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David Hall National Clinical Lead Scottish Patient Safety Programme Mental Health IMPROVING SAFETY IN MENTAL HEALTH SETTINGS: PROMISING APPROACHES

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David Hall National Clinical Lead Scottish Patient Safety Programme Mental Health Conflicts of interest David Hall is an NHS employee. He is also employed as an IHI Faculty member. He has previously received honoraria from a pharmaceutical company (Janssen-cilag) for chairing and speaking at educational events and for sitting on advisory panels.

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The Scottish Patient Safety Programme- Mental Health Our journey so far...

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What kind of harm is occurring? What is distinctive about it? What matters to patients? What can we do about it? How can we measure improvement? Are we seeing any changes yet?

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What is distinctive about harm in mental health care? Existing Patient Safety Programmes generally focus on reducing unintended physical injury resulting from or contributed to by medical care. In mental health services, harms may also occur that the service user causes to themselves or to others. This is nearly always the result of a complex interaction between patient factors (such as age, gender etc), their mental illness, staff factors, their treatment and their environment

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What is distinctive about harm in mental health care?

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Subsets of Harm Incidents Category A Harm caused to a person which results from their involvement with a care provider. Medication and treatment harm are included this category.

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Analysis of Category A

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Subsets of Harm Incidents Category B Harm that the service user causes to themselves or to others Suicide, self harming behaviour and violent and/or aggressive behaviour are included in this category.

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Analysis of Category B

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Types of Harm Social SexualPhysicalPsychological Category A Harm Incidents Harm caused to person resulting from interaction with service Category B Harm Incidents Harm behaviours of service user to self and others Can result from one causal factor or a combination of factors Complex interaction between patient factors, environment, staff factors, illness and treatment and far more prevalent in mental health services Treatment Medication Interventions Accidents including falls Self Harm Aggression and Violence Suicide Sexual Harm Self Neglect Overall Aim: Reduction in harm experienced by individuals receiving care from mental health services

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Programme Objective (1)To systematically (2)Reduce harm experienced by people using mental health services in Scotland (3)By empowering staff to work with service users and carers (4)To identify opportunities for improvement (5)To test and (6)reliably implement interventions (7)And to then spread successful changes across NHS Board areas

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This model is not magic, but it is probably the most useful single framework I have encountered in twenty years of my own work on quality improvement Dr Donald M. Berwick Former Administrator of the Centres for Medicare & Medicaid Services Professor of Paediatrics and Health Care Policy at the Harvard Medical School The Model for Improvement

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Hunches Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA Testing and refining ideas Implementing new procedures & systems - sustaining change Repeating the Cycles

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With an initial focus on adult psychiatric inpatient units, including admission and discharge processes To include: Forensic inpatient units To exclude: Inpatient units caring for people with dementia Older adult functional illness units. Preparation Phase Jan 12 May 12 Pre-work Phase May 12 Aug 12 Phase One (Testing) Aug 12 Sep 13 Phase Two Sep 13 May 16

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Programme Workstreams

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Measurement Design measures around aims - How Good, By When Establish a reliable baseline Track progress over time Use sampling where appropriate Integrate measurement into daily routine Use qualitative and quantitative data The key purpose of measurement for improvement is for learning. Teams need measures to give them feedback that the changes they are making are having the desired effect and are resulting in improvement.

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Measurement SPSP-MH Outcome measures Safety Culture Measures (safety climate tool- service users and staff) Process Measures

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Scottish Patient Safety Programme- Mental Health Outcome Measures Rate of violence and aggression per ward Percentage of patients engaged in violent and aggressive behaviour Rate of patients being restrained per ward Percentage of patients being restrained per ward Percentage of patients who experience one or more episodes of seclusion Percentage of patients who experience self harm Days between inpatient suicide Percentage of patients who have emergency detention or use of nurse holding power

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Scottish Patient Safety Programme- Mental Health Outcome Measures Balancing measures will be: Average length of stay Total number of HOURS of patients receiving high level observations Percentage of patients receiving high level observations Average hours per patient on high level observations

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Patient Safety Climate Tool

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Developed in partnership with Patient and Carer representation plus Psychology input. Real time look a safety climate on a ward from the Patients perspective; not an exit survey. Facilitation is by a combination of Patient and Carer Groups, Peer Support Workers and Patient Advocacy.

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Patient safety in Mental Health- some real examples Daily updates of Risk Management Plans in an IPCU Multi-disciplinary team engagement Management support Clinical leadership Use of real time data

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May 2013 Leadership report

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Phase 1 Total number of eligible wards in Scotland 123 Percentage involved in pilot stage 24%

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Phase 1 Total number of eligible wards in Scotland 123 Percentage involved in pilot stage 24% Phase 2 Year 1 Total of 59% of eligible wards are involved as of today Predicted to have 93% involved by September 2014

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The Scottish Patient Safety Programme is without doubt one of the most ambitious patient safety initiatives in the world national in scale, bold in aims, and disciplined in science. It harnesses the energies and wisdom of Scotlands health care leaders NHS executives, QIS experts, clinical professionals, civil servants, and more all aligned toward a common vision, making Scotland the safest nation on earth from the viewpoint of health care. Don Berwick, IHI

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Michelangelo The greatest danger for most of us is not that our aim is too high and we miss it, but that it is too low and we reach it

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For more information: Knowledge Network www.knowledge.scot.nhs.uk/spspmh.aspx www.knowledge.scot.nhs.uk/spspmh.aspx S @SPSP_MH dhall2@nhs.net