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So, Hello - ihub.scot · 2 012 12 012 2 2 3 013 13 013 3 3 4 014 14 014 4 4 5 015 15 5 BMI ... (between HSC staff, teams and with other agencies) LEADERSHIP • Agree core components

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  • So, Hello ..

  • MENTAL HEALTH

    QUALITY AND SAFETY COLLABORATIVE

    - Our journey

    http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiKg4mz85_LAhXJyRQKHTJsCBgQjRwIBw&url=http://northernireland-awealthofhistory.doomby.com/pages/the-dark-hedges-co-antrim.html&bvm=bv.115339255,d.ZWU&psig=AFQjCNE-eIilRctsz_TB50SLLEKlrhk9Nw&ust=1456935900843672http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiKg4mz85_LAhXJyRQKHTJsCBgQjRwIBw&url=http://northernireland-awealthofhistory.doomby.com/pages/the-dark-hedges-co-antrim.html&bvm=bv.115339255,d.ZWU&psig=AFQjCNE-eIilRctsz_TB50SLLEKlrhk9Nw&ust=1456935900843672

  • Providing leadership in

    Patient Safety and Quality Improvement

    across Health & Social Care

  • What do we do?

    Promote Quality Improvement (QI)

    Engage staff

    Help design reliable processes & systems

    Facilitate standardisation/reduce variation

    Use data to uncover the real story

  • Unscheduled Care

    Community Care

    Maternity Care

    Paediatric

    Care

    Mental Health

    Primary Care

    Scheduled Care

    HSC SAFETY FORUM WORK PROGRAMME

    Personal/Public Involvement

    Communication Human FactorsUnder/post

    graduate programmes

    Building capacity Sharing &

    Networking

  • LS 0

    1.4.14

    Action Period 1

    Trusts to form improvement

    teams

    Development of local driver

    diagrams

    ? Identifying areas for

    change testing

    Pre-work: August 2013

    April 2014

    Agreement at Strategic

    Partnership Group to begin

    QI Collab in Mental heatlh

    Letter to MH Leads

    August 2013 asking for

    rep. on Advisory Group

    (AG)|

    1st AG meeting held

    August 2013 to identify

    areas of focus

    2nd AG meeting

    December 2013 areas of

    focus: crisis

    management and

    improving physical

    health needs

    1st stage driver diagrams

    developed for discussion

    Mental Health Collaborative

    The Journey

    Action Period 2

    Refine Driver Diagrams

    Beginning tests of change

    Measurement

    Action Period 3 and 4

    Continue tests of change

    Measurement

  • AIM OF WORK

    The overall aim is to reduce

    harm to mental health

    patients by:

    < number of suicides?

    < episodes of self-harm?

    < number of

    visits/admissions to

    hospital?

    < number crisis presentations

    Identifying

    Risk/Assessment

    Communication

    Risk

    Management/

    Planning

    Risk Screen tool

    Comprehensive risk

    assessment tool

    Recovery Colleges

    Telephone Help-line

    Trigger List

    Education

    Mental Health SBAR (see eg)

    Use of hand held notes

    (health passport)

    Management Plan

    What are we trying to

    accomplish?

    What specific changes can we

    make which will result in

    improvement?

    Risk Screening

    Comp. risk

    assessment

    (currently under

    review)

    Out of hours

    service

    Available

    information

    Crisis Management

    Plan

    Care Pathway

    Patient/Client and

    family/carer

    involvement

    Link with out of hours service

    Signposting

    Patient information/education

    Availability of patients info to

    family/carers

    Person Centredness

    awareness training

    Recognition of

    problems (signals)

    Education,

    awareness raising

    DRIVERS:

    PRIMARY/SECONDARY

    Crisis

    Management

  • AIM OF WORK

    The overall aim is to improve

    the physical health and well

    being of mental health

    patients:

    < no. patients who stop

    smoking

    < no. patient who reduce

    smoking

    < no. mental health patients

    received health checks

    SMOKING(cessation and

    reduction)

    COMMUNICATION

    IMPROVED

    PHYSICAL CARE

    Public health - campaign

    Access to services

    Family involvement

    Common pathways/ templates

    Key worker

    Mental Health Team (review

    patients GP record)

    Training

    Key worker

    Accessing services

    Use of hand held notes

    (health passport)

    What are we trying to

    accomplish?

    What specific changes can we

    make which will result in

    improvement?

    Stop smoking

    (pathway see eg

    NHS Health

    Development

    Agency)

    Information

    Between health and

    social care

    professionals

    Weight loss and

    improved fitness

    Monitoring of

    antipsychotic

    medication

    Recognition and

    rescue of

    deterioration

    Patient/Client and

    family/carer

    involvement

    Patient information/education

    Availability of patients info to

    family/carers

    Education

    DRIVERS:

    PRIMARY/SECONDARY

    PHYSICAL HEALTH NEEDS

  • EXAMPLE OF RESULTS

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    Family History

    Collaborative began early 2014

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    BMI

    Collaborative began early 2014

  • 0%

    10%

    20%

    30%

    40%

    50%

    60%

    70%

    80%

    90%

    100%

    Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15

    BP

    PHYSICAL HEALTH MONITORING, Example

  • 0%

    10%

    20%

    30%

    40%

    50%

    60%

    70%

    Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15

    HPP given out

    HEALTH PASSPORT (HPP) ON TRANSFER

  • AND NOW ..

    a continuing journey

    Action Period:

    Confirm team

    membership and meet to

    plan improvement work

    Meeting of Advisory

    Group to plan further work

    BACKGROUND

    Meeting with MH

    Commissioners Feb 2015

    Met with MH

    Commissioning Team Feb

    2015

    Meeting to discuss

    recommendations of

    Thematic Review with MH

    Comm. Team May 2015

    Initial Driver Diagram

    development for future work

    related to Review

    discussed and amended

    MH Advisory Group 25.8.15

    to discuss work further

    MH LS on 4.9.15 to

    introduce future work with

    participants and agree way

    forward

    Action Period:

    Staff Safety Climate

    Survey

    Safety Briefings test

    Reflective Practice

    Data

  • KEY THEMES:

    Communication

    Care Planning

    Policy Adherence

    Record Keeping

    Risk Assessment

  • RECOMMENDATIONS (synopsis):

    Role of Team Manager

    Teams need to be given time to reflect

    on their practice and Team Leaders/Ward Managers

    should facilitate their staff at team meetings

    to reflect on practice

    Patient Journey

    Services need to be organised to minimise the number

    of handovers, ensure continuity of care and clarity of roles

    and responsibilities. All patients should have a named

    nominated person, who will be a constant, to co-ordinate their care

    Quality of Investigation Reports

    Teams should follow root cause analysis process to address

    systemic, contextual and cultural contributors to care as

    well as individual practice

  • AIM:

    To improve

    the culture of

    learning and

    reflective

    practice

    in mental

    health

    services

    CULTURE

    COMMUNICATION(with patients, family,

    carers & friends)

    COMMUNICATION(between HSC staff,

    teams and with other

    agencies)

    LEADERSHIP

    Agree core components for QI training

    Train the trainers

    Human Factors Training

    SBAR/SBARD training Build confidence in communication

    Mentoring

    Information provided to families & carers

    Family /carer engagement

    Measurement of current strategies

    Involve families in all SAI reviews

    Transitions of care/Handovers

    Safety briefings Named co-ordinator for all complex cases

    Safety plans and appropriate sharing of

    same (regional work ongoing in this)

    Leadership - support for QI work

    Transformational leadership training for key

    staff

    Measurement of safety and quality

    Review what is currently measured

    Support for reflective practice Debriefings

    COMPETENCE

    Staff Safety Climate Survey Patient Safety Climate Survey

    Positive risk taking

    Followership

    Ver 8

  • PROPOSED MEASURES

    Staff Safety Culture Survey

    Safety Briefings/SBARD

    Reflective practice

  • REFLECTIVE PRACTICE

    Definition

    Process

    Measurement

  • LEARNING

    Early QI work gave teams opportunity to become familiar with

    Collaborative model of working and QI methods

    Time out to network, learn and reflect and permission to

    test out changes

    Involvement with Commissioners and future work linked to

    strategic drivers has really driven the current work

    of collaborative

    Having opportunity to have both community and in-patient

    pilot team will further facilitate communication and learning

    across interfaces

    http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwi7953uwKTLAhXJFJoKHTXxAkMQjRwIBw&url=http://eflpodblog.com/learning/&psig=AFQjCNFvD2TeNLDlemwtW1PhEQy3qHJfFw&ust=1457094050595406http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwi7953uwKTLAhXJFJoKHTXxAkMQjRwIBw&url=http://eflpodblog.com/learning/&psig=AFQjCNFvD2TeNLDlemwtW1PhEQy3qHJfFw&ust=1457094050595406

  • Coming together is a Beginning,

    Keeping together is Progress,

    Working together is Success

    Henry Ford

  • CONTACTS

    Dr Gavin Lavery, Clinical Director, HSC Safety Forum

    [email protected]

    Ms Janet Haines-Wood, Regional Patient Safety Advisor,

    HSC Safety Forum

    [email protected]

    TEL: 02892 501302