People with serious mental illness (SMI), such as schizophrenia and bipolar disorder, die earlier than the rest of the population due to preventable disease and remains an intractable problem. In response, our clinical team set out to design a strategy to improve the physical health of inpatients within our mental health unit.
This brought together a multi-professional team of doctors, psychologists, nurses and pharmacists and physical activity co-ordinators, and importantly included service users, who could bring a whole new perspective to the problem. We used a range of quality improvement methods and approaches to assess the local problem, identify potential solutions based on current guidelines and subsequently design, implement and test interventions to improve physical health.
This initiative explicitly draws on relevant recommendations from NICE Clinical guidelines: recommendations 1.1.3 from CG178 - Psychosis and schizophrenia in adults; recommendations 1.2 and 1.8 from CG185 - Bipolar disorder: assessment and management; and recommendations 1.1.9 and 1.6.3 from CG136 - Service user experience in adult mental health.
- Psychosis and schizophrenia in adults: prevention and management (CG178)
- Bipolar disorder: assessment and management (CG185)
- Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services (CG136)
- Psychosis and schizophrenia in adults (QS80)
Aims & Objectives
The aim of the initiative was to improve the physical health of people with serious mental illness within an inpatient setting through early identification of cardiovascular and diabetes risk factors and subsequent access to information and to services to support risk reduction strategies.
This was achieved through:
- Improving the inpatient physical health assessment processes;
- Improving the mechanisms for recording and monitoring inpatient physical health assessments;
- Developing a patient held physical health record to improve communication of physical health risk factors and support shared decision making about access to interventions;
- Develop educational materials and activities to encourage and support self-management of patients’ physical health conditions.
People with SMI have a significantly reduced life expectancy and a higher prevalence of physical health disorders than the general population. The monitoring of indicators and risk factors for cardiovascular and metabolic disease in people with psychosis and schizophrenia should be routinely conducted, as recommended in NICE clinical guidelines 178 - Psychosis and schizophrenia in adults: prevention and management and 185 - Bipolar disorder: assessment and management.
Furthermore, the Lester Tool, based on NICE guidelines and recommendations including Quality Standard 80 - Psychosis and schizophrenia in adults, provides an evidence-based framework for the diagnosis and management of cardiovascular and metabolic diseases, such as diabetes.
Admission to hospital offers an opportunity to assess the cardio-metabolic risk factors of patients and provide advice and support on risk reduction strategies and access to appropriate services on discharge. The National Audit of Schizophrenia in 2014 identified that only a third of patients were having five or more metabolic factors regularly assessed, which included: smoking, body mass index (BMI), blood glucose, blood lipids and blood pressure; within the Trust this was shown to be just one in five patients.
To explore this ‘gap’ locally we carried out an audit to assess the rates of recording of physical health assessment between April 2014 and January 2015 for patients admitted to an acute admission ward within the Trust. The ward sees approximately 25 direct admissions per month and covers and ethnically and economically diverse region of inner London. The audit reviewed three of the five factors which showed that whilst smoking status was recorded for 80.2% of patients, systolic blood pressure and BMI was only recorded for 21.5% and 22.3% of patients, respectively. This suggested there was evidently room for improvement.
Crucial to exploring the problem and testing potential solutions was securing funding to release staff to be involved in the project and identifying the right tools and approaches. Funding was secured from The Health Foundation’s SHINE programme and technical support and facilitation was provided by the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London.
We established a representative team including three service users. Their involvement was guided using the National Involvement Standards which ensured there was clarity around the process and purpose of involvement, shared principles amongst the team, service user presence at different phases and an understanding of their impact on both the project and all team members.
We used the Action Effect Method, a quality improvement approach developed by CLAHRC, to facilitate discussion and consensus building to explore the views and ideas of the project team. This identified a shared aim for the project and potential solutions aligned to existing evidence/guidelines, which included three mains areas of work: improving physical health assessment and monitoring; developing a shared decision making tool; developing education and training for staff and patients. Process mapping was undertaken to explore systems and processes linked to the assessment of physical health on the ward and provided platform for healthcare professionals and service users to bring their different perspectives.
The process mapping highlighted several key areas for improvement, but also identified areas that were outside of the scope of the project, such as improving the blood test reporting system.
The comprehensive physical health assessment was subsequently tested on the ward by clinical staff using Plan-Do-Study-Act cycles to undertake small-scale testing to iteratively assess and refine the content.
Weekly improvement measures were designed to report on the completion of physical health assessment and monitoring using five key indicators that assess the percentage of patients that had:
- Received a physical health assessment;
- Documented smoking status in the physical health assessment;
- Documented Body Mass Index in the physical health assessment;
- Documented systolic blood pressure in the physical health assessment;
- Documented cardio-vascular risk score (JBS-3) in the physical health assessment
Simultaneously, work was proceeding to co-design a patient-held physical health plan by team members with experience of using services. The physical health plan was based on several existing tools, developed within the NHS and by other organizations, including the Lester Tool. The booklet was designed to act as a record of the patients’ physical health assessment, provide educational support about physical health and promote a healthy lifestyle and self-management.
Results and evaluation
Improving physical health assessment and monitoring: The process mapping identified two existing parallel systems for collecting information about the physical health of patients following admission, one by doctors the other by nurses, each not aware of the other, and recorded in two separate places.
A solution that was to combine these processes for assessment through a comprehensive physical health assessment form, created by combining the information that was being collected by the independent forms. The ward staff undertook trials of change using the Plan-Do-Study-Act cycle framework to iteratively develop the content and structure of the assessment and ensure its acceptability with staff and patients.
The new assessment form also included the introduction of risk calculator for cardiovascular disease and diabetes. Implementation was monitored using the weekly improvement measures and analysed using statistical process control with data were reported to the project team and ward staff monthly. Improvements over 24-months of the data collection were seen in the recording of BMI, 21.5% to 63%, and systolic blood pressure, 22.3% to 87%. Additionally, nearly one in four patients had a recorded cardiovascular risk, which was not previously done, and provided a mechanism for identifying modifiable risk factors that could inform shared-decision to support risk-reduction strategies. These results have demonstrated that sustainable improvements can be achieved in the monitoring of metabolic risk factors as part of a comprehensive physical health assessment.
Developing a shared decision making tool:
Service user project team members led the development of a patient held physical health record, based on existing materials and their own experience. They also engaged with current inpatients to obtain feedback on its design and use. The booklet was developed to act as a patient held record with individualised information about their physical health, including a cardiovascular disease or diabetes risk score. It also provides patients with information about physical health e.g. what blood pressure means and why is it important, and guides shared decision making with staff about appropriate interventions and services to support risk-reduction strategies. Furthermore, the book aims to empower patients to take charge of their physical health and as such support self-care.
Developing education and training for staff and patients:
The Recovery College within the organisation has led on the development of training and educational materials for both staff and patients about physical health with input from the project team. The team hope to monitor signposting and referrals to support services over the next 18 months to assess the effect of the initiative on access to services that can support people with SMI to reduce their risk of developing cardiovascular and metabolic diseases.
Key learning points
Several key aspects have contributed to the success of this project.
- Service user involvement within the project has been critical, but not only an instrumental way through the development of the patient held record, but also in establishing an ethos for improvement, one of candour and collaboration. For many staff within the team this was the first time they had worked with service users in this way and it set a tone for inclusivity and flattened hierarchies.
- The availability of dedicated resources, especially a project manager to oversee the day to day responsibilities and co-ordinate activities has been essential in preventing fatigue within the team and ensuring regular meetings were held to monitor progress of the different aspects of the project.
- The range of quality improvement approaches used within the project provided significant insight into the problem and developing potential solutions that could be tested and scaled up. The collection and reporting of improvement measures was particularly useful to feedback to the team and the wider clinical staff to demonstrate the successes of the project. Also, attending collaborative learning events hosted by CLAHRC Northwest London has enabled team members to acquire skills in these methods themselves.
- The high-level commitment from ward staff has been achieved through regular opportunities to attend meetings and provide input. The ward manager and staff nurse, as ward champions for the project, have had key roles in brokering this link.
- Organisational support has been generated through opportunities to promote the project and has garnered support from senior management and executive leaders, including the CEO. Additionally, the work has been recognised by the Care Quality Commission as part of their inspection of the Trust.
- Although the project has started on a single ward it has been designed using a systems approach to, identifying links across and within the organisation with the aim of extending beyond this.
The work was funded by The Health Foundation and supported by National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care (CLAHRC) North West London.