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Incidents of violence and aggression are serious concerns on a secure ward for people with intellectual disabilities and are often met with increases in physical and restrictive interventions. However, these interventions are usually high risk for both patients and staff and are ineffectual in promoting long-term behaviour change. This study aimed to promote positive culture change and embed the evidence-based practice of positive behaviour support by shifting focus and efforts from the use of physical and restrictive interventions to manage crises to intervening positively and proactively to prevent crises from occurring. The key drivers for change involved increasing access to positive engagement opportunities, expanding the staff team's repertoire of proactive interventions through training and skill development and supporting staff well-being and resilience. Change ideas occurred alongside a shift in culture that promoted the development of a learning culture, psychological safety and consideration of contextual fit. Quality improvement methods helped the project increase the rate of positive and proactive interventions from 70.65% in December 2018 to 97.18% in January 2020. Increases in staff's knowledge, confidence and safety were also reported. Lessons and limitations of the project are discussed., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Long waiting times for Child and Adolescent Mental Health Services (CAMHS) have been linked to poorer outcomes for those seeking care. CAMHS teams in England have seen recent increases in referrals, resulting in challenging waiting times nationally. Although recent health policy has brought an increase in funding and staffing, it is believed that only 25% of those needing care receive it. Between trusts, there is considerable variation in waiting times, leaving many waiting longer than others waiting for care. East London Foundation Trust has been seen to have higher waiting times for CAMHS than other organisations across the country between June 2017 and September 2018, seven CAMHS teams were supported to use quality improvement (QI) as part of a collaborative learning system with the aim of improving access and flow. Each team was encouraged to understand their system using basic demand and capacity modelling alongside process mapping. From this teams created project aims, driver diagrams and used Plan Do Study Act cycles to test changes iteratively. Measurement and data were displayed on control charts to help teams learn from changes. Teams were brought together to help learn from each other and accelerate change through a facilitated collaborative learning system. Of the seven teams that began the collaborative learning system, six completed a project. Across the collaborative learning system collectively there were improvements in average waiting times for first, second and third appointments, and an improvement in the number of appointments cancelled. For the individual teams involved, three saw an improvement in their project outcome measures, two just saw improvements in their process measures and one did not see an improvement in any measure. In addition to service improvements, teams used the process to learn more about their pathway, engage with service users and staff, build QI capability and learn together., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

This article describes the application of quality improvement (QI) to solve a long-standing, ongoing problem where service users or their carers felt they were not given enough information regarding diagnosis and medication during clinic assessments in a community mental health setting. Service users and carers had shared feedback that some of the information documented on clinic letters was not accurate and the service users were not given the opportunity to discuss these letters with the clinician. The aim of this QI project was to improve the communication between the community mental health team (CMHT) and service users and their carers. Wardown CMHT volunteered to take on this project. The stakeholders involved were the team manager and deputy manager, the team consultant, the team specialist registrar, team administrative manager, two carers and one service user. The project had access to QI learning and support through East London NHS Foundation Trust's QI programme. The team organised weekly meetings to brainstorm ideas, plan tests of change to review progress and to agree on the next course of action. The outcome was an increase in service user satisfaction from 59.9% to 78% over a period of 6 months, and a reduction in complaints to zero., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Ward-based violence is the most significant cause of reported safety incidents at East London NHS Foundation Trust (ELFT). It impacts on patient and staff safety, well-being, clinical care and the broader hospital community in various direct and indirect ways. The contributing factors are varied and complex. Several factors differentiate the forensic setting, which has been identified as a particularly stressful work environment. Staff must constantly balance addressing therapeutic needs with robust risk management in a complex patient cohort. ELFT identified reducing inpatient physical violence on mental health wards as a major quality improvement (QI) priority. The aim was to use a QI methodology to reduce incidents of inpatient violence and aggression across two secure hospital sites by at least 30% between July 2016 and March 2018. Collaborative learning was central to this project. It sought to foster a culture of openness within the organisation around violence and to support service users and staff to work together to understand and address it. A QI methodology was applied in medium and low secure inpatient settings. A change bundle was tested for effectiveness, which included: safety huddles, safety crosses and weekly community safety discussions. Operational definitions for non-physical violence, physical violence and sexual harassment were developed and used. Reductions of 8% and 16.6% in rates of physical and non-physical violent incidents, respectively, were achieved and sustained. Compared with baseline, this equated to one less incident of physical and 17 less of non-physical violence per week averaged across seven wards. Three wards achieved at least a 30% reduction in incidents of physical violence per week. Five wards achieved at least a 30% reduction in incidents of non-physical violence per week. This collaborative brought significant improvements and a cultural shift towards openness around inpatient violence., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Early intervention following initial referral into healthcare services can have a significant impact on the prognosis and outcomes of patients. Long waiting times and non-attendance can have an immediate and enduring negative impact on patients and healthcare service providers. The traditional management options in reducing waiting times have largely revolved around setting performance targets, providing financial incentives or additional resourcing. This large-scale quality improvement project aimed to reduce waiting times from referral to first appointment and non-attendance for a wide range of services providing primary and secondary care mental health and community health services at East London NHS Foundation Trust (ELFT). Fifteen community-based teams across ELFT came together with the shared goal of improving access. These teams were diverse in both nature and geography and included adult community mental health teams, child and adolescent mental health services, secondary care psychological therapy services, memory services, a musculoskeletal physiotherapy service and a sickle cell service. A collaborative learning system was developed to support the teams to come together at regular intervals, share data, test and scale-up ideas through quality improvement and have access to coaching from skilled improvement advisors in the ELFT central quality improvement team. Over the course of the 2-year project, waiting time from referral to first face-to-face appointment reduced from an average of 60.6 days to 46.7 days (a 23% reduction), non-attendance at first face-to-face appointment reduced from an average of 31.7% to an average of 20.5% (a 36% reduction), while referral volume increased from an average of 1021 per month to an average of 1280 per month (a 25% increase)., Competing Interests: Competing interests: None declared.

A quality improvement project was initiated on Ivory ward, a functional older adult psychiatric inpatient ward at Newham Centre for Mental Health, part of the East London NHS Foundation Trust. The project was started by staff on the ward after it had come to their attention that their ward had the highest bed occupancy and length of stay across similar wards in the trust. The mean bed occupancy in the 9 months before the project started was 87.7%. The mean length of stay on the ward in the 9 months before the project started was 70 days. The team used the model for improvement, which is the trust's methodology of choice for quality improvement projects, to reduce bed occupancy and length of stay. The focus was on running small-scale tests of change to see whether these could lead to improvement. These change ideas were refined, scaled up or discontinued as appropriate to help achieve the aim. The project's aim was to promote quality of care by reducing patient length of stay on Ivory ward to 45 days and bed occupancy to ≤70% or by 1 January 2016. The project team managed to reduce bed occupancy to 58% and length of stay to an average of 35 days., Competing Interests: Competing interests: None declared.

The East London National Health Service Foundation Trust (ELFT) Community Musculoskeletal (MSK) Physiotherapy Service had reported a high rate of non-attendance at scheduled appointments. This was leading to delayed access to treatment for patients and a reduced capacity for service users, as well as a waste of clinical resources. The aim of this quality improvement project was therefore to reduce the percentage of missed appointments within this department. This study was undertaken by the ELFT community MSK service, with support from the ELFT Quality Improvement team. To begin with, patient complaints were explored; these indicated that the main reason for missing appointments was due to issues with the patient booking service. Baseline data were initially collected for both new referrals and follow-up patients. The proposed changes were then introduced, which included text message reminders, first via a manual platform and then via an automated system. Ongoing data were recorded to note the effectiveness of these changes. Following the intervention, non-attendance of newly referred patients reduced by 43.35% (23.76%-13.46%) after both cycles. Non-attendance of follow-up patients reduced by 44.14% (23.74%-13.26%) after the second cycle alone. By listening to the opinions of service users, it was possible to improve the patient booking system and the flexibility of appointments. This resulted in a reduction in the percentage of appointments missed. These changes will continue to be monitored within this department to ensure sustainability but there is also now potential for similar interventions to be trialled in other health service departments., Competing Interests: Competing interests: None declared.

City and Hackney Adult Mental Health Referral and Assessment Service (CHAMHRAS) is the single point of entry for all mental health referrals to secondary services, with the exception of perinatal referrals, in the City and Hackney region of London, UK. CHAMHRAS was established in 2013 with the objective of providing a one-stop point of referral which screens urgent and non-urgent referrals of adults aged 18-65 to mental health services. This single point of entry simplifies the referral process to secondary mental health services-something service users have requested. It also enables rapid feedback on all referrals taken from general practitioners as well as other sources. The centralised nature of CHAMHRAS has also facilitated the monitoring of waiting times from receipt of referral to first face-to-face assessment across services. It was noted that the waiting time for the majority of patients was exceeding the 28-day target set by local commissioners. Indeed, in December 2014, only 30% of patients were being seen within this time frame. The aim of this quality improvement project has been to decrease the average waiting time from referral to first face-to-face assessment, and concomitantly increase the proportion of patients being assessed within the 28-day target period. The team identified potential sources of delay in the process of handling referrals, from receipt and triage, to forwarding to the relevant secondary service, and have tested change ideas such as the implementation of daily meetings to review referrals and the centralisation of appointment bookings to streamline the processes and minimise delays. The average waiting time from referral to first face-to-face assessment decreased by 34% and the proportion of patients being assessed within 28 days increased accordingly, exceeding 95% in the case of referrals from general practitioners (GP). We have listed changes that we intend to introduce with the aim of bringing waiting times down further., Competing Interests: Competing interests: None declared.