four steps to safety - nhs england · changes – toolkit four steps to safety toolkit - evidenced...

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 CareThinking 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 EngagementHealthcare 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. EnvironmentExploring 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 tryingto accomplish?

How will we know that achange is an improvement ?

What change can we makethat will result in improvement?

Plan

DoStudy

Act

Aim

Measurement

Cycle for Learning

and Improvement

Change

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

Qualitative Data Feedback

Feedback outcomes

Project Charter

Develop a project plan

Plan for sustainability

Training NeedsAnalysis

Assess skills of team

Training Programme

In-depth training, brief training, weekly

follow up

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: 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

Environment: 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

Process Measures

Balancing Measures

Violent and Aggressive Incidents

Safety Cross data

Industrial Injuries

% evidenced completion of interventions

5 sets of clinical records for each intervention, per week, per ward

Reporting rates

Use of seclusion

Use of restraint

Example – Data

Using data at ward level

9.90

3.94

0

2

4

6

8

10

12

01/09/2015 12/10/2015 23/11/2015 04/01/2016 15/02/2016 28/03/2016

Nu

mb

er o

f I

ncid

en

ts

Weeks

PICU Safety Cross Incidents (Reds)

6.01

1.89

0

1

2

3

4

5

6

7

01/09/2015 12/10/2015 23/11/2015 04/01/2016 15/02/2016 28/03/2016

Nu

mb

er o

f I

ncid

en

ts

Weeks

PICU Safety Cross Incidents (Ambers)

66.60

46.21

0

20

40

60

80

100

120

24/08/2015 12/10/2015 30/11/2015 18/01/2016 07/03/2016 25/04/2016

% C

om

ple

tio

n

Weeks

PICU DASA Percentage Completion

Rate108.84

81.72

0

20

40

60

80

100

120

27/07/2015 21/09/2015 16/11/2015 11/01/2016 07/03/2016 02/05/2016

% C

om

ple

tio

n

Weeks

PICU Intentional Rounding

Percentage Completion Rate

74.98

53.12

0

10

20

30

40

50

60

70

80

90

100

27/07/2015 21/09/2015 16/11/2015 11/01/2016 07/03/2016 02/05/2016

% C

om

ple

tio

n

Weeks

PICU Risk Management Percentage

Completion Rate

97.37

71.92

0

20

40

60

80

100

120

23/11/2015 28/12/2015 01/02/2016 07/03/2016 11/04/2016 16/05/2016

% C

om

ple

tio

n

Weeks

PICU SBAR Percentage Completion

Rate

130.00

100.00

0

20

40

60

80

100

120

140

27/07/2015 14/09/2015 02/11/2015 21/12/2015 08/02/2016 28/03/2016

% C

om

ple

tio

n

Weeks

PICU Zoning Percentage Completion

Rate

CL 0.03

UCL 0.10

0.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

0.16

0.18

0.20

28/07/2014 17/11/2014 09/03/2015 29/06/2015 19/10/2015 08/02/2016

Nu

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to

r C

ase

s

Weeks

PICU Violent Incidents/OBDs

CL 0.02

UCL 0.07

0.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

0.16

28/07/2014 17/11/2014 09/03/2015 29/06/2015 19/10/2015 08/02/2016

Nu

mb

er o

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um

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to

r C

ase

s

Weeks

PICU Aggression Incidents/OBDs

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?