an implementation plan for full roll out across the services by March 2019

− Training has commenced for all staff on NEWS2

v. Just and Learning Culture

• The Centre for Perfect Care has supported a number of Just and Learning Culture objectives including:

− Good practice stories

− The 72 hour review process

− Just and Learning check-ins

− As an outcome of the implementation of a Just Learning Culture disciplinary cases across the Trust have reduced by 59%

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vi. Learning from Deaths

− This is a new objective from April 2018 but the scope has been agreed and a new reporting system will commence from November 2018.

− The newly established team have completed a number of thematic reviews and developed action plans which will be monitored by the Mortality Review Group.

• Design Thinking has been used to support a number of initiatives:

− Community model development programme

− Learning Disability Specialist Support Team development

− Effective Multi-Disciplinary Team working

• A Medical Senate has been established to ensure reciprocal engagement between the Consultants and Trust Board. The Senate provides a forum to:

− Enhance two-way communication on key strategic issues

− Encourage constructive challenge in the pursuit of Perfect Care

− Offer peer support and promote psychological safety

We have made significant progress in driving forward improvements across the Trust as is evidenced by the progress noted above. These achievements have been recognised by securing a number of national prestigious awards We will review the key priorities on a regular basis at the Quality Assurance Committee and in response to key service challenges, however we are committed to long term aspirational zero based goals in our key priorities as these are central tenets of providing Perfect Care from our service user feedback and local and national directives.

4. ASSURANCE Our progress in delivering this quality improvement plan is monitored by the Quality Assurance Committee and the Performance, Investment and Finance Committee. To date we have made significant progress towards reducing harm and increasing positive outcomes for both service users and staff in these key areas.

We have developed an Integrated Quality and Safety Framework (as shown below) which will support the oversight of safety huddles across the organisation. The safety huddles are informed by a range of data sources from the teams which is analysed against Care Quality Commission Key Lines of Enquiry and also STEEEP indicators of quality. It ensures that teams are supported with safety and quality challenges and these become the focus for improvement and are governed and monitored by the appropriate management and performance committees. It provides a Team to Board line of sight throughout the organisation of the clinical quality and safety of our services and allows us to identify and resolve issues quickly and effectively. The Centre for Perfect Care will be supported by the divisions in identifying emerging themes/ new clinical risks and help with addressing them before they increase substantially and enter Trust risk register.

In addition to this process (represented at the bottom of the diagram) we will be accrediting wards’ ability to meet standards of perfect care. This will be built into our Quality Review process and visits (which assess on CQC standards), enabling us to support teams who are delivering exceptional care, to spread it across the organisation, so all teams can benefit from successful innovations. It will also ensure access to adequate resources and support for teams who are facing difficult challenges. We will be developing our quality control processes to ensure that the gains we have made in improving services are monitored and maintained and so that we highlight any unhelpful variation in our services, understand the causes and take corrective action where necessary as we need to ensure our approaches are sustainable and reliable in the future. Teams will also develop internal quality control checks to ensure that their hard earned improvements continue in everyday practice. The Framework details how we improve and maintain the quality and safety of our services by creating a structure which reduces differences in standards of care and ensures the everyday care provided is of the high standard we expect for the people who use our services and their families.

“Making a quality improvement on my ward gave me a real sense of confidence .... I thought quietly to myself – that was my idea and it works ! ....I felt really pleased and actually proud that I was doing a good job.”Member of Staff

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INTEGRATED QUALITY AND SAFETY FRAMEWORK

DEL

IVER

Y O

F K

EY P

RIO

RIT

IES

KEY

LIN

ES O

F EN

QU

IRY

(K

LOE)

TH

EMED

AN

ALY

SIS

/ IN

TELL

IGEN

CE

REV

IEW

TEA

M

DATIX SAFESAFE

WELL LED

WELL LED

STAFF SIDE CHAIR

COMPLAINTS

CARING

PATIENTEXPERIENCE

PERSONCENTRED

SERVICE US-ERS/CARERS

PATIENTEXPERIENCE EFFECTIVE

SAFE WARDS

TIMELY

GOVERNORS

STEIS

RESPONSIVE

WHISTLE BLOWING

EFFECTIVE

REVIEWS

Sources(e.g.)

STRUCTURED COLLECTION OF DATA/CONCERNS

QUALITY ASSURANCE AGAINST THECQC DOMAINS & STEEEP

IMPROVING EVERYDAY SAFETY AND PRACTICE

ASSESSMENT, ACCREDITATION

EACH WARD

OR TEAM’S HUDDLE

LIVERPOOL & SOUTH SEFTON COMMUNITY

DIVISION

LOCAL SERVICES DIVISION

SECURE DIVISION

SPECIALIST LD

DIVISION

QUALITY REVIEW VISITS AND DATA METRICS

EQUITABLE

EFFICIENT

15

BO

AR

D D

IREC

TOR

S

CONSIDERING THE RESPONSE AND IMPROVEMENT ACTION

BOARD ASSURANCE AND QUALITY CONTROL

SUPPORT AND SPREAD

EXECUTIVECOMMITTEE

OPERATIONALMANAGEMENT

BOARDS

BOARDCOMMITTEE

DIVISIONALGOVERNANCE

LEARNING& PREVENTION INTELLIGENCE

HUB

CENTRE FOR

PERFECT CARE

ORGANISATIONEFFECTIVENESS

TEAM

ENHANCED INTERVENTION

REQUIRED

• Solutions to challenges not agreed, planned or activated

REQUIRES FURTHER WORK

• Solutions to Challenges understood

• Action plans under way with signs of progress being made

PERFORMING WELL

• High confidence based on evidence

• Challenges identified, action taken

EXCELLING

• Outstanding and setting new improvement benchmarks

EXECUTIVESAFETYHUDDLE

(WEEKLY)

QUALITYASSURANCECOMMITTEE

PERFORMANCE,INVESTMENT &

FINANCIAL COMMITTEE

From Team/Ward to Board

From Board to Team/Ward

For more information contact:Mersey Care NHS Foundation TrustV7 Building, Kings Business ParkPrescot, Merseyside L34 1PJ

Tel: 0151 473 0303

FOR MORE INFORMATION To find out more about quality Improvement and get involved please contact one of the Centre for Perfect Care Team: perfectcare@merseycare.nhs.uk

Or visit the website: CentreforPerfectCareWebsite

The following documents are helpful guides:

• AQuA; A Sense of Urgency, A Sense of Hope; Building a culture and system for continuous improvement; David Fill-ingham, Lesley Massey (March 2018)

• MINDSet Introduction to Quality Improvement in Mental Health; MINDSet

• The King’s Fund; Quality Improvement in mental health; Shilpa Ross, Chris Naylor (July 2017)

• Quality Improvement Hub; The Spread and Sustainability of Quality Improvement in Healthcare NHS Scotland (2014)

• NHS Improvement 2018; Valued care in mental health: Improving for excellence;