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 the 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 Support & facilitation Safety climate survey Data collection Tests of change using the QI methodology Trigger tool (targeted case review & analysis) Patient focus groups Review on completion of collaborative
Work streams Leadership Medication Safety Communication Patient Perception of Safety (Hampshire)
Model for improvement What are we trying to achieve 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 20 Communications Improve a culture of safety by 20% within the identified mental health pilot sites by Dec 20. Reduce the incidents of adverse events related to falls by % by December 20 Reduce the number of control and restraint incidents by % by December 20 Medicines safety 30% Reduction in reported adverse drug event rate by Dec 2011
Measures Leadership % of NHS Tayside s Patient Safety Leadership annual walk rounds will take place within Mental Health Services by December 20. 0% of actionable items identified during leadership walk rounds that are completed each month by June 20 0% 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 20.
Measures Communication 95% Compliance with using Daily Safety Briefings. 0% Staff trained in the use of SBAR by Dec 20 0% 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 20 95% patients with medicines reconciliation performed on discharge for all patients by June 20 0% 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 Patient Safety as a standing agenda item at Senior Management Team meetings. Peer review visits
No of Patient Safety Leadership annual walkarounds taking place within Mental Health Services by December 20. NHS Tayside Walkrounds Cummulative Total 215 2 205 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 20 180 175 170 One walkround carried out in Mental Health Services in July Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Month Measure : % of NHS Tayside s Patient Safety Leadership annual walkarounds will take place within Mental Health Services by December 20.
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 To establish a baseline to then measure the impact of changes upon the safety culture within Mental Health
0 90 80 70 60 50 40 30 20 0 Response Analysis Response Analysis Positve Neutral Negative Q18 Q19 Q17 Q16 Q6 Q7 Q8 Q9 Q 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
Communication Changes for Improvement Introduce training in the use of the SBAR tool 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 Deliver educational sessions on improving safety within Mental Health to clinical and non clinical staff
No. of incidents re. control and restraint (Sunnyside Royal Hospital, Ward 8) 9 8 7 Number 6 5 4 3 2 1 0 Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Month
Safety Briefings % Co mpliance 0 90 80 70 60 50 40 30 20 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- Nov- Dec- Jan- Feb- Mar- Apr- Month
Trained in the use of SBAR Compliance % 120 0 esbar 80 training carried out 60 40 20 Ward 8 Sunnyside %Trained in use of SBAR SBAR training carried out 0 Nov- Dec- Jan- Feb- Mar- Apr- 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
% patients in Moredun A and B wards with medicine reconciled on Admission with 24 hours 0 90 pharmacist attends meeting with consultants to discuss medicine reconciliation PDSA.3 consultants given information on progress 80 70 60 Percent 50 40 PDSA.2 implementation of medicine reconciliation ` PDSA 4 a supply of forms available in ward 30 20 PDSA1 testing of medicine reconciliation forms medicine reconciliation incorporated into junior doctor induction 0 Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec-
% TPAR Charts Accurately Completed in Moredun A and B (Completed in accordance with Prescribing Standards (error free prescribing approach) 0 90 PDSA 4 Supervisor made aware of errors 80 70 60 Percent 50 40 30 20 PDSA 2 & 3 Recording errors in diary Check errors have been rectified 0 Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan-11 Feb-11 Mar-11
% Patients at Murray Royal Hospital with Medicine Reconciliation Performed on Discharge 0 90 80 70 60 Percent 50 40 PDSA 1 poster on wards about pharmacist prescription check PDSA 3 prescription check poster predominantly displayed 30 20 PDSA 2 trays on wards for prescriptions ready to be checked 0 Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec-
Successes Error free prescribing Baseline in November 20-35% of prescriptions written correctly. In mid April 84% correct Medicine reconciliation on discharge In April 20-26% patient t medicine i reconciled, in January 20 0% Challenges Medicine e Reconciliation c o ensuring junior doctors o understand the benefits to completing the form and do so consistently Engaging all consultants by ensuring a feedback mechanism is in place
Insights The variation in staff and patients knowledge of safety/safety 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 id 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 pilot sites Testing to refine and improve the tool ongoing Global trigger tool Work underway in England. Not yet able to share Tayside & others considering what else could be included
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.
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
NHS Tayside Board Mental Health Joint Clinical Board 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