After a little pause in activity due to Covid-19, I am delighted to say we have started work on this project again over the last couple of weeks. We are having to adapt the way we deliver the collaborative and this in itself is a huge learning curve, but in true QI style we are testing and adapting as we go! The GP practices so far have been very receptive and keen to get cracking with this work. I think they are all pleased to be doing something other than Covid related work!

We’ve started with a series of individual practice update sessions and specific coaching session have followed this. Most practices are still at the diagnostic phase of trying to properly understand the problem and what the data is telling them.

We’ve also re-established the project steering group and the next meeting is 15th July.

Watch this space for more updates soon!

Lisa

Learning set 1 done! Well, what a day! Had a fantastic introduction to Quality Improvement from Dr John Bibby including a patient story to really help us understand why this is so important. We talked through the Improvement Model itself and our experiences with QI projects in the past and what made these a success or not!  We discussed our shared problem and began to think about how to express our project aims.

After some not-so-great-coffee and a cookie, Maureen followed up with some learning form a QI project she had been involved in with a Mental Health Assertive Outreach Team and shocked us with the statistic that life expectancy for people with severe mental illness such as schizophrenia is reduced by 25 years and that the major cause of death is not suicide (as we may have imagined) but cardiovascular disease! Maureen covered each of that teams challenges and how they overcame them as well as their key factors in success – something we need to replicate – team motivation and backing from top management and medical staff.

Dr Bibby then took us through a more detailed look at our data which had been taken from our clinical systems by the Data Quality Team and showed Q3 2019/20 achievement against each of the indicators and the overall specifications. We then discussed this on our tables and what we thought it meant. Overall each practice had similarly low figures in certain areas, particularly around bloods and we also highlighted some issues where interventions appeared to be lacking following the identification of an area for improvement, we were unsure how much of these were coding issues.

Lunch was good, although very beige, and happily received by all – we so often don’t get fed at events anymore so it really makes you appreciate it when there is food – and people stay in the room to keep the discussions and relationship building going! Win-win!

Our next session was on measurement and Dr Bibby talked us through run charts and how to recognise improvement in figures as well as the danger of selecting the wrong measures with a hilarious picture of undies on a washing line as proof of global warming – you’d have to see it to understand.

We then talked about what we needed to do to cleanse our data, ensuring the appropriate patients were on the register with some drug to diagnosis searches, CQUIN data from our Mental Health Trust, as well as looking at patients who may have been coded as in remission but were not or maybe shouldn’t be for this. Then there is the issue where problems or interventions may have been freetext and not coded. It was recognised that our data would never be perfect but that we could do some work to make it more accurate.

We next reviewed what we might need to do in the way of further information gathering to properly diagnose our problem. We have our hunches but were trying to learn QI processes to analyse the problem and not jump to conclusions! Do we need to do a short patient survey, the 5 Whys, brainstorm, process map or use the fishbone and then once we’ve done this using the Pareto principle to get the biggest bang for our buck.

We agreed our measures, most of us the same 3, and Maureen tasked us with our homework during the action period. Each team was a assigned a coach to help support them and meetings planned for 3-4 weeks hence to review progress and support the baseline data gathering and aim-setting. Each team will present their baseline data and aims at the next learning set on the 28th April.

Dr Bibby then introduced the idea of a culture survey and this was really well received. As a developing organisation, our PCN are eager for this breakthrough series to build trust and familiarity within our Network particularly as we learn to work together in new ways. Some of us met staff in the additional roles and allied healthcare professionals for the first time today; learning these new skills and celebrating our success at improving the quality of care for this vulnerable group of patients together should be a great bonding experience.

The feedback has been fantastic – I mean, it felt positive and enthusiastic on the day, but it’s great to see that reflected in the feedback forms, particularly as some attendees were a little unsure of what this all involved when they first walked in that room on Thursday.

Some of the most standout comments were; “Thought it would be medical/over my head but it turned out not to be. Understood all that was being spoken about. Well worth meeting with others today.” “Interesting and in-depth. Shocked to think I haven’t covered issues in consultations/reviews. Very informative and gave practice staff a chance for brainstorming these issues.” “Well paced presentation. Very relevant to job role and helping progress”, “Structure worked very well and format was excellent. Content was clearly presented and explained. Helped consolidate earlier learning”

Sally

At our first steering group meeting we discussed getting some data, and appropriate data so that we could use it to analyse the problem further. We posed questions such as: are practices not seeing these patients? or are some of the checks not being done? is there a problem with the templates that’s failing to record  everything  needed for this check; is there a lack of understanding among clinicians of what is actually involved in this check?

The initial data we had from our primary care dashboard, created by the CCG for “Quality Assurance” and contractual monitoring, showed all 8 of the practices in the PCN to be pretty poor at doing physical health checks in SMI patients, but we felt it would be interesting to compare this to our Quality Outcomes Framework (QOF) data to see if we were better at checks required for that. QOF, however,  is looking for far less measures plus, and not to by cynical,  has £ attached. Serious Mental Illness (SMI) checks historically did not. Also for consideration is that where a patient has something missing that needs recording for QOF, the clinical systems used in our Primary Care Network,  Emis and Systmone, make this really visible with alerts and easy to action data entry, telling you exactly what you need to record and how to do it. These alert a clinician with a patient in front of them that they needed to check something. Also admin teams when they are making contact with the patient for prescriptions or other recalls can easily see what else the patient needs.

Unfortunately there are currently no system alerts that tell us when items are missing from the SMI checks. Perhaps that’s something we could potentially test out, but here we go, jumping to solutions before we have properly analysed the problem!!

We have a local Data Quality Team, commissioned by our CCG, who can run searches on our systems and extract them for us and I contacted the local team for assistance with this. Initially they needed sight of our data sharing agreement from the Primary Care Network (PCN), where each practice had agreed to share information to make the business of being a PCN possible. After a few emails I was able to track that down and get some overall data for each practice, the size of their SMI register and their achievement for each part of the health check.

I also investigated some options for searches we could use to cleanse and validate our SMI register. Arden’s templates provide  a case finding search that shows patients that seem to have a serious mental illness due to their medications but no SMI diagnosis on record. We also need to research for recording of codes for remission or resolved to check this is still the case. If someone was in remission but now back on an antipsychotic, they need putting back on the SMI register.

Unfortunately the SMI register requires patients with a very specific diagnoses or on lithium medication to be eligible for the register, which in discussions with clinicians seemed a little restrictive as some patients with severe depression and multiple inpatient stays would not qualify as being on the SMI register. Maybe that’s a problem for another day!!

Sally

We had our first project steering group meeting yesterday where we chose the Primary Care Network (PCN) we will be working with in Huddersfield. There was a great deal of excitement and enthusiasm in the room!

Tolson Care Partnership is the PCN we will be working with. They cover 8 GP practices and have a combined population of just over 50,000. They are quite diverse and atypical compared to the other PCNs in Huddersfield in that one practice is the University Health Centre; another practice predominantly looks after asylum seekers; and another practice has a very elderly population with a large number of their patients living in care homes.

Despite this diversity, they have identified using their population health management data packs, that the care of patients with mental illness could be improved.  Their proposal is to use QI to test out different ways of undertaking physical health checks for patients with Serious Mental Illness (SMI).

Work to drill down and understand the data better will happen over the next few weeks before the first full day learning event on the 5th March.

Exciting times in Huddersfield!