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We have recently implemented a new service in the PICU for early mobility. The area I want to focus on is activities for patients under 2 years old. Over 50% of patients admitted into our PICU are infants and the activities we have proposed for them are limited. I want to look at the option of introducing baby massage or baby yoga which staff could teach to parents, allowing both early mobility and facilitating positive touch. My manager is very keen that I investigate whether this would be something that parents and families would be interested in prior to carrying out training of staff etc.

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We have recently implemented a new service in the PICU for early mobility. The area I want to focus on is activities for patients under 2 years old. Over 50% of patients admitted into our PICU are infants and the activities we have proposed for them are limited. I want to look at the option of introducing baby massage or baby yoga which staff could teach to parents, allowing both early mobility and facilitating positive touch. My manager is very keen that I investigate whether this would be something that parents and families would be interested in prior to carrying out training of staff etc.
I have previously used SWOT, PDSA and SMART goals. However the CATOWE and Lean thinking were among the new strategies which I felt most useful. I like that the lean thinking encourages focus on what value is essential to service users. Determining this will be key to they type of activities we provide. I think we can be guilty of assuming we know what values are most important, so that is an aspect I will investigate further. I also liked the idea of concentrating on the pathway to these values, and assessing what the obstacles may be.
I found the systems analysis not to be as relevant, not focusing on specific points enough, and it didn't facilitate any new thinking that other tools hadn't already covered.
The CATOWE works well for me as I like organising each segment in a strategic manner. However it didn't have a focus on the pathway as much so I would definitely combine a couple of methods. My idea hasn't changed as such, rather I feel the tools have helped to enhance the service change and what to focus on.

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My service development idea is using a computer based SMS system to deliver messages to patients and to get their responses via mobile phone. A system used elsewhere in the NHS called Florence or just FLO can provide this service and integration with electronic records (System One) is a likely development. In other areas it has been used for patients self monitoring BP, BMs and other obs to pass this back to clinicians. Other uses can be medication prompts or in my case exercise/therapy prompting and feedback to gain improved engagement with home interventions + get immediate feedback from patients. The system automatically sends out SMS messages according to the algorithm set up so can respond in different ways to different scenarios - alerting staff of problems according to the responses or lack of by the patient.
The most relevant model for this development seemed to be the PDSA. The planning phase would include the technical set up, identification of data to be collected (quantitative - perhaps looking at compliance or clinical progress markers) (qualitative looking at staff and patient engagement or patient's experience) Also in the planning stage would be the who is doing what and when.
In the do section could be a pilot or small scale roll out to test the tech and get patient and staff feedback.
Study would be looking at the data gathered from the initial roll out.
Act would be amending the plans in light of the numbers and the feedback from stakeholders.
The PEST model did highlight the potential economics of the service change as less phone or face to face consultations may be required if patients are monitoring and giving live feedback on their progress. Technology and social developments also mean that an increasing proportion of service users have access to and can use a mobile device.
The CATOWE, Systems thinking and Lean approaches did not spark new considerations and the RCA is a more suitable tool for problem solving an existing service.
SWOT analysis was useful to identify potential weaknesses: poor staff and patient engagement. Threats: withdrawal or failure of the partnering technology or the company providing the service. Opportunities: Increasing the profile of the team if the development is a success.
This project could fit into the SMART goal criteria eg.
S: 20 patients using by the end of the year.
M: Compliance rates or stakeholder feedback measured.
A: Implementation plan agreed with patients and staff.
R: Yes - with support of staff, patients and managers.
T: Pilot could be set to complete in 6 months.

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Hi my name is Ed I'm a Physio...
I have worked in my current community neurology team for almost 10 years. The team is based in North Nottinghamshire and includes both Stroke rehabilitation and Neuro rehab services.
One of the best aspects of the team is the MDT working and diversity. The team includes Physios, OTs, SALTs, Rehab assistants, a Dietitian and a Neuropsychologist. We are not constrained by short time scales for intervening with patients which is a big positive for patients in our patch. We have had to work hard recently to bring the waiting lists down for getting first contact with our neuro referrals.

One area we could do better in is measuring what we do. The effectiveness of intervention is hard to measure as patients needs are so diverse. Previously we have used general outcome measures of function such as Barthel or measured goal achievement. Currently we are using a patient scored quality of life measure EQ5D but I am not sure how useful it will be as patients struggle to score themselves.

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Hi all

Many thanks for all of your contributions to the Padlet discussion.

I’ve put together a few thoughts to prompt further discussion over the coming week.

Tsp prehab idea:

Could consider using parts of the PEST tool too ie politics of Physio Vs Nursing teams/nursing encroachment, directorate organisation – who wields power locally, budget holders.

Technology use: standardised prehab info (leaflet, website, skype style, tel review, class based etc etc).

Lean thinking: long term decrease in secondary issues would mean cost savings overall and could enable a business plan proposition method to show decreased cost.  Cost of additional Physio input Vs lower complication rates analysis.

Examples from other areas of Physio include ACL prehab and TKR/THR services with pre-op Ax/Rx.

Staff engagement from the off re what they feel would work best for them/enable compliance.

Are there national standards of complication rates or other services that work differently to demonstrate where your department sits on this topic?

MS case: Lean thinking may well work here (the acute relapses were being seen by the maintenance service, why was this, what were the factors behind this, what factors generated a long waiting list – a root cause analysis method may work well for this).

RCA needs to be thought of ideally as a starting point to analyse but could as you say be used during a project to reflect ‘in action’ as it were.  The better we analyse the origins of the issue at the start, the less likely we will need to analyse the projects failings during it though.

General Points:

Several people mention working through different tools and finding the one that worked best for them but why were the other models less effective? Could you combine them?

Any negatives for the overall favourite that is SWOT/CATWOE?

Think about the kind of MSc critique you may have used before for clinical tools and methods and try to apply this to these models too.  How robust are they? How well evidenced? Any proof of their usefulness over other methods etc etc.

Thanks again for your contributions and do not worry about the practical rolling out of these improvement plans for now as that will be covered in the next folder.

Simon

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I have decided to look at reduction of falls in nursing homes. This is something that I have been recruited to do over the next year. Currently there are high numbers of falls, falls related ambulance call outs, admissions and referrals to community services.
LEAN appeared to focus upon the patent and their journey which I didn’t think was appropriate for my service improvement project which needs to be sustainable without a physio within 12 months, therefore it needed to focus more on the nursing home staff.
The systems thinking is interesting for my project, looking at the different links and interactions between different components and partially the underperformance aspect however it didn’t seem to follow this through into a completion, it was more an analysis of the system, which could quite possibly be carried out though a root cause analysis. I also felt the PEST system was a beginning analysis but needed to be followed by another system.
I felt CATOWE was comprehensive for analysis particularly appropriate with my project however should be followed by PDSA as it is important not only to plan the change and implement it but to also study the cycle and act upon anything that needs amendments or rolling out further.

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I have looked one area of improvement retrospectively within  one of our service user facility, used as a post operative assessment room. I have found the PDSA useful to start the analysis with, however it became many circles as it was a timely process. The CATOWE tool helpful to analyse the participants but does not lead to the complete implementation. In this case, I was unable to use the SMART criterias because the change was not planned as SMART goals. Worked lengthy, missing the agent's interest.
The other area as I have been thinking about, it is our enhanced recovery system. Introduced few years ago and still changing. I would like to analyse how could we ensure the high quality, patient safety, reliability within 1-2 hospitalitised days following elective orthopaedic surgery. A very useful tool could be the Lean Thinking tool. It can give a broad perspective flow discussion to achieve the expected enhancement.

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Here are the references for my attached CATWOE and SWOT analysis.
NSF for long term conditions https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198114/National_Service_Framework_for_Long_Term_Conditions.pdf
NICE guidelines for MS management
https://www.nice.org.uk/guidance/CG186/chapter/1-Recommendations#ms-symptom-management-and-rehabilitation-2

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I have chosen to look at the Multiple Sclerosis maintenance exercise group.  A part of a service which, when I took over, which had lost focus and with unspecified benefit to the patients who attended.  Our service had responsibility for the ongoing physiotherapy needs of the local MS population, excluding major relapse.  However, the community based neuro rehab team (CBNRT) had significant waiting lists and acute relapses frequently ended up being picked up by our team instead.  I have taken the approach of analysing the situation retrospectively (as I am not currently in practice) to see if anything could/should have been done differently.

Lean thinking is not really applicable in this situation as we are not looking for bottle necks, delays or stream lining.  I found it difficult to see what PEST analysis would add to the information above for this particular situation.  I also didn't feel that systems thinking would be appropriate for this scenario.

RCA might be useful further down the process of the project when analysing the results of the newly restructured service especially if issues such as a poor rate of return of patient satisfaction questionnaires persists.

PDSA will also be of use once the initial plan has been formed for how the restructuring will begin and be evaluated and modified.

I have attached my spider diagram, CATWOE and SWOT analysis

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I have looked at using different service improvement models for starting a late shift service at weekends as an extension of what we have in the week. The day after working on call 9pm-8.30am that staff member works 1pm-9pm. They are clinical til 5.30 and then can do non-clinical work but are on site and on call. To extend this to weekends would most likely save money and stop staff being on call into their days off but would decrease staffing on weekend mornings.
I really liked the PDSA model to look at intricacies of who would be involved and how and auditing advantages/disadvantages and implementing changes identified.
I found it really hard to apply the LEAN thinking model as I didn't this as relevant to my example. However, this may have been due to it being a fairly new model for me to use and due to my unfamiliarity.
PEST also wasn't as relevant and I found it hard to put enough information under each heading.
CATWOE seemed pretty useable and thorough and covered all bases but didn't look at auditing or reassessing the situation in the same way that the PDSA model did and therefore I prefer the PDSA model.

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Ben's favourite service improvement models and why!!! 

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Ben's favourite service improvement models and why!!! 

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Hi Everyone,

Hope you are all well, and enjoying the ITS module so far!!!

I have decided to focus my project on the On- call / out of hours respiratory physiotherapy service that I am clinical lead for in my trust. Over the course of the past 18 months, my team and I have spent a lot of time and effort on re-designing and re-launching the induction / training programme that we offer to new people joining our trust. This work seems to now have come to fruition, whereby the new programme is now classed as the “norm” and seems to have become embedded in our department which is amazing.

However, now comes the big task which is looking at the training package that we offer to the pre-existing members of the on-call team where I work. This is going to prove to be very challenging, because our team comprises a range of bands (5, 6 and 7) and also a range of specialities, not just respiratory. I feel that, as was the case originally when we were looking at the induction package for new starters, this is going to be a massive piece of work, but I feel this is also going to be more challenging because I anticipate that I am going to face a lot of resistance from some key stakeholders and also due to the sheer number of people that are in our team I am going to have to develop a training package / programme which satisfies a lot of stakeholders with differing needs and also priorities.

As requested I used the various different models in the Approaches to Service Improvements Presentation, I feel that the two best models which worked the best for me were the CATOWE and PDSA models.

The CATOWE model I thought was a great model because it solely doesn’t focus on the “doing” it actually encourages and facilitates the person using it to analyse and evaluate key contextual factors which have the potential to impact on the success of service improvement and implementation. Undertaking a project which is focussed on education of a team, it would be very easy to rush in and focus on the “doing” and implementation. Yet, I felt that using the CATOWE model enabled me to identify all of the key stakeholders which are going to need to be engaged throughout the course of my service improvement project. Complimenting this, I feel that the PDSA model proved to be very helpful in-terms of the diagnostic and problem identification and evaluation phase, because again it prevented me from rushing straight into the “doing” and encouraged me to step back, view things from a wider contextual viewpoint and ask the question why, what, who and when.

I hope this helps, and I look forward to your responses,

Thanks,

Ben

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I found it useful to start thinking about how to implement the change and what things I want to look at when you have set up the change.

My Statement: Improve pre-op optimisation prior to thoracic surgery.  Increase patient’s knowledge on exercise & ACT to improve patient’s post-op experience & reduce post-op complications.

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Also I have found the Lean Thinking one that I need to think more about. I like the concept of creating more value to patients without extra cost / fewer resources. By giving patients an extra service without a finical / staffing / resource implication. I feel my service improvement could be more lean thinking if the right people were involved & people engaged with it so that we deliver an extra service but staffing / finances were not effected by the change.

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After looking through all the different tools the ones I have found most useful are the SWOT analysis and the CATWOE. I have attached them onto the paddle for everyone to see / comment.

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I have attached my mind map for my service improvement plan - of involving physiotherapy into pre-opertaive clinic.

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Hi, Angela here, I run a small but growing therapy team including 3 band 6 physios, 2 band 6 OTs and 3 assistants. We provide services to long term conditions patients, complex non functioning head injuries, MS, spinal injuries, SAH and bariatrics. We also have step up and long term slow feed neuro rehab patients. At about 4-6 weeks some hospital rehab unit discharged TBI patients, with life changing disability, psychologically hit a wall and compliance reduces considerably. Myself and my staff currently have one to one discussions with the patients explaining the consequences of their non compliance (loss of independence, increased length of stay, exacerbation of depression and ultimately loss of funding) but this is not always successful. I am aware that staff education on approach and motivation of independence works, but staff turnover and limitation of resources makes specific training in this 'unappealing' to the organisation. I would like to find a way to minimise or prevent the stumbling block experienced by these patients. 

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Hi, Angela here, I run a small but growing therapy team including 3 band 6 physios, 2 band 6 OTs and 3 assistants. We provide services to long term conditions patients, complex non functioning head injuries, MS, spinal injuries, SAH and bariatrics. We also have step up and long term slow feed neuro rehab patients. At about 4-6 weeks some hospital rehab unit discharged TBI patients, with life changing disability, psychologically hit a wall and compliance reduces considerably. Myself and my staff currently have one to one discussions with the patients explaining the consequences of their non compliance (loss of independence, increased length of stay, exacerbation of depression and ultimately loss of funding) but this is not always successful. I am aware that staff education on approach and motivation of independence works, but staff turnover and limitation of resources makes specific training in this 'unappealing' to the organisation. I would like to find a way to minimise or prevent the stumbling block experienced by these patients. 

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Hi Gina, Siobhan, Ben, Zoe, Elizabeth, Heather and Jenna,

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Hi Gina, Siobhan, Ben, Zoe, Elizabeth, Heather and Jenna,

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Thanks for your comments so far and for sharing some aspects of your practice. It feels like we have a really good mix of clinical experience on the module, and that you will be in a position to apply aspects of the module to your practice as we progress over the next few weeks.
Ben - I am quite interested to pick up on one of your comments about the difficulties with engaging your stakeholders.....
This is something which in my experience can be really challenging, but often trying to unpick the "why can't I engage them" helps to present some of the solution.
Has anyone else had any experience of this - or indeed any successful approaches to engaging the 'less engaged' stakeholders?
Kathryn.

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My name is Jenna and this is my second year of DL. I've found the modules to be very useful, albeit sometimes difficult to prioritise around getting married and moving house!
I am a respiratory physiotherapist and I am one year into a two year post within the Pediatric Intensive care unit at The children's hospital in Glasgow. My job role is advanced practice and early mobility.
I am in the process of launching our early mobility service and while we do provide activity for our patients we don't provide it early enough or consistently enough. I also want to ensure the types of activity we provide are suitable for our patients ad their families. I'm hoping this module will help me focus on that aspect and how best to improve our service.

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This is my first year in DL. I am in the first week of my new post, it is pilot funding aimed at preventing falls in nursing homes. I am based in London and have recently moved from Exeter. My new role centres around service improvement- hence the module.
You'll have to bare with me for a few weeks while I get to grips with the post, stake holders, what is to be done and the challenges for this.
In my previous post a positive area of the service was the discharged orientation of the community hospital ward. We would review discharge goals on admission and rehabilitate them to achieve these goals and get home as soon as possible. Before this discharge focus there was increased length of stay and reduced quality of care for the patients. However a challenge when implementing this was staff attitude to change and how to get them on board (I'm sure this will be the big challenge in my new post too!)
Heather

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This is my second year in DL. I am working in an orthopaedic specialty hospital at Barlborough. One of the positive area in our service, - the same as Zoe's-, the enhanced recovery program to reduce the length of stay as well as maintain the quality of care, patient satisfaction within the best possible clinical outcome. ...and I think, this is the challenging aspect as well. I am looking forward to find possible ways/areas to achieve all of those within the successful time scale.
Elizabeth

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I am a respiratory physiotherapist, currently working as a Deputy Team Leader for the Thoracic Surgical Service at Papworth Hospital.

A positive area of service improvement that I have been involved with is the Enhanced Recovery Programme for all the Thoracic surgical patients. This includes using the whole MDT to improve patient outcome & reduce length of stay. Although its been a concept at Papworth for many years, we lost our way a while back & needed it remodelled to ensure it was successful from now on. This included: pre-operative education, twice daily physio including mobilising, exercise bikes / pulmonary rehab style exercises (until the patients are able to independently exercise), the use of topaz (portable suction) drains & optimising pain management. As a physiotherapy team we have always kept to the enhanced recovery guidelines but there was a change in thoracic surgeons (approx. 12 months ago) and the closure of the thoracic ward (incorporating the thoracic patients to the other surgical wards). I played a very important role as a consistent member of staff to re-educate the new staff / surgeons / thoracic team to ensure we got up & running with the programme again. Organising & running a rolling MDT teaching programme together plus MDT meetings to ensure we were keeping to the standards in a  timely manner. This has allowed for non-thoracic trained nurses to be trained & are up-to-date with Rx / management of these patients. It has been very successful & continues now for all new staff / students / HCA's etc.

One area I have noticed that needs improving is the pre-opertaive sessions the patients get in clinic. They are given all the surgical information (what to expect / time scales post surgery / met their surgeon / anaesthetist etc.) however the physio advice / education is carried out by a specialist nurse (with only the basic knowledge of exercise). I feel this could be done by a physiotherapist in the clinic appointment to ensure we are giving all the correct advice on exercises discussing pulmonary rehab but also talking about airway clearance (so they are optimised before the surgery) - as lot of our patients are smokers / COPD etc. Looking at does this improve patient outcome post operatively / improves patient experience, reduce pulmonary complications +/- reduce length of stay.

Zoe

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This is my 6th module, and I am studying part time. I've done a mix of DL and face:face modules over the course of the past 2 years. I work in Scarborough and York as Clinical Lead Physio for Acute Respiratory Care.

A positive aspect of service improvement that I have been involved in has been revamping the on call training programme that we offer to new starters, feedback that I have had from trainee's has been amazing, but I have struggled to get all stakeholders to engage with the new concept. SO, I'm really looking forward to doing this module, because I hope it will help me be able to rectify this problem!!!

Looking forward to the next few weeks,
Ben :-)

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This is my 6th module on the distance learning course. I have just started maternity leave with my 1st baby due on june 11th so am trying to get ahead as not sure how much time i will have (or brain power) once baby is here.
I normally work at Papworth Hospital as team leader for the lung defence and interstitial lung disease Physio team with inpatients and outpatients.
A positive area of recent service improvement i reflected on was creation of a home IV service. This means patients can be taught to administer their own IV antibiotics and continue this at home for the 2 weeks rather than needing a 14 day admission. This free's up beds for those more acutely unwell or unable to administer their own, reduces infection risks, saves masses of clinical time and money and promotes patient independence. We review these patients day 1, 7 and 14 which is great for promoting importance of correct Physio routine and reviewing techniques plus graduation of advice over more than 1 session.
An area in need of service improvement is our outpatient clinics as these are over booked, run over time with significant waiting periods and not enough rooms for all of the MDT to see patients therefore wasting time. With a move to a new hospital in the next year and even tighter clinic constraints this is vital that some improvement is seen. Evening clinics and changes to frequency of seeing patients is being considered.
Apologies for the essay!
Siobhan

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Hi, my name is Gina, I am on the DL MSc course.  My specialist area of practice is neuro. I've worked in most areas of neuro over the past 10+ years from acute to long term conditions, in patients, out patients and community, NHS and private.  I am not currently working as we are living in Germany for 2 years (hence the DL MSc) but I'm hoping to return to neuro in the UK next summer.  This means that I do not have a current service to reflect upon which might make certain aspects of reflection a bit more challenging, but I can use examples of both positive experiences and challenges from previous employers

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Hi, my name is Gina, I am on the DL MSc course.  My specialist area of practice is neuro. I've worked in most areas of neuro over the past 10+ years from acute to long term conditions, in patients, out patients and community, NHS and private.  I am not currently working as we are living in Germany for 2 years (hence the DL MSc) but I'm hoping to return to neuro in the UK next summer.  This means that I do not have a current service to reflect upon which might make certain aspects of reflection a bit more challenging, but I can use examples of both positive experiences and challenges from previous employers

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My most recent employment was with a PCT managing neuro long term conditions in the community.  It was a great service and highly valued by our client base.  We were well resourced in terms of time and access to specialist services, the team worked extremely well together and communication was fluid.
A challenge came to the team, when a very long standing member of the team left, she had set up the service many years previously and knew every client on the list personally.  Many patients would ring up and would expect to speak to her personally and issues would arise because she was no longer available.  On reflection, this highlights the importance of succession planning within a team.  The team could have been structured so that clients came into contact with a wider variety of professionals so that they did not become so dependent on one staff member which would have made their adjustment to staffing changes a much easier process.
Gina Turner

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Welcome to the discussion padlet that will run throughout the module.  After you have listened to the module introduction screencast, it would be great for you to introduce yourselves and your area of practice on this stream.  I would also be interested to hear about any key reflections you would like to share regarding your reflection of either positive or challenging aspects of your service.

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Welcome to the discussion padlet that will run throughout the module.  After you have listened to the module introduction screencast, it would be great for you to introduce yourselves and your area of practice on this stream.  I would also be interested to hear about any key reflections you would like to share regarding your reflection of either positive or challenging aspects of your service.

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Kathryn.