Patient Safety in Mental Health Improving Lives, Improving Services Dr Denise Coia, Principal Medical Officer (Mental Health)
Quality Strategy IOM 6 Quality Dimensions Efficient Equitable Timely Patient t Centred Effective SAFE
Mental Health Patient Safety Programme What aspects of acute patient safety agenda are relevant to mental health? What is unique to mental health? What other patients safety programmes are relevant (primary care, long term conditions) What are the key areas we should prioritise? What can we learn from other countries with established programmes (Canada, USA, Australia, England)
Mental Disorders Long term conditions Longitudinal as well as acute care Community care rather than hospital care Across agencies NHS, Social Work, Education, Justice
Patient Factors Patient safety incidents in mental health codependent eg absconding, aggression, self harm, non compliant behaviour (Bowers 2006) (Quirk, Lelliot & Seale 2006) Psychiatric Diagnosis Psychiatric i symptomatology t Poor Communication between patient and health care providers Reduced help seeking Comorbid substance misuse, increased self harm
Provider Factors Staff cultures that value patients have adverse events (Bowers 2006) Large case loads, inexperienced i staff, high h turnover (Mark & Marcus 2006) Fragmentation between systems and transitional care (Mental Health Canada 2007) General medical setting poor treatment of mentally ill (miss cognitive impairment depression)
Organisational Systems Admission/discharge processes Policies and procedures for reporting (CIRs) Organisational culture of patient safety Fragmentation between systems and transitional care
Patient Safety and Mental Health Violence and aggression Patient victimisation/reduced capacity for self advocacy Suicide and self harm Seclusion and restraint Falls and other accidents Absconding and missing patients Adverse medication events Adverse diagnostic events NPSA 2006
Safer Mental Health Checklists Risk assessment CPA Protocols at transition points Rapid Responses Reports Quality Alerts Scorecard
Gaps in Patient Safety Literature Difficult to translate research across countries due to different health care, legal systems, cultural and social norms Focus mainly on adults (less on older people and children) Lack of empirically validated risk assessment tools or training in their use Lack of well researched interventions and poor implementation
Develop a Patient Safety Culture Make patient safety an organisational priority.
NHS Tayside Safety in Mental Health Collaborative
Improving Safety in Mental Health Programme Aims supported by an Improvement Advisor: Dr Noeleen Devaney Support 4 UK organisations to: reduce harm improving the reliability of care raise safety awareness Produce a tested set of change packages replicable across other mental health care providers See if lessons drawn from its Safer Patients Initiative (SPI) were transferable to Mental Health organisations
The 4 Organisations Devon Partnership NHS Trust Hampshire Partnership NHS Foundation Trust NHS Tayside South London and Maudsley NHS Foundation Trust
Format of Collaborative Learning sets X 4 Support & facilitation to work on chosen areas Safety climate survey, start and finish of pilot Baseline data followed by ongoing data collection Trigger tool (targeted case review & analysis) Patient focus groups Tests of change using the QI methodology Review work to date on completion of collaborative
Work streams Leadership Medication Safety Communication Patient Perception of Safety (Hampshire)
Model for improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in the improvements that we seek? aims measurements change ideas Act Plan testing ideas before implementing changes Study Do Langley et al 1996
Safety in Mental Health Collaborative Driver Diagram Outcome Pi Primary Drivers Di Secondary Drivers Processes, Rules of Conduct, Structure Components, Activities Making care safer for mental health patients Transitional Leadership which improves Safety Culture Climate Medication safety Communication at transition points Improving patients perception of safety Safety/Quality comprises 25% of Exec Team agendas. Implement PS Leadership walk rounds within MHS Improvement Aims are in Strategic Plan and defined within governance framework Build the right team/improvement capability Implement safety climate survey Identify Champion Develop sustainability plan Develop safety culture, safety briefings, safety champions in every unit. Involve patients Ensure Med Rec. at all transition points Reduce Harm from High Hazard Medication. Improve core medication processes Common mental model SBAR, Ask me three, assertion, critical language, briefing, debriefing, situational awareness. Create an environment of respect, conflict resolution Develop Policies, procedures, protocols and checklists Change how nurses spend their time (R.t.C) Dignity, privacy, Information sharing Key safety information, Single rooms Clear expectations of behaviours and rules Minimise LOS
Aim statements Leadership Increase Mental Health Staff perception of a positive safety climate by 50% by December 2010 Communications Improve a culture of safety by 20% within the identified mental health pilot sites by Dec 2010. Reduce the incidents of adverse events e related to falls by 10% by December 2010 Reduce the number of control and restraint incidents by 10% by December 2010 Medicines safety 30% Reduction in reported adverse drug event rate by Dec 2011
Measures Leadership 10% of NHS Tayside s Patient Safety Leadership annual walk rounds will take place within Mental Health Services by December 2010. 100% of actionable items identified during leadership walk rounds that are completed each month by June 2010 100% of Heads of Integrated t Mental Health Services Senior Management Team agendas in General Adult Psychiatry have patient safety as a standing item by June 2010.
Measures Communication 95% Compliance with using Daily Safety Briefings. 100% Staff trained in the use of SBAR by Dec 2010 100% Nursing staff using SBAR by June 2011 95% of SBAR exchanges which are of high quality by Dec 2011
Medication safety Measures 95% of patients have their medication reconciled within 24 hrs of admission (except for weekends and public holidays where it will be 72 hrs) by December 2010 95% patients with medicines reconciliation performed on discharge for all patients by June 2010 100% TPAR charts accurately completed in accordance with the error free prescribing guidance by June 2011
Leadership Changes for Improvement Leadership walk rounds Safety Climate Survey Senior Management Team Patient Safety as a standing agenda item Future - Peer review visits
No of Patient Safety Leadership annual walkarounds taking place within Mental Health Services by December 2010. NHS Tayside Walkrounds Cummulative Total 215 210 205 Walkround cancelled Walkround MA MRH Number 200 195 190 185 Mental Health Collaborative starts 2 walkrounds carried out in Mental Health Services in August Walkround cancelled No walkrounds in Jan, Feb, Mar or Apr next one in May 2010 180 175 170 One walkround carried out in Mental Health Services in July Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Month Measure : 10% of NHS Tayside s Patient Safety Leadership annual walkarounds will take place within Mental Health Services by December 2010.
Safety Climate Survey Aim: To determine the current level of safety culture within Mental Health Services, NHS Tayside by staff completion of the Safety Climate Survey. Objectives: To gain information about the perceptions of frontline clinical staff in relation to safety within their clinical area Determine management and senior leader s commitment to safety Explore the differing professional group s perceptions of safety To establish a baseline to then measure the impact of changes upon the safety culture within Mental Health
100 90 80 70 60 50 40 30 20 10 0 Response Analysis Response Analysis Positve Neutral Negative Q18 Q19 Q17 Q16 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14a Q14b Q14c Q15 Question Number Q5 Q4 Q3 Q2 Q1 Percent
Successes Leadership Walk rounds are embedded Patient safety is a standing item on SMT agendas Climate survey carried out Road shows undertaken &newsletters produced Challenges Mental Health is one component part of the organisation. Raising awareness across Mental Health through this learning process alone is patchy. Ensuring internal patient safety meetings are well Ensuring internal patient safety meetings are well utilised & responsible for ongoing work
Changes for Improvement By introducing SBAR as a communication tool and establishing daily safety briefings there will be a 10% reduction in the number of control and restraint incidents within Wards 4 and 8 at Sunnyside by December 2010: Introduce training in the use of SBAR to nursing staff within Ward 8 Introduce daily safety briefings at the ward handover within Ward 4 Developed information folder for Wards 4 and 8 Deliver educational sessions on improving safety within Mental Health for the following groups of staff (nurses, consultant psychiatrists, domestic staff & porters
No. of incidents re. control and restraint (Sunnyside Royal Hospital, Ward 8) 10 9 8 7 Number 6 5 4 3 2 1 0 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Month
Safety Briefings % Compliance 100 90 80 70 60 50 40 30 20 10 0 Ward 4 Sunnyside Hospital %Compliance with Using Daily Safety Briefings Due to increased activity it in the ward less safety briefings were carried out Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 Month
Trained in the use of SBAR Compliance % 120 100 esbar 80 training carried out 60 40 20 Ward 8 Sunnyside %Trained in use of SBAR SBAR training carried out 0 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 Month
Successes Engaging staff with the collaborative and developing their enthusiasm to participate i t Beginning to link the methodology with other strategic improvements e.g. releasing time to care No formal plans to a much more focused approach. Challenges When wards are busy that it is essential to give priority to safety briefings Co-ordinating ordinating SBAR training for outstanding % of staff still to be trained e.g. night duty, staff movement Making safety everyone s business and getting involvement from the wider MDT
Changes for Improvement Medication safety Medicine Reconciliation on admission Error free prescribing Medicine reconciliation on discharge
100 % patients in Moredun A and B wards with medicine reconciled on Admission with 24 hours 90 pharmacist attends meeting with consultants to discuss medicine reconciliation PDSA.3 consultants given information on progress 80 70 60 Percent 50 40 30 20 PDSA.2 implementation of medicine reconciliation ` PDSA1 testing of medicine reconciliation forms PDSA 4 a supply of forms available in ward medicine reconciliation incorporated into junior doctor induction 10 0 Feb- 09 Mar- 09 Apr- 09 May- 09 Jun- 09 Jul- 09 Aug- 09 Sep- 09 Oct- 09 Nov- 09 Dec- 09 Jan- 10 Feb- 10 Mar- 10 Apr- 10 May- 10 Jun- 10 Jul- 10 Aug- 10 Sep- 10 Oct- 10 Nov- 10 Dec- 10
% TPAR Charts Accurately Completed in Moredun A and B (Completed in accordance with Prescribing Standards (error free prescribing approach) 100 90 80 PDSA 4 Supervisor made aware 70 60 Percent 50 40 30 20 10 PDSA 2 & 3 Recording errors in diary Check errors have been rectified 0 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11
% Patients at Murray Royal Hospital with Medicine Reconciliation Performed on Discharge 100 90 80 70 60 Percent 50 PDSA 1 poster on wards about pharmacist prescription check PDSA 3 prescription check poster predominantly displayed 40 30 20 10 PDSA 2 trays on wards for prescriptions ready to be checked 0 Apr- 09 May- 09 Jun- 09 Jul- 09 Aug- 09 Sep- 09 Oct- 09 Nov- 09 Dec- 09 Jan- 10 Feb- 10 Mar- 10 Apr- 10 May- 10 Jun- 10 Jul- 10 Aug- 10 Sep- 10 Oct- 10 Nov- 10 Dec- 10
Successes Error free prescribing Baseline in November 2009-35% of prescriptions written correctly. In mid April 84% correct Medicine reconciliation on discharge In April 2009-26% patient medicine reconciled, in January 2010 100% Challenges Medicine Reconciliation ensuring junior doctors understand the benefits to completing the form and do so consistently tl Engaging all consultants by ensuring a feedback mechanism is in place
Insights The variation in staff and patients knowledge of safety/safety y issues No matter how disheartening it gets at times to make progress keep going as a team and believe change will come Continue to learn and develop the use of improvement methodology The importance of data as a catalyst for change & it being integral to practice. How this pilot fits in with all the other pieces of Improvement work
Outcomes Health Foundation A set of aims and measures which can be used universally across MHS Raised Safety Awareness across MHS MH PS Collaborative Team Structured approach to patient safety Developed capacity and capability to deliver Wider sharing of knowledge and skills Time out to develop, learn and share experiences Opportunity to visit sites south of the border Improved patient outcomes & experience Early in the process, time will tell in respect of reduction in falls and C&R incidents leading to a reduction in reported adverse events. We will continue to plot progress to achieve sustainable change.
Trigger tools Medication Safety Not in use across all sites Testing to refine and improve the tool Global trigger tool Work underway in England. Not yet able to share Tayside & others considering what else could be included e.g. readmission target and improvement measures
NHS Tayside Board Improvement and Quality Committee Tayside Improvement Panel Patient Safety Leads Group (Operational) NHS Tayside Patient Safety Development Forum Access Directorate Surgical Directorate Medical Directorate Dundee CHP Angus CHP Perth CHP Mental Health Services
Sustainability Ensure work streams are embedded into the day to day work of the organisation Utilise supporting infrastructure Use expertise developed to increase capacity and capability Implementation & sustainability plan to be developed Implementation & sustainability plan to be developed and owned by each locality.
Next Steps for Tayside New Joint Clinical Board being set up across MHS Building for the future Other Patient Safety work in Tayside
NHS Tayside Delivery Unit Joint Clinical Board for Improvement in Mental Health Building capacity Strategic Improvement Programme ` Plan Referral pathway & Crisis Response (inc. Readmissions & LOS) Health Foundation Patient Safety Mental Health Collaborative The Scottish Mental Health Collaborative Supporting Mental Health work streams Work streams for: Leadership Medicines Safety Communications Global and Medicines Safety Antipsychotic Prescribing Safe and effective Heat Targets for: Readmissions Antidepressant Prescribing Improvement in the Early Diagnosis and management of patients with Dementia Access to Psychological Therapies coming on stream Suicide Prevention & associated Training Integrated Care Pathways Mental Health Nursing Review (Rights, Relationships & Recovery) Leading Better Care (Releasing time to care) Patient Experience Efficient and productive Person centred Mutuality and equality
Improving Patient Safety by the use of an Admission Booklet
Audit of Impact of Admission Booklet on Clerking of New Admissions to GA Psych Ward Dr G Wethers (ST2 Psych) GG&C Health Board Dr J Brown (ST4 GA Psych) Forth Valley Health Board
Background Increased Turnover of FY2/GP trainees (4 monthly) Psychiatry y Assessment is new skill to develop Good Psych Practice Guidelines (RCPsych 09) :..competence in full history, mental state examination, evaluating and documenting clinical risk, physical examination and investigations
Previous Studies Dinnes et al (2006) Improvement in most information obtained, they noted a drop in the recording of a complete management plan
Aim of Audit To assess the completeness of admission clerking by junior trainee doctors before and after the introduction of a standardised admission booklet
Method Cycle 1 Assessed fullness of clerk-in completed free-hand on continuation sheets 48 Patients Acute Admissions Wards of Leverndale Hospital, Glasgow Pro-forma checklist and 2 Assessors Deemed satisfactory t if attempt t made at specific aspect of clerk-in
Method Cycle 2 Intervention Standardised Admission Form Consensus from Consultants Completeness of Clerk-in assessed in same way as Cycle 1 50 Patients t from Acute Wards
Results Patient Details History Mental State Examination Management Plan
Results Patient Details Fig. 1 Completeness of patient details 100 80 % 60 40 20 Percentage 0 Date Time Patien ent Details Patie tient's GP Doctor tor's Name Doctor or's Grade Signature Legib ible writing Continuation Sheets Admission Booklet
d Personality Results - History Fig. 2 Completeness of history taking 100 80 60 40 20 Percentage % 0 Refe ferral Source Presenting ng Complaint Past Psychia hiatric History Past Med edical History Drug History Family History Alcohol ol / Drug Use Fore ensic History Social History Perso sonal History Premorbid
Risk Results MSE Fig. 3 Completeness of mental state examination 100 80 60 40 20 0 Percentage % A+B Speech Mood Thou ought Form Though ght Content Perception Cognition Insight Differential Diagnosis
Results Management Plan Fig. 4 Completeness of management plan 100 80 60 40 20 0 Percentage % Contact acted Senior Observa vation Level Legal Status Kardex /Medication Glasgow Risk Screen Physical Examination Admiss ssion Bloods
Discussion Admission Booklet Improves Clerk-in Improves Risk Assessment Forensic History 50% to 96% (p=0.001) 001) Documented Risk 50% to 98% (p=0.001) Glasgow Risk Screen 67% to 88% (p=0.015)
Discussion Likely Improving Patient Care e.g. Recording of Alcohol/Drug History improved from 56% to 98% (p<0.001) Teaching Role with Trainees e g Recording of Thought Form in MSE e.g. Recording of Thought Form in MSE improved from 42% to 96% (p<0.001)
Conclusion Admission Booklet Improves Patient Safety by Increasing the Documentation of the History and MSE, as well as improving the recording of Risk Assessment/Management
Acknowledgements Charlie Sellar, Policy Manager, Leverndale Hospital, Glasgow Dr Jones-Edwards Junior Doctors and Nursing Staff of Leverndale Hospital Dr J Taylor, Dr N Masson, Dr A Liew
References Stephen Dinniss, Jocelyn Dawe, and Michael Cooper. Psychiatric admission booking: audit of the impact of a standardised admission form. Psychiatric Bull., Sep 2006; 30: 334-336. Royal College of Psychiatrists (2009) Good Psychiatric Practice (Council Report CR154). London: Royal College of Psychiatrists Ian Pullen and John Loudon. Improving standards in clinical record-keeping. Advan. Psychiatr. Treat., Jul 2006; 12: 280-286. Andrew Carroll. How to make good-enough risk decisions. Advances in Psychiatric Treatment 2009 v. 15, p. 192-198. Joe Bouch and John James Marshall. Suicide risk: structured professional judgment. Advances in Psychiatric Treatment 2005 v. 11, p. 84-91