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
mb
er o
f N
um
era
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
f N
um
era
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?