One of the key issues for SHSC has been how to drive and accelerate the implementation of microsystem improvement methodology across the organisation, in order to enhance the quality of care for service users, carers and the workplace wellbeing of staff, whilst evidencing the broader elements of return on investment. From September 2013 the Trust had begun to support a very small number of staff to undertake formal Microsystem coach training in association with the Microsystems academy. Since this time the Quality Improvement team have worked energetically and creatively to deliver and support the development of a QI culture within the organisation. Recently the QI team have been supported with this by input from an expert by experience – supporting our training delivering, our coaching service and our drive to increase the use of co-production
What We Did
Sheffield Health and Social Care Trust consists of approximately 3,000 employees serving a population of around 500,000. We offer a variety of integrated services related to mental health, social care, learning disabilities and substance misuse, as well as a wide range of specialist services.
SHSC Strategic Plan https://shsc.nhs.uk/wp-content/uploads/2016/03/Item-6-Quality-Improvement-and-Assurance-Strategy-and-Implementation-Plan.pdf outlines a commitment to prioritising continuous quality improvement (QI). Recognising the need for long-term improvement capability, the Trust committed to investing in an internally led QI approach, known as the Microsystem improvement methodology. This approach places staff, service users and carers at the centre of service improvement – providing them with the structure and support needed to implement change.
One of the key issues for SHSC has been how to drive and accelerate the implementation of microsystem improvement methodology across the organisation, in order to enhance the quality of care for service users, carers and the workplace wellbeing of staff, whilst evidencing the broader elements of return on investment.
From September 2013 the Trust had begun to support a very small number of staff to undertake formal Microsystem coach training in association with the Microsystems academy http://www.sheffieldmca.org.uk/. To enable a more robust implementation of this process a Continuous Improvement Manager was appointed in September 2015. A further 2 Improvement Facilitators were appointed by June 2016 forming the Quality Improvement Team. http://www.sheffieldmca.org.uk/stories/sheffield-health-and-social-care
Since this time the Quality Improvement team have worked energetically and creatively to deliver and support the development of a QI culture within the organisation. Recently the QI team have been supported with this by input from an expert by experience – supporting our training delivering, our coaching service and our drive to increase the use of co-production (with service users and carers) across the trust when looking at QI work. He has also contributed to the Microsystems Expo in the Patient Panel in 2016. This role (expert by experience input) is shortly to be formalised with the appointment of an Improvement Coach to the team to enhance the concept of coproduction in all QI activity.
Impact of the Quality Improvement Team
Since the establishment of the Quality Improvement (QI) Team the awareness and understanding of Microsystem improvement within the organisation has increased considerably. For example, the number of teams from across the organisation currently engaged with the Microsystem approach and working actively with a dedicated coach has increased from 9 in September 2015 to 26 at the current time.
A total of 25 coaches from SHSC have completed their Microsystem coach training with a further 7 undertaking the training currently. To ensure consistency of methodology and support for coaches a process of supervision and peer support has been introduced by the Quality Improvement Team. Coaches now meet regularly to support their practice and development.
The QI team have established a rolling programme of training for staff within SHSC – providing a 2 day course covering quality improvement methodology and tools for practical application.
To further raise the profile and understanding of the Microsystem approach to QI presentations, stalls and workshops have been delivered at events both internal and external to the organisation. This years submission for Fab Change Day 2016 demonstrated support for the QI teams work from the Chief Executive level.
An Annual Quality Improvement event / conference has been established. The first one in 2016 linked in with NHS Improvement and the Health Foundation helencrimlisk/sheffield-health-and-social-care-foudation-trust-q to support the development of a QI culture within the organisation. The 2nd Conference is planned for June and will be building on our key Service User engagement strategy which links Quality and Engagement entitled “Building Improvement Capability through Coaching and Co-Production.”
A process for collating and sharing improvement stories has commenced, which will be progressed further over the forthcoming months by the development of a website presence on the Trust intranet.
The Quality Improvement team is also happy to support areas of QI work that do not fit with the Microsystems approach. This has included supporting teams considering service redesign and meeting with teams to examine discrete pathway work. At all times flexibility and accessibility has been central to our approach to ensure that an improvement culture further develop within the organisation.
The Quality Improvement Team is committed to:
– Increase the number of Microsystem coaches at SHSC
– Ensure consistency of the methodology through peer support and supervision
– Continue to increase the number of teams using the microsystem methodology
– Offer QI training to all SHSC staff
– Develop and deliver an Annual QI event for all levels of staff, service users and carers
– Expand service user and carer engagement within the Microsystem improvement process
– Share outcomes, learning and best practice through promotion of QI initiatives
– Continue to be a key partner of the Sheffield Microsystem Coaching Academy
– Support the development of a QI culture, developing capability and providing opportunities for staff, service users and carers to engage in service improvement work.
Currently the QI team are directly working in a variety of areas across the trust using the Microsystem methodology including Adult Acute Wards, Intensive Care Inpatient services, Community Recovery Teams, Respite Unit, Early Intervention Service, Pharmacy, Mental Health Act Office, Learning Disability Inpatient services and Community Recovery Services. Details of some of these projects are to be found here: https://storify.com/helencrimlisk/sheffield-health-and-social-care-foudation-trust-q http://www.sheffieldmca.org.uk/stories/sheffield-health-and-social-care
The QI team also continue to offer supervision and support to coaches (trained and undertaking training) across the organisation to ensure consistency of methodology and professional development.
The teams listed above are being supported to look at a diverse range of issues such as staff wellbeing, therapeutic activities, MDT working, profile and quality of service provided and role development for staff. As work progresses we are confident that further stories of positive change will emerge and more importantly that teams will be empowered to see QI as a routine part of work life and given the opportunity and capability to take this forward.
As mentioned the QI Team also continues to also work outside of the Microsystem approach supporting individual teams and directorates with QI related work as requested.
The organisation has strong support for QI through its linked Quality Improvement Strategy and the Service User Engagement Strategy. The CEO, Chair and a number of Execs, Non-Execs and Governors took part in the 1st QI Day.
We have active links with the Microsystems Academy which links us in with partner organisations across the city including Sheffield Teaching Hospitals and Sheffield Children’s Hospital.
Through the Deputy Medical Director, who is a Generation Q Fellow, we have good links with the Health Foundation, the Q Community and Q Labs, with whom we are collaborating on Peer Support Development.
We have always seen QI and Service User engagement as important partners. The first QI Day was co facilitated by a Service User who also chairs a number of Service User (patient) groups across the city. We have supported his training as a Microsystems Coach and he has now joined the team as a fellow employee. His role, which he has previously being doing as a volunteer has ensured the development of a culture whereby coproduction is seen as the norm within the QI team and this methodology has been seen as a key strength of the organisation as demonstrated by the HSJ award for acute care transformation https://shsc.nhs.uk/news/transformation-programme-wins-health-service-journal-award/ which, demonstrated our commitment to coproduction and prompted the formal adoption of coproduction as a Trust strategy.
The development of a QI culture within an organisation involves engaging and empowering staff, service users and carers to have the opportunity and capability to implement improvements. Here are some of the comments staff have made about Microsystems work.
““Microsystems provides our team with a regular forum and structure for whole team discussion, with a view to prioritising areas for service development and improvement.”
“Microsystems has taught us to trial things and to consider other options and it has allowed complex decision making to be broken down into tasks that appear more manageable”
“It is a systematic way of looking at using existing resources to improve services/ patient care.”
“It helps to have an external objective person to help to guide the process along.”
“Teams need to develop an improvement mind-set and Microsystems approach can
demonstrate how improvement is achievable.”
“Microsystems allows everyone in the team to feel valued and experience a sense of ownership and responsibility.”
Looking Back/Challenges Overcome
Whilst the implementation of the Microsystem improvement methodology is proving successful with an increasing number of areas of the organisation, a number of challenges to achieving outcomes within the Strategy Implementation Plan have become apparent to the QI Team.
With respect to those relating to embedding Microsystem improvement methodology at a Trust level these include:
– teams having difficulty finding time to meet or difficulty sticking to meeting times due to the nature of their service and workload demands;
– staff prioritising other work/activities;
– ‘top-down’ demands overtaking the ability and freedom of the ‘bottom-up’ approach;
– restructure/reconfiguration/tendering of services having a huge impact on staff morale, enthusiasm and engagement with QI;
– some trained SHSC microsystem coaches being unable to have dedicated time to utilise their microsystem coaching skills beyond completion of the six-month course due to pressures of their ‘day job’;
– Some areas experiencing difficulty in developing a representative Microsystem group membership – especially ensuring regular service user / carer input
In response to this the QI team continue to work closely across all levels within the organisation – including Executive, Operational management and front line staff and service users. Some of the responses to the problems identified include:
– Requesting support from the Trust Management Group and senior leaders to help teams that demonstrate the will and enthusiasm to commit to QI and Microsystem improvement to have the opportunity and space to invest in this methodology
– The QI team alerting senior operational managers when problems become apparent.
– Requesting support to enable the trained SHSC MCA coaches to have dedicated time to utilise their coaching skills with Microsystems requesting improvement support.
– For the QI Team to continue to raise the profile of the Microsystem approach and the opportunities it brings via providing training opportunities for all staff within the Trust, continuing to support individuals undertaking the Microsystem Team Coaching course, Developing and Delivering the annual QI Event / Conference open to all staff and service users / carers and sharing stories (via website, posters etc) of how teams have benefitted from engaging with this approach
– The QI team to support Coaches resilience when working within this climate via supervision and fortnightly coaches meetings.
– To ensure that in clinical areas where engagement is likely to be problematic (due to identified pressures) that the teams receive the best opportunity of engaging with the process by having an Improvement Facilitator from the QI Team allocated to them.
– The QI team in collaboration with the wider microsystem coaching network set itself the task of improving the percentage of microsystem team meetings across the Trust having regular service user / carer representation on. This has included developing a clearer contract with teams about appropriate membership in the pre-phase stage (in meetings with relevant team leads) and using the Microsystems coaching meeting to set a target for improved membership and developing a range of change ideas to support achieving this.
As we know Health and Social Care continues to exist within a challenging environment. The Quality Improvement team are aware of and experience this on a daily basis. It is our commitment to continue to support the development of a QI culture within the organisation by tackling problems in a creative and collaborative manner wherever they appear.
The QI team work intensively and creatively to support the Microsystem approach to quality improvement embedding across the organisation.
This approach involves a coach supporting a team for up to 2 years to ensure that the team are confident with the methodology and structure before the coach begins a process of transitioning out – leaving the team to continue using the Microsystem methodology to support their ongoing QI work. Should the team require further input from the coach (e.g. for some QI technical support or to help structure the meeting process) all they have to do is ask.
This approach ensures that changes are not reliant upon one (or a small number) of individuals with a passion to implement a project. The QI team are working to embed a culture where teams are empowered and supported to take regular time to asses their service, identify areas they want to work on and trial change ideas to assess which are the most effective in improving service outcomes.
Alongside the many improvement stories it is the desire to support, enable and deliver this underlying cultural shift that is at the heart of what the QI team are trying to achieve.
To further support this staff (via the 2 day QI training on offer) and individual teams (via the coach) are supported to ensure that beneficial changes become standardised using a variety of QI tools.
It is our wish that by continuing to work hard, being creative and by learning from all that we do that we will help the organisation in its drive to develop a QI culture that embraces co-production and strives to provide care of the highest quality.
The QI team have suggested they be considered for nomination in part to celebrate the work they have been involved in to date but more significantly to celebrate the work of the various coaches, service users, carers and teams across the organisation who have taken on the opportunity to engage in QI work, to improve the care delivered and the experience for service users, carers and staff.
SHSC is completely committed through the development of a QI team and its key position under the Medical Directorate Brief of Quality to develop a culture of continuous improvement in all its staff and service users. The recent decision to commission a local social enterprise Care Opinion to get routine service user feedback is planned as a mechanism to ensure that the views of service users and cares feeds straight into the quality team and ensures a link in with the QI programme.
Evaluation (Peer or Academic)
At the micro level each individual meeting is evaluated – allowing each team member to rate the meeting (scored 0-10) and to identify what went well (building a model of appreciative enquiry) and what could be improved.
With respect to the Microsystem Improvement work taking place across the Trust the individual coaches receive supervision from members of the QI team, a process that is structured around the normative, formative and developmental model to ensure wellbeing of coaches, appropriateness of practice and exploration of developmental opportunities.
The training and annual QI events are evaluated by a review of attendee’s feedback. Both have been extremely positive to date with the QI team noting areas to be consolidated and built upon whilst also acknowledging any areas for development.
The impact of the QI team is reviewed and supported by links with the Quality Improvement Forum, Clinical Effectiveness Group, Executive Directors Group and the Trust Management Group.
As a key partner to the Sheffield Microsystem Coaching Academy we are able to access review of the quality of training courses provided and ensure our work is compatible with the aims and values of the Microsystem Approach.
This constant process of review – from the immediate feedback of teams to the strategic considerations of the Executives helps ensure that the QI Team remains confident in its approach to supporting the development of a QI culture and open to challenge and change where needed.
Some of the improvement stories from Microsystem work undertaken by the QI team and by trained coaches within the organisation include:
o Reduction in length of stay for step-down patients from an average of 47 days to an average of 24, bringing potential cost savings of £162,590 per annum (Wainwright Crescent)
o MHA tribunals occurring within time frame from approx 20% – 99% (Mental health Act Office)
o Improvement in teams offer / provision of key interventions – e.g. Increase in CBT from 20 to 42% (Early Intervention South East)
o Development of the staff supervision proforma and supervision contract, resulting in improved efficiency and outcome of supervision
process and enhanced staff wellbeing (Recovery Team South East)
o Elimination of overrunning handovers and reduction from 2 to 1 handover per day, resulting in additional clinical hours for direct service user contact (Dementia Rapid Response)
o Completion rates of life story forms increased from 12% to 66% (Dementia Rapid Response)
o Improved communication between staff groups and between staff and service users (Community Enhanced Recovery Team)
o Reduction in number of information systems to improve access to relevant clinical information (Brain Injury Team)
o Increased efficiency of staff time through revised contact schedules and collaboratively writing notes with clients (CERT)
o Introduction of new letters and proformas to improve communication with service users and encourage timely feedback on service user experience (Community Learning Difficulties Team)
Sharing good practice is fundamental to a QI culture and something that the QI team is fully committed to.
Currently a number of the QI stories are available on the MCA website – with many more stories completed and awaiting uploading. This allows easy access to this QI work and is open to everybody.
Within the organisation the QI team are developing their own Intranet page – planned to capture all the QI stories within the organisation alongside QI resources and training opportunities. This will allow teams to learn from peers and see what is happening across the wider organisation. This resource will be open to all staff.
Also supporting sharing of work is the QI Conferences where teams (via workshops, presentations and poster displays) are able to communicate their work with a wider audience. These events are open to all staff, service users and carers.
As previously mentioned the QI teams links with the Quality Improvement Forum, Clinical Effectiveness Group and Trust management Group encourage appropriate sharing of QI work with senior staff.
Is there any other information you would like to add?
The Quality Improvement Team is a small (approx 3wte staff) but highly motivated team. We are strongly committed to the principles of co-production, Microsystem team coaching and providing creative and accessible QI support where it is wanted within the organisation.
As mentioned earlier, the application for this award is in part to reflect the work of the small QI Team. More importantly it represents an opportunity to celebrate the excellent work occurring across the organisation being undertaken by coaches, teams, service users and carers as they work to improve services within the current challenging environment for health and social care.