Transcript

So, Hello ……..

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 patient’s 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

patient’s 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 patient’s info to

family/carers

• Education

DRIVERS:

PRIMARY/SECONDARY

PHYSICAL HEALTH NEEDS

EXAMPLE OF RESULTS

0

20

40

60

80

100

120

Family History

Collaborative began early 2014

0

20

40

60

80

100

120

01

Jan

uar

y 2

01

2

01

Mar

ch 2

01

2

01

May

20

12

01

Ju

ly 2

01

2

01

Sep

tem

ber

20

12

01

No

vem

ber

20

12

01

Jan

uar

y 2

01

3

01

Mar

ch 2

01

3

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May

20

13

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Ju

ly 2

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3

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Sep

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13

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No

vem

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13

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Jan

uar

y 2

01

4

01

Mar

ch 2

01

4

01

May

20

14

01

Ju

ly 2

01

4

01

Sep

tem

ber

20

14

01

No

vem

ber

20

14

01

Jan

uar

y 2

01

5

01

Mar

ch 2

01

5

01

May

20

15

01

Ju

ly 2

01

5

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

“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


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