Glasgow City CHP Item No. 6 CHP Committee Meeting Date: Thursday, 28 th February 2013 Paper No 2013/006 Subject: Presented by: Recommendation(s) Summary/ Background Scottish Patient Safety Programme - Mental Health Michael Smith, Lead Associate Medical Director, Mental Health Services The CHP Committee is asked to: note the work being progressed in Mental Health as part of the voluntary programme In June 2009 the Cabinet Secretary for Health and Wellbeing announced a commitment to extend the Scottish Patient Safety Programme into paediatrics, mental health and primary care. The Healthcare Quality Strategy for NHS Scotland (2010) outlines the requirement for the establishment of a programme of mental health patient safety work. The programme has been designed to complement other existing mental health programmes of improvement work. The SPSP-Mental Health will be a four year programme with an overall aim of systematically reducing harm experienced by people using mental health services in Scotland, by supporting frontline staff to test, gather real-time data and reliably implement interventions, before spreading across their NHS board area. Policy/ Legislative Context The Healthcare Quality Strategy for NHS Scotland (2010) Financial Implications Human Resources Implications A small sum of money has been allocated from the Patient Safety portion of Quest funding to support travel, training and some nursing backfill in support of the SPSP-Mental Health Programme. The programme is otherwise managed by Linda Davidson from existing resources. N/A Service User/Carer Involvement Equalities Implications Service User & Carer representation is provided to the group from the Mental Health Network. N/A FoI/EIR Status Public tick If not to be made public, exemption (Section/Regulation) to be relied on under FoI/EIR legislation must be inserted below. Not Public Contains Personal Data DPA applies S.38
Scottish Patient Safety Programme - Mental Health Purpose of Report This paper provides background information on the Scottish Patient Safety Programme (SPSP) for Mental Health and the work being progressed in our board. The report has been produced for Glasgow CHP Committee meeting of 28 February 2013. Glasgow City CHP Committee is asked to:- note the work being progressed in Mental Health as part of the voluntary programme. Policy Context and Background In June 2009 the Cabinet Secretary for Health and Wellbeing announced a commitment to extend the Scottish Patient Safety Programme into paediatrics, mental health and primary care. The Healthcare Quality Strategy for NHSScotland (2010) outlines the requirement for the establishment of a programme of mental health patient safety work. The programme has been designed to complement other existing mental health programmes of improvement work. The SPSP-Mental Health will be a four year programme with an overall aim of systematically reducing harm experienced by people using mental health services in Scotland, by supporting frontline staff to test, gather real-time data and reliably implement interventions, before spreading across their NHS board area. It will start with a focus on adult psychiatric inpatient units, including admission and discharge processes. This will include forensic inpatient units but will exclude inpatient units caring for people with dementia and exclude older adult functional illness units. The boards are asked to undertake a minimum of one of the following areas of work: Reliable implementation of risk assessment and safety planning Reliable implementation of processes to enable effective communication at key transition points The appropriate use of restraint, seclusion and emergency sedation Safer medicines management including medication reconciliation and reducing adverse medication events Leadership and culture Phase Two: August 2013 Onwards At this point it will become mandatory for all boards to engage in the programme. The content of phase two will be informed by the outcomes of the phase one testing. At this point, consideration will also be given to extending the focus of the work beyond adult psychiatric inpatient unit. 2
Participation and Area of Work Mental Health have agreed to participate in phase one of the voluntary programme and have selected to undertake work on reliable implementation of risk assessment and safety planning. Two wards, Elm Ward, Rowanbank and Rutherford Ward, Gartnavel Royal Hospital have been identified to take the work forward. The leadership and culture work stream is mandatory for all boards participating in the voluntary phase of the programme. Infrastructure to Support the Programme Steering Group A Steering Group chaired by the Lead Associate Medical Director for Mental Health has been established to co-ordinate and support the programme. Terms of Reference and membership (appendix1) for the Steering Group have been approved. The Steering Group held its first meeting in May 2012 and meets bi-monthly. Local Teams Local teams have been identified drawn from clinical staff working in the wards participating in the programme and a team leader identified for each ward to support the work. In addition coaching support is provided from clinical governance staff to each of the clinical teams. A clinical lead and project manager has been identified to work alongside the teams. Building Capacity and Capability National Learning Sessions Learning sessions have been scheduled for the duration of the programme and are designed to introduce the methods and develop the skills and knowledge of staff who are working on the new SPSP-Mental Health programme. The learning sessions teach improvement skills, develop networks with individuals in other NHS boards working on the same issues. Sharing the experiences of and the learning from conducting tests of change. Six staff from the ward teams the Clinical Lead and Project Manager attended the first Learning Session in August 2012. Learning Session two is scheduled for 14 February 2013 with 16 places allocated to the board. All places have been taken up and staff have registered for the event. Work is underway with the Teams to prepare a story board for the event outlining progress made. Progress of the Clinical Teams The Teams have commenced work on the change package and are currently applying improvement methods to include PDSA s and tests of change. The teams will begin to develop useful process measure that will inform the roll out of the programme in Phase 2. One area of focus for the Clinical Teams in the early part of the programme has been to undertake a feasibility study to establish if baseline data is available and to test the data collection tool feeding back issues to the national team. A complete set of baseline data for the past year has been collected and submitted to the national team at the end of October as scheduled. Monthly data returns continue to be submitted. An information sheet is also completed each month and returned to the national team outlining progress made. A communication plan has been put in place to ensure that staff are aware of the programme and participating teams have access to information. Clinical Teams have been participating in regular web-ex calls sharing their experiences and challenges in implementing the 3
programme. Information has been sent to clinical teams to make them aware of the Community of Practice set up through Knowledge net. An article has also been prepared and communicated in the Core Brief to raise general awareness of the programme in the Board. Work has commenced to implement the Leadership and Culture driver diagram with an infrastructure to support the programme now in place as described above. Work will continue to take forward and implement the various strands of the driver diagram in the coming months. Discussions are underway to begin to introduce leadership and service user walk rounds. Other Elements of the Programme Staff Safety Climate Survey Organisations working to develop or improve a culture of safety need a reliable measure to monitor the success of their initiative. A survey has been developed for this purpose and the clinical teams have now completed the survey. NHS Greater Glasgow and Clyde along with two other boards tested a tool to analyse the information for rolled out to other boards. The survey will enable the organisation to gain information about the perceptions of front-line clinical teams about safety in their clinical area and management s commitment to safety. The team s tests will lead to changes required to improve the culture and the survey will be repeated to assess the impact of those changes. Teams are being supported to analyse survey findings and agree actions for improvement. Service User Safety Climate Survey Work is being progressed at a national level to develop a survey tool for service users. It is anticipated that this will be available for use early 2013. The board has volunteered to test the survey prior to full roll out. Funding A funding application to the QuEST fund has been successful providing a small amount of funding support to replace the cost of clinical staff attending the Learning Sessions. Development There are other areas of work that will be considered by the Steering Group that will contribute to the development of the patient safety programme for mental health services to reduce harm experienced by patients using mental health services. This work will focus on topics that have been identified locally for improvement and will included safe and effective medicines management. Together with the work that will be undertaken to reliably implement risk assessment and safety planning, this will ensure that mental health is prepared to move forward and implement the mandatory programme in 2013. 4
Appendix 1 NHS Greater Glasgow & Clyde Scottish Patient Safety Programme Mental Health (SPSP MH) Steering Group 1. Aims and Objectives Terms of Reference The aim of the Patient Safety in Mental Health Steering Group is to develop and coordinate a patient safety programme for mental health services by providing effective leadership, developing a culture of safety that will drive improvements in patient safety. The Steering Group will provide guidance and support to implement the patient safety programme by identifying key priorities, developing and testing change packages, measures and spread. It is also responsible for monitoring progress and preparing reports to a variety of partnership and board committees. The overall aim will be underpinned by the following:- Phase One Engage in at least one of the areas of work described in phase one of the national programme and in addition one specific additional area of work for the team to address Develop driver diagrams, change packages and measures Support the collection of data to assess levels of harm to include: - establish mechanisms to routinely record data on the use of seclusion and restraint Provide information for scoping exercise of patients safety work already underway in mental health services Develop support infrastructure for the teams Communicate and engage with key stakeholders Build capacity and capability for the programme Recruit multi-disciplinary teams to participate in the programme Participate in the national Scottish Patient Safety Programme Mental Health Group that will oversee the development of this work Provide regular progress reports to Clinical Governance Forum, Directors Meeting, Mental Health Strategic Planning Group and Quality & Performance Committee Participate in evaluation of the programme 5
Phase Two Plan for implementation of Phase Two of the mandatory programme in May 2013 Continue to build capacity and capability to support the programme Secure funding 2. Patient Safety Programme Mental Health Steering Group The Steering Group will operate as a sub group of the Mental Health Clinical Governance Committee. Frequency of Meetings The Steering Group will meet bi-monthly. The group may require to meet more frequently at the early stage of the programme to establish the foundations for the programme. Membership of the Steering Group will include:- Membership Michael Smith (Chair) Andrew Walker Andy Crawford Ian Clarke Joan Blackwood Martin Montgomery Mark Gillespie Gwen Agnew Linda Davidson Janice Turnbull Elaine Park Being recruited Lead Associate Clinical Director, Mental Health Lead, Clinical Pharmacist Head of Clinical Governance Consultant Psychiatrist SPSP:MH Clinical Lead Clinical Lead, Mental Health Services Redesign General Manager, Forensic Services Nurse Consultant, Forensic Services Lead Allied Health Profession South Head of Department, Clinical Governance Support Unit SPSP:MH Project Manager Senior Organisational Development Advisor Public Partner Mental Health Network Public Partner 6