Acute wards: problems and solutions Implementing real change in acute in-patient care - more than just bringing in the builders . . .

AIMS AND METHOD To develop an evidence-based approach that supports the improvement of
 
front-line delivery of adult acute in-patient services. Key factors of
 
effective organisational change were identified from the literature. These
 
were adopted as part of an ‘evidence-based service development’
 
programme. This approach was used by the Health Advisory Service in a project
 
with an NHS Trust in south east England. RESULTS Significant progress was made in improving the quality of local acute
 
in-patient services. CLINICAL IMPLICATIONS Further development and evaluation of this approach should be undertaken,
 
since it seems to offer significant opportunities to deliver real improvements
 
in the quality of services.


AIMS AND METHOD
To develop an evidence-based approach that supports the improvement of front-line delivery of adult acute in-patient services. Key factors of effective organisational change were identified from the literature. These were adopted as part of an 'evidence-based service development' programme. This approach was used by the Health Advisory Service in a project with an NHS Trust in south east England.

RESULTS
Significant progress was made in improving the quality of local acute in-patient services.

CLINICAL IMPLICATIONS
Further development and evaluation of this approach should be undertaken, since it seems to offer significant opportunities to deliver real improvements in the quality of services.
Improving the standard of adult acute in-patient care remains one of the core challenges faced by mental health services. Change is needed to improve the physical environment, the quality of care planning, the range of therapeutic interventions and the 'interface' between in-patient and community services.
It is increasingly difficult to accept that failure to improve the quality of adult acute in-patient services could be due to a lack of awareness of the problems that they face. High-profile reports such as that of the Sainsbury Centre for Mental Health (1998) have highlighted the issues in relation to the operation of adult acute inpatient services in this country. Current mental health policy also underlines the need to improve these services, including a recently published addition to the Department of Health Mental Health Policy Implementation Guide (Department of Health, 2002).
Considerable improvement has been made to in-patient environments through the re-provision of old wards. It is easy to see the benefits to both staff and patients of replacing older facilities, which are no longer fit for their intended purpose, with state-of-the-art, 'hotel-style' accommodation. However, as recognised in the report Not Just Bricks and Mortar (Royal College of Psychiatrists, 1998), improvement cannot be brought about through re-provision or improvement of the physical environment alone. Changes in ward culture and operational practices must also be addressed and implemented, through means other than just 'bringing in the builders'.

Evidence-based change
The past few years have seen unprecedented changes to the infrastructure of organisations responsible for providing mental health services. Health and social care managers have become skilled at delivering the many complexities of organisational mergers, integration of health and social care, financial initiatives and other strategic changes. However, despite the continuing demand for improvements in methods of service delivery, comparatively little seems to be known about effective methods to facilitate change in 'front-line' teams.
It is clear that services will not change through 'top-down' interventions alone. Similarly, there is evidence that simple training interventions, aimed at equipping front-line clinicians with new therapeutic skills, will be ineffective unless attention is also paid to creating the right kind of organisational conditions, both in terms of the immediate clinical environment and the overall strategic direction. In order to implement meaningful change, action is therefore required at a number of levels in the organisation: from chief executives, senior and middle managers, to front-line staff of all disciplines. A successful programme of service development needs to address different levels of organisational functioning simultaneously in order to achieve the necessary 'depth' for real change to take place and to be maintained.
Any service development programme also needs to achieve the right balance between external help and internal ownership of the process. Services cannot be 'prodded' into action if there is little interest or willingness on the part of key local stakeholders to engage in the change process. Conversely, internal commitment and enthusiasm is seldom sufficient on its own, and the likelihood of positive change is enhanced if there is some kind of external support.

Delivering support to frontline services
The literature on organisational change (e.g. NHS Centre for Reviews & Dissemination, 1999;Iles & Sutherland, 2001) highlights a number of key elements for effective organisational change. These were incorporated into an Rix & Shepherd Implementing real change in acute in-patient care special articles approach intended to support service development in frontline teams (Table 1).
A pilot project in 1999 aimed to facilitate improvement in acute in-patient services, provided by a trust in south east England that was in the process of opening a new acute in-patient unit.
The project was delivered through a series of four one-day workshops, held over an 8-month period, facilitated by the authors but coordinated by a local trust representative. The workshops were attended by a 'development group' of local stakeholders, committed to the change process for the duration of the project. These included senior and middle managers, consultant and staff grade psychiatrists, clinical psychologists, senior and junior nurses, the local health authority commissioner and representatives of a local user group.
At the first workshop, we introduced the development group to the aims and the approach of the project. A detailed presentation was provided about contemporary research for effective adult acute inpatient services, and the issues raised were discussed. In preparation for the second workshop, a first draft set of standards for adult acute in-patient care were drawn from the research literature, professional guidance and policy. The standards provided a structured operational outline of a small number of key goals for change, including improvements to: . assessment and care planning . the interface between acute in-patient and community services . the ward environment . the range of therapeutic interventions provided . clinical governance issues including risk management, staff training and supervision.
At the second workshop, the group were asked to develop this template into a set of standards for adult acute in-patient services that they would like to see implemented locally. Adaptations made included changes to terminology, 're-calibration' of some criteria and addition of further detail. By participating in the workshops, the group were able to achieve a consensus and a shared vision for local acute in-patient services, as detailed in a systematic set of service standards.
In preparation for the third workshop, the group reviewed existing local services against these standards. Individual group members were asked, confidentially, to appraise the extent to which current services met the standards. A service user interviewed patients on the acute in-patient ward, using a structured interview based on the standards.
Anonymised summaries of the raw appraisal findings were presented to the development group at the third workshop. The group worked through these to reach a consensus appraisal for each standard. This provided the opportunity to explore the inconsistencies in the appraisals given by different stakeholders, and 'triangulate' from their views at different levels in the organisation (including service users). This led to detailed exploration of the problems of delivering effective services.
The group developed an 'action plan' of tasks to begin to address the problems that they had identified. Use of the standards as a framework allowed for the issues to be broken down into 'bite-size' pieces, and detailed actions were drawn up for the specific operational issues covered by the standards. Named leads and estimated timescales for completion were included for each task. The breadth of the group membership Rix & Shepherd Implementing real change in acute in-patient care special articles The agreement of a target theme for the work programme and required commitment by members of the development group The use of service standards as a framework for the project The development of initial template standards into local standards through adaptation by development group 2. The need to actively work through any local resistance or obstacles Membership of a development group to reflect a 'cross-section' of representatives of the service able to work together within the group to identify actions and solutions to problems The use of re-appraisal to identify any obstacles or resistance encountered 3. The importance of implementing direct changes in practice, if possible using existing structures or through the use of pilots The use of multiple-level actions consisting of a series of individual tasks Representation of existing groups and structures on the development group The incorporation of actions from the development group into the work of existing groups or structures 4. The need to review progress made not necessarily through measuring 'hard' outcome data, but also by measuring 'soft' outcomes Methods for appraisal of standards allow the use of both quantitative and qualitative data in review of standards The use of re-appraisal of standards and action plans 5. The importance of ensuring that any change made is maintained The adoption of the project plan by the full range of local stakeholders and the use of multiple-level action plans allowed multiple-level actions, consisting of several individual tasks identified for different members of the group. An action plan review date was set. In the intervening 4 months, the development group worked through the action plan and, at the final workshop, progress was reviewed together with any obstacles that had been encountered. After discussion about how to overcome the obstacles identified, the action plan was then amended and updated.

Outcomes
An example of how change was achieved in relation to one of about 70 standards included in the project is given in Table 2.
Members of the group felt that the project had helped to improve local standards of acute in-patient care. Specific examples of improved areas included: . development of more comprehensive individual needs assessment for in-patients . introduction of a broader spectrum of activities for in-patients . reduction of physical hazards in acute in-patient areas . introduction of new strategies for reviewing discharge plans for in-patients with longer lengths of stay.
In this pilot project, the group identified 69 tasks in their initial action plan. When these were reviewed at 4 months, progress had been made in 43 (62%) of these tasks. Most progress had been made on tasks of a more simple or discrete nature requiring operational changes. The majority of the changes identified were also costneutral, relating to changes in policy or practice rather than increased resources.
Where only partial success was achieved, or further progress was needed, this was often due to conflicting demands on the time of team members. In about half of cases, this was because the task initially identified needed to be revised, in the light of obstacles that only emerged when progress had been attempted.
The development group agreed to re-appraise their progress after a further 6-month period. This review revealed continued improvement across their action plan, including a demonstrable impact of the changes made earlier in the project. For example, service users reported greater satisfaction with the range of activities available for in-patients.
In all, two further re-appraisals of the action plans were produced, and the locally-adapted standards were gradually incorporated into the operational policy for the ward. Despite the inevitable effects of organisational change and staff turnover, the development group remained committed and enthusiastic about the project throughout. Managers subsequently obtained similar support in the development of other aspects of mental health services.

Conclusions
The approach used in this project appeared to be effective in facilitating change in front-line adult acute in-patient teams and making significant improvements in the services that they provide. It has been used successfully in other service settings, and has striking similarities to service development approaches used by other agencies. For example, the process mapping and 'PDSA' cycles used by the National Patients Access Team and the 'RAID' model used by the Clinical Governance Support Team, both part of the Modernisation Agency. These approaches all make use of a focused multistakeholder development group, underpinning internal ownership, a clear focus on key goals, review of existing service operation and concepts of continuous quality improvement.
The success of these projects requires commitment at all levels of the organisation including clinical leadership, management support and a wide range of stakeholder input. Their advantage lies in effective tailoring to local circumstances and their focus on realistic, practical changes. Although further development and evaluation of this type of approach is required, this project provides an illustration of the potential of genuine, local, multidisciplinary audit and the value of providing effective, structured, external facilitation.
Rix & Shepherd Implementing real change in acute in-patient care special articles In-patient team identify no problems saying that they fill out the form promptly and give it to a secretary to forward to the CMHT CMHT say they often do not receive forms for over a week Service users report experiences of poorly coordinated discharge Problems identified Part-time secretary only able to forward forms to CMHT by post and only about once a week Action plan In-patient staff decide to send forms directly to CMHT by fax Progress at 4 months Task not implemented. No fax machine on the ward and locality manager post vacant so no one able to authorise purchase Outcome Senior manager on the group authorises purchase of fax machine. Fax machine purchased and forms sent by fax rather than by post CMHT, community mental health team.