Four Steps to Safety Amanda Pithouse - Deputy Director of Nursing and Quality Katherine Quilty Service User Consultant
Background Fundamental ethos of service user co-production MDT review team conducted an assessment of interventions that reduce incidence of violence within in-patient settings. Conducted design phase over 18 months, focussing on two acute male service. Working with clinical team and service user consultants decided on final interventions to incorporate in project. Rolled out across 4 wards including forensic and CAMHS. Average of 55% reduction in violence across all services. Commenced formal pilot phase across further 4 wards. Pilot phase focussed on methods for disseminating the training programme, implementation and reliability. Applied for funding to the Health Foundation Scaling up for Improvement to roll out the programme Trust wide. Partnered with Devon NHS PT to increase reliability. KCL carrying out the formal evaluation. Formalised Four Steps to Safety Programme.
Co-production The value of service user consultants: Important at every stage Project design Training design and delivery Data Analysis Adding value to facilitation, making changes within services Evaluation
Four Steps System for safer care - A toolkit which: Uses quality improvement methods to reduce violence, focussing on four key elements: 1. Proactive Care Thinking and acting ahead of anticipated risk events, taking proactive and preventive approaches to risk management as opposed to reactive solutions to risk events. 2. Service User Engagement Healthcare professionals to encourage active service user participation by collaboratively planning for care needs with the service user. 3. Teamwork Multi-professional teams working together with the service user to attain the service user s recovery goals. 4. Environment Exploring external and internal factors within the environment that may have an impact on violence and putting plans in place to remove or minimise these.
Project Plan 2 x WTE Quality Improvement Facilitators. 1 x WTE Service User Consultant (2x0.5). Delivery across 52 SLaM wards and 22 DPT wards. Wards allocated to cohorts, 4-6 wards per cohort in SLaM, new cohort commences every 2-3 months. Project to run over 2yrs. Formal training for team members at commencement of project. Design of interactive learning hub.
The Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Aim Measurement Change Act Study Plan Do Cycle for Learning and Improvement
Process Ward Recruitment Recruit teams using recruitment form Data Collection Commence data collection for specific areas Meeting the Team Assess previous history of violence, working systems, challenges. Qualitative Data Collection Ward Team Service Users Training Programme In-depth training, brief training, weekly follow up Training Needs Analysis Assess skills of team Project Charter Develop a project plan Plan for sustainability Qualitative Data Feedback Feedback outcomes Project delivery Implementation of the interventions Measurement of reliability Clinical records, datix Continuous Improvement Embedding and Sustainability
Changes Toolkit Four steps to safety Toolkit - Evidenced Based Interventions Proactive care: DASA - tool used to predict risk Risk management - Plans formulated by clinicians in response to identified risks of the patient. Zoning - A system where a Red Amber Green rating is used to identify care need for the patient Specific interventions are delivered in relation to the zone. Patient engagement: Compact - The community code of conduct between patients and staff on the ward. Foster a therapeutic atmosphere enhancing the development of community wellbeing. Intentional Rounding - Involves health professionals regularly engaging with patients. Offers patients comfort, and ease their anxiety and make them feel safer. Teamwork: Environment: Report Out - Morning Meeting with the multi-professional team- discussion of patient care. SBAR - is structured method for communicating information which improves communication Escalating Risk - Set of standard identified steps to take when a patient is deteriorating Safe Wards - Intervention introduced by the team to make the ward environment safer Mapping of violent incidents - provides useful information about where incidents most commonly happen on the ward Staff are then better able to target interventions to reduce incidents.
Measurement Outcome Measures Violent and Aggressive Incidents Safety Cross data Industrial Injuries Process Measures % evidenced completion of interventions 5 sets of clinical records for each intervention, per week, per ward Balancing Measures Reporting rates Use of seclusion Use of restraint
Example Data
Using data at ward level 0.20 0.18 0.16 0.14 Number of Numerator Cases PICU Violent Incidents/OBDs 0.12 0.10 UCL 0.10 0.08 0.06 0.04 CL 0.03 0.02 0.00 28/07/201417/11/201409/03/201529/06/201519/10/201508/02/2016 0.16 0.14 0.12 0.10 Number of Numerator Cases PICU Aggression Incidents/OBDs 0.08 UCL 0.07 0.06 0.04 0.02 CL 0.02 0.00 28/07/201417/11/201409/03/201529/06/201519/10/201508/02/2016 120 100 80 66.60 60 46.21 40 20 0 24/08/2015 12/10/2015 30/11/2015 18/01/2016 07/03/2016 25/04/2016 % Completion PICU DASA Percentage Completion 120 Rate 108.84 100 81.72 80 60 40 20 0 27/07/2015 21/09/2015 16/11/2015 11/01/2016 07/03/2016 02/05/2016 % Completion PICU Intentional Rounding Percentage Completion Rate 130.00 120 100.00 100 80 60 % Completion 140 PICU Zoning Percentage Completion Rate 40 20 0 27/07/201514/09/2015 02/11/201521/12/201508/02/2016 28/03/2016 Number of Incidents 12 10 8 6 4 2 PICU Safety Cross Incidents (Reds) 9.90 3.94 Number of Incidents 7 6 5 4 3 2 1 PICU Safety Cross Incidents (Ambers) 6.01 1.89 % Completion 100 90 80 70 60 50 40 30 20 10 PICU Risk Management Percentage Completion Rate 74.98 53.12 % Completion 120 100 80 60 40 20 PICU SBAR Percentage Completion Rate 97.37 71.92 0 01/09/201512/10/201523/11/201504/01/201615/02/201628/03/2016 0 01/09/201512/10/201523/11/2015 04/01/201615/02/201628/03/2016 0 27/07/2015 21/09/2015 16/11/2015 11/01/2016 07/03/2016 02/05/2016 0 23/11/2015 28/12/2015 01/02/2016 07/03/2016 11/04/2016 16/05/2016
Key Lessons Leadership key to implementation Multi-professional team working Reliability of interventions Engagement Training flexibility Sustainability Governance structures and processes Staffing challenge when there are deficits in leadership
Next Steps and Results Collaborative events Website design Assessing outcomes Results so far: Cohorts one and two implemented 4-5 interventions at over 85% reliability. Reductions in violence are evident but not yet sustained.
Thank You! Questions?