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What is the challenge your project is going to address and how does it connect to your chosen theme?

Improving healthcare within prison settings presents particular challenges as it involves multiple systems – those that support healthcare specific activities, and those that drive and support the prison.  These latter form the wider environment for healthcare service delivery.  To date QI activity within Offender Care has focused on relatively small scale improvement projects which are restricted to processes directly within the control of healthcare providers.  However, there is huge potential for significant improvement in service delivery outcomes for patients and staff if we work beyond healthcare boundaries, and develop quality improvement partnerships with our prison colleagues and healthcare colleagues working in community and/ or hospital settings.  Our work will develop skills and knowledge of QI approaches across  organisations working to support prisoners at HMP Woodhill, with a focus on two large scale improvement programmes, beneath which will sit multiple QI projects.

What does your project aim to achieve?

We aim to develop QI knowledge and skills within the CNWL healthcare team, prison staff, and our partners using two large scale thematic projects, with several QI projects driving our aims.

  • Eradicating Hep C by the end of June 2020:  this work involves developing QI skills and knowledge within primary care, addictions and our ODN partners.  It will will build on a 2018 QI project on screening within healthcare to include partners in Addictions, the ODN, the Prison and service users for better care outcomes.
  • Reducing Self Harm among prisoners will be co-lead by CNWL Mental Health and the prison’s Safer Custody department.  It will involve representatives from across several prison departments.  Using QI allows us to design a whole system approach to improvement, tracking changes leading to develop consistent approaches to non-clinical support, clear pathways to care and treatment, and improved levels of knowledge among prison staff about risk factors for self harm among prisoners.

How will the project be delivered?

We aim to secure one day a week of dedicated, IA support for these projects which would allow:

  • delivery of training and skills sessions related to QI
  • provision of specialized software to allow initial and ongoing data analysis
  • support the project team, including involving patients in the work
  • support with project design
  • support data collection and analysis
  • support to develop and carry out PDSA cycles
  • develop and maintain robust communication across partners
  • project management, aligning multiple QI projects towards specific strategic aims
  • promoting learning within the partnership and beyond

The biggest risks to this work include a lack of understanding of local systems, and that staff will be pulled from project activity into routine operational tasks.  The proposed QI lead is familiar with the setting, has already established good working relationships with the key stakeholders and is fully cleared to work in high security settings.

Governance will be provided locally and via the CNWL QI Board.

What and how is your project going to share learning throughout?

Two types of learning will be generated from this work:

* developing skills and knowledge to deliver QI projects in custodial environments, working across professional and organisational boundaries.  This will be shared with CNWL teams in other prisons and through local networks via NHS England Commissioning groups.  We are not aware of similar projects using QI of this scale being conducted in the prison estate.

* subject matter learning relating to working with prison populations on self harm and on blood borne virus identification and management.  These are both priorities for the prison population and eradication of Hep C is an NHS England priority with a particular focus on prison populations.  Our work will provide valuable learning which will be shared across CNWL services, NHS England Commissioning groups and local ODNs as well to support similar work in other custodial settings.

We will use a range of methods including papers, presentations, video and posters, website, articles

How you can contribute

  • Any comments or views on our ideas, or learning from similar type work would be welcome. We are also keen to contribute to research conversations involving other Q Community members, sharing our learning and enriching our work with the constructive criticism, support and learning that members are able to provide.

Plan timeline

31 Jul 2019 further development of idea with local staff groups
31 Oct 2019 final report
30 Nov 2019 Project team has met and agreed schedule
31 Dec 2019 driver diagrams complete, measures identified, first PDSAs
31 Mar 2020 interim report on progress
30 Jun 2020 Further update on progress

Project updates

  • 1 Jun 2020

    Crossing boundaries with QI to improve prisoner health

    Update June 2020.

    This work had two key strands:

    Reducing self harm at HMP Woodhill
    Eradicating Hepatitis C at HMP Woodhill
    In addition to this, we hoped to be able to spread learning on the use of QI methods into other prisons, particularly those where CNWL provide healthcare services.

    We started our work at HMP Woodhill in February 2020 with a session for staff from across the prison and healthcare to explore the processes involved in the ACCT (Assessment in Custody, Care and Teamwork) approach across the prison (21 Feb).  ACCT is used to support prisoners who have expressed suicidal ideation or threatened to self harm.  It is intended to support the individual through a period of crisis as safely as possible.  The process has been highlighted as an area of concern following a recent inquest, and the team was keen to explore how we might improve the experience for both prisoners and staff.

    A report was prepared for the Safety Committee held on 26 February outlining what we had covered at the session, and the actions that came from it.  This has been uploaded as a separate up-date on the project.  A follow up meeting with the Safety Governor and the Residential Governor was held in early March to discuss a second session with a different group of staff where we could explore their experience of the ACCT process and how we might improve it.  However, before any dates were set, the prison went into lockdown due to Coronavirus and work was suspended.

    The final discussion before lock down was held on the 2 March with the lead psychiatrist in the team to discuss how we best use QI methods to support the development of a multi-tiered pathway to support mental health and well being for all men within the prison.  He agreed to set up a meeting with a number of other staff in the mental health team later in March, but again this was suspended due to lock down.

    A meeting to look at processes associated with eradicating Hep C was held on the 25 February. This involved the practice nurse from Woodhill, the specialist hepatology nurse from the John Radcliffe (we are linked to JR through the ODN for these services), and staff from the Woodhill Addictions team.  (Note: CNWL provides all healthcare services at HMP Woodhill.  Primary care and mental health services are provided through Offender Care and substance misuse services are provided as a sub-contract by the CNWL Addictions team).  The key points from this meeting were:

    The prison has been recatagorised as a Cat B trainer, which has meant a significant reduction in new prisoners coming to the prison each day.  In addition, all men have already been sentenced and are coming to Woodhill from another prison rather than from the courts.  The majority were coming to Woodhill having had a recent test for Hep C and other blood borne viruses (BBV) at another site.  This reduced the number of men accepting a test on arrival at Woodhill.
    Best practice suggests that we should offer all patients a test every 6-12 months.  Our discussion focused on how we review our current processes to look at introducing recall for testing as standard.  We also looked at the current processes followed by Addictions.  At present, addictions staff refer any man who wants a test to the practice nurse for testing.  Previous work has suggested that this approach introduces a delay and increases the likelihood that the patient does not attend the appointment for a test.  We agreed to re-draw the Addictions process to equip their staff to carry out dry blood tests at the time they are offered.  Training would be provided for staff by the practice nurse.
    Process maps were to be drawn up for discussion within the Addictions team.
    The group also discussed a education/ information campaign that would use a rolling programme of wing based sessions to promote regular testing for BBVs, as well as helping men to understand the treatment pathway.  We contacted the Hep C Trust to start work on developing some patient stories and to see if we could bring them into the team to develop some peer support within the prison.
    We had planned to start the rolling programme of events in late March, but this was all paused following lockdown.  At the time of writing our specialised Hepatology nurse has been redeployed into another service and we haven’t yet had any update on when services might resume.  All men who had been on Hep C treatment in the prison have now finished it and some testing is being carried out by the practice nurse team.  As lock down within the prison continues, all clinical activity is being carried out on a one to one basis on the wings – not in out-patient settings –  and no group activity is possible.

    At the time of writing, 1 June 2020, the prison continues to have a restricted regime with out-patient clinics suspended, and all clinical activity taking part as required on the wings.  We have had some tentative conversations with staff in healthcare and feel there is scope to look at some new ways of working in more detail using QI approaches.  For example, the mental health team has had to cancel all group work, but are offering telephone consultations and welfare checks to the men.  There should also be scope to look at how Hep C has been managed over the past 10 weeks, and consider any lessons for the future.

    Beyond these two areas of work, we had planned to carry out two sessions of bespoke QI training for staff at HMP Bronzefield and pharmacy and addictions staff at HMP Woodhill.  These were both scheduled for March/ April and were cancelled due to restrictions on numbers meeting, and pressures of work within the prisons as services responded to the Covid-19 situation.

    The CNWL QI team, including the Q Project team, were all redeployed to support operational planning for Covid-19 in late March, and have only just been brought back together to bring QI approaches to bear in planning for the future of services within the Trust.  This will allow at least some of the work to start again although it may look different to what we expected when we developed the project plan in 2019.

    The QI team is currently looking at re-writing its training programmes as virtual training, and we hope to be able to explore this approach with the prison teams over the next few months.

    Michele Dowling, 1 June 2020.

  • 1 Jun 2020

    Report to: Woodhill Safety Committee, February 26, 2020
    Report by: Michele Dowling
    Date: 24 February 2020
    Title: ACCT Process Deep Dive – summary of activity and actions
    Background and introduction
    Following a recent inquest, the Coroner identified weaknesses in the ACCT process in Woodhill.  A number of actions have already been implemented to address some of these weaknesses, but to date the Woodhill team has not had the opportunity to take a full system overview of the process, thereby giving a clearer view of areas of potential delay and risk.

    Funding from Q Exchange (NHS England and the Health Foundation) has provided resource to allow the prison to take a systems approach to improving prisoner health, and this includes exploring processes such as the ACCT process.

    A full day’s facilitated session was held on Friday 21 February 2020.  It included staff from Safety, Residential, Envision, Psychology and Healthcare.  The purpose was to start a systems approach to improving the ACCT process by mapping the full system as it currently is, and then identifying possible areas for improvement across the full system.
    Discussion of key points:

    We started by identifying what the ACCT process was for.  It was agreed that the ACCT process was:

    To keep people safe and alive; and

    To support people through periods of crisis.

    We discussed the concept of the team, and explored who was actually involved in the ACCT process.  This allowed us to think about the wider inputs to the process from across the prison.  The group used this information to prepare a systems map showing all of the groups within the prison who are involved in the process.  This is included as appendix 1 to this report.  This has highlighted the need to involve a wide range of staff from across the prison in future work to improve how we use ACCTs to support prisoners.

    The majority of the day was spent exploring the processes already in place across different teams.  Occupational groups were asked to work separately to map what actually happened at the moment.  We then used this as the basis of an in-depth discussion where we talked about the different parts of the ACCT process and how they came together.  A summary of this is included at Appendix 2 to this report.  A graphic process map is being prepared and will be shared with the group and the prison SMT shortly.

    The teams spoke frankly and everyone contributed to the discussions.  This allowed us to identify a number of potential issues:

    This work identified:

    ·         Pressure within the first 24 hours for assessment and first review.

    ·         Multiple handovers between different staff groups.

    ·         Different recording systems across groups which introduces risk of incomplete information being available to any one member of the team.  This highlights the importance of ensuring MDT meetings

    ·         Changes in staff and staff roles across the prison highlighted the need for ongoing refresher instruction and guidance, and in particular easy access to key points for staff involved in the process.

    The final part of the day explored possible areas for improvement and how we might test improvements to see if they have the impact that we need.

    The group looked at the use of Plan, Do, Study, Act cycles to test change ideas at small scale, before deciding to make larger scale changes across the prison.  With this in mind there are three changes that are being proposed:

    ·         B4 Mental health team to attend the meeting with prisoners held by the assessor.  This will put patient confidentiality to the fore, but has the potential to work more efficiently across departments, by co-ordinating meetings/ checks carried out with the prisoner once the ACCT is opened.  Suggested this is tested for one week in early March and then reviewed for effectiveness.

    ·         Assessors to attend first review meetings with wing staff.  This will have the dual purpose of building capacity and confidence among wing staff as well as ensuring consistency in sharing information across the teams working with the prisoner.  This to be tested for one week and reviewed for effectiveness.

    ·         Quality checks to be carried out by the wing S/O each week, with any issues identified and discussed with staff as they arise.  This will give ownership of the process back to the wings, and should address quality issues in a more timely manner than currently.  This will also be tested for one week and reviewed.

    ·         That three PDSA cycles are carried out in early March, with time set aside to review the effectiveness of the changes being tested at the end of the week designated for the test.

    ·         That a full report of the session is prepared for the Prison SMT, including a full process map of current arrangements, highlighting areas for improvement

    ·         That further sessions are held with staff of varying bands and from the full range of departments identified in the systems map.  These sessions will be bespoke and are designed to encourage involvement from all staff in the ongoing process to improve how we carry out ACCTs and keep men safe at Woodhill


  1. This is a very topical issue at the moment and I find it really encouraging to see our Q community working to address it. You've got my support.


  2. Guest

    Great to see a project bringing in partners outside of health care to focus on blood-borne viruses in this population -- it's a perfect example of where effective cross-sector working is needed.  I'd be really interested to hear more about your plans to involve patients in the work, especially how you're thinking about approaching it in a custodial setting.

    1. Guest

      Michele Dowling 1 year, 6 months ago

      Sam, thanks for your comment.

      We're really keen to get patients involved at a range of levels - this was something that was missing in an initial piece of work we did on screening rates last year.  We've already done some patient experience feedback, and through this have identified a couple of men who are willing to act as patient reps to promote better awareness about BBV and especially Hep C among their peers. We'll hopefully be able to draw on the Hep C Trust for some support in this regard too - the precise details need to be worked out and this is something we will hopefully be able to work on this with our first volunteer patient reps.

      Over the next few months, we will also be developing a wider healthcare rep role in the prison so we hope to engage more than just patients who've been directly affected by Hep C or other BBVs.

  3. Hi Michele, have you already come across

  4. This is a really important topic Michele. I used to work as a 'harm reduction' nurse providing healthcare to substance misusers in Sheffield. One of the research projects I've been involved in recently used co-production methods to improve access to hepatitis C treatments. Engaging clients in the process was essential to developing interventions that were acceptable, for example implementing a buddy system.

    1. thanks for the support Rachel - we know that patient engagement will be a really significant part of the work.  I will probably be in touch to find out more about your work and the things that made a difference!

  5. What a great idea team! Such an important area of work. What if any help do you need from us Qs?

    best wishes



    1. Anna, thanks for the comment.  if anyone has some tips about similar work that would be really welcome.

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