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Transforming patient care using a clinical governance programme

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Val Parker, RMN.

Ward Manager

Concerns about the standards and quality of care in acute inpatient psychiatric wards have been well documented (Sainsbury Centre for Mental Health, 1998; Standing Nursing and Midwifery Advisory Committee, 1999; Royal College of Psychiatrists, 1996; Rose, 2000; Moore, 1998).
Concerns about the standards and quality of care in acute inpatient psychiatric wards have been well documented (Sainsbury Centre for Mental Health, 1998; Standing Nursing and Midwifery Advisory Committee, 1999; Royal College of Psychiatrists, 1996; Rose, 2000; Moore, 1998).

The clinical area in which we work is a busy 25-bed mixed gender adult acute admission ward that provides inpatient psychiatric treatment for people living within the London Boroughs of Redbridge and of Barking and Dagenham. The ward had been going through a steady period of decline since 1996 when the sole consultant psychiatrist retired. We had staffing and other problems and, due to the large catchment area of 90 000 covered by the ward, the trust decided to create a further two registered medical officer (RMO) posts in line with recommendations from the Royal College of Psychiatry (1996). However, because recruitment of consultant psychiatrists was becoming increasingly difficult at this time, the RMO posts remained vacant for several years.

The rapid turnover of medical staff had a huge impact on the nursing staff who had to adjust to a series of short-term locum consultants who had little interest in or commitment to the ward. One of the consequences of this was that nurses began to leave the ward, and recruiting quality nursing staff became increasingly more difficult. The result was a huge staff deficit; the ward had eight staff nurse vacancies, along with two RMO vacancies and no administrator.

Our work environment reflected these circumstances: the ward was chaotic and disorganised; there was non-involvement of users and carers; there were minimal structured/therapeutic activities and there was a lack of community and multidisciplinary team input.

At this time the ward was situated in an old decaying building that was poorly maintained; the plans were to move the ward to a new building that was under construction and due for completion in March 2002.

As a team we were aware that we were not functioning well, our morale was low and we were all demotivated. We had excellent crisis management skills but were providing reactive care delivery as opposed to being proactive. There were no admission criteria; we had a high turnover of patients, delayed discharges and a high readmission rate.

Several things occurred within the first three months of 2001 that eventually resulted in positive significant change to the service we were able to offer patients in the ward. One of these was the opportunity of attending the Clinical Governance Development Programme (CGDP). To gain a place on the programme we had to put forward a proposal. This paper describes the proposal and the processes we undertook, with the support of the Clinical Governance Support Team (CGST) to address the problems we had identified.

The team leaders got together and compiled a vision of our expectations for our ward in the future. Our aim was to provide a comprehensive specialised service that addressed and rectified the negative perceptions of acute inpatient care described in numerous studies and articles. We also wanted to provide a service in which our clients would receive the optimum standard of care in a ward of which we clinicians could be proud.

Furthermore, we aimed to bring clinical governance to life at ward level and develop a new modern acute inpatient service. This would be highly specialised and meet the needs of seriously mentally ill people through continuous quality improvement, complementing the services provided within the community mental health team (CMHT) and the future home-based treatment teams.

With this in mind we believed that certain principles should underpin this service development. Evidence came from the Sainsbury Centre for Mental Health briefing papers (SCMH, 1998; 2001a; 2001b) and from our own staff opinions on how we would like our ward to develop:

- The ward should provide a therapeutic experience. This implies the development of health-promoting activities, psychologically meaningful interactions with peers and staff and an environment that helps patients heal and grow. It is expected that patients, carers and staff will all help to achieve this environment

- The ward culture and programme structure should be developed co-operatively and promoted by patients, carers and staff. Mechanisms for ongoing consultation and review should be established

- Patients should have individually tailored management plans. Included in these would be rapid assessment and diagnosis, a weekly treatment plan and daily activities that are assured. A variety of therapies should be available. Discharge should be planned, with clear communication with all involved in community follow up

- A multidisciplinary management approach should be used, involving patients, their carers and the CMHT. This implies full integration of the Care Programme Approach (CPA) and development of more opportunities for wider consultation in patient management. The CPA requires that those clients who have been diagnosed with severe mental illness have regular multiprofessional team/client/carer review meetings to assess, plan and implement discharge and after-care services

- The ward should provide opportunities for staff training and development. As a result it is expected that some staff will become highly skilled in relevant areas of service

- Assessment and management of risk should be prioritised and all staff should integrate this into their daily work

- Clear definitions should be developed on which patients should be admitted to the ward. Extensive liaison will need to occur with all other areas of service to ensure that all psychiatric patients' needs are suitably catered for and an immediate link with acute community-based treatment teams is envisaged. The ward will be able to focus on special patient groups and develop high standards of care using the most modern psychiatric methods

- The ward should remain at the forefront of psychiatric practice by proactively reviewing itself, by using input from patients and their carers, by monitoring the literature and by promoting research. In this way staff of the highest calibre will also be drawn to and retained by the service.

We had set our aims very high and it was clear from the onset that we would have quite a task on our hands. We were trying to change the culture of the ward and embed quality improvement within our organisation.

The principles of the clinical governance programme demonstrated to us the need to engage people as the first step of implementing change. This exercise enables the identification and clarification of the hidden resisting forces, and personal opinions.

We used the RAID (review, agree, implement, demonstrate and develop) change model recommended to us by the CGST (Cullen et al, 2000). This model enabled us to critically explore our current practices with all of our stakeholders, listen to their opinions of problems and solutions, and agree an action. Only then could we work together in implementing the changes. The model demonstrated to us that we needed to be prepared to let go of our own hierarchical perceived outcomes, for what we believed needed to change may not be the perception of our stakeholders.

Putting planning into action
There were five clinical governance delegates heading the project: the ward manager, the deputy manager, two consultant psychiatrists and the psychologist. Our first task was to conduct a thorough review of the current service.

The Review stage The review component of the RAID change model generates engagement from staff, patients, carers and the organisation. This engagement establishes shared ownership of change, and change is generated from the bottom up. Evidence supports this method of involvement of staff and other stakeholders in the change process (Cutliffe et al, 1998/99; Jackson et al, 1999; Harvey and Kitson, 1996).

The delegates drew up a list of those people who have immediate and intensive contact with the ward, including patients, carers, ward-based clinical staff, non-clinical staff and CMHT staff. This resulted in a sample of 50 people.

Initially we attempted to compile a tick box-style questionnaire and sought advice from the trust's clinical audit department. However, our questions were too broad and needed to be more specific. The CGST advised that we keep things simple, and so it was decided to interview each stakeholder using a very broad, open interview schedule. We encouraged people to express their views about what they felt was wrong with the ward, what they thought we were doing well and what they felt we could do better. The outcome of this exercise highlighted a huge number of problems, but themes were beginning to emerge. These included common issues such as communication, ward structure, boredom and team work. The review phase began in March 2001 and was completed in July 2001.

The Agree phase In September 2001 a workshop for our stakeholders was held. Senior management supported us by covering the ward in our absence. We held a half-day workshop that allowed the ward team, patient advocates and CMHT to discuss the themes that had emerged from the review and explore, negotiate and agree on the solutions. The exercise also enabled us to identify the helpers and the hinderers within the organisation.

As we delegates were all part of the ward team, we thought it best if we employ an independent person to facilitate the workshop. Our designated CGST mentor agreed to facilitate this for us.

During the workshop the central themes of the ward's problematic areas were discussed, and small groups were formed to explore and agree solutions. These were then fed back to the larger group and decisions to move forward were made.

We were able to break some of the problems down into those that had 'quick-fix' solutions (Box 1) and those that required a greater degree of time and effort to resolve (Box 2). Our initial review phase identified that the ward required intensive modernisation.

The idea of having a single lead consultant was also raised during the workshop. It was unanimously agreed by nursing staff that much of the chaos and lack of teamwork was a direct result of working with three consultants who all had very different approaches to individual patient care, which from a nurse's perspective trebled the workload and created inconsistencies within the team.

By going through this process of engaging others and involving them in the ownership of problems, we were beginning to challenge traditions and assumptions. This created an atmosphere where solutions were welcomed.

The outcome of the workshop was that leaders emerged and six small working groups were formed of ward staff and users whose role was to work on the agreed solutions.

Success fuels greater motivation, therefore to motivate people to change and maintain the enthusiasm we needed some 'quick wins' - changes that were reasonably easy to make (Box 1).

The Implementation phase Deadline dates had been set. The sub-groups worked hard on their individual projects. The delegates continued to meet regularly and worked on an operational policy for the ward that reflected our new ward philosophy. The delegates had regular meetings with the individual sub-groups along with meetings with the stakeholders to provide feedback on the progress of the projects in hand. The ward gradually began to take on a structure. Patients' time in hospital was divided into three phases: assessment, treatment and discharge.

This allowed patients to understand exactly where they were during their inpatient stay, and feel a sense of achievement when they moved from one phase to the next. The therapeutic activity programme began to take shape. Patients were now able to choose from a range of activities and there was a selection of activities suitable for patients who were at different stages of recovery from acute episodes of their illness.

By the end of March 2002 six of the seven 'quick wins' had been achieved and we had moved into our new purpose-built unit. We had still to agree on a structured assessment tool that would be suitable for our many needs.

Demonstrate and develop The most difficult part of this exercise has been finding the tools to accurately measure our outcomes. The question was, have the patients benefited?

In an attempt to demonstrate that we have achieved improvements in the standard of care provided in our ward, we have devised a patient-satisfaction questionnaire. We have also trawled through the ward statistics over the past two years for past bed occupancy, length of stay, readmission rates and violent incidents in an attempt to have a baseline against which to measure our outcomes. Our evidence to date indicates an overall improvement in the ward in general that has been of no financial cost to the trust.

A repeat RAID
In August 2002 we began the review stage of the RAID model again. The whole concept of the RAID model is based on Continuous Quality Improvement and sustaining and embedding the improvements within the system. The method our team has adopted to implement change allows us to focus on the needs and opinions of the people not the organisation. This results in change being generated from the bottom up.

Consultant psychiatrist post One of the changes that had most impact in the ward was the transition from having three consultant psychiatrists to having only one. Nursing staff instigated this radical shift approximately two months before the recommendations from the Department of Health (2002) that acute wards should have single lead consultants. This recommendation reassured us that we were on the right track, and has resulted in a huge amount of interest from other acute wards, in our own and neighbouring trusts, as to how this was achieved. The impact this change has had on our ward is significant. There is now a consistent approach to care delivery and we are functioning as a team. Although we have the same number of inpatient beds, the nurses' workload has been significantly reduced, as there are not so many meetings to attend.

Therapeutic activity programme Our therapeutic activity programme has been running since January 2002. It is an extensive programme that offers choice to our patients. In retrospect, we believe the therapeutic activity programme was a little over-ambitious: the programme is so extensive that there is little time left for one-to-one work with our patients. Also documentation of the groups, for example attendance registers and patient-satisfaction feedback, has been somewhat sporadic, resulting in difficulties completing an accurate evaluation of their worth.

Training for group work is vital if therapeutic groups are to be sustained. We currently have four members of staff who are highly skilled and competent in facilitating groups and supervision from our psychologist is available twice a week. In order for the therapeutic group culture to remain embedded in the ward, successors need to be identified in case current staff leave. However, funding and availability for courses in therapeutic group work is not readily available at this time.

Involving users in their information needs The service users instigated an information book and photo gallery project. Users had stated that name badges were often difficult and embarrassing to read, they could not distinguish easily between regular staff and bank staff, and also thought it would be reassuring on admission to know whether there were staff still working in the ward with whom they were familiar from previous admissions.

The information book was designed to give clear and concise information that might be overlooked during the patients' orientation to the ward. A user volunteered to be on the subgroup for this project and had a lead role in deciding what should be included. Each patient has an information book placed in his or her bedroom on admission. Feedback from our patients confirm that this was a valuable project and has resulted in many of the books being taken home as souvenirs.

Until we embarked on this improvement project we had little understanding of the term clinical governance and believed it to be yet another paper exercise. This project has brought clinical governance alive in our work environment. Our standards are improving, but our process of change is ongoing. Our ward has structure and organisation and we now function well as a team.

Staff and patients know that their views and opinions are now being heard and acted upon. The despair has gone and it has been replaced with enthusiasm and commitment to provide the best service possible. Staff are now keen to be involved and they share a sense of achievement. Patients comment regularly on the relaxed and friendly atmosphere in the ward and have said that they feel they are treated as equals. Our ward's esteem has risen within the organisation, and we are spreading the word to other wards. Our staffing levels have increased to full establishment and staff are being retained.

The clinical governance delegates were not responsible for the changes that have occurred in our ward, we were purely catalysts enabling the change of culture to happen.

Cullen, R., Nicholls, S., Halligan, A. (2000) NHS Support Team: reviewing a service - discovering the unwritten rules. British Journal of Clinical Governance 5: 4, 233-239.

Cutliffe, J., Jackson, A., Ward, M. et al. (1998/99)Practice development in mental health nursing (part 1). Mental Health Practice 2: 4, 27-31.

Department of Health. (2002)Adult Acute Inpatient Care Provision (Mental Health Policy Implementing Guide). London: DoH.

Harvey, J., Kitson, A. (1996)Achieving improvements through quality: an evaluation of key factors in the implementation process. Journal of Advanced Nursing 24: 185-195.

Jackson, A., Ward, M., Cutliffe, J. et al. (1999)Practice development in mental health nursing (part 2). Mental Health Practice 2: 5, 20-25.

Moore, C. (1998)Acute in-patient care could do better says survey. Nursing Times 94: 3, 54-56.

Moos, R.H. (1974)Ward Atmosphere Scale. Palo Alto, Ca: Consulting Psychologists Press.

Rose, D. (2000)Users' Voices. London: The Sainsbury Centre for Mental Health.

Royal College of Psychiatrists. (1996)Wish You Were Here? Ethical considerations in the admission of patients to substandard psychiatric units. (Council Report CR50). London: Royal College of Psychiatrists.

Standing Nursing and Midwifery Advisory Committee. (1999)Mental Health Nursing: Addressing acute concerns. London: Department of Health.

Sainsbury Centre for Mental Health. (1998)Acute Problems: A survey of the quality of care in acute psychiatric wards (Executive Summary). London: Sainsbury Centre for Mental Health.

Sainsbury Centre for Mental Health. (2001a)Acute Solutions. London: Sainsbury Centre for Mental Health.

Sainsbury Centre for Mental Health. (2001b)Acute Inpatient Care. London: Sainsbury Centre for Mental Health.

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