Seclusion is a method used by mental health teams around the world to manage aggressive and disturbed behaviour in psychiatric patients in situations where there is immediate risk of harms to others.

A quality improvement project was carried out over two hospital in-patient sites containing 6 wards to see if seclusion reviews were completed safely and documented appropriately according to the guidelines set out by South West Yorkshire Mental Health Trust and the Royal College of Psychiatrists.

The quality improvement project was carried out to first audit data to see if seclusion reviews were being done to the local guidelines and standards set by the Mental Health Legislation and Royal College of Psychiatrists. This was followed by training junior doctors and reauditing date to see if any improvements were observed.

A retrospective quality improvement project was conducted assessing medical seclusion reviews carried out by on-call junior doctors between November 2022 and January 2023. Data was initially collected retrospectively spanning over a period of 4 weeks over the month of November 2023 including the analysis of 30 seclusion reviews. These results were presented as an audit to doctors and managerial staff at the end of November. Post training seclusion review data was collected over a period of 4 weeks over January 2023.

An overall improvement in 7/9 domains. The biggest improvement (54% rise) was checking for side effects and EPSEs which was only documented 4/23 times in the first pre-training run. 18% improvements were also noted for assessing and documenting if the patient had any distress or pain, clinical appearance in terms of the cardiac domains such as perfusion and colour of the skin and also their level of orientation in place person and Glasgow Coma Score.

The only two domains in which an increase was not observed was to document if seclusion should continue and justification for why this is the case. These two domains were already at 100% and the System 1 seclusion review template prompts doctors to do this at the end of the review which is possibly one of the reasons it was done well both before and after the training.

A great deal of interest and feedback was garnered and the idea was agreed that a further audit could be carried out after providing training for the current doctors and to gather post-training medical seclusion review data for comparison.

Rosewood Mother and Baby Unit (MBU) aims to provide inpatient psychiatric care to women with severe mental illness in Kent, Surrey & Sussex (KSS) in UK. Data from admissions during 2022 demonstrated discernible inequalities in admissions. A quality improvement project was undertaken to improve equity of access for admission of women with severe mental illness to Rosewood MBU, specifically, those under 18 years old, black and minority ethnicities, and across counties in KSS. The aim was to improve quality of care and patient experience for vulnerable groups across all ethnicities, not limited to their location or age.

Baseline data of MBU admissions in 2022 was collated, including demographics, age, origin of referrals, diagnosis, ethnicity, length of stay, parity, previous MBU admissions, safeguarding concerns.

The project group, inclusive of an expert by lived experience, presented the data at various network meetings and stakeholder events that helped to share information and gather experiences on barriers to referrals to Rosewood MBU, barriers for women of black and ethnic minority background accessing MBU, differences in service provisions for under-18-year-old women with perinatal mental illness in various counties.

Data for women discharged from Rosewood MBU in 2023 was collated and compared against the findings from the previous year.

In the first half of 2022, there were 20% more women admitted from Kent than Surrey and Sussex combined. This improved following interventions with a better spread of patients across counties in July–December 2023 and a 11% rise in admissions of women from Surrey and Sussex compared with Kent.

There was a greater number of ethnicities and a greater number of women from different ethnicities admitted to Rosewood MBU when comparing 2022 with 2023, and specifically across each of the 6-monthly periods. In January–June 2022, 3 women of non-White British ethnicity were admitted, compared with a 400% increase in July–December 2023 with 12 women. Overall there was 260% increase in admissions of women of Black, Asian, Mixed, White-Other ethnicity in 2023 compared with 2022. Also, in 2023, there were 2 referrals and 1 admission of a women under the age of 18, compared with no referrals in 2022.

Overall, the project demonstrates the positive impact of streamlining referral pathway, fostering collaborative working and integrating expertise from diverse professionals including experts by experience that can reduce service inequalities and improve patient outcomes.

The aim of this project is to improve the monitoring of patients on lithium under the South Gloucestershire Later Life Community Mental Health Team and to clarify the process for this monitoring with the aim of improving patient care and safety. We aim to try to achieve 100% compliance with agreed standards based on NICE and Trust guidelines.

Following a meeting with team medics we agreed a series of nine standards derived from local and national guidelines. We then used a locally held database of patients on the later life CMHT caseload on lithium therapy to identify our sample and devised a simple audit tool to collate the information. We used Rio electronic health records and ICE blood results to obtain baseline data from June 2022 to December 2022.

We used the plan-do-study-act (PDSA) cycle model for quality improvement. Following analysis of the baseline data, we planned and implemented key changes of the physical health nursing team taking over investigations from primary care and utilising a bespoke database. We also completed an education session for staff. Following these changes, data was collected and analysed from June until November 2023. From the analysis of these results, a further change was planned for PDSA cycle 2 and further data collection is planned.

Results from baseline data showed that six out of eight standards had compliance of < 60%, which included the time-sensitive investigations such as lithium levels every 3 months; kidney function tests every 3–6 months; calcium level every 6 months. Weight/BMI monitoring and documentation of side effects also had poor results. Average compliance across all standards was 57%.

Following the agreed steps to improve compliance, PDSA cycle 1 results showed improvement across the board, with average compliance increasing to 94%. Time-sensitive investigations now had 100% compliance (lithium level, kidney function, calcium level). Areas for improvement remain, namely in weight/BMI monitoring every 6 months and clear action plans for results falling out of range being clearly documented in patient notes.

By working closely with the physical health nursing team to devise a bespoke local database of information and taking over the investigations from primary care, we have shown an improvement across all standards, therefore improving the quality of care and patient safety.

Cognitive disorders, such as dementia, are a possible comorbidity and an important differential diagnosis to consider in older adults admitted to psychiatric wards with a functional disorder. Whilst cognitive assessment tools (e.g. ACE-III) and neuroimaging (e.g. MRI scans) are well established, there is significant variability in how and when they are used, which can result in inconsistences in their use. The aim was to identify the types of inconsistencies that may occur, and to provide a standardised framework in order for these tools to be used consistently on our functional rehabilitation ward.

This QIP retrospectively assessed data for all patients discharged over a 7-month period between October 2022 and May 2023, from an older adult functional rehabilitation ward. Clinical notes were reviewed to determine whether a cognitive assessment and neuroimaging had been considered, and if so, whether the assessment or investigation was appropriate and completed without delay. Correspondence to the GP or CMHT was reviewed to determine whether this had appropriate information about the relevant cognitive screening completed, and had included an appropriate follow-up plan. Data collected was checked for accuracy through screening by a second clinician, after which a consensus meeting was held to account for discrepancies.

25 patients were discharged during the 7-month period. 52% were identified as having an issue or delay in their cognitive screening and correspondence; 32% had a delay in completing a cognitive assessment; 32% did not have an appropriate follow-up plan communicated in their discharge summary regarding future monitoring of their cognition; and 8% had a delay in considering or requesting neuroimaging.

Team discussion identified that staff uncertainty relating to the use of cognitive tools and neuroimaging was a significant contributing factor to the issues identified in our results. We subsequently delivered training using a flowchart for doctors, nurses and allied healthcare professionals on the ward, which included information about the benefits and disadvantages of different screening tools and imaging modalities, in order to assist selection of the most appropriate tools on a case-by-case basis. The flowchart included the need for MDT discussion and senior psychiatrist involvement, but aimed to improve team confidence in understanding the rationale for these decisions. Based on the results of our post-intervention data, we will consider adapting the training and flowchart delivered to meet the needs of other older adult services in the trust.

To create a safe and effective induction programme for Higher Specialist Trainees (HST) at Nottinghamshire Healthcare NHS Foundation Trust.

An effective induction improves trainees' satisfaction, they feel welcomed and valued. It improves patient safety, retention, and recruitment (GMC Report 2020).

Based on GMC report, published in 2020, a survey was developed locally and data for 2021 HST induction was collected using digital platform. Initial stakeholder analysis completed, and relevant parties were invited to share the results. Two key deliverables were identified after consultation, one was a dedicated induction programme for HST which was co-produced along with trainees and stakeholders. The other deliverable was updating the induction booklet. The proposed induction plan was implemented in August 2023, the survey was repeated to the new HST cohort following induction via digital platform. Results of the survey were analysed via mixed methods (qualitative & quantitative).

The surveys conducted in 2021 and 2023 were compared and there was an increase in response rate from 50% to 64%. The domains were devised from GMC standards and assessed by if staff had received everything in the domain within a week of starting their placement and results evaluated using a t-test.

Domain A is gaining access to places and system (keys, fobs, security passes, computers, ID badges, mobile phones, IT system). This significantly improved from 27% to 88% with a p-value of < 0.001.

Domain B is physical orientation of the setting (staff facilities such as lockers, parking, library, and site layout). This significantly improved from 45% to 88% with a p-value of < 0.018.

Domain C is gaining day to day knowledge (HR, rota, annual leave, study leave, pay-roll, mandatory training, e-expenses, and guardian of safe working). There was no significant change between 9% and 19% with a p-value of < 0.48.

Domain D is an understanding of expectations (duties and responsibility during working hours, on-call, team introduction). This significantly improved from 9% to 69% with a p-value of < 0.002.

HSTs were given the chance to add comments and the responses in 2023 were more positive “excellent induction compared to previous years” compared with 2021 when HSTs felt isolated and devalued “worst ever induction in whole career in NHS”.

Overall, the results of the 2023 survey showed considerable improvement in all the key areas of induction within one week of starting the placement. Domain C demonstrates a challenge still and needs further work.

This pilot study addresses the implementation of trauma-informed practice within healthcare settings. Given the profound impact of trauma on individuals’ health and well-being, there's an increasing recognition of the importance of integrating trauma-informed care into healthcare systems. This project aims to evaluate and enhance healthcare professionals' understanding, awareness, and confidence in implementing trauma-informed practices through targeted interventions.

The project initiated with a baseline assessment through surveys among healthcare professionals to gauge their initial understanding, awareness, and confidence levels in applying trauma-informed practices in their work environments (n = 9). Subsequently, a structured teaching session was conducted to provide education and training on trauma-informed care. Post-session, a reassessment survey measured improvements in awareness, understanding, and confidence levels (n = 5).

Following this, a visual aid – a comprehensive poster summarizing key aspects of trauma-informed practice – was created and displayed prominently in healthcare settings. A second cycle of the quality improvement initiative was undertaken, measuring outcomes after the implementation of the poster. Surveys were administered again to evaluate the impact of the visual aid on sustaining and further enhancing healthcare professionals’ adherence to trauma-informed practices (n = 3).

Post-teaching session assessments demonstrated a notable improvement in levels of awareness (44%), and confidence (56%) among healthcare professionals regarding trauma-informed practices, as well as recognition of signs & symptoms of trauma (44%). Subsequent to the poster's introduction, the second cycle of assessments showcased sustained levels of awareness, understanding, and confidence among the participants.

The project underscores the effectiveness of targeted interventions – educational sessions and visual aids – in augmenting healthcare professionals’ understanding, awareness, and confidence in implementing trauma-informed practices. The improvement in these metrics post-interventions emphasizes the value of ongoing education and visual support tools in fostering a trauma-informed approach within healthcare settings. Embedding such practices can significantly impact patient care, fostering a more supportive and empathetic environment for individuals affected by trauma.

1. 1. Identify changes in the services rendered in the Enhanced access/emergency service following the previously suggested modifications.

2. 2. Identify areas of possible improvement within the service to provide seamless emergency and out-of-hours mental health support to patients.

3. 3. Evaluate adherence to current guidelines for the Enhanced access/emergency service.

An audit of a total of 100 patients on the list was selected in chronological order. Patient documentation was reviewed against the current criteria for patients on the list, which included having a documented care plan in place, remaining open to a community mental health team, and having been reviewed at least within the last 6 months.

The data was then analysed and compared with the previous year's results to see if there was any significant change year over year.

Year on Year improvement:

1. 1. Total number of patients on the list had increased by 16.7%.

2. 2. The number of patients without a care plan on the list reduced by 6.

3. 3. The number of discharged patients on the list was also reduced by 1.

4. 4. The number of patients who had not been reviewed in six months reduced by 9.

While there had been some improvement in the service provision and adherence to the guidelines, there was still ample room for improvement, which would be achieved by adherence to the guidelines and protocols, to ensure better service improvement for enhanced access and out-of-hours emergency services to patients.

Clinical Global Impression Scale (CGI) is a recognised scoring system used to assess patients across a variety of medical specialties. In this study we aim to evaluate the use of the severity scale (CGI-S) in a female adult mental health unit. We aim to explore how frequently it is used to assess patients on admission and discharge and investigate its utility in predicting a variety of patient outcomes. We hypothesise that gaining a greater understanding of the significance of CGI-S scoring can enhance in-patient care by offering insights into factors such as probable length of stay and potential benefits of in-patient admission.

Patient data was collected retrospectively for the last 60 patients discharged. The resulting population data from an inpatient female ward which was then analysed using Microsoft Excel and Jamovi.

59 patients were included in the final data set. Population age at time of admission ranged from 18–68 years with a mean age of 38. The mean length of stay was found to be 40.2 days. 80% of patients had an admission CGI-S recorded with a mean score of 2.77. 71% had a discharge CGI-S recorded with a mean score of 1.79. 58% of patients had both admission and discharge CGI-S score recorded. The key findings of the study were a mean reduction of 1.09 in CGI-S scores, indicating an overall improvement in patient presentation by the point of discharge. Length of admission was increased by 14 days per 1 integer increase in admission CGI-S score. The data also suggests that the correlation between admission CGI-S and length of stay is statistically significant (p value of 0.016). It was also noted that patients with a discharge diagnosis of ‘Emotionally Unstable Personality Disorder’ had a smaller reduction in CGI-S score at point of discharge and required shorter hospital stays, compared with other diagnoses.

The results of this study imply that use of CGI-S scoring in adult inpatient units is beneficial. However, its value can be better seen with improved adherence to regular completion of scores during patient reviews and is an important step to prioritise. Increase in utilisation of this tool will also likely provide clinicians with guidance in predicting which patients are likely to benefit from lengthier admissions and those that might fare better with community support.

1. 1. To assess the current video gaming provisions on an inpatient CAMHS ward.

2. 2. To gather feedback from young people on the ward on the current provisions and gather suggestions for improvements.

3. 3. To implement any suggestions of improvements.

4. 4. To organise regular group gaming sessions for groups and to allow access for individual use.

5. 5. To gather feedback following implementation on how to improve further.

Using surveys, we gathered feedback on attitudes to recreational gaming, interest in gaming social events, preference for individual gaming and on thoughts of the current gaming facilities in a London inpatient CAMHS unit, from a cohort of young people admitted to the ward.

Based on this feedback we sourced funding for a Nintendo Switch from Gaming the Mind Charity and purchased a Nintendo Switch for the Unit along with preferred games.

Regular group gaming sessions were integrated into the ward activity schedule. Additionally, access for individual use was also facilitated.

Further feedback on implementation was gathered from the young people.

Based on initial survey feedback, a majority of young people on the ward indicated that they enjoyed gaming and that it was a good way to “have fun, relax or socialise”.

Feedback suggested the current provisions on the ward (consoles and games) were outdated and not used frequently.

Nintendo Switch received most suggestions for best new addition to the ward.

Game suggestions included: Mario Kart 8 deluxe, Wii sports, Splatoon 3, Mario super smash bros and Minecraft.

After implementation of social gaming events into ward timetable, follow up feedback was positive, suggesting that the majority of young people who engaged in recreational gaming activities on the ward benefited from this. Feedback suggested it was beneficial in terms of mood, socialising, and as a distraction from difficult emotions.

Improving access to recreational video gaming consoles and games within inpatient settings is a valuable way to offer activities to improve mood and social interactions between young people in an inpatient CAMHS setting. Follow up research into efficacy would be of benefit.

Mental health professionals are very likely to experience a patient death at least once in their careers. The Royal College of Psychiatrists published a framework for supporting mental health staff following the death of a patient by suicide. It states that ‘how the news about a patient's suicide is imparted influences the emotional impact of the death and is therefore very important'. We sought to explore how healthcare professionals are informed about patient deaths within Birmingham and Solihull Mental Health NHS Foundation Trust.

A 25-question survey was devised to explore how staff have been informed about patient deaths and the impact it had on them. This was emailed to all grades of doctors, nurses and allied healthcare professionals within the trust and results were collected over 11 days.

83 healthcare professionals completed the survey.72 respondents had experienced a patient death within the trust. Of 72, 48.6% of respondents felt they had not been informed about their most recent patient death in a sensitive manner. There was wide variability in the method by which staff were first informed. 27.8% of respondents first learned of the patient's death via an email from the trust lawyers, patient safety team or another party. Of these 20, 17 felt they had not been informed in a sensitive manner. 63.9% (n = 46) reported that they had not been signposted to any support. Qualitative data suggested that the way in which people were informed had a wide-ranging impact. Many respondents felt shocked and upset. With hindsight, people would have appreciated being informed face to face and being given time to reflect. Of the total 83 responses, 82% (n = 68) felt that there should be a specific policy about how staff are informed about patient deaths.

Results from this survey demonstrate a large scope for improvement in the way that staff are informed of patient deaths. Using these results, we will generate change ideas for a quality improvement project which aims to inform staff more sensitively about patient deaths. Feedback suggested implementation of a new protocol to guide team managers and consultants on how to inform staff; it may help to standardise the process and the support provided. Patient deaths have a significant impact on the mental health of staff; communicating this matter compassionately may help to alleviate immediate feelings of distress and mediate the long-term impact on staff wellbeing and satisfaction.

The key aim of this project was to update and modernise the hospital procedure on how patients access pornographic material whilst detained at Wathwood Hospital. Within the update, we aimed to promote inclusivity and acceptance of all patients’ sexual identities as well as utilising the opportunity to emphasise healthy consenting sexual relationships.

Patients in Forensic Mental Health settings are often inpatients for a significant amount of time, with multiple restrictions imposed on their private and family life. Current policy allows patients to purchase pornography for private use in their own room. It must be material of the same nature available in a main street outlet. In practice, material is usually purchased in DVD format from the Amazon website and subsequently screened for suitability by Security staff and finally approval by the Responsible Clinician. There have been numerous incident reports involving the trading of pornographic material.

Qualitative semi-structured group interviews (up to 5 people at a time) were conducted with patients in the medium-secure forensic services of Wathwood Hospital. They were recruited from the fortnightly Patient Forum. Anonymised questionnaires involving Likert scales and free text response spaces were also distributed at the Patient Forum. Data gathered investigated the percentage of patients who were aware of the current procedure, if they felt it worked well and what they thought the impact of accessing pornographic material might be. Staff were invited to complete a similar anonymised questionnaire, again considering their opinions on the positive or negative impacts of pornography for patients. In addition, we gathered data on whether there was a difference on the degree of comfort/discomfort about pornography, depending on whether the material involved opposite sex or same sex couples. In total, there were 40 survey participants.

Some key areas for concern were found, for example, only 17% of staff and 16% of patients thought the current policy works well despite 69% of staff and 84% of patients feeling it is a patient's right to access pornography. Free text and focus group feedback established many benefits to it. It was clear that there were some areas of difficulty in the hospital policy, which would benefit from being refreshed.

Staff and patients overall feel that access to pornography is important for many of the patients. We identified areas for improvement in how this is accessed and a need to continually be considering the need to consider meeting the holistic needs for the patients.

Child and Adolescent Mental Health Services (CAMHS) is a highly specialised service to which children with severe mental health problems are referred. The COVID-19 pandemic brought with it a lot of uncertainty, and healthcare systems across the UK struggled to cope with the added pressure. The aim of this systematic review is to analyse the literature exploring the effects of the COVID-19 pandemic on the severity of mental health conditions and referral rates to CAMHS services in the UK. The findings from this study will help the services understand the impact of the pandemic on referral rates to CAMHS, the severity of various mental health conditions, and how the services are managing.

An extensive search, following PRISMA guidelines, was undertaken across multiple electronic databases using a predetermined search strategy. Studies reporting on mental health conditions in children post-pandemic and on referral rates to CAMHS in the UK were included. Subsequently, data extraction, quality appraisal and qualitative analysis were performed in a descriptive style.

Initially, referrals to CAMHS decreased during the first lockdown, followed by a significant increase in referrals throughout the pandemic period. The referral rate to CAMHS remains steady until adolescence, with a rapid increase in referrals to the services during the teenage years. More adolescent girls were referred to CAMHS compared with boys and are at an increased risk of developing mental health conditions. A higher number of children and young persons presented with urgent referrals and heightened symptoms during the pandemic compared with the pre-pandemic levels. In particular, there was a significant increase in children presenting with eating disorder problems, accompanied by an increased severity of symptoms. Furthermore, there was an observed rise in depression and anxiety among children and young people, along with an increase in the use of antidepressant medication.

Referrals to CAMHS increased during the pandemic, with increased severity of symptoms observed, particularly in children and young people with eating disorders and neurodevelopmental conditions. Future research should explore the enduring impact of the pandemic on referral rates and presentations to CAMHS. This exploration is essential to aid senior managers and policymakers in decision-making, enabling the implementation of appropriate measures to manage the pattern of demands on CAMHS and shape the future service delivery of CAMHS in the UK.

To improve the detection of delirium amongst patients aged over 65 in Queen's Hospital, and then incorporate a clearer management pathway for these patients to be treated safely with more appropriate intervention and better follow up care. As part of the management pathway, the aim was to increase the delirium referrals made to the local Dementia and Delirium Team for quicker implementation and education regarding non-pharmacological interventions in treating delirium, whilst ensuring that Psychiatric Liaison Service (PLS) referrals for delirium were also appropriate.

A multi-phase approach to quality improvement and service development for patients with delirium has been adopted, and the first step is to improve the screening of patients over 65 years old with delirium and then to refer to appropriate teams accordingly. Our first intervention was changing the PLS referral form. It has been simplified with less input data required, and now includes a mandatory 4AT screening score for delirium, as well as a mandatory referral to the Dementia and Delirium Team for any patient with positive screening for delirium. The intervention was implemented in November 2023, with pre and post intervention data collected in October and December 2023 respectively. Data was collected prospectively and retrospectively using medical notes.

Queen's Hospital PLS received a total of 60 older adult referrals in October 2023 and 49 referrals in December 2023, of which the total proportion of referrals diagnosed with delirium was 47% and 35% respectively (12% absolute reduction). The proportion of patients referred to the PLS team with delirium, who did not require further intervention after initial assessment, had reduced by 29% (87% to 58%). The proportion of patients with delirium referred to PLS, who had also been appropriately screened and referred to the Dementia and Delirium Team prior to PLS assessment, has also increased by 4%. There has been a marked increase in total delirium referrals to the Dementia and Delirium team after intervention, from 31 referrals in October to 85 referrals in December (174% increase).

There is an improvement in screening for delirium, with marked increase in referrals made to the Dementia and Delirium team. There is a decrease in uncomplicated delirium referrals who do not require further PLS intervention and can be appropriately managed with the Dementia and Delirium team input.

An evaluation of the service and care provided to eating disordered patients referred to Tier 3 CAMHS within NHS Lanarkshire. Eating disorders are recognised as a relatively common disease with preventable mortality. The primary aim was to determine if patients with eating disorders adhere to the assessment and management as outlined in MEED and SIGN 164. The secondary aim was to scope the number of eating disordered cases to plan recruitment and training of specialist staff.

The pilot study was carried out in November 2022 and repeated in January 2024. The Electronic Patient Record and paper notes of eating disordered cases assessed in 2023 were used to audit against MEED and SIGN 164. Additional patient demographics including patient's age, sex, median BMI at initial appointment, working diagnosis and suspected co-morbidity were also collected. The service was further evaluated on its processes from source of referral, time taken to be seen, therapies offered and duration within service.

A total of 46 cases were identified in the audit compared to 57 in the pilot study. Most of the cases seen in 2023 were girls in their early teens (89% between the ages 13–16). 10% have a median % BMI <80%. 15 were given a diagnosis of AN (33%), 4 with BN (9%), 4 with ARFID (9%), 2 with OSFED (4%) and 19 with no formal diagnosis (42%). There was a high level of suspected comorbidity (80%).

Referrals were mostly made by GPs (87%), followed by school (11%) and other professionals (2%). The average time taken for the initial assessment was 63 days (40% were seen within 4 weeks). 14 (30%) of cases were offered FBT only whereas 3 (7%) had CBT-E. 7 (15%) did not receive any intervention and 19 (41%) were given other therapies.

With respect to the MEED risk markers, there had been improved recording of weight changes (40% to 80%), hydration status (40% to 70%), temperature (5% to 30%), bloods, over exercising (85% to 90%), purging (75% to 85%) and self-harm behaviours (85% to 90%). However there had been reduction in the recording of BP/HR (80% to 50%), ECG (75% to 40%) and engagement with services (75% to 60%).

Overall, there's some improvement in assessment and management of ED cases but the standard remains inadequate. This project has helped understand the gaps in services and provisions available. Ongoing evaluation is required to help steer service development and optimise patient care.

This project was launched in January 2022 to improve handover between on-call teams and wards, following GMC concerns in 2020 with the out-of-hours handover process. In 2021, a ‘Hospital At Night’ Microsoft Teams evening meeting was successfully introduced. However there remained low satisfaction with other areas of the handover process, including use of paper forms to handover between shifts. The aims of the project were to review the current handover process and improve quality and satisfaction of handover. The target was to improve baseline satisfaction with the handover process by 20% (6 months after change implementation).

A driver diagram was built to identify factors contributing to quality and satisfaction with handover and develop change ideas.

Qualitative surveys using Likert rating scales were sent to all doctors to explore satisfaction with handover format and quality of information received. Opinions of doctors and the wider MDT were used to develop ideas and evaluate support for change. Surveys were repeated following each cycle.

From July 2022, interventions were introduced and monitored over four QIP cycles. This included an electronic handover in the form of a twice-daily email handover list, which was updated following feedback. Microsoft Teams morning weekend meetings were then introduced and modelled on the existing ‘Hospital At Night' protocol.

Following interventions, the percentage satisfaction with handover format improved from a baseline of 14% and was maintained at an average of 81% across 15 months.

The satisfaction with the quality of handover improved from 36% and was maintained at an average of 97%.

The weekend virtual handover has also been well received with 71% satisfaction. This maintains the satisfaction levels achieved with the ‘Hospital At Night' virtual handover. The involvement of the MDT has been high with 71% of doctors satisfied that the necessary team members are attending.

Introducing a standardised electronic twice-daily handover has improved satisfaction with and quality of handover. It has also improved communication between on-call teams and wards.

The introduction of additional virtual handover meetings at the weekend has also been well received. It allows another opportunity to strengthen clinical leadership and the MDT to work more effectively out-of-hours. Future intervention will be targeted at standardising the content of these meetings and attendance in line with the ‘Hospital At Night' protocol.

We aim to monitor local benefit from these changes, and expand this project to other hospital sites which are not yet using an electronic handover system.

NHS England defines serious incidents as events in health care where the consequences are so significant that they warrant a comprehensive response. Serious incidents are individually reviewed, as per national standard practice, in our liaison psychiatry service line at West London NHS Trust. The aims of these individual reviews include system wide learning, organizational accountability and to make changes to the system to prevent a repetition.

There is currently no mandated requirement for thematic review of incidents. Therefore, there is a risk that long-term learning may be limited and overarching themes spanning the incidents may be missed. To improve this process, we have undertaken a thematic review of all serious incidents over a 2-year period, across the three teams in the liaison psychiatry service line.

The aims of this quality improvement project therefore were:

To understand persistent or recurrent systemic factors that contribute to serious incidents.

To identify priority areas for system changes in order to improve the safety of liaison psychiatry services.

To ensure lessons learnt from incidents are embedded within the liaison psychiatry service.

This was a joint project undertaken by liaison psychiatry clinicians and the clinical governance team. Initially an inductive analysis of ten serious incidents took place. Over six months, we combed through the serious incident reports and collated the data. We then identified and stratified the key themes.

The 5 headline themes identified were:

1. 1. Risk assessment and risk management.

2. 2. Human factors.

3. 3. Issues with referrals.

4. 4. Triangle of care.

5. 5. Organisational factors.

The dominant theme which occurred across all cases was risk assessment and risk management. A narrow focus when considering risk and underestimation of risk led to the creation of suboptimal safety plans for patients. Our thematic analysis found a range of organisational factors, including the excessive demand on staff and resource limitations. Human factors are usually a reflection of organisational culture or system wide approaches. The issues we found with the implementation of the Triangle of Care reflect the need for a greater focus on involving families and carers.

The learning was shared with all staff in our annual development day, and this is planned to be an annual review of serious incidents across the liaison service. This approach should improve the depth of our learning and enable the service line to have an overview of the key themes which need to be addressed to deliver safer services.

Aim: To compare and evaluate three improvement collaboratives designs in terms of tangible and non-tangible benefits.

Background: Leading health systems have invested in substantial quality improvement capacity building, but little is known about the aggregate effect of these investments at the health system level.

Collaborative learning is one of the educational approaches of using groups to enhance learning through working together. Research shows that collaborative experiences that are active, social, contextual, engaging and student-owned leads to deeper learning.

CNWL organised three collaborative programmes with varying duration and distinct approaches to team selection, wrap-around support mechanisms, training design and post-collaborative QI support.

These three virtual collaborative programmes were co-designed with service users and carers to support 24 teams each in planning, delivering and sustaining improvements aligned with the Trust's Strategic Priorities.

All programmes provided knowledge on the Model for Improvement and co-production, enabling frontline ownership of safety solutions while building organisational QI capacity and capability.

Each collaborative was divided into Planning and Delivery phases. The evaluation, which covers a 3-year period, compares programme metrics to assess effectiveness, impact and identify areas for improvement.

Incorporating cognitive diversity is crucial in improving the learning process. Collaboratives play a vital role in achieving this, as they bring together different services, staff, and SU&C to drive improvement.

The benefits of collaborative work in quality improvement extend beyond the project data, as it can lead to positive unintended consequences such as a shift in team culture and the adoption of an improvement mindset. These outcomes gained on the journey should be evaluated and celebrated. Moreover, collaboration fosters a culture and platform for sharing and spreading learning beyond the team/service.

However, it is important to take the time to consider and compare different designs of collaboratives during the scoping phase. Factors such as the duration of the collaborative programme, the need for additional wrap-around support and the selection of measures to evaluate the programme should be carefully considered before proceeding.

Effects of changes

1. 1. Comparing different collaborative designs identified the key enablers to a successful project. They were application process brought teams together that were ready and willing to improve; targeted wrap-around support to Sponsors, SU&Cs, Coaches and having decision gateways in design enabled focused and candid conversations about team progression.

2. 2. Collaborative with longer time frame were more resource intensive but had a greater positive impact on safety culture, successful projects and sustained gains than the shorter duration.

3. 3. CNWL Added Value framework evaluated tangible and non-tangible benefits, i.e. staff experience, safety and learning culture, patient experience, streamlined processes and efficiencies gained.

It is important to look at the local context when designing a collaborative with their clinical setting.

A consideration should be based on resources available to support the entire duration of collaborative and what are the desired outcomes of the collaborative.

Aim:

80% of Central and North West London NHS Foundation Trust (CNWL) QI projects will have meaningful Service User & Carer involvement by August 2023 (baseline was 46%).

Background:

Service user and carer (SU&C) involvement is increasingly recognised as integral to healthcare improvement efforts. However, despite its many benefits, the meaningful involvement of service users and carers remains a challenge.

Thus, it is necessary to get an in-depth understanding of the barriers and enablers to embedding involvement in improvement practice at the individual, service and organisational levels. With this understanding and staff can then co-produce evidence-informed behaviour change interventions to improve SU&C involvement.

Patient representation and lived experience

This improvement work embraces a full and continuous partnership with SU&Cs.

SU&C worked with CNWL staff in the conception, execution, delivery and dissemination of this work including EbE Improvement Forum.

They, thus, serve as integral members of the project team where they provide valuable input based on their lived experiences and perspectives to help shape the direction of the work. As equal partners, it also helps foster a culture of mutual respect, collaboration, and trust between all the parties involved.

This work adopts the COM-B model. The approach to conduct semi-structured interviews (interview questions were based on COM-B model and behavioural change wheel) with frontline healthcare staff and SU&Cs. The interviews gave insights on the barriers and facilitators to SU&C involvement in healthcare improvement work.

This then generated operational-level and actionable change ideas to guide tailored strategies for enhancing involvement capabilities, widening involvement opportunities and enabling motivations using the model for Improvement. These change ideas were then co-tested with SU&C using the Model for Improvement approach.

This systematic approach enabled a cultural shift towards collaborative partnerships between healthcare staff and SU&C to contribute to the service improvement.

Measurement of improvement

1. 1. Qualitative data to understand enablers and barriers to involvement in improvement work.

2. 2. Percentage of all QI projects (registered on Life QI and scoring 1 or more on IHI Project Score) that have a SU&C involvement.

Effects of changes

Staff and SU&C interviews identified the key barriers as inadequate capability (lack of understanding and skills), limited opportunities (leadership, resources, access) and insufficient motivation (discomfort, inability, time limitations). Enablers included appreciating diverse perspectives, leadership support and buy-in, established processes, valuing insights and patient empowerment.

The outcome measure also showed an increase in the number of improvement projects at CNWL that have SU&C involvement from 46% to 80%.

Lesson Learnt:

This work has shown that by bringing multi-disciplinary staff and SU&Cs together generates cognitive diversity to the learning to drive improvement and sustain the gains. Furthermore, partnership working helped to create and establish learning culture within the healthcare service.

Message to others:

1. 1. Strong executive sponsorship helps to drive involvement across the organisation.

2. 2. By bringing staff and SU&Cs together generates cognitive diversity to the learning to drive improvement.

3. 3. Using well-known and established behavioural change model, such as COM-B model, helped to identify, design and synthesize behaviour change interventions.

Currently, there is an absence of clear guidelines or recommendations for individuals with an eating disorder (ED) and comorbid autism spectrum conditions (ASC).

The Maudsley ED team has pioneered a tailored approach for comorbid ED and ASC called the PEACE pathway.

Our aim is to adapt and implement a similar pathway within the Eden Unit (NHS Grampian inpatient eating disorder service).

Questionnaires targeted two key stakeholders: patients and staff.

Patient questionnaires had 18 multiple-choice questions on a Likert scale, along with space for comments. The questions aimed to assess inpatient care adequacy in terms of care, routine, environment, mealtimes, and staff members. There were also specific questions related to ASC, examining whether sensory and communicative needs are being met and taken into account.

Staff questionnaires had 10 ‘yes-or-no' questions, along with space for comments, and gauged attitudes toward managing comorbid ED and ASC.

6/7 patient questionnaires were completed. 3 patients have comorbid ASC.

One patient found the ward overwhelming due to ASC, while others found it suitable. All experienced distress transitioning from outpatient to inpatient services, with subsequent admissions proving less challenging when they knew what to expect. They were allowed to have safe sensory items e.g comfort toys, headphones etc.

Generally, they felt well-supported during distress and felt their communication needs were met by nurses and HCSWs but not always by dietitians and clinicians due to a lack of availability. Some were frustrated with vague menu descriptions and there was some diagnostic overshadowing over dislike of certain foods.

13/20 staff questionnaires were completed. It showed most staff did not have formal training in managing comorbid ASC and ED, and confidence and skills varied in proportion to time and experience in the service. All staff members expressed they would like formal training, through sessions such as monthly training, weekly huddles, or psychoeducation.

A significant proportion of inpatients have comorbid ED and ASC. Therefore, awareness of potentially greater needs around communication, environment, and sensory hyper- or hyposensitivity is important. There is a risk of diagnostic overshadowing as both ED and ASC can mimic similar symptoms: cognitive rigidity, fixation on certain things etc. So while not straightforward it is important to differentiate which symptoms are due to ASC and which are due to ED. Leveraging resources from the PEACE pathway website, both staff and patients can enhance their understanding of this complex comorbidity.

To audit the Shepway CMHSOP against the NICE guidelines in dementia and the Royal College of Psychiatrists recommendations for service provision in young onset dementia.

Data was collected retrospectively for all patients open to CMHSOP within the last 2 years with a diagnosis listed as dementia under the age of 65 years old.

The work up prior to diagnosis met some standards but improvements could be made in other areas. Mood was considered in all patients. The majority of patients (89%) had young onset blood tests if there was a clinical indication. However physical examination was only carried out in 43% of patients. In addition to this where physical examination was completed it was often limited to a brief note about the patient's gait and tremor.

Imaging standards were met within the Shepway CMHSOP with all patients having a scan, some patients being referred for additional specialist scans where indicated. There is also a neuroimaging MDT in which scans can be discussed with a neuro-radiologist.

The follow up care and support was an area that needs further development within Shepway CMHSOP. There is no named lead for those diagnosed with young onset dementia. Furthermore, only half of patients received a named practitioner to support their care. In addition to this only 79% were offered cognitive stimulation therapy and post diagnostic support which incorporate education for the carers. It is difficult to know if these options were discussed and declined by the patients, but if this is the case it would have been good practice to document.

The time from referral to diagnosis was similar in those with a dementia with a well established and clear subtype (Down syndrome) to those diagnosed with other types of young onset dementia, 6 months and 5.5 months respectively.

My audit identified areas for improvement in the workup to diagnosis and the aftercare to support those diagnosed and their carers in order to meet NICE guidelines and the Royal College of Psychiatrists recommendations for service provision in young onset dementia.

Shepway CMHSOP will develop a young onset dementia pathway to ensure those diagnosed are offered the appropriate investigations and support following their diagnosis in line with these guidelines.