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TRANSCRIPT
MENTAL HEALTH
QUALITY AND SAFETY COLLABORATIVE
- Our journey ……
What do we do?
Promote Quality Improvement (QI)
Engage staff
Help design reliable processes & systems
Facilitate standardisation/reduce variation
Use data to uncover the real story
Unscheduled Care
Community Care
Maternity Care
Paediatric
Care
Mental Health
Primary Care
Scheduled Care
HSC SAFETY FORUM WORK PROGRAMME
Personal/Public Involvement
Communication Human FactorsUnder/post
graduate programmes
Building capacity Sharing &
Networking
LS 0–
1.4.14
Action Period 1
• Trusts to form improvement
teams
• Development of local driver
diagrams
• ? Identifying areas for
change –testing
Pre-work: August 2013 –
April 2014
• Agreement at Strategic
Partnership Group to begin
QI Collab in Mental heatlh
• Letter to MH Leads
August 2013 asking for
rep. on Advisory Group
(AG)|
• 1st AG meeting held
August 2013 to identify
areas of focus
• 2nd AG meeting
December 2013 – areas of
focus: crisis
management and
improving physical
health needs
• 1st stage driver diagrams
developed for discussion
Mental Health Collaborative –
The Journey
Action Period 2
• Refine Driver Diagrams
• Beginning tests of change
• Measurement
Action Period 3 and 4
• Continue tests of change
• Measurement
AIM OF WORK
The overall aim is to reduce
harm to mental health
patients by:
< number of suicides?
< episodes of self-harm?
< number of
visits/admissions to
hospital?
< number crisis presentations
Identifying
Risk/Assessment
Communication
Risk
Management/
Planning
• Risk Screen tool
• Comprehensive risk
assessment tool
• Recovery Colleges
• Telephone Help-line
• Trigger List
• Education
• Mental Health SBAR (see eg)
• Use of hand held notes
(health passport)
• Management Plan
What are we trying to
accomplish?
What specific changes can we
make which will result in
improvement?
• Risk Screening
• Comp. risk
assessment
(currently under
review)
• Out of hours
service
• Available
information
• Crisis Management
Plan
• Care Pathway
Patient/Client and
family/carer
involvement
• Link with out of hours service
• Signposting
• Patient information/education
• Availability of patient’s info to
family/carers
• Person Centredness
awareness training
• Recognition of
problems (signals)
• Education,
awareness raising
DRIVERS:
PRIMARY/SECONDARY
Crisis
Management
AIM OF WORK
The overall aim is to improve
the physical health and well
being of mental health
patients:
< no. patients who stop
smoking
< no. patient who reduce
smoking
< no. mental health patients
received health checks
SMOKING(cessation and
reduction)
COMMUNICATION
IMPROVED
PHYSICAL CARE
• Public health - campaign
• Access to services
• Family involvement
• Common pathways/ templates
• Key worker
• Mental Health Team (review
patient’s GP record)
• Training
• Key worker
• Accessing services
• Use of hand held notes
(health passport)
What are we trying to
accomplish?
What specific changes can we
make which will result in
improvement?
• Stop smoking
• (pathway – see eg
NHS Health
Development
Agency)
• Information
• Between health and
social care
professionals
• Weight loss and
improved fitness
• Monitoring of
antipsychotic
medication
• Recognition and
rescue of
deterioration
Patient/Client and
family/carer
involvement
• Patient information/education
• Availability of patient’s info to
family/carers
• Education
DRIVERS:
PRIMARY/SECONDARY
PHYSICAL HEALTH NEEDS
0
20
40
60
80
100
120
01
Jan
uar
y 2
01
2
01
Mar
ch 2
01
2
01
May
20
12
01
Ju
ly 2
01
2
01
Sep
tem
ber
20
12
01
No
vem
ber
20
12
01
Jan
uar
y 2
01
3
01
Mar
ch 2
01
3
01
May
20
13
01
Ju
ly 2
01
3
01
Sep
tem
ber
20
13
01
No
vem
ber
20
13
01
Jan
uar
y 2
01
4
01
Mar
ch 2
01
4
01
May
20
14
01
Ju
ly 2
01
4
01
Sep
tem
ber
20
14
01
No
vem
ber
20
14
01
Jan
uar
y 2
01
5
01
Mar
ch 2
01
5
01
May
20
15
01
Ju
ly 2
01
5
BMI
Collaborative began early 2014
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15
BP
PHYSICAL HEALTH MONITORING, Example
0%
10%
20%
30%
40%
50%
60%
70%
Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15
HPP given out
HEALTH PASSPORT (HPP) ON TRANSFER
AND NOW ……………………..
a continuing journey
Action Period:
• Confirm team
membership and meet to
plan improvement work
• Meeting of Advisory
Group to plan further work
BACKGROUND
• Meeting with MH
Commissioners Feb 2015
• Met with MH
Commissioning Team Feb
2015
• Meeting to discuss
recommendations of
Thematic Review with MH
Comm. Team May 2015
• Initial Driver Diagram
development for future work
related to Review –
discussed and amended
• MH Advisory Group 25.8.15
to discuss work further
• MH LS on 4.9.15 to
introduce future work with
participants and agree way
forward
Action Period:
• Staff Safety Climate
Survey
• Safety Briefings – test
• Reflective Practice
• Data
RECOMMENDATIONS (synopsis):
Role of Team Manager
Teams need to be given time to reflect
on their practice and Team Leaders/Ward Managers
should facilitate their staff at team meetings
to reflect on practice
Patient Journey
Services need to be organised to minimise the number
of handovers, ensure continuity of care and clarity of roles
and responsibilities. All patients should have a named
nominated person, who will be a constant, to co-ordinate their care
Quality of Investigation Reports
Teams should follow root cause analysis process to address
systemic, contextual and cultural contributors to care as
well as individual practice
AIM:
To improve
the culture of
learning and
reflective
practice
in mental
health
services
CULTURE
COMMUNICATION(with patients, family,
carers & friends)
COMMUNICATION(between HSC staff,
teams and with other
agencies)
LEADERSHIP
• Agree core components for QI training
• Train the trainers
• Human Factors Training
• SBAR/SBARD training• Build confidence in communication
• Mentoring
• Information provided to families & carers
• Family /carer engagement
• Measurement of current strategies
• Involve families in all SAI reviews
• Transitions of care/Handovers
• Safety briefings• Named co-ordinator for all complex cases
• Safety plans and appropriate sharing of
same (regional work ongoing in this)
• Leadership - support for QI work
• Transformational leadership training for key
staff
• Measurement of safety and quality
• Review what is currently measured
• Support for reflective practice • Debriefings
COMPETENCE
• Staff Safety Climate Survey• Patient Safety Climate Survey
• Positive risk taking
• Followership
Ver 8
LEARNING
Early QI work gave teams opportunity to become familiar with
Collaborative model of working and QI methods
Time out to network, learn and reflect and permission to
test out changes
Involvement with Commissioners and future work linked to
strategic drivers has really driven the current work
of collaborative
Having opportunity to have both community and in-patient
pilot team will further facilitate communication and learning
across interfaces
“Coming together is a Beginning,
Keeping together is Progress,
Working together is Success”
Henry Ford
CONTACTS
Dr Gavin Lavery, Clinical Director, HSC Safety Forum
Ms Janet Haines-Wood, Regional Patient Safety Advisor,
HSC Safety Forum
TEL: 02892 501302