Want to start reducing restrictive practice in your area? Here’s how to plan your project and measure its impact.
In the Reducing Restrictive Practice Collaborative, we used a QI approach based on the 'Model for Improvement'. This model is explained on the Institute for Healthcare Improvement's (IHI) website.
We created a number of planning resources for the Reducing Restrictive Practice Collaborative. They are free to use and outline the key steps in setting up a similar programme.
1. Set up a project team
First, establish a project team to carry out the QI work. It is useful for your team to be comprised of people who have different roles. For example, teams in the Reducing Restrictive Practice Collaborative had:
- a project lead to drive the work
- a senior sponsor to support the team and unblock any barriers
- a data champion to support with data collection and entry
- a patient or patient representative to ensure collaboration.
We’ve outlined the different project roles and responsibilities that you may have in your team.
Your team should meet regularly (this can be fortnightly or monthly) to ensure the work is moving forward and to discuss learning.
2. Develop an aim
Develop an aim to outline what you are trying to improve. It should be specific, measurable and have a time frame. The aim for wards in the Reducing Restrictive Practice Collaborative was to “reduce restrictive practice by a third within 18 months”. Some of the specific aims for teams in the Reducing Restrictive Practice Collaborative were:
- reducing the length of time in long-term segregation
- focusing on monthly admissions to review the correlation between admission and patient acuity against the use of restrictive practices
- reducing the total amount of hours in seclusion.
3. Develop a measurement plan
Set measurements to determine whether you are achieving your aim. It is important to collect data regularly to track and reflect on your progress. The following measurements were set for the Reducing Restrictive Practice Collaborative and defined in the operational definitions poster:
- Number of episodes of physical restraint
- Number of episodes of seclusion
- Number of times that rapid tranquillisation was administered.
You can use a measurement plan we created for the Reducing Restrictive Practice Collaborative to track your own measurements. We recommend that you use a ‘safety cross’ to record the number of incidents of restrictive practice. You can use our safety cross templates:
To find out more about safety crosses, see the section on Good communication and transparency in the Ideas for changing practice page.
You should also decide on your reporting periods and set dates to reflect on the progress you have made. Within the Reducing Restrictive Practice Collaborative, all wards collected data on the three outcome measures every month and inputted them into the LifeQI platform. We encouraged wards to reflect on their progress and consider what changes or factors on the ward were contributing to this.
You can use our RRP measurement 101 slides to help you understand and interpret your data.
4. Create ‘change ideas’
Before making any changes to practice, it is important that you understand what factors affect your organisation and its ability to achieve its aims. We recommend using a ‘driver diagram’ for this – a model that illustrates the aim you are trying to achieve, the primary drivers that affect this aim and the secondary drivers that are required to achieve it.
Here is a change theory driver diagram we created for the Reducing Restrictive Practice Collaborative. A driver diagram is a live document that changes over time. This driver diagram has grown as the work in the Reducing Restrictive Practice Collaborative progressed. Each participating ward also created their own unique driver diagram.
When you’ve completed your driver diagram, the next step is to generate change ideas – actions that can be tested to try to achieve improvement – to address each secondary driver. You can generate ideas by brainstorming as a team, including the wider staff team, patients and carers. See our guidance for generating change ideas.
At the beginning of the Reducing Restrictive Practice Collaborative, we used the secondary drivers from the original driver diagram to create a list of suggested change ideas. Each ward then did the same with their own driver diagram. As well as creating your own, take a look at these great ideas for changing practice that participating wards have tested, to see if any would work for you.
5. Test your change ideas
Not all change ideas will lead to improvement, but QI focuses on testing changes on a smaller scale to determine how effective they are. It is best to only test a few change ideas at a time.
We recommend using the plan-do-study-act (PDSA) cycle to test change ideas and determine if they lead to improvement:
- Plan – develop a plan to test the change
- Do – carry out the test
- Study – observe, analyse and learn from the test
- Act – determine what modifications, if any, to make for the next cycle.
Watch the IHI’s videos to learn more about how to use PDSA cycles:
To help you work through each stage of a PDSA cycle, you can use this worksheet template. If you would like to present to a wider team a PDSA you have tested and your reflections on how it went, you can use our PDSA poster template.
Participating wards created and presented their own PDSA posters. See what you can learn from them:
- Amber Ward – Sussex Partnership NHS FT
- Christopher Ward – Essex Partnership University NHS FT
- Colne Ward – Central and North West London NHS FT
- Coral Ward – Camden and Islington NHS FT
- Endcliffe Ward – Sheffield Health and Social Care NHS FT
- Fraser House – Northumberland, Tyne and Wear NHS FT
- Great Yarmouth Acute Service – Norfolk and Suffolk NHS FT
- Harvest Ward – Cornwall Partnership NHS FT
- Hawthorns 1 – Southern Health NHS FT
- Irwell Ward – Greater Manchester Mental Health NHS FT
- Kestrel Ward – Oxford Health NHS FT
- Lark Ward – Norfolk and Suffolk NHS FT
- MacArthur Ward – Black Country Partnership NHS FT
- Maplewood 3 – Mersey Care NHS FT
- Marina PICU – Northamptonshire Healthcare NHS FT
- Nostell Ward – South West Yorkshire Partnership NHS FT
- Pavilion Ward – Sussex Partnership NHS FT
- Rowans Ward – Coventry and Warwickshire Partnership NHS FT
- Stewart Ward – Southern Health NHS FT
- Newberry, Evergreen and Westwood – Tees, Esk and Wear Valleys NHS FT
- Willows Unit – Nottinghamshire Healthcare NHS FT
- Woburn Ward – West London NHS FT