Health Foundation Closing the Gap in Patient Safety Programme Safer Care Pathways in Mental Health Services: Project Overview 11 August 2014.

Health FoundationClosing the Gap in Patient Safety Programme

Safer Care Pathways in Mental Health Services:

Project Overview

11 August 2014

HPFT is the lead partner

Closing the Gap in Patient Safety

• The Health Foundation is an independent charity working to improve the quality of healthcare in the UK

• Two priority areas: i) patient safety and ii) person-centred care

• CtG - £4 million to support ten projects to implement and evaluate tested, evidence-based patient safety interventions at scale

• Substantial two year projects

Safer Care Pathways in MH – Project Aims

• To address patient safety hazards and create safer and more reliable MH care pathways

• To enable sustainable learning and capacity in patient safety skills and tools

• Five project sites: one in each mental health trust in East of England

• Project sites to include dementia care pathway and adult and older adult mental health care pathways

Shifting the balance towards prospective

Prospective

543

2

1

67

8

9

Approach to patient safety: Retrospective vs. Prospective

Retrospective

LimitationsWhat hasgone wrong?

What could possiblygo wrong?

Focus on people, culture and systems“processes are essential but values and behaviour are critical”

(DH, 2010) Review of early warning systems

• Good practice relies on good systems used by good people

Mental health patient safety concerns

• Avoidable deaths - NCISH (Dec 2006)• Suicides: ‘most preventable’ suicides consisting of 1,108

cases, 18% of the total or 233 per year.• 436 suicides by patients who were not subject to enhanced

CPA despite diagnosis of SMI, and previous self-harm or previous admission under MHA.

• Homicides: ‘most preventable’ 34 cases, 14% of all homicides, or 7 per year.

• Avoidable harm – falls, medication errors, harm from aggression

Patient safety in mental health

• ‘Poor communication between health providers and between healthcare providers and patients and family has been linked to patient safety incidents.’ (Canadian Patient safety Institute, 2009).

• Risk enablement – balancing the positive benefits from taking risks against the negative effects of attempting to avoid risk altogether’. (DH Nothing Ventured, Nothing Gained, 2010).

Project key deliverables

• Implementation of the PHA process: completed PHA for each care pathway

• Creation of a cohort of PHA trained champions in each trust• Implementation of the human factors training and processes• Creation of a cohort of human factors trained champions in

each trust• Implementation of a minimum of 1 service improvement

project within each care pathway site• Systematic evaluation of the intervention package

Project Summary• Patient Safety Intervention package– Prospective hazard analysis (PHA) tool (CLAHRC –

Cambridge University EDC)– Human factors training & implementation (L&D NHS

FT/Hertfordshire University approach)– Service improvement methods (e.g. PDSA cycles)

• Evaluation work stream• Regional MH patient safety learning collaborative

What is Prospective Hazard Analysis ?

• Systematic, holistic and prospective analysis of care pathway risks

• Helps teams to identify, prioritise and solve complex safety issues through redesign of pathways or interventions

• Teams and team leaders trained and coached in use of PHA toolkit

• Adapted from other industries: process mapping and redesign/re-engineering

• Developed 2007-10, tested across Eastern region and beyond, and positively evaluated

Definition of ‘human factors’ approach

Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace , culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings

Catchpole 2011

What is Human Factors Training & Implementation ?

• Human factors (HF) training is a well established patient safety improvement approach

• HF training & implementation approach created and tested extensively at Luton & Dunstable NHS FT

• Improves multidisciplinary teamwork and communication to enhance safety, patient and staff experience

• Involves training & coaching change leaders and key staff in psychosocial factors and teamwork practices

• Key teamwork practice interventions:• Briefings and de-briefings• SBAR• Closed loop communication• Critical language

Project schedule – high levelClinical team Evaluation

Project site establishment Baseline evaluation

Care pathway mapping

Completed PHA process - diagnostic Mid-point evaluation

Completed human factors training and team coaching

Service improvement project activity Final evaluation

Project sitesTrust Site

NEPFT Older adults functional care ward, and dementia care ward

NSFT Dementia care ward and community team (DIST)

CPFT Dementia care ward and older adults functional care ward

SEPT Adult acute ward and CRHT

HPFT Adult acute day treatment unit and CRHT

Stakeholder engagement

• Project site level and senior trust level• Opportunities to involve service users, carers,

GPs, other agencies alongside front line staff• Project board and team• Service user and carer advisor roles• Stakeholders in key events

Project Governance• Project sponsor – Oliver Shanley, HPFT• Project manager – Tim Bryson• Project Board will include senior trust involvement and

service users and carers. It reports to the Health Foundation.• Project will run from June 2014 to June 2016• The project will include periodic regional learning events,

dedicated website and project communications for all stakeholders.

The Health FoundationClosing the Gap in Patient Safety:

Patient Safety Intervention Package (PSIP)

Overview

Summary of Intervention SequencePATIENT SAFETY

INTERVENTION - STEPS ACTIVITY

1 Collate and review existing data on patient harm Assess the existing patient safety culture

2 Define and map the care pathway

3 Use the PHA with team and stakeholders to undertake a care pathway diagnosis Identify and prioritise patient safety hazards PHA training

4 Use ARC to identify and evaluate risk control options for high priority hazards ARC training

5 Improvement project planning: improvement objectives and structure Establish improvement measures

6 Human factors training Human factors coaching aligned to improvement objectives

7 Improvement cycles with measurement of change Improvement training and/or coaching

The Health FoundationClosing the Gap in Patient Safety:

Evaluation

Overview

Evaluation questions and data

Evaluation Questions• Risk management

approach – maturity ?• Safety culture

assessment ?• Intervention utility ?• Learning ?• Impact on patient

safety and outcomes ?

Evaluation Data• Key informant interviews• Patient safety data – risk

registers, datix and patient experience reports

• Safety culture survey questionnaire

• Training experience questionnaire

• Reflective diaries• Observations

Safety culture survey

• CRHT project – 50 completed questionnaires.• Positive responses (70-80%)• Teamwork within units, supervisor expectations, actions to

promote patient safety, communication about error and openness

• Negative responses (33-48%)• Teamwork across units, staffing, hand-offs and transitions,

and nonpunitive responses to errors.

Key project benefits for sites and trusts

• Care pathway improvements – safer and more reliable• Strengthened patient safety culture in the care teams• Acquired patient safety skills in organisations• Shared learning between organisations• Improved understanding of the interventions and potential

development of them, especially in a mental health setting

Project communications

• Key events• Project updates and newsletters• Currently HPFT website – www.hpft.nhs.uk• New website from September• Twitter - #safercarepathways• Health Foundation – www.health.org.uk

Next steps• Project site establishment meetings – July/August• Trust Governance committee/Executive committee

presentations – August/Sept• Evaluation baseline data collection – July to end August• Patient safety intervention package introduction – ‘immersion

event’ – 23 October 2014• Care pathway mapping and PHA training/PHA completion –

September to December 2014

Key contacts

• Tim Bryson – Project Manager - 07767354620• [email protected]• Jeremy Wallman – Project Officer - 07719555412• [email protected]• Charlotte Copley – Project Administrator - 07540294317• [email protected]• Caroline Jacobi – Communications – 07825356601• [email protected]