NHS Chief Executives

Our Ref F4046894

21 October 2011

Dear Colleague

An Integrated Approach to Continuous QualityImprovement in Mental Health

Both Healthcare Improvement Scotland and the Scottish Government are currently leading continuous quality improvement (CQI) work with Mental Health Services. The purpose of this letter is to provide a brief update on the respective areas of work and highlight the mechanisms we have put in place to ensure effective national co-ordination of CQI work across Mental Health Services. Further, we are encouraging NHS Boards and key partners to ensure that mechanisms are in place locally to ensure effective co-ordination of the different strands of CQI work across Mental Health.

CQI work led by Healthcare Improvement Scotland

Healthcare Improvement Scotland leads on the following key areas of improvement work across NHSScotland’s Mental Health Services:

  • The development of the Mental Health Patient Safety Programme
  • The implementation of Integrated Care Pathways
  • Releasing Time to Care – Mental Health

Please see Appendix A for more information on each of these strands of work.

CQI work led by Scottish Government

The Mental Health Division and the Quality and Efficiency Support Team in the Scottish Government are currently working in partnership to lead the following key areas of improvement work across NHSScotland’s Mental Health Services:

  • Psychological Therapies HEAT DCAQ Early Implementers
  • Releasing Time to Care Community – scoping customisation needs for mental health
  • Dementia Demonstrators

Please see Appendix B for more information on each of these strands of work.

These programmes all use a common range of CQI methods as identified in Appendix C.

Given this considerable overlap in approaches, it is important that effective co-ordination is in place both nationally and locally on the issues held in common so as to reduce duplication and contradictory messages. To this end, the Mental Health Delivery Team (which includes representatives from Healthcare Improvement Scotland, NES, ISD, Health Scotland and relevant Scottish Government Departments) in partnership with the Scottish Hub for Quality Improvement, will oversee the implementation of an integrated approach to CQI in Mental Health. In doing this we will ensure:

  • there is clarity on the commonalities and differences between the key national improvement programmes
  • a consistent use of terminology across the programmes
  • a consistent approach to skills development, integrating training resources where possible, and
  • when working on a similar issues, that we reference the same support resources/tools across where-ever possible.

In addition to this work focused on using CQI approaches, there are a number of other national programmes which also have a vital role to play in supporting improvement across Mental Health Services including:

  • NHS Education for Scotland’s work to ensure mental health clinicians are skilled to deliver high quality interventions, including the continuation of their current work to develop the capacity of the workforce to deliver a range of psychological therapies.
  • The Scottish Recovery Network which provides support towards developing recovery focused services. We hope to incorporate the revised Scottish Recovery Indicator more directly into the work of Releasing Time to Care within Mental Health.
  • The Joint Improvement Team (JIT) which provides support to develop integrated working across Health and Social Care
  • Health Scotland which continues to lead vital programmes of work focused on reducing our levels of suicide and improving mental health promotion.

All of this work combined will ensure that mental health is well placed to deliver the three ambitions of the Healthcare Quality Strategy for NHSScotland and the national priorities for the development of mental health services.

Thank you for your continued support and engagement with developing a culture of continuous quality improvement across Mental Health Services. We will be contacting you shortly with more detailed information. In the meantime if you wish to discuss any of the detail in this letter please do not hesitate to get in touch.

Yours sincerely

Dr Frances M Elliot Geoff Huggins

Chief Executive Head, Reshaping Care and Mental Health Division

Healthcare Improvement ScotlandScottish Government

cc

Denise Coia

Jan Warner

Malcolm Wright

Mental Health Delivery Team

Stephen Gallagher

APPENDIX A

Healthcare Improvement Scotlandled CQI Programmes

The development of the Mental Health Patient Safety Programme

Building on work already completed during 2010/11, Healthcare Improvement Scotland is now undertaking a 90 day process to further refine and focus these proposals. There is a recognition that, whilst some of the patient safety issues across health care settings are common and interrelated, mental health has unique patient safety issues that warrant further consideration. In particular there is a complex interaction between the mental health environment and the diagnosis/patient population.

The 90 day process will enable a better understanding of those interventions which lend themselves to a CQI approach to implementation and those issues that are more appropriately located within a wider approach to patient safety in mental health. Further it will help clarify those interventions which have a clear evidence base to support implementation and those that require further testing. The outputs of this will then be used to finalise the scope and structure of the national Mental Health Patient Safety Programme for implementation from April 2012.

In addition, work has also started to scope a potential programme around dementia in acute hospitals, with the intention being to identify interventions for testing across a couple of sites prior to then rolling out across NHSScotland.

The implementation of Integrated Care Pathways

The implementation of Integrated Care Pathways, developed by NHS Quality Improvement Scotland, including the diagnostic specific pathways for people with dementia, depression, borderline personality disorder, schizophrenia and bipolar disorder, remain a key priority for Mental Health Services. Healthcare Improvement Scotland will continue to support NHS Boards to implement these standards with the focus for 2011/12 being:

  • Working with NHS Fife and NHSForthValley to test a small range of national variance measures that support the use ofIntegrated Care Pathways to drive improvement. The aim is to then share the learning from these test sites to support the roll out of these national variance measures across NHSScotland from April 2012 onwards.
  • Shifting the focus away from a formal system of accreditation and instead, taking an assurance-based approach whereby NHS boards will be asked to report against specific data points to evidence the contribution of ICPs to ongoing to service improvement, and aligning the ICP work into the broader improvement and scrutiny programme based on the new Healthcare Scrutiny Model (HSM).
  • The Dementia Standards were published June 2011 in response to the Dementia Strategy and the ICP for dementia will support services to improve dementia care and will be aligned to provide a comprehensive assessment of dementia care in Scotland.
  • Promoting the new ICP standards for child and adolescent mental health services which were published in June 2011 and have extended the age spectrum of the ICP work.

Releasing Time to Care – Mental Health

Healthcare Improvement Scotland will be taking on the national oversight and direction for the Releasing Time to Care Programme which includes RTC Mental Health Ward and the roll out of RTC Community to mental health. It is committed to ensuring the Mental Health components of this work link to both the wider RTC programme of work and the wider programme of improvement work in Mental Health.

APPENDIX B – Scottish Government led CQI Programmes

Psychological Therapies HEAT DCAQ Early Implementers

QuEST is working in partnership with two NHS Boards (NHS Lothian and NHS Ayrshire and Arran) to demonstrate how improvement approaches can be used to deliver quicker access to psychological therapies within current resources, whilst delivering the same or better clinical outcomes. It is using these ‘early implementer’ sites to generate guidance, resources and tools that support the application of systems improvement methods to deliver improved access to Psychological Therapies. It will also use the learning from these early implementer sites to inform an assessment around what, if any, national improvement support is needed from April 2012 onwards.

Releasing Time to Care Community – scoping customisation needs for mental health

The Releasing Time to Care Community resource was developed primarily with a focus on District Nursing and Health Visiting. Though the resources have applicability to community mental health services, there is a need to customise them to this context. Further, we are keen to ensure effective integration between this resource and the work already in place across a number of community mental health teams to better manage their demand and capacity. Therefore a short term project, led by QuEST, and working in partnership with the Mental Health Division and the RTC Programme has been set up to:

  1. Assess the applicability of RTCC resources, as they stand, to Community Mental Health Services. This will provide clarity on the level of customisation needed.
  2. Correlate RTCC resources with Demand, Capacity, Activity and Queue (DCAQ) resources, particularly those already adapted for use in mental health and identify any overlaps with other existing tools to support improvement in community mental health services in Scotland (i.e. SRI, ICPs etc)
  3. Produce a proposal for applying RTCC and customising, testing and recording evidence based modifications specifically for community mental health services

Dementia Demonstrators

The Mental Health Division, QuEST, Joint Improvement Team and Healthcare Improvement Scotland are working in partnership with three CHPs (Perth and Kinross, Midlothian andNorth Lanarkshire) to demonstrate how whole system pathway redesign can be used to deliver better quality of care for more people, within the current resource constraints. One of the key aims of the work is to generate learning that can then be rapidly disseminated across the wider system.

Appendix C: How the different CQI programmes fit together

The following table highlights the fundamentals that all the programmes have in common as well as the specific areas of focus of particular programmes.

Systems Theory and Process Redesign
  • Recognising that we work in a system where changes in one part can have much wider impacts
  • Recognising the importance of well designed processes in delivering high quality care
Person Centred/Recovery Approach
  • Recognises that everyone is a unique individual and that support and care should be designed in partnership with the person receiving it to enable them to maximise their own wellbeing.
Model for Improvement
  • Setting measurable aims for improvement work
  • Using small tests of change (PDSA)
  • Using data to see if change has led to improvement
Measurement for Improvement
  • Understanding variation and acting accordingly
  • Run charts/SPC Charts
  • Using a mixture of outcome, process and balancing Measures
Human Dimensions of Change
  • Recognising the importance of human factors including visual management
  • Empowering frontline staff to take responsibility for improvement

Efficiency and Productivity for Mental Health / MH Patient Safety / Psychological Therapies and CAMHS Access / Dementia Demonstrator / RTC / ICP Implementation
In additional to fundamentals also has a key focus on /
  • Lean including DCAQ
/
  • Reliability Theory
  • Evidence based care interventions
/
  • Lean including DCAQ
  • Evidence based care interventions
/
  • Lean
  • Whole system pathway redesign
  • Partnership Working
/
  • Lean including DCAQ in community
/
  • Evidence based care interventions

Primary Quality Dimension /
  • Efficient
/
  • Safety
/
  • Timely
/
  • Effective and Efficient
/
  • Efficient
/
  • Effective

Other Dimensions of Quality that are key /
  • Equitable
  • Effective
  • Person Centred
/
  • Effective
  • Person Centred
/
  • Effective
  • Efficient
  • Equitable
  • Person Centred
/
  • Person Centred
  • Equitable
  • Timely
/
  • Effective
  • Person Centred
/
  • Person Centred
  • Equitable