Leadership

Quality Improvement for Non-Clinical Teams

Article · April 19, 2018

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.

Building Teams

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:

East London NHS Foundation Trust Non-Clinical Quality Improvement Projects Example

  Click To Enlarge.

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.

East London NHS Foundation Trust Non-Clinical Quality Improvement Days Taken to Complete Disciplinary Process

  Click To Enlarge.

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.

East London NHS Foundation Trust Non-Clinical Quality Improvement - Weekly Microsite Views

  Click To Enlarge.

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.

Moving Forward

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.

Call for submissions:

Now inviting expert articles, longform articles, and case studies for peer review

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Leadership
Action Steps for Risk-Share Contracts for Medical Devices

Challenges and Best Practices for Health Systems to Consider When Implementing Risk-Share Contracts for Medical Devices

When done right, value-based contracting for medical devices can ameliorate shrinking margins at health systems, leading to a virtuous circle.

Health Care Organizational Culture Emphasizes Patient Care Only Slightly More Than the Bottom Line

Survey Snapshot: Who Should Lead Culture Change?

NEJM Catalyst Insights Council members feel that culture change at their organizations is heading in the right direction, but differ on who it should come from, and reveal too much balance between emphasis on bottom line and emphasis on patient care.

Culture Change Within Health Care Organizations Is Changing for the Better

Leadership Survey: Organizational Culture Is the Key to Better Health Care

Although three-quarters of Insights Council survey respondents say culture change is a high or moderate priority at their organizations, survey results show a lot of work on organizational culture remains to be done.

Metraux01_pullquote - dinners to combat burnout in the health care community

“Breaking Bread” to Combat Burnout

Can a simple dinner create community among health care providers?

IHI HPMS Visual Management Board Example

The Answer to Culture Change: Everyday Management Tactics

Adoption of a clear rhythm-of-performance measurement and communication via huddles and visual management can affect a culture of staff engagement and continuous value improvement.

ajor Themes from Cleveland Clinic Town Halls 2016

Reigniting the Passion to Practice Through a Multi-Pronged Approach

Cleveland Clinic formed the Practice Innovation and Professional Fulfillment Office to create and sustain an environment that allows clinicians and scientists to thrive through barrier removal, culture change, and support for personal well-being.

Percent in Highest Bracket in Patient Satisfaction Scores - Pre-Post Arm Differences for Hospitalists - Duke Coaching Communication Skills Study

Coach, Don’t Just Teach

The effect of one-on-one communication coaching on clinicians’ communication skills and patients’ satisfaction.

Two-Thirds of Organizations Have a Nurse Leader Career Path

Survey Snapshot: Do Nurse Leaders Need Advanced Degrees?

Though NEJM Catalyst Insights Council members acknowledge a lack of advancement opportunities for nurse leaders, two-thirds of their organizations have a nurse leader career path.

Nurse Leaders and Physician Leaders Should Be Considered Equals in Care Delivery - but Views of Nurses and Non-Nurses Differ

Leadership Survey: Nurses as Leaders: Broad Acceptance, Room to Grow

Nurses are traditionally the backbone of patient care. They form the largest percentage of the health care workforce, far outstripping physicians. But are nurses leaders as well as doers?

The CMO Role of the Future - Baptist Health Survey Results

Examining the Continuously Evolving Role of the Chief Medical Officer

Hospital and system leaders need to sharpen the focus of CMO roles to include system-wide considerations beyond the walls of the hospital.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Physician Burnout

45 Articles

“Breaking Bread” to Combat Burnout

Can a simple dinner create community among health care providers?

Leading Transformation

264 Articles

Finding the Cause of the Crises:…

Until we redesign our health care system to address our patients’ personal determinants of health,…

Leading Teams

164 Articles

Survey Snapshot: Who Should Lead Culture…

NEJM Catalyst Insights Council members feel that culture change at their organizations is heading in…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now