East London NHS Foundation Trust (ELFT) delivers mental health, primary care, community health services, and some specialist care to 1.5 million patients. ELFT provides services in East London, a densely populated and culturally heterogeneous part of the city, and Bedfordshire and Luton, an area just north of London with a less concentrated and less diverse population. ELFT has approximately 5,500 employees working in more than 70 locations.
Approximately 200 of those staff members work in corporate services, which includes information technology, finance, risk management, quality, business development, human resources and organization development, estates and facilities, and communications.
Over the last 4 years, ELFT has introduced continuous quality improvement (QI) across its clinical and corporate services, with encouraging results. This has been supported by a strategic partnership with the Institute for Healthcare Improvement (IHI). This article focuses on QI in the corporate services context, exploring the challenges and what we did to address them, our results to date, and lessons learned along the journey.
While there is a growing body of evidence confirming the benefits of quality improvement in clinical settings, there has been little exploration of or published literature on applying a systematic approach to improvement in non-clinical areas. These corporate functions are key to delivering high-quality care and critical to the staff experience at work.
ELFT has aimed to develop a culture of continuous improvement within its corporate services to help staff better understand customer needs and then test and implement ideas aimed at solving complex service quality issues — delivering improved value for money.
Laying the Groundwork
ELFT has partnered with the U.S.-based Institute for Healthcare Improvement to provide support along its long-term quality improvement journey. The Trust utilizes the IHI’s Model for Improvement methodology, developed by Associates in Process Improvement, a straightforward framework for carrying out any QI project. The model encourages teams of staff and service users to tackle issues that matter most to them, develop their own ideas about what might help improve the service and achieve the collective goal, test these out, and learn from the data.
The ELFT approach trains staff at all levels of the organization in improvement skills and embeds continuous improvement efforts into daily work. The challenge for organizational leaders is to try and remove as many barriers as possible for the teams working to solve complex quality issues. Barriers might include insufficient budgets or corporate policies that stymie certain QI activities. Most of the ELFT staff has had little exposure to systems thinking and improvement methods, so a variety of training is offered, tailored to the different levels of knowledge and the skills each role requires. An online platform supports the learning system, making all work transparent across the Trust.
QI successes are shared and celebrated — through newsletters, and at meetings and awards ceremonies — both successes in outcomes improvement, but also the experience of being empowered to find solutions and test them out.
Since 2014, corporate services has run 24 quality improvement projects. Each project has a project lead and is assigned a QI sponsor and a coach to provide support. The QI sponsor, a senior staff member, helps the team resolve any organizational impediments and champions its work at a senior level. QI coaches undertake a 6-month training course and spend part of their week coaching two to three teams. Coaches come from different functional areas than their teams.
The teams also have access to an improvement advisor — a full-time member of the ELFT’s central QI team — a function that supports the entire organization. Improvement advisors also help senior management think about the strategic direction of the organization’s QI work. There are currently six sponsors, four QI coaches, and 100 staff members working on corporate QI teams. Training varies depending on the person’s role, with the coaches receiving the most training — 6 months.
Project leads, sponsors, and coaches hold a monthly forum to share progress as well as to think through any barriers that might need to be overcome. Strategic decisions about future improvement efforts are also made here, with consideration paid to coaching capacity, new projects, and corporate services priorities.
The table below shows some of the projects that have been undertaken:
Telescoping the Disciplinary Process
A team from human resources and organization development carried out a QI project to reduce the amount of time taken to complete the disciplinary process. The process took, on average, 113 days to complete. There was also wide variation in time to complete, with some cases taking up to 350 days. With the support of a QI coach, the team met weekly to develop and test ideas for change, including:
- a new investigation planning tool
- a new standard documentation pack
- pairing of inexperienced investigating officers with more experienced ones to build the former’s skills
- training for investigating officers
- guidance pack for the panel that will be hearing and making a judgement on the case
- offering a range of potential dates for the disciplinary hearing
- amending the disciplinary policy
The project was extremely successful, and the average disciplinary process now takes 75 days — a 35% reduction. With cases resolved more quickly, the amount of salaries paid to suspended staff members has been reduced by £500,000 annually — almost $700,000.
Increasing Use of Online QI Resources
A second QI project was undertaken by communications and QI, focusing on increasing weekly page views of the Trust’s QI microsite, which offers resources to people inside and outside the organization seeking to embark on quality improvement projects. The team tested a number of ideas, including using Twitter to promote the microsite and providing links to the microsite from the Trust’s main website. The team theorized that the QI newsletter — which was published every other month — was the major driver of interest in the microsite, so the team developed and tested a number of changes, including publishing monthly and changing the publication’s title, content, and design to be more appealing. All these changes helped increase microsite views from inside and outside ELFT (the site gets hits from 50 countries) by 95% over 12 months.
Tackling the Challenges
Despite a number of successful projects attributable to the use of quality improvement methodology, there have been several key challenges. As with many health care systems, ELFT has substantial data collection and presentation systems for clinical information, but not for non-clinical. So it’s been challenging for corporate services to gain access to and collect meaningful data to help understand performance and customer satisfaction.
Corporate services at ELFT are largely centralized, but assist clinical services in geographically dispersed locations with differing approaches to change. For example, some have a more top-down approach, while others are more collaborative. This presents both an opportunity to have significant impact over a large, spread-out system, but also a challenge in how to engage and involve a range of culturally (in the corporate sense) and geographically dissimilar services. The IHI’s Model for Improvement approach encourages projects to test in one area of the Trust to build confidence in ideas and theories, before attempting to scale up and spread to other areas. It’s also been challenging to retain focus on quality improvement in the face of changing business priorities, for example, at times of major new acquisitions or pressure from external regulators.
ELFT hopes to further integrate QI to support key business objectives within corporate services. Senior leaders are encouraged to think about which core business and operational problems they would like to use QI methodology to tackle. Because it’s always difficult to find time for meetings dedicated solely to QI brainstorming and planning, ELFT will begin integrating these activities into business operations meetings.
One of ELFT’s relatively new strategic priorities for QI has been improving value for money. Projects will target areas of waste, including printing and procurement costs as well as laborious administrative processes. We also will continue our work reducing salary overpayments.
Key takeaways from our 4-year journey include:
- Continuous quality improvement is applicable to corporate strategic and support services, as well as clinical services.
- Applying quality improvement in corporate services can influence the clinical realm, including patient experience, outcomes, and value for money.
- Quality improvement in corporate services can help bring corporate staff closer to the clinical staff by better understanding their needs and EFLT’s mission.
- Challenges to applying quality improvement have included access to data to understand process performance, and balancing time and energy for improvement with operational and business priorities.