To compare current trust practice to NICE clinical guideline 91. To identify patients with a history of depression or chronic physical illness on admission to acute medical services. To assess such patients for evidence of new or ongoing depression and establish prevalence of depressive symptoms in high risk patient groups. To establish appropriate pathways for referral to mental health services

Cycle one: Eligible adult medical patients were screened for self-reported symptoms of low mood and anhedonia over the 2 weeks prior to admission. Inclusion criteria required patients to have either a past history of a chronic physical health condition or a past history of depression.

For those who answered “YES” to depressive symptoms, clinicians were prompted to refer to mental health services.

Intervention:

Screening questions were added to the adult medical clerking proforma for routine screening of admitted patients.

Patients self-identifying as depressed were triaged as requiring either inpatient liaison psychiatry team support or were referred to Improving Access to Psychological Therapies (IAPT) team on discharge with GP follow up.

Acute Medical departmental teaching session held on CG91 and new referral pathway created with input from liaison psychiatry team.

Cycle two:

Audit cycle repeated, including audit of outcomes following identification of patients with depressive symptoms.

In cycle one, of 123 patients, 90 were eligible for inclusion (PPHx depression n=39; PMHx chronic physical condition n=51).

Of those with a past history of depression, 85% reported YES to current symptoms.

Of patients with a chronic physical condition, without prior history of depression, 48% reported low mood or anhedonia in the past two weeks.

Following introduction of electronic screening questions, completion rate by clinicians was 65% (eligible patients n=102; PPHx depression n=43; PMHx chronic physical condition n=59). 44% of patients with a chronic physical health problem self-reported symptoms of depression.

After local educational meeting, 84% of identified patients had a planned referral to primary or secondary care for further mental health assessment and support.

Around half of patients with chronic physical health conditions self-report high levels of depressive symptoms, without a known mental health diagnosis or support in place.

Screening of patients on admission provides an opportunity for appropriate intervention.

Establishing clear referral pathways and ongoing education is needed to ensure all identified patients are referred for further assessment.

Admission to a Psychiatric inpatient unit can be a stressful time for patients and families. Patient's and carers have advised staff on the ward that there is a lack of information available regarding the policies and procedures in the unit. This includes information on ward rounds, leave arrangements and discharge planning. The aim is to enhance the ward-based experience of patients and their families by attempting to explore areas to improved, particularly about providing information that will help them to understand the process of admission to an inpatient Psychiatric as well as what to expect throughout their admission and on discharge.

A questionnaire was distributed to all the ‘current’ in-patients and their families. The questionnaire was kept anonymous to encourage everyone to contribute honestly. Data were collected from 20 patients admitted to the ward from 01.02.2022 to 30.04.2022. Data were analysed and shared with the rest of the team to identify gaps in provision of information.

Half of patients reported not receiving an introduction to the ward on admission and being unaware of the roles of different staff members. 70% of the patients and relatives were aware of the facilities of the ward and how to use them. There was a mixed response about satisfaction with running of Multidisciplinary Team Meetings(MDTs), availability of name nurse and medical team and information provision around MDTs, leave arrangement, discharge planning and follow up.

This quality improvement project has highlighted inconsistencies in the quality of and satisfaction with information provision during admission and has helped to recognised areas that needed to be improved. Several steps have been taken to improve quality of care such as copies of care plan and "Welcome to Tissington" booklet have provided. Discharge pathways and name board displayed in reception. Ward round appointments given to patients in advance and named nurse to support patients in writing MDT meeting plan. Invite families to attend care plan reviews, ward rounds and discharge meeting in person/via online. Additional craft items made available for activity, and exercise and walking groups have been introduced. Additional time made available for carers to speak with ward staff. Recruitment of Psychologist and occupational therapists now in post and Carers meeting to commence.

It is important to repeat this quality improvement project regularly to monitor the progress and get more information from families and patients to improve the quality of care given by the ward.

Our aim was to improve service user satisfaction by increasing the interval between their depot injections where clinically feasible. By doing this, we aimed to reduce attendance at the South Kensington and Chelsea Community Mental Health Team (SK&C CMHT) depot clinic by 25% over a period of 3 months, improving the workload for nurses running the clinic.

Our first baseline measure was data gathered about service user satisfaction with their depot. Our second baseline measure was the average number of service users attending the depot clinic per week between May and November 2022. The balance measure was a medical review 3 months post-interval change to ensure there were no negative impacts from this change.

10 service users on 3-weekly anti-psychotic depots were identified. Our team devised criteria to select service users who were appropriate for our project. This included: a stable mental state, minimal side effects on the current dose, no breakthrough symptoms, good engagement with the depot clinic, and scope to increase the current dose. These service users were discussed with their care coordinator, consultant and depot clinic nurse. If the criteria were met, the dose and interval change was discussed with our pharmacist. Finally, service users were consented and their depot charts were amended.

The interval between depot injections for 2 service users was increased from 3 to 4 weeks on December 5th, 2022. The other 8 service users failed to meet the criteria set out in our methodology.

These 2 service users were asked to fill in a questionnaire on January 23rd, 2023. They reported that “it was not comfortable having an injection” and that “having it every 4 weeks was better” and “less hassle”. Their first medical review did not raise any safety concerns.

On average, 20 service users attend the SK&C CMHT depot clinic every week. There was no change in the average number of patients attending the depot clinic in the last two months as only 2 service users had their depot interval successfully altered.

Service users on depot injections can benefit from increasing the interval between their injections where clinically feasible. We would like to repeat this project for service users on 2-weekly depots and reassess if that makes an impact on satisfaction levels and attendance numbers at our depot clinic.

COVID-19 lockdown had reduced face-to-face interaction amongst staff with work-from-home and hybrid models adapted by most NHS organisations which had impacted team morale and reduced learning opportunities within the team. Book clubs are an effective way to enhance social process of learning especially in mental health. Our aims were to improve face-to-face interaction to boost morale within the Community Mental Health Team (CMHT) and increase the reading habit within the team around mental health fiction.

A questionnaire was sent initially to gauge interest on the idea of a book club and how it should be conducted. Next, we digitalised the book club with a WhatsApp group to facilitate discussion on selection of books and the first book was selected via polling (The Fat Lady Sings by Jacqueline Roy). After 4 weeks reading time, we gathered on a selected day (30th September 2022) for moderated discussions with potluck-style lunch. Anonymous feedback was collected via surveys. The cycle was repeated on 28th October 2022 (second book was Inheritance of Loss by Kiran Desai).

Questionnaire to gauge interest and how the book club should be conducted revealed that the majority preferred a once-a-month discussion during working hours on a mental health and/or social care-related fiction of about 200-300 pages in length. The 8 respondents were made up of 6 doctors, 1 nurse and 1 social worker.

Feedback surveys on the impact of the book club on interaction with colleagues showed 30% improvement after the first book club (50% to 80%) and was 100% after the second cycle. Respondents also noted 60% improvement in interest in mental health-related fiction and 60% felt that the book club and discussions generated would help them in their day-to-day work in psychiatry (this figure rose to 100% after the second cycle).

Staff well-being is paramount to ensure staff satisfaction and reduce burnout. Initiatives to address this must be tailored to specific teams. It is also essential to encourage medical education in informal settings to create a culture of learning and improvement from healthcare professionals of diverse backgrounds.

The Royal College of Psychiatrists' core standards include a comprehensive physical health review as a vital part of an inpatient admission.

To determine whether using the KardiaMobile 6 lead (KM6L) device on an inpatient psychiatric ward would increase:

1. a. the percentage of patients who receive an ECG during an inpatient stay

2. b. the percentage of patients who receive an ECG within 24 hours of admission

The KM6L device provides a 6 lead ECG recording within 30 seconds. It enables ECGs to be performed more efficiently and less intrusively than a 12 lead ECG machine.

The study aimed to offer all patients (101) admitted to an acute inpatient ward (July 2022 – Jan 2023) an ECG using the KM6L device, unless reporting chest pain, having significant cardiac history, or doctor otherwise concerned – in that event a 12L ECG would be done instead.

The percentage of patients receiving an ECG during an inpatient stay and the percentage who received an ECG within 24 hours of admission were compared on the same ward when using:

1. a. the KM6L device between July 2022 and Jan 2023; and

2. b. a 12L ECG between July 2021 and July 2022

QT intervals were calculated manually as the automatic feature is still in development

Between July 2021 – July 2022, using a 12L ECG:

• • 217 patients admitted

• • 142 (65.4%) had a 12L ECG during their inpatient stay. Of these, 83 were done within 24 hours of admission (58.5%). Overall, 83/217 (38.2%) of patients had an ECG within 24 hours of admission.

Between July 2022 – Jan 2023, when KM6L device available on ward:

• • 101 patients admitted

• • 66* (65.3%) had an ECG during their inpatient stay. Of these, 46 were done within 24 hours of admission (69.7%). Overall, 46/101 (45.6%) of patients had an ECG within 24 hours of admission

*Note: 15/66 patients had a 12L ECG as available clinician did not know how to operate KM6L device

KM6L, despite being easier to use and less intrusive, did not increase the percentage of patients who received an ECG during an inpatient stay. However, there was a notable increase in the percentage of ECGs performed within 24 hours of admission. KM6L offers a cost and time saving alternative for obtaining ECGs; earlier cardiac screening may also reduce risk.

Future work will consider further training of healthcare professionals in how to use the KM6L device and expand its use across healthcare settings.

This QI was designed in collaboration with Trust's PMVA team to reduce the prevalence of physical restraints across inpatient wards by utilising model of improvement and measuring changes by studying number of restraints every six monthly. Secondary outcome considered were improvisation of recording of restraints, appropriate use of de-escalation measures and improvement in care planning surrounding the use of restraints.

The baseline audit was carried out to measure the prevalence of restraints and evaluate the practise of restraints in inpatient units during April to June 2020. The audit highlighted although there was 100% compliance in documentation of type and outcome of restraints , there were about 20 to 30 % restraints which did not utilise de-escalation measures, post incident debriefing and reflection within MDT. Only 12% of the restraints involved patients in post incident reflection. Using improvement model Plan- Do- Study- Act, following action plan was devised in 2021- 2022

1. 1. To improve education and training of inpatient staff in management of crisis behaviour through de-escalation strategies via PMVA training and sharing good practise/ gaps via MDT processes.

2. 2. To perform root cause analysis via quantitative and qualitative research to understand the clinical and demographic factors that influence restrictive practice.

There has been downward trend or reduction of restraints by 10 to 30% in eleven wards across the trust from 2020 to 2022 and there has been reduction of violent incidents that resulted in restraints by 30% and self harm incidents that resulted in restraints has reduced in average by 10 to 30%.

In parallel there has been 30% improvement in the use of de-escalation measures, PRN medications and use of safety pods.

Re-audit was conducted during April to June 2022 concluded improvement in compliance of post incident debriefing and reflection, and involvement of patients for post incident reflection has increased by 60 % . The use of care -planning, and de-escalation strategies has improved by 10 to 15%.

The project has shown that improvement of training standards, holding monthly restrictive practise hub meetings sharing knowledge and reflection of ongoing practise relating to restraints in inpatient wards and monitoring of practise via continuous staff feedback has reduced the prevalence of restraints by 10 to 30% and improvement in secondary outcome measures as outlined.

Handover is an integral aspect of clinical work for all doctors. During on calls it involves the transfer of responsibility and accountability for some or all aspects of patient care, to another person on a temporary basis. It is potentially a highly perilous step, and when carried out improperly can cause errors compromising patient safety. In recent times, handover is more important than ever due to the increase in shift patterns of working. Further the General Medical Council (GMC) has clear exceptions that all doctors should ‘keep colleagues well informed when sharing the care of patients.’

At Hammersmith and Fulham Mental Health Unit there was no formal junior doctor handover in place between changes of shift. Handover of clinical information between regular teams and the long day on call doctor was adhoc, informal and disorganised.

In 2021, we identified this significant patient safety concern, and introduced a handover sheet with a populated table contained pertinent information: date of the request, the location of the patient, the demographic details of the patient, the clinical information regarding the patient, the requested job and whether the task was completed. Junior doctors were instructed to complete the table which was kept in a folder in the junior doctor room when handing over information to the on call doctor. If the request was urgent and a face to face handover was not possible, doctors were encouraged to telephone the on call doctor to provide an additional verbal handover.

The GMC trainee survey identified that handover was a strong negative outlier with a trainee satisfaction rate of 44.79% in 2018. This was evident again in the GMC trainee survey 2019, where handover was again identified as negative outcome in comparison to the average with a trainee satisfaction score of 48.26%.

Having formalised the handover, the GMC trainee survey in 2021 identified a significant improvement in the trainee satisfaction rate of 59.03%; together with the results now being within the national average. Local trainee feedback survey also supported this finding with increased confidence being reported in the handover process.

Good handover does not happen by chance; this was clearly demonstrated following the implementation of a formal and structured proforma within the junior doctor handover at the Hammersmith and Fulham Mental Health Unit. This intervention not only improved the trainee confidence in the handover process but ultimately reduced the potential risk to patient safety.

This Quality Improvement Project (QIP) was undertaken within a Liaison Psychiatry (LP) department at a district general hospital in North West London. The current service model has LP nurses and junior doctors providing first contact with patients, and subsequently discussing assessments with the team psychiatrists. A need for effective communication when presenting clinical cases has emerged given high rates of staff turnover. The aims of this QIP were; (1) To assess the quality of presentations within the multidisciplinary team (2) to deliver a targeted teaching session focused on frameworks for assessment presentation and (3) to evaluate the effectiveness of the intervention.

The ‘SBAR: Situation, Background, Assessment, Recommendation’ communication tool already used widely within healthcare was adapted for LP by an MDT including doctors, senior nurses and pharmacist.

A survey was designed with MDT input to collect data about the content of presentations using adapted Likert scales, a quantitative global score and qualitative data highlighting areas for improvement. Over two weeks, senior team members completed surveys for every patient discussion.

A targeted teaching session was delivered on the adapted LP SBAR including: presenting complaint, current medical issues, referral question, psychiatric background, mental state examination, delirium/cognitive screening, risk assessment, impression and management plan. The session included breakout groups with clinical vignettes to practice presenting. All team members filled in a pre- and post-intervention surveys rating their confidence in presenting assessments and received copies of teaching materials.

Data were collected over a 2-week period post-intervention using the same methodology as pre-intervention. Post-intervention data were presented to the MDT and feedback was sought for improvement in the next cycle.

Pre-intervention data (n=30) indicated a risk assessment, impression and plan were often missed from presentations.

Following targeted teaching, team members felt more confident presenting assessments, formulating impressions, and management plans. Post-intervention data (n=22) showed an improvement in inclusion of all key information covered in the LP SBAR except management plans. The percentage of presentations with a global score ≥7 increased from 41% to 57%.

This ‘Plan, Do, Study, Act’ cycle has modestly improved the quality of assessment presentations within LP and has identified a critical need for communication tools within LP. We will perform another cycle in February 2023 given the high turnover of staff and continue to seek feedback from the MDT on the effectiveness of this targeted teaching session to continue to improve the presentation of assessments in LP.

There are increasing amounts of documented evidence that Black and Ethnic Minority (BME) NHS staff are more likely to face exclusion and discrimination. The MWRES- Medical Workforce Race Equality Standards Report details the disadvantages faced by BME doctors in the NHS. This piece of work shows a strategy to support doctors of African and Caribbean origin working in HPFT. Launched in 2021, the HPFT African and Caribbean Doctors Buddy Group (ACDBG) is a group for all doctors of any grade working in HPFT from African and Caribbean backgrounds. The group aims to bring together doctors of these backgrounds to build a group of clinicians who advocate for equity for African and Caribbean patients and medical professionals. Another key focus of the group is to support and motivate each other, focusing on individual health and well-being and sharing mutually beneficial experiences.

Doctors of the groups' ethnic backgrounds across all grades identified 34 (20.1%) African-Caribbean doctors out of the 169 BAME doctors in Hertfordshire Partnership University NHS Foundation Trust (HPFT). Of this, there are 30 doctors of African and 4 of Caribbean backgrounds, with 14 in Consultant, 7 in Staff Grade, Associate Specialist and Specialty (SAS) and 13 in Training posts.

The identified doctors received an invitation to attend the group meeting. Attendance was optional; membership was free with no long-term commitment. The group has an active social media presence to communicate and attract interested colleagues.

The group has met at least three times a year to provide opportunities for meaningful engagement and networking. These have included formal meetings as well as informal dinner events. Feedback from attendees has been very positive, with members mainly commenting on having found support from fellow members in navigating new experiences or learning from how others have sorted culturally unique challenges encountered in their working lives. Our international doctors have expressed joy in finding a resource to obtain guidance in settling into work and support with career development.

Feedback received from members of the group indicate that the doctors have found the group extremely useful. It gives an opportunity for expressive communication to promptly address concerns of any form or nature, on a personal or collective level, thereby improving positive well-being and career progression. Their positive experiences in pastoral care improved inclusion, productivity, retention and ultimately quality of care provided to service users.

1. 1. To increase the proportion of patients having their BMI documented on admission to the PICU.

2. 2. To improve rates of standardised interventions when abnormalities in BMI found.

Among patients admitted to PICU, there is lack of consistency in monitoring of BMI and in offering interventions for those with abnormal BMI. We expect an improvement in both the parameter with the quality improvement project. Background: Service users admitted to PICU have severe mental health illnesses, and are known to have several high risk cardiometabolic parameters including excessive weight. In addition, they are often treated with medications known to cause weight gain. Without effective management, this is likely to cause increased morbidity and mortality

Initial baseline data were collected by reviewing patient notes.

We then tested interventions to improve weight and BMI screening process on the PICU. We used the Plan-Do-Study-Act (PDSA) methodology over 2 cycles. In the first cycle, we engaged the nursing staff to improve screening on admission, including training to overcome the glitch in the electronic form that prevented automatic BMI calculation. In the second cycle, we introduced a protocol to ensure consistent interventions were offered to patients with abnormal BMI. The interventions offered were referral to dietician, referral to PICU gym instructor and MDT discussion about lifestyle changes and medication to manage weight.

Data were collected after each PDSA cycle to monitor change.

Baseline: 47% of PICU patients had their BMIs recorded on admission. 69% of those patients that met the overweight criteria were offered an intervention.

After the first PDSA cycle, 91% of patients had their BMIs recorded. 71% of those patients that met the overweight criteria were offered an intervention.

After the second PDSA cycle, all the consenting patients had their BMIs recorded. 100% of those patients that met the overweight criteria were offered all the interventions in the protocol but not all agreed to engage with the interventions.

As a result of this quality improvement project there has been an improvement in screening for BMI on admission to PICU and in the standardised interventions offered to those with high BMI. The next steps will be to implement this across the other wards and to improve patients’ engagement with the interventions.

The aim was for 80% of adults aged over 65 years to be screened for delirium at the point of admission to hospital.

We implemented multiple interventions including:

• • Teaching sessions for doctors, nursing staff and healthcare assistants on delirium.

• • Designed a new proforma using a more specific tool for screening delirium (4AT)

• • Making the clerking proforma and delirium screening tool more user friendly

Results have shown statistically significant improvement in the detection of delirium with a sample in October 2022 showing 68% of older adults admitted to Hillingdon Hospital having been appropriately screened for delirium.

Current results suggest significant improvements with our interventions, however further progress is still required to reach our aims with regular data collection being paramount.

Meadowview Ward is a dementia assessment unit based at Thurrock Community Hospital as part of Essex Partnership University NHS Foundation Trust. Patients with advanced dementia are routinely admitted with significant physical comorbidities and, as such, robust physical health monitoring is required. Members of the nursing team felt that it would be helpful to formalise the approach to physical health monitoring in order to allow all members of the multidisciplinary team to be aware of the necessary requirements. It was decided to formulate a physical health monitoring prompt sheet to facilitate discussion regarding physical health during ward rounds.

A multidisciplinary discussion took place to identify the areas of monitoring which should be routinely highlighted in ward rounds. Items labelled as routine monitoring requirements were also listed. A prompt sheet was then devised which divided ward round discussion into nursing and medical feedback, with each section having specific areas for discussion (for example oral intake, recent blood results, any pending investigations). This included prompts for other staff groups including physiotherapists and occupational therapists. A section was also added regarding ongoing monitoring requirements, such as routine outpatient appointments and whether transport had been booked.

In order to assess the impact of the introduction of the prompt sheet a questionnaire was provided to members of the multidisciplinary team who regularly attend ward round. This assessed their perception of the quality of physical health monitoring both before and after the introduction of the prompt sheet, the impact of the sheet on ward rounds and whether they wished the intervention to continue.

There was a significant increase in staff satisfaction with physical health monitoring on the ward (n=7, P = 0.0065). 100% of staff surveyed rated the introduction of the prompt sheet as “strongly helpful” and that they “strongly agree” the use of the prompt sheet should continue. An initial concern from the team had been the potential for the use of the sheet to delay ward rounds, however 57% of respondents reported no impact on ward round duration and 43% felt it strongly expedites assessments.

The introduction of the physical health monitoring prompt sheet has been widely perceived as a success within our multidisciplinary team. It has also demonstrated the effectiveness of a multidisciplinary approach to quality improvement projects, ensuring the wide variety of expertise within teams is utilised.

Trans and non-binary people present with condition-specific health needs. General Practitioners (GPs) face increased demand to care for this population. The Royal College of General Practitioners note that “the gaps in education, guidance and training for GPs around treating gender dysphoria… and managing broader trans health issues… needs to be urgently addressed.” We are an interdisciplinary team using QI methodology to assess current self-reported knowledge and confidence amongst GP Specialty Trainees in the North-West of England (NWGPSTs) and deliver interventions targeting problem areas.

Following engagement with Health Education England North-West, a preliminary questionnaire was distributed to all NWGPSTs to assess baseline knowledge and confidence regarding gender-diverse peoples' healthcare.

Results were used to design a teaching session covering basic language and concepts; history and physical exam; gender affirming therapies; psychiatric, medical, and sexual health.

Teaching was delivered in a pilot scheme at four NWGPST training locations. Data were gathered before and after each session, with 3 additional questions to assess the quality of teaching and open-text feedback.

In the preliminary questionnaire (n=150) the most common answer was the lowest amount of knowledge, confidence, or training (1 out of 6) for 11 out of 17 questions. Most reported no training during medical school or GP training programmes. Lack of knowledge in gender affirming therapies, fertility preservation, legal framework and referral pathways were identified.

Using a Likert scale (1 to 5), comparison between pre (n=61) and post-teaching (n=49) questionnaires showed improvement in knowledge in all areas (CI 95%). Overall knowledge improved with a mean of 1.05 (95% CI 0.72–1.38). Teaching quality feedback achieved a total mean score of 4.18. Open-text feedback was overwhelmingly positive about teaching material, enthusiasm of presenters, and contained useful suggestions for improvement.

Baseline knowledge of trans and non-binary healthcare is generally very low. A brief educational intervention made a statistically significant improvement to self-reported knowledge and confidence.

We have adapted the teaching based on participant feedback and with involvement from Experts by Experience and Experts by Training. We have enriched teaching with video submissions from Experts by Experience. We have continued to engage with stakeholders, including partners at The LGBT Foundation and Indigo (GP-based Manchester gender service). To grow further, we have trained a faculty of 10 GPSTs to provide teaching, with 11 sessions now delivered to over 300 GPSTs and 5 sessions upcoming. We are planning a nationwide virtual training day.

To identify and explore remediable factors in the clinical and organisation of the physical healthcare provided to adult patients admitted to a mental health inpatient setting.

Data from 291 clinical, 56 Trust-level and 224 Hospital-level organisational questionnaires were completed; 285 sets of case notes were peer reviewed; 168 service user and 79 carer surveys were reviewed to assess the care provided to patients aged 18 years and older who were admitted to a mental health inpatient setting in the UK for at least one week during 01/11/2018 to 31/10/2019, and who:

• • Had existing chronic obstructive pulmonary disease/ asthma/ cardiovascular disease/ diabetes

• • Had experienced a transfer to a physical health hospital

• • Died in the mental health inpatient setting or within 30 days of discharge

• • Specialist commissioned mental health services and suicides, homicides and self-harm related deaths were excluded from this study.

The report highlighted 5 key messages:

1. 1. Assess patients for acute physical health conditions on arrival at a mental health inpatient setting and then undertake a detailed physical health assessment once the patient is admitted A detailed physical health assessment was not undertaken appropriately for 28/126 (22.2%) patients.

2. 2. Develop a physical healthcare plan for patients admitted to a mental health inpatient setting A plan for physical health observations was not documented for 48/217 (22.1%) patients.

3. 3. Formalise clinical networks/pathways between mental healthcare and physical healthcare Local care pathways or pre-existing arrangements with physical healthcare providers were used as part of the care plan for 71/291 (24.4%) patients.

4. 4. Involve patients and their carers/friends/family in their physical healthcare and use the admission as an opportunity to assess, and involve patients in their general health In 100/188 (53.2%) sets of notes reviewed, there was no record that the physical health review had been discussed with the patient's family/ carers.

5. 5. Include mental health and physical health conditions on electronic patient records and allow sharing across healthcare providers

6. 6. 20/56 (35.7%) organisations reported that all elements of the clinical record were available in the electronic patient record

The NCEPOD report provided an in-depth review of the quality of physical healthcare in mental health inpatient settings and found that there is room for improvement in physical healthcare of patients. Key aspects of care requiring improvement were treatment of long-term physical health conditions (62/119; 52.1%), documentation of physical health observations (61/119; 51.3%) and delays in identifying acute deterioration (19/119; 16.0%) patients.

The report makes twelve recommendations for clinicians and management to implement in practice.

It is widely recognised that the performance of the health care system falls far short of its potential on a wide range of quality indicators, particularly for racial and ethnic minorities and other disadvantaged groups. Within the Adolescent and Young Adult Service, data from the clinical intake meeting have been previously collected and stratified, identifying disparity conditions and populations based on gender (accepted females to males ratio = 7:1); ethnicity (low proportion of Black/Asian/Mixed background represented within the service); age (vast majority of accepted being in their 17s); disability (low proportion of disabled seen). Primary aim for this project was to evaluate whether the introduction of an EDI champion plus an EDI discussion within the intake clinical meeting could improve our department performance in terms of Equality, Diversity and Inclusion (EDI) quality indicators comparing to historical data.

A comprehensive Excel spreadsheet has been designed. All new referrals from November 22 till January 23 were included (N=29). Data collection included: non identifiable patients details, gender, date of birth, occupation, ethnicity, language, disability, outcome of the meeting, details of outcome, reason if outcome being negative. A further column on EDI comments.

Following the introduction of the EDI champion for this cohort of patients, a decreased percentage of females (73.9% vs 69.2%) and increased percentage of transgender males (4.3% vs 15.4%) were offered an assessment. In terms of ethnicity, the number of Black/Asians/Mixed rejected for an assessment decreased. Respectively, 36.4% vs 11.1% (chi-square = 4.14, p-value = 0.47); 18.2% vs 11.1% (chi-square = 0.08, p-value ≈ 0 being statistically significant); 18.2% vs 0% (chi-square = 2.47, p-value = 0.26). An increased number of White people were rejected for an assessment which was also statistically significant (27.3% vs 66.7%; chi-square=1.96, p-value ≈ 0). Reasons for rejection have been recorded. More age groups (19, 20, 22 years old) were more widely represented in the new cohort of patients.

The introduction of an EDI champion and an EDI discussion, within the clinic intake meeting selection process, seems a valuable instrument to tailor intervention for disparity groups (e.g. ethnicity), assessing both quality and disparities at the same time aiming for a Culturally Competent Quality Improvement within the service. This findings can be easily applied to other departments and implemented more broadly.

The purpose of induction is to welcome our new employees and also ensure that they have the information and support to carry out their roles effectively. A robust induction not only benefits the doctor but also helps employers to ensure the delivery of high-quality patient care, increases retention, reduces absenteeism, and will promote the organization as a good employer. Doctors need to be supported in the workplace to provide safe, high-quality patient care. Induction as a minimum should introduce doctors to employer procedures and rules, arrangements for clinical governance (patient safety, clinical errors, clinical risk management, complaints, and litigation), orientation, and support. We have developed a new Induction folder containing all the necessary information for a beginner in Psychiatry in North Wales

We initially arranged for a preintervention questionnaire for the Junior doctors in Psychiatry in North Wales. That included Core trainees, Foundation year doctors, Senior house officers (LAS CT- SHO, JCF- non-training post), and GP trainees.

The QIP started in 2019 August with Audits followed by PDSA cycles. Over a period of 2 years, various doctors both from the present and from the last 3 years were contacted via email and google forms. We completed 3 PDSA cycles.

During these 2 years, we included certain topics that were missed, such as medication during an emergency, contact details from the deanery, etc. We have been following up on the Induction folder with the new doctors as and when there is new recruitment.

The first PDSA showed promising results. Following the first PDSA, we amended a few changes in order to improve the response which resulted in an overwhelmingly positive response from the new doctors/ old doctors in Psychiatry. Following the third PDSA, we included details from the deanery contact and updated the contact details from our own trust.

2 years of work on this project has yielded good results. However, the sustainability of changes is questionable. This indicates continuity in changes. We are hoping that the new trainee doctors, either junior or senior trainees can consider working on this project and continue to amend changes on yearly basis.

The amended version of the folder can be completed at least 4 weeks prior to the major induction that happens every August.

We will consider sharing the Induction folder as handbooks/ pdf versions to all the trainees and non-trainees in our trust. Apart from this, we will continue to keep the information at a high quality and standards. We will achieve this by ensuring feedback from the new doctors.

At Farmfield Hospital, medical emergency drills are conducted monthly, as well as at all other Elysium Healthcare sites. Managing medical emergencies is an expected component of inpatient care, though without regular practice of Immediate Life Support (ILS) skills they can degrade rapidly. We propose that medical emergency drills should be considered an essential component of inpatient care, and explore how we have used them to create targeted teaching and to build skills after significant events.

We reviewed all medical emergency drills at Farmfield Hospital over the previous 12 months, looking through standardised event reports and feedback on quality and timing of response. We explore and compare qualitative feedback from involved staff members, and detail methods by which medical emergency drills can be used to create targeted teaching and training where skill gaps are noted.

Staff fed back that these drills are key to building their confidence in managing medical emergencies. Core reports include that without these drills, for some staff the only regular practice would be at annual ILS recertification, and reports that they would feel considerably less confident to manage medical emergencies without regular practice and feedback. We use a case study exploring human factors and leadership skills being highlighted in one emergency drill as needing improvement, and how through targeted training and reassessment through subsequent drills we improved this skill gap and enabled staff to become more confident leaders in emergency situations as measured by direct feedback and assessment in subsequent drills.

Medical emergency drills are not currently standard practice across psychiatric inpatient services, and this creates several challenges. While ILS recertification is annual, these are perishable skills, and without regular practice confidence falls rapidly. Moreover, specific skill gaps such as leadership or even technical competencies such as familiarity with specific emergency equipment may go unnoticed until needed in a live medical emergency call. Organising these drills does not require a significant time investment, and we have found the increase in quality of response and staff confidence in managing emergencies makes these drills an essential part of our standard practice. We propose a simple structure for drill design and assessment as part of an ongoing Quality Improvement architecture.

Patients with Functional Neurological Disorder (FND) experience neurological symptoms which may impair motor control, sensory function, or awareness. Long waiting lists before treatment mean the risk of relapse during this period is high. A lack of knowledge around FND also results in a lower quality of life. Therefore, it is important patients with FND receive appropriate psychoeducation to empower them to understand and manage their symptoms. We aimed to strengthen our symptom self-management booklet for patients in a community neuropsychiatry setting, using a co-production model and taking forward improvements into a digital audiovisual format.

We used co-production as part of a quality improvement project (QIP) at East Kent Neuropsychiatry Service to identify improvements to our existing symptom self-management booklet and apply these in the production of a digital resource. Initially, the symptom self-management booklet was distributed to 10 patients, awaiting further assessment and treatment, chosen by the multidisciplinary team following triage appointments. Two weeks later, 7 patients reviewed the booklet with 4 medical students by phone and qualitative and quantitative feedback was obtained from patients and carers. Quantitative feedback was collected using an adapted 20-point Ensuring Quality Information for Patients (EQIP) tool. Informed by this feedback, scripts were developed for the audiovisual resource. The scripts were further reviewed by a medical student, 2 multidisciplinary team members and 3 Trust Communications Department members.

The first QIP cycle highlighted the importance of the symptom self-management booklet. Most patients had used the booklet. Patients found it a helpful source of information. Two patients noticed a considerable improvement in their quality of life, others did not due to the short length of booklet use. . EQIP tool demonstrated an improved score of 80.51% compared to previous round of feedback (53.33%). Carers identified the booklet as reassuring. Additional links to external information was identified as an area for development.

Patient feedback informed the development of scripts for the audiovisual resource. Consultation with the Trust Communications Department identified three themes of improvement: accessibility to patients, increased clarity and concise language, and an appropriate visual format, therefore scripts were further refined.

Our QIP shows the value of a psychoeducation and symptom self-management tool for FND patients which was positively received by patients and carers. Collaborating with patients in the digitalisation of this information allows for a more accessible resource which effectively addresses patient concerns and empowers symptom self-management.

The aim of the QI project was to promote patient involvement, choice and recovery using effective communication and collaborative planning. To achieve this, we aimed to ensure that patient's voice remained central to the decision making process in meetings . Using 5-Why QI methodology, the MDT of Delfryn-House—a private 28-bedded rehabilitation unit, reviewed the communication interruptions between the internal and external CMHT (especially after the pandemic), which in turn was hampering patients’ progress towards positive discharge. It was also noticed that patients' attendance was significantly dropped and they were not showing interest in their CPA/CTP meetings, as they were not seeing any benefits of them. The MDT planned the project to improve the communication for continuity of care and to have better involvement of patients, their families and external teams.

The Intervention project, based on QI model-of-improvement, established that effective communication was the main aim, to be achieved with new change ideas. The outcomes were both qualitatively and quantitatively measured e.g.using feedback questionnaires from CMHT and patients and carers, attendance and discussion of discharge goals for the admitted patients. Driver diagrams were used for change ideas e.g. Microsoft teams invites to all teams for the patient review and care plan review meetings, MDT adding the progress feedback to the patient review meeting proforma to be shared internally and externally prior to the meetings, informing the care coordinators prior to change in Mental health act status, same day email to CCOs about medication changes, incidents, safeguarding, and ensuring discharge goals are discussed at every meeting. Satisfaction surveys to the CMHTs and patients were conducted pre- and post-intervention. Qualitative data were collated, helping to generate quantitative statistical analysis of the satisfaction ratings. The attendance of meetings and positive discharge from the unit were also used to measure the outcomes.

There was significant improvement in both commissioners and CMHT's satisfaction of improved communication from Delfryn House. There was increase in attendance (44% by patients, 20% by carers, 64%by CMHT and 40% by Commissioners). There was increase (45%) in patients reading and signing their care plans. A notable increase in positive stepdown discharge plans were noted, however, as the QI project was run in a rehabilitation unit requiring longer admissions, there were not many actual discharges to show a noticeable difference.

The QI-project helped in establishing clearer pathways towards positive discharge and continuity of care, signifying the importance of effective communication between teams and co-producing the care plans and meeting agendas with the patients and their carers.

To improve the efficiency of MHA documentation, patient education on MHA and implementation of guidelines of Code of Practice in in-patient unit. We also aimed to involve patients at some stages of the QI project to ensure they remain updated about the legal framework and associated documents and their voice remains central.

The QI Project was started after an initial audit was conducted which included MHA documentation on admission and during the length of stay, patients’ legal rights, section-17 leaves, capacity and treatment forms, tribunal reports, section-117 meetings and arrangement of independent managers hearings prior to Section Renewals. Using 5-Why QI methodology, the medical team and the MHA administrator reviewed the gaps in the initial audit. Using the QI “theory of change” model, three primary drivers of “Responsible Clinician and MHA Administration Liaison”, “Patient Education on MHA” and “Policies and Guidelines Implementation” were established. Secondary drivers for “RC and MHA Administration Liaison” required inputs from doctors, secretaries, nurses and MHA Admin. Change ideas of introducing weekly email template for required MHA actions, section paper scrutiny template made for approval by MHA Admin/ RC prior to patient's admission, Introduction of MHA relevant actions section in the morning handover and patient's review record form.

Secondary drivers and change ideas for “Patient Education on MHA” included discussions with MDT, easy- language information leaflets, discussion slots with pharmacists about medications before consenting for treatment forms, discussion slots with the key nurse and RC about MHA related decisions and going through statutory reports together to understand the nature and degree of illness, and risks necessitating the renewal of admission.

Secondary drivers and change ideas for “Policies and Guidelines Implementation” included teaching sessions for nurses on report writing, giving evidence at tribunals, and how to inform patients about legal rights, and liaison with medical management QI committee to ensure capacity and treatment certificates are up to date and filed in the medical folders. The initial audit tool was repeated on quarterly basis in addition to the PDSAs to measure results.

Results showed 100% score in capacity assessments, treatment certificates and timely reports. There was still improvement needed in organising managers hearing prior to section renewal, likely section renewals left till late. A pre-and-post intervention score on patients’ knowledge of rights and MHA showed an improvement of 68%.

The QI-project helped in implementing MHA code of practice guiding principles and patients’ knowledge about MHA and their rights.