1. ‘Learning To Make a Difference’ for our patients Dr Emma Vaux

2. Learning To Make a Difference The aim of the pilot A (supervised) trainee completes a quality improvement ‘Learning To Make Difference’ project (LTMD) within a 4-6 month training post 2

3. Learning to Make a Difference: Rationale All core medical trainees are required to perform an audit each year as part of their training. Most projects achieve little but simply consist of an initial data collection exercise As a result they learn little and make no difference to their own practice or the experience of their patients. They learn little about the real power of quality improvement in practice.

4. What is Learning to Make a Difference? An initiative to enhance the training of core medical trainees To enable them to learn, develop and embed new skills in quality improvement and put these new skills into practice. To make a real difference to the quality of their clinical practice and patient care.

5. What did the pilot involve? A CMT would complete a QI project within a 4 -6 month training post (or can decide to do a project over the whole year) Each trainee had a supervisor – this might be their educational or clinical supervisor The trainee worked on their own, as a group and/or involve the multi-disciplinary team The trainee would decide on a project and then follow the guidelines outlined in the ‘trainee tool kit’ Ideally the project was a trainee-led idea August 2010 to April 2011

6. Simple approach Use the PDSA (Plan, Do, study, act) Cycle How? 6

7. An example Measure Number of catheters inserted according to trust guidelines measured on a weekly basis….start with baseline before any change made and then keep measuring frequently Measure Number of catheters inserted according to trust guidelines measured on a weekly basis….start with baseline before any change made and then keep measuring frequently Aim To reduce the number of inappropriate urinary catheters inserted into patients admitted to the Clinical Decision Unit by 50% by January 2012 Aim To reduce the number of inappropriate urinary catheters inserted into patients admitted to the Clinical Decision Unit by 50% by January 2012 Change Introduce a checklist to be completed prior to any catheter insertion Change Introduce a checklist to be completed prior to any catheter insertion Test out the next change and keep measuring………….

8. Measurement 8

9. Learning to make a difference pilot project Anxiety and Depression in Acute Stroke Patients Dr Olivia Walker

10. Reason’s behind the Project NICE guidelines - Agreed local policies and guidelines for screening patients with stroke within 6 weeks of diagnosis, using a validated tool, to identify mood disturbance. Meets the need identified in addressing mood in acute stroke patients in the biannual RCP National Sentinel Stroke Audit. Research suggests that undiagnosed anxiety and depression can have a negative impact upon rehabilitation.

11. The objective To develop a local protocol that can be used to screen all acute stroke patients for anxiety and depression.

12. Project Aim (1) 100% of stroke patients should have a Depression Scale completed within 5 days of admission and recorded in the notes 100% of patients will have a repeat DEPRESSION SCALE completed in the MDT after 2-3 weeks.

13. Project Aim (2) 100% of patient’s identified with anxiety and/or depression will be referred to the neuropsychologist. All aims to be completed within 4 month time frame on the ASU

14. Change 1 The identification of an appropriate anxiety and depression tool which can be implemented in the RBH acute stroke unit. Discussion with the neuropsychologist identified 2 suitable assessments: o Hospital Anxiety and Depression Scale (HADS) o Numeric Graphic Rating Scale (NGRS)

15. Review of 20 stroke patient’s notes on the unit, on one particular day, using my pro forma. Assessing each patient using either the HADS or the NGRS in the stroke unit on one particular day. 1.Need specific guidelines/flow chart to identify which scale to use. 2.Completing the scales is time consuming, therefore a briefer assessment initially would be useful. 3.Need additional scale for patients with aphasia/dysphasia. 4.Patients with cognitive impairment need assistance with completing a scale. What I Tested Outcomes

16. Change 2 1. The identification of additional scales The Signs of Depression Scale – to be completed for each patient within 5 days of admission either by the OT or in the twice weekly MDT meeting. HADS – to be used with patient’s without aphasia. If cognitive impairment the OT will go through each question with the patient. NGRS or the DISCs Scale – for patients who struggle with the HADS. The Stroke Aphasic Depression Questionnaire – for patients with aphasia. 2. The development of a flow chart

17. I reviewed the notes of 20 patients on the acute stroke unit after the implementation of the flow chart. All stroke patients should have an SDSS documented in the notes by the OT’s, within 5 days of admission to the acute stroke unit. 1.Poor completion of the SDSS within 5 days 2.Barriers identified following discussion with OT’s - Not part of their routine assessments and therefore can be forgotten. Having the SDSS printed on white paper doesn’t highlight it resulting in it often being overlooked. What I tested Outcomes

18. Change 3 The SDSS is included in the initial patient assessment by the OT’s. The SDSS is printed on yellow paper.

19. 2 weeks later I reviewed the notes of 20 patients on the stroke unit following the new changes. 1.Improved completion of the SDSS but not yet 100% achieved. 2.New issue identified- Only having an initial SDSS may miss patient’s who develop anxiety/depression later in their admission. What I Tested Outcome

20. Acute stroke unit mood assessment pathway Yes SALT input required to allow for comprehensive screening to take place SADQ DISCS/ NGRS No HADS Score ≥ 9 refer urgently to medical team and neuropsychologist Does the patient have a language problem?

21. A run chart to demonstrate the change over time since the introduction of the SDSS Modified Flow Chart Introduced SSDS printed on yellow paper SDSS Introduced Flow chart

22. The Differences Made An MDT approach to tackling anxiety and depression in acute stroke patients The RBH Stroke Unit is now compliant with the NICE Guidelines and the biannual RCP National Sentinel Stroke Audit. The new assessment tool identifies patients who may have previously remained undetected.

23. Next Steps 1.The continued assessment and re-assessment of acute stroke patients during their admission for anxiety and depression. 2.To consider risk factors that may predispose a patient to anxiety or depression following a stroke. 3.Lead OT identified to audit the new tool on a regular basis.

24. Learning Points 1.As a junior doctor you can make a difference to patient care. 2.Change takes time and requires dedicated and enthusiastic colleagues to maintain them. 3.It is important to be able to adapt the project as problems arise and accept that timescales often need to be modified.

25. Other QI project ideas Improving care on Acute Stroke Unit using a patient feedback questionnaire Improve to >90% the proportion of nurses on medical wards who can identify the correct doctor to bleep on a Saturday or Sunday Improving Final Year Medical Students’ Learning and Clinical Experiences on the Medical Firms All biopsies should have the right tests performed on them (which means sending them to the right place in the right transport medium) Use of sharps bins Medical handover Warfarin prescription End of life prescriptions

26. Pilot Study 2010/11 61 Trainees undertook 46 quality improvement projects across 5 deaneries LTMD has demonstrated more evidence of benefit to patients than any of the current workplace based assessments. (Clin Med Dec 2012) Participant Reaction- positive learning experience Acquisition of skills and knowledge – QIP assessment tool Change in behaviour- putting new skills into practice Organisational practice and benefit to patients – QIP impact, return on investment

27. Comments from Judges ‘Very impressive group of projects’ 'Moving to see so many SHOs bringing and putting ideas into practice to improve patient care‘ ‘I was so impressed by the standard of the work and the presentations. I was also really pleased to see how passionate people were about developing and taking practice forward, and very reassuring for the future of our patients.’ 27

28. Moving forward: LTMD programme LTMD is no longer a pilot but expected practice LTMD programme enables training in improvement methodology for the development of new skills relevant to being a physician in the 21 st century Embed improvement methodology in CMT training Developing right infrastructure to facilitate delivery Develop networks to support this process

29. Website Trainee and supervisor pack resources Presentations from peers How to get started Templates to use http://www.rcplondon.ac.uk/r esources/clinical- resources/learning-to-make-a- difference Emma.vaux@royalberkshire.nhs.uk 01183227968 07788780214