March 2012 | Volume 18 | Number 10 NURSING MANAGEMENT30

Feature Feature

The need for the nhS to have a coherent, stable and enduring framework on which to base quality and service improvements has been recognised by the government (department of health (dh) 2010) following publication of former health minister Lord darzi’s next Stage Review (dh 2008). The remit of the Care Quality Commission has been extended to include developing quality-based outcome frameworks and devolving responsibility for improvements to health professionals (dh 2010).

Successful implementation of any quality initiative depends on how it is applied in a local context (Powell et al 2009). This article reports on how the ‘plan, do, study, act’ (PdSA) service improvement tool (deming 1986) (Figure 1) was used by nurses to address one quality issue, namely to provide clients with appropriate and timely physical care.

Improvement approachesThe need to improve health services is an international concern (World health Organization (WhO) 2008) and a strategic aim of many healthcare organisations (nolan 2007). Various organisational

approaches to quality improvement have been applied to UK health care, including:■■ Use of clear standards of care as a basis for identifying what services should deliver (Morrell et al 1997, Williamson 2000).

■■ Application of medical audits (Packwood 1991, Packwood et al 1994) and clinical audits (Lord and Littlejohns 1994, Johnston et al 2000) to monitor adherence to standards.

■■ Introduction of system-wide frameworks such as clinical governance, incorporating audits (Freeman 2003, Tait 2004), to put quality at the heart of management.

Powell et al (2009) identify five approaches to quality improvement (Box 1), which were first developed in industry. They are now applied in healthcare settings, and require organisational commitment and the development of comprehensive support systems to be effective.

Selecting the PDSA tool no specific organisational approach to service improvement was in place in the mental health unit where this quality initiative was undertaken.

The PdSA tool (deming 1986) was selected because, in contrast to large-scale approaches, it results in small changes that minimise risk and disruption, require little financial investment and can be quick (Powell et al 2009).

The PdSA tool can also be adjusted to meet local needs (dopson and Fitzgerald 2005, WhO 2008); it requires front line staff to determine the issues to be addressed, and suggest and test solutions. This means change is generated from the bottom up, rather than imposed from the top (Langley et al 1996, Boaden et al 2008, Powell et al 2009), increasing staff

How to address the physical needs of clients in a mental health settingNutmeg Hallett and Alistair Hewison describe a nurse-led initiative to improve the care of patients in a medium secure unit. A bottom-up approach was used to identify the issues, with staff across all wards contributing solutions

AbstractPeople with mental health illness, particularly those affected in the long term, experience higher rates of morbidity and mortality than the general population. It is, therefore, crucial to meet their physical health needs as part of delivering a high quality service. This article reports on how nurses in a medium secure mental health unit used the ‘plan, do, study, act’ approach (Deming 1986) as a practice improvement tool to introduce a system of monitoring the physical health of service users.

KeywordsMental health, medium secure unit, physical health, practice improvement

Correspondencenutmeg.hallett@bsmhft.nhs.uk

Nutmeg Hallett is an registered mental nurse at Reaside Clinic, Birmingham and Solihull Mental Health NHS Foundation Trust

Alistair Hewison is senior lecturer, school of health and population sciences, University of Birmingham

Date of acceptanceJanuary 30 2012

Peer reviewThis article has been subject to double blind review and checked using antiplagiarism software

Author guidelineswww.nursingmanagement.co.uk

NURSING MANAGEMENT March 2012 | Volume 18 | Number 10 31

Feature Feature

ownership of change, a requirement for success (Greenhalgh et al 2004).

The rationale for the PdSA approach is rooted in systems theory, which suggests that organisations are made up of interdependent, interacting systems that are unpredictable and non-linear. This means small actions can result in change as the effects spread throughout the organisation. Short-cycle, small-scale tests linked to reflection enable healthcare teams to learn on the basis of action and its observed effects (Berwick 1998, Iles and Sutherland 2001).

The PdSA approach involves the following cycle of activity (Figure 1):■■ Plan: plan the change to be tested or implemented.

■■ do: carry out the change.■■ Study: study the data before and after the change and reflect on what has been learned.

■■ Act: act on the information and plan the next change cycle (Kilo 1998, Ketley and Bevan 2007).

The quality issue identified in the medium secure unit was to be addressed by the unit’s nurses, requiring a tool that would not involve major organisational change. The PdSA tool has been shown to initiate change successfully in this way.

Box 1 Quality improvement approaches

(Powell et al 2009)

Total quality management/continuous quality improvementThe terms total quality management and continuous quality improvement (QI) are often used interchangeably. QI is a continuous activity focused on the needs of ‘internal and external customers’ and these approaches have been used in UK health care (Øvretveit 1994, Joss and Kogan 1995, Appleby and Jackson 2000, Lim and Tang 2000). However, the initial changes were not sustained because the approach was implemented in a piecemeal way, with only some of the principles being consistently applied (Powell et al 2009).

Business process re-engineeringThis is based on a ‘radical clean break’ approach to organisational change. However, two substantial three-year NHS re-engineering pilots in the 1990s produced only modest changes.

Although there were differences in experience at each site, the radical re-engineering vision was not realised at either site in practice. Instead, initiatives

went through several redefinitions and were watered down into more modest changes with more limited improvements.

Institute for Healthcare Improvement (IHI) rapid cycle changeRapid cycle change is based on Langley et al’s (1996) model for improvement, which asks three questions:■■ What are we trying to accomplish?■■ How will we know that a change is an improvement?

■■ What changes can we make that will result in improvement?

Action to address the questions is taken by frontline staff using ‘plan, do, study, act’ cycles (Boaden et al 2008), to provide a framework for repeated short-cycle and small-scale tests of change linked to reflection.

Lean thinkingThis focuses on improving organisational processes to provide what ‘internal or external customers’ want with minimal wasted time, effort or cost. It involves a range of tools such as ‘value-stream mapping’, to

remove any unnecessary steps in a process (Jones and Mitchell 2006), and it is useful in streamlining processes to support departments rather than mainstream clinical services. Although it has been deemed successful in the public sector (Radnor et al 2006), effective wholesale application has not been demonstrated in healthcare settings (Fillingham 2008, Powell et al 2009).

Six SigmaThis approach to quality improvement in health care originated in industry in the 1980s. It incorporates a structured approach – define, measure, analyse, improve, control – and statistical process-control tools to identify variations in processes and their cause.

Its application has been limited in health care, although Powell et al (2009) suggest it can enable prospective and retrospective analyses of variations in a process, and identify unwarranted variation, such as reducing the turnaround time for the analysis of pathology specimens, that needs to be reduced.

Figure 1 The ‘plan, do, study, act’ cycle

(Adapted from NHS Institute 2007)

How do we make change?

How to answer the questions?

What are you trying to accomplish?

How will you know that a change is an improvement?

What changes can you make that will result in the

improvement you seek?

Act

Study

Plan

Do

Three fundamental questions for improvement

Aims

Measurement

Ideas

March 2012 | Volume 18 | Number 10 NURSING MANAGEMENT32

Feature Feature

For example, Tehan and O-Keefe (2008) describe how it was used by intensive care unit (ICU) staff in a district general hospital to reduce the number of preventable patient-adverse events such as ventilator-acquired pneumonia. The researchers found that, because staff were actively involved in the change process, they embraced the changes, which were sustained over two years.

ProjectPeople with mental health problems, particularly those with severe mental illness, experience higher rates of morbidity and mortality than the general population and are at greater risk of premature death. Research from the US (Parks et al 2006) shows that, on average, people with severe mental illness die 25 years earlier than the general population. Up to 40 per cent of these deaths are caused by suicide and injury, but the rest are the result of medical conditions such as cardiovascular and pulmonary disease.

In the UK, for example, people with severe mental illness are at greater risk of dying from coronary heart disease and stroke than the rest of the population. The risk increases if they take antipsychotic medication (Osborn et al 2007).

Weight gain induced by antipsychotic medication is a common problem and can have associated serious physical and psychological consequences, including ischaemic heart disease, stroke, respiratory disease and diabetes (Whitlock et al 2009). It also has a negative effect on individuals’ self-image, a factor implicated in non-adherence to treatment that in turn can contribute to relapse (haupt 2006).

People with severe mental illness are at greater risk of developing diabetes mellitus, which is a side effect of second-generation, or atypical, antipsychotic

medications (Bushe and holt 2004, Üçok and Gaebel 2008), such as clozapine.

Atypical antipsychotics are also associated with hyperlipidaemia, prolongation of the QTc interval on electrocardiogram readings and myocarditis (Üçok and Gaebel 2008).

The number of people with severe mental illness prescribed atypical antipsychotic medications is increasing (nhS Business Services Authority 2009), so there is an urgent need to monitor and optimise their physical health.

Initiating the project Researchers (Marder et al 2004, Ohlsen et al 2005) recommend careful monitoring of the physical health of people with severe mental illness to detect problems early and identify the need to support lifestyle changes or initiate prompt treatment.

The medium secure mental health unit involved in this study introduced a care package to monitor and maintain the physical health of its clients. This included the creation of a healthy lifestyle co-ordinator post, designating identified nurses as physical health leads, and holding regular meetings with stakeholders to raise awareness of the initiative and to report on progress. The physical health leads are ward based and therefore ideally placed to ensure that physical health monitoring is carried out.

One of the roles of physical health leads is to audit the physical health monitoring of clients. This was initially conducted on a ward-by-ward basis with no overview of the unit as a whole. To address this, a proposal was made to the unit’s audit committee to formalise the process of auditing physical health monitoring across the unit. This was accepted, and one of the physical health leads was assigned to action the audit.

The PdSA cycle was used to ensure that the audit process improves clients’ care by focusing on action as well as monitoring. The audit process had three main objectives:■■ To track current levels of physical health monitoring undertaken by the unit’s nurses.

■■ To raise awareness of the monitoring procedures in place.

■■ To provide data to inform action to improve completion rates for physical monitoring if necessary.

The unit’s policy is to record clients’ temperature, pulse, blood pressure (TPBP) and weight at least once a week, and assess individuals’ nutritional status on admission, and monthly thereafter (Box 2). A monitoring form was developed so that the physical health lead on each ward could audit

Box 2 Two-part nutritional assessment

Part 1 is completed for every patient and involves the following four steps:■■ Record client’s weight.■■ Calculate client’s body mass index (BMI).■■ Record any unintentional weight loss or gain in the past three months.■■ Record medication regimen to identify if a prescribed medication, such as atypical antipsychotic medication, is likely to affect weight.

■■ Take a history of existing conditions, such as diabetes, that might affect weight.

Part 2 is completed if a client’s BMI is below 18 or above 30, or if any risk factors are identified in part 1 of the assessment. It involves a more detailed examination of issues identified in part 1.

Specific items relating to these areas are rated on a severity scale of between zero and four, and an overall risk score is calculated. If a patient’s final score is between zero and three, nutritional screening is repeated a week later. If it is higher, the client is referred to a dietician and, if necessary, to a physiotherapist.

NURSING MANAGEMENT March 2012 | Volume 18 | Number 10 33

Feature Feature

the level of compliance with agreed trust policy. The purpose of this was twofold:■■ To prompt for staff to undertake observations and assessments.

■■ To highlight problems at ward and unit level.

ImplementationPlan The monitoring form includes sections for recording the frequency and consistency of completion of the required observations and assessments. This is designed as a simple checklist comprising the names of each service user on the ward, with columns to record:■■ Whether they had nutritional screening.■■ Whether they had been weighed that week.■■ Frequency of required observations.■■ number of observations that week.

The content and format was verified by the unit’s audit committee.

Do The unit comprises seven wards: one intensive care ward, two acute wards and four rehabilitation wards. Since all seven were participating in the initiative, the physical observations monitoring form was introduced beforehand to all physical health leads in the unit at their monthly meeting and emailed to them so that additional copies could be produced as necessary.

The importance of the tool was emphasised at the meeting and in a follow-up email, and the leads were reminded of their responsibility to ensure forms were completed weekly. The audit took place over three months and completed forms

were collated so the study phase of the PdSA cycle could begin.

Study When the results of the audit were analysed, it emerged that only one of the unit’s seven wards had 100 per cent compliance for completing the monitoring form during the review period (Table 1, page 34).

The data demonstrate that, although observations and nutritional assessments were carried out broadly in line with trust policy on some wards, improvement was needed in other areas. The greatest variation between wards was for ‘assessment of nutritional status’, with compliance ranging from 0 to 100 per cent.

Act A number of changes were put in place as a result of the data collection. For example, the monitoring form was simplified because not all the data collected were necessary. Initially, there was a column to show the percentage of TPBP observations undertaken for each client. however, staff found this unhelpful and confusing, so it was removed in the hope that it would increase completion rates.

In view of the variation in completion rates across the unit, all physical health leads and ward managers were reminded, face to face and by email, of the importance of undertaking the observations and assessments, and the need to complete the monitoring form. In addition, a folder containing guidance notes and a full set of forms for the next audit round was created for each ward and given to each ward manager.

Yvon

ne L

ee

March 2012 | Volume 18 | Number 10 NURSING MANAGEMENT34

Feature Feature

One of the issues highlighted was that scales were not available on every ward; this was raised with the supplies manager and seven sets of scales ordered. It was also found that the nutritional screening tool and TPBP observation charts were not passed on when clients transferred between wards, so a transfer checklist was designed to ensure all necessary paperwork accompanied clients.

To address the problem of incomplete nutritional screening, the clinical lead for physical observations spoke with each of the physical health leads

to ensure they knew how to complete the forms. They were then able to encourage ward staff to complete them regularly for all clients in line with trust policy.

OutcomesThree months after the changes were implemented the audit was repeated to determine whether there was any improvement in monitoring rates (Table 2). Overall compliance levels increased by 42 per cent, and at least some forms were completed on every ward.

There was an increase on all but one ward in the number of clients’ whose weight was checked weekly, and the greatest improvement was seen on a rehabilitation ward, which saw an increase in compliance from 68 per cent to 92 per cent. The simple action of providing each ward with a set of scales was regarded as crucial to this improvement.

however, there were also some reductions in measurement. For example, one ward had a decline in the rate of weighing patients, although this might have been because of changes in how data were recorded. Originally, if service users refused to be weighed, it was recorded that their weight had been checked as long as they had been asked, but over the second audit period this was recorded as ‘not checked’.

This might also account for the same ward’s reduction from 90 per cent to 88 per cent in completion of TPBP observations. The rate of compliance for recording TPBP in the unit ranged from 77 to 94 per cent in the second audit period (Table 2).

Appleby A, Jackson C (2000) The impact of IiP on TQM and staff motivation in general practice. International Journal of Health Care Quality Assurance. 13, 2, 53-64.

Berwick D (1998) developing and testing changes in the delivery of care. Annals of Internal Medicine. 128, 8, 651-656.

Boaden R, Harvey G, Moxham C et al (2008) Quality Improvement: Theory and Practice in Health Care. national health Service Institute for Innovation and Improvement, Coventry.

Bushe C, Holt R (2004) Prevalence of diabetes and impaired glucose intolerance in patients with schizophrenia. British Journal of Psychiatry. 184, Suppl 47, S67-S71.

Deming W (1986) Out of the Crisis. Massachusetts Institute of Technology, Cambridge MA.

Department of Health (2008) High Quality Care for All: NHS Next Stage Review Final Report. dh, London.

Department of Health (2010) Equity and Excellence: Liberating the NHS. dh, London.

Dopson S, Fitzgerald L (eds) (2005) Knowledge to Action: Evidence-based Health Care in Context. Oxford University Press, Oxford.

Fillingham D (2008) Lean Healthcare, Improving the Patient’s Experience. Kingsham Press, Chichester.

Freeman T (2003) Measuring progress in clinical governance: assessing the reliability and validity of the clinical governance climate questionnaire. Health Services Management Research. 16, 4, 234-250.

Greenhalgh T, Robert G, Bate P et al (2004) How to Spread Good Ideas: A Systematic Review of the Literature on Diffusion, Dissemination and Sustainability of Innovations in Health Service Delivery and Organisation. national Co-ordinating Centre for Service delivery and Organisation, London.

Haupt D (2006) differential metabolic affects of antipsychotic treatments. European Psychopharmacology. 16, Suppl 3, 149-155.

Iles V, Sutherland K (2001) Organisational Change: A Review for Health Care Managers, Professionals and Researchers. national Co-ordinating Centre for Service delivery and Organisation, London.

Johnston G, Crombie I, Davies H et al (2000) Reviewing audit: barriers and facilitating factors for effective clinical audit. Quality in Health Care. 9, 1, 23-36.

Jones D, Mitchell A (2006) Lean Thinking for the NHS. nhS Confederation, London.

Joss R, Kogan M (1995) Advancing Quality: Total Quality Management in the NHS. Open University Press, Buckingham.

Ketley D, Bevan H (2007) Changing by numbers. In Buchanan d, Fitzgerald L, Ketley d (eds) The Sustainability and Spread of Organizational Change. Routledge, London.

Kilo C (1998) A framework for collaborative improvement: lessons from the Institute for healthcare Improvement’s Breakthrough Series. Quality Management in Health Care. 6, 4, 1-13.

Langley G, Nolan K, Nolan T et al (1996) The Improvement Guide: A Practical Approach to Enhancing Organisational Performance. Jossey Bass, San Francisco CA.

Lim P, Tang N (2000) The development of a model for total quality healthcare. Managing Service Quality. 10, 2, 103-111.

Lord J, Littlejohns P (1994) Secret garden. Health Service Journal. 104, 5417, 18-20.

Marder S, Essock S, Miller A et al (2004) Physical health monitoring of patients with schizophrenia. American Journal of Psychiatry. 161, 8, 1334-1349.

Morrell C, Harvey G, Kitson A (1997) Practitioner based quality improvement: a review of the Royal College of nursing’s dynamic standard setting system. Quality in Health Care. 6, 29-34.

References

Table 1 Rates of observations, weight recordings and completed nutritional assessment for the first audit period

Percentage of forms returned

Temperature, pulse, blood pressure observations (%)

Weight (%) Nutritional screening (%)

Intensive care unit

0 Data not available

Data not available

Data not available

Acute A 100 66 79 76

Acute B 45 82 88 49

Rehab A 36 66 74 0

Rehab B 64 90 98 100

Rehab C 27 85 68 41

Rehab D 0 Data not available

Data not available

Data not available

NURSING MANAGEMENT March 2012 | Volume 18 | Number 10 35

Feature Feature

ChallengesThe nhS Institute (2008) suggests it is important to generate enthusiasm for proposed changes to overcome inevitable barriers. In this project, the introduction of the monitoring form was a challenge; although completing it was part of the physical health leads’ role, initially this was not being done. When this was brought up at monthly meetings, it was found that insufficient guidance had been provided to persuade the leads that doing so was necessary.

discussions were held at monthly meetings to correct this oversight and to give everyone involved in the initiative the chance to identify problems and solutions. This fostered group ‘ownership’ of the process as the relevant issues were discussed and the audit results were shared.

A team approach supports change. Robertson and Jochelson (2008) state that small-scale, interactive meetings are an effective way of supporting change, while Watt et al (2004) point out that a lack of teamwork is a barrier.

Feedback is also crucial and its effects are greatest when clinicians are actively involved in discussions about its implications (Robertson and Jochelson 2006).

ConclusionIt is hoped that improvements in monitoring clients’ physical health will reinforce the work undertaken by the physical health leads, and that there will be further improvements in observation and assessment rates to achieve full

compliance. Although this is a relatively small change in practice, it will serve as a foundation for improving the physical health of clients with severe mental illness.

The PdSA cycle is useful for implementing and assessing incremental changes as part of a continuing cycle of quality improvement and can be used in a range of settings. Changes in practice have been made and further cycles of the PdSA will be undertaken to try to ensure that clients who attend the unit receive appropriate physical health care.

Conflict of interestNone declared

Online archiveFor related information, visit our online archive of more than 6,000 articles and search using the keywords

Table 2 Rates of observations, weight recordings and completed nutritional assessment for the second audit period

Percentage of forms returned

Temperature, pulse and blood pressure observations (%)

Weight (%) Nutritional screening (%)

Intensive care unit

91 89 74 77

Acute A 100 82 87 80

Acute B 100 94 95 83

Rehab A 82 83 96 37

Rehab B 64 88 91 100

Rehab C 55 77 92 31

Rehab D 73 89 99 20

NHS Business Services Authority (2009) PCT Prescribing Report (August 2009) Antipsychotic Drugs – Prescribing Guidance and Discussion Points. nhS Business Services Authority, newcastle upon Tyne.

NHS Institute for Innovation and Improvement (2008) Human Barriers to Change. http://tiny.cc/7ic0n (Last accessed: February 1 2012.)

NHS Institute for Innovation and Improvement (2007) The Improvement Leaders’ Guides. www.institute.nhs.uk/improvementleadersguides (Last accessed: February 1 2012.)

Nolan T (2007) Execution of Strategic Improvement Initiatives to Produce System-Level Results. IHI Innovation Series White Paper. Institute for healthcare Improvement. Cambridge MA.

Ohlsen R, Peacock G, Smith S (2005) developing a service to monitor and improve physical health in people with serious mental

illness. Journal of Psychiatric and Mental Health Nursing. 12, 5, 614-619.

Osborn D, Levy G, Nazareth I et al (2007) Relative risk of cardiovascular and cancer mortality in people with severe mental illness from the United Kingdom’s general practice research database. Archives of General Psychiatry. 64, 2, 242-249.

Øvretveit J (1994) All together now. Health Service Journal. 104, 5437, 24-26.

Packwood T (1991) The three faces of medical audit. Health Service Journal. 101, 5271, 24-26.

Packwood T, Kerrison S, Buxton M (1994) The implementation of medial audit. Social Policy & Administration. 28, 4, 299-316.

Parks J, Svendsen D, Singer P et al (2006) Morbidity and Mortality in People with Serious Mental Illness. national Association of State Mental health Program directors, Alexandria VA.

Powell A, Rushmer R, Davies H (2009) A Systematic Narrative Review of Quality Improvement Models in Health Care. healthcare Improvement Scotland, edinburgh.

Radnor Z, Walley P, Stephens A et al (2006) Evaluation of the Lean Approach to Business Management and its Use in the Public Sector. Scottish Government, edinburgh.

Robertson R, Jochelson K (2006) Interventions hat Change Clinician Behaviour: Mapping the Literature. national Institute for health and Clinical excellence, London.

Tait A (2004) Clinical governance in primary care. Journal of Clinical Nursing. 13, 6, 723-730.

Tehan B, O’Keefe S (2008) Implementing change – the experience of the district general ICU. Journal of the Intensive Care Society. 9, 3, 224-227.

Üçok A, Gaebel W (2008) Side effects of atypical antipsychotics: a brief overview. World Psychiatry. 7, 1, 58-62.

Watt R, McGlone P, Evans D et al (2004) The facilitating factors and barriers influencing change in dental practice in a sample of english general dental practitioners. British Journal of Dental Practice. 197, 8, 485-489.

Whitlock G, Lewington S, Sherliker P et al (2009) Body-mass index and cause specific mortality in 900,000 adults: collaborative analyses of 57 prospective studies. Lancet. 373, 9669, 1083-1096.

World Health Organization (2008) Guidance on Developing Quality and Safety Strategies with a Health System Approach. WhO Regional Office for europe, Copenhagen.

Williamson C (2000) Consumer and professional standards: working towards consensus. Quality in Health Care. 9, 3, 190-194.

References

Copyright of Nursing Management - UK is the property of RCN Publishing Company and its content may not

be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written

permission. However, users may print, download, or email articles for individual use.