Trust project site presentations
2 July 2015
Cambridgeshire & Peterborough
NHS FT (CPFT)
Older people inpatient services
Ramesh Subbiah
Presented by
Safer Care Pathways in Mental Health
Project sites
• Willow ward is an 18-bed purpose built assessment ward for
people who have an acute mental health need who require
treatment in hospital.
• Denbigh ward is an 14 bed purpose build acute assessment
and treatment unit for people with behavioural and
psychological disturbance who living with dementia.
• We provide comprehensive mental health assessment and
intensive treatment in a safe environment.
• Within a framework of individualised patient care by which
we identify the needs of each service user, through collective
commitment from the multidisciplinary team.
Patient Flow – High Level
Admission
Care &
Treatment
Decision
Care &
Treatment
Assessment
Investigations e.g.
X-rays, CT Scans,
DOLS Assessment
Self Care,
Physiotherapy,
Dietetics, Pharmacy,
Discharge Planning,
Therapeutic
Assessment
TTOs,
Accommodation,
Home Visits,
Transfers,
OT Assessment,
Relatives,
Service User Input
Handover (Willow)
Transport Organised,
Carers Aware,
Handover complete
Re-assess
Discharge
Plan
Discharge
Planning
Discharge
Yes/No
Discharge
Admission (First 24 hours)
Admission
Welcome & Orientation
Patient
Interview
Patient
Activity
OBS.
Carer
Interview
Medical
Exam
MEDS
REC
Tests
Nursing
Assessment
New
Prescription
Risk
Screen/Assessment
Inc. Falls
Initial Care Plan
1 WK Fluid +
Food
Assessment
Care and Treatment
WHO:
Doctor
Physio/OT
SALT/Dietician
Nurse/HCA
Servive
User/Carer/Family
Advocates
WHEN:
Timeframe
HOW:
Intensity of the Input
Psychological
- Anxiety Management
(1:1)
- Talking Therapies
Physical
- OT; Activities of Daily
Living
- Physio; Exercise,
Mobility
Planning
Delivery &
Treatment
Questions:
Why are we dong
this?
When – Timeframe
Who and What do
they do
How are will this be
delivered?
Psychological
Pharmacological
Physical Interventions
ECT
Review
Observations
Intended
Outcome
Discharge
Planning
Discharge
Discharge Priorities
Health Care
Professional
Min- MH State
Service User
If not
improved
Ref. to PDSA
Notes/RIO
TTOs
Transport
Fax Disch. Info
to GP/CMHT
Belongings
Hand over plan
date/time
Money
Follow Up
e.g. Dentist, Dietitian,
Diabetic Clinic
Referrals
s117 Meetings
Home
Assessment
Home Essentials
e.g. Bread, Milk
If not
improved
Ref. to PDSA
Care Package
Informing
Family/Carer
Mobility Aids
Housing
Home Leave
Chosen patient safety improvement project
• We have chosen Falls prevention and management
as the patient safety improvement project.
• Following the review of the inpatient service risk
registers and the Datix trends, we decided to
concentrate more on the falls prevention and
management
Rationale – Falls
•Number falls in the OPMH inpatient services
2013 & 2014 – 733
•Number serious incidents
2013 & 2014- 13
Rationale – falls
Time of the – Falls
Since the project
• Every person admitted to older adult inpatient service to have
compulsory falls risk assessment and no need to complete falls
risk screen.
• Falls lead to feedback in the team meeting about the latest
trust wide initiatives and changes.
• Falls prevention and management e-learning has been made
mandatory for OPMH inpatient staff.
• Patients were involved in the pathway mapping process
• Patient input via Patient forum.
• Easier access to the COSHH cupboard- spill kit
Plan
• More staff trained in frontline staff human factors training
• Analyze the data further identify the environmental cause, i.e
where the fall took place.
• Install the grab rails in the shower rooms
• Explore other assistive technology equipment support with
falls prevention
• Access to mobility aids over the weekend and bank holidays.
Hertfordshire Partnership NHS Foundation Trust
Acute day Treatment Unit(ADTU),
Crisis Assessment and Treatment Team (CATT),
Helen Dudeney and Sarah Biggs
Presented by
Safer Care Pathways in Mental Health
About the service
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CATT
24 hour crisis service
• Third level
Crisis solution and Home Treatment
Gate keeps admission
Facilitates early discharge
Works in A & E at night
Work in to the wards and assessment unit.
Works with the Host Family Scheme
Runs the Mental Health Helpline
MDT
About the service
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ADTU
Alternative to Admission
• Third level
7 day Acute support and Treatment
Offers a therapeutic group programme
MDT
Facilitates early discharge from Wards
About the chosen risk focus
• Medication issues
• Communication with family members & friends
• Decision making after assessment – no further follow
up
• Service user involvement – did not always
understand what was going on
All pointed to the transfer between service so
this became our main focus.
About the chosen patient safety improvement project
• Care call for people not continuing care in
HPFT.
• Next Step Planning
Project progress so far
Care Call
• Plan in place: We are 1 month into a 3 month pilot
• Engagement: fairly successful need to revisit all teams to ensure they
understand it.
• Early successes: 40 % of people couldn’t get hold of and 60% appreciated
it. Service users and carers felt it positive – all wanted it in other services
eg Child and Adolescence mental health services (CAMHS)
• Problem solving: Revisit it with all teams – may misunderstand what it is
about. Chinese whispers.
• Barriers: Getting the message out, using forms properly, collating the data.
• Measure(s): Evaluation forms (summarise), looked at serious incidents
post assessment as baseline data – people seen who did end their lives ,
not sure it will make a difference but people think its positive and
reassuring.
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Project progress so far
Next step Planning
Plan in place: Algorithm in place
Engagement: Service users and carers fully engaged need to introduce to the
teams
Early successes: Service users wanted to change language and make it recovery
orientated/Shared document/coproduced
Problem solving: Repeating work already done in paperwork on electronic systems
– want to work in a different way. Really include service user & have more
information so when they leave to next step they can tell other professionals what
the next step is so not waiting for the services all the time.
Barriers: Difficult in engaging all professionals – don’t just want another
document
Measure(s): We still need to collate at the data around transfer and incident s
Future plans
• Looking at care call – roll out into other areas
• Piloting next step planning in ADTU but will be
good in CATT too
• Revisit and look at pathway and see if we have
missed anything
• Feed into the service review
Key learning points from your experience of the
SSA process
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Vital for it to be collaborative with service users and carer’s to ensure rounded
viewpoint and thinking, to appreciate lived experience, to avoid assumptions.
We found we identified same hazards i.e. discharge transfer but from different
perspectives
Needed to keep revisiting the pathways and SSA documents to keep focused and
to ensure all thoughts captured/can’t solve all the complaints and unhappiness in
the system .
Recovery language and what this means to people – language can create a risk.
If people do not understand what is happening it is not good for self esteem and
therefore their whole recovery.
We can’t make improvements without service users and carers.
General learning points about your
improvement work
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Good base line data
Getting everyone on board
Keeping momentum
look at ways in which project profile can be raised with other
teams trust wide
• Having the support of the organisation has been vital
• Be patient with the process – felt like we weren’t getting
anywhere but can see how it all works
• Keeping the human factor element alive in our planning
North East Partnership
University NHS Foundation Trust
Benita Christie - Operational Services Manager
Denise Cracknell - Matron
Julie King – Ward Manager
Angie Butcher – Area Chief Nurse
About the service
Two Wards at Kingwood Centre in Colchester
•Henneage Ward – Functional Older Adults, 16 beds
• Bernard Ward - Organic Older Adult , 14 beds
Recent transformation of Community services – impact on
service
Changes in Senior Management – resulting in two parallel
projects
About the chosen risk focus
Henneage Ward - self harm
 Changing service user population with increased risk profiles
 Discharge planning and aftercare
 Staff confidence
Bernard Ward - Violence & Aggression
Personal care interventions
Patient – patient incidents
Leadership and co-ordination of clinical team
About the chosen patient safety improvement project
Henneage
 Increase staffs’ confidence via training, KUF & STORM,
 Review handover process
Bernard
Review systems for gathering key life story information on
patient’s normal routines at the point of admission
Detailed analysis of incidents to inform areas for improvement
Review ward communication systems, personal development
plans for staff focusing on leadership
Project progress so far
 Staff engaged in project – Human Factors training
 Patient Safety Champions in place, and trained
 Dedicated medical leadership – one consultant
working with the teams
 Care plans for personal care interventions being
signed off by Matron
 Detailed analysis of incidents started
 Virtual dementia tour training 6.7.15
 New STORM trainers trained w/c 29.6.15
Future plans
Henneage
Role out STORM training
Provide KUF (knowledge and understanding
framework) training internally
Develop Trust personality disorder pathway
incorporating Henneage Ward
Future plans cont.
Bernard Ward
All staff virtual dementia trained
Set up staff focus group to review patient –
patient, and patient - staff incidents
Review staff competencies and training needs
Agree 5 key pieces of information required for
each new patient on admission re their routine
Key learning points from your experience of the
SSA process
Helped to focus on what the issues were
Broadened thinking about the whole system
and root causes
Whole team could participate which supports
ownership of the issues identified, and finding
solutions
General learning points about your
improvement work
Involves the whole team
Promotes reflective practice
Support a culture of continuous improvement
Norfolk and Suffolk NHS Foundation
Trust Dementia and Complexity in
Later Life - Inpatient wards
Presented by Debbie Thompson and Sarah Nichols
Safer Care Pathways in Mental Health
About the service
Julian Hospital
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Hammerton Court is the inpatient element of our mental health services for
service users with dementia and complexity in later life (DCLL), within Norfolk and
Suffolk.
Hammerton Court opened in March 2012 for service users with continuing health
care needs. It is a hospital environment purpose built for service users with
dementia. Service users requiring admission for assessment and treatment have
been accommodated in Hammerton Court since May 2015.
Our patients have complex needs which cannot be met in a community, nursing or
residential setting.
Beach, Rose and Reed Wards have a philosophy of person centred care to
facilitate.
Discharges from our services can be home with a package of care, to residential or
nursing care facilities.
About the chosen risk focus
Initially there was a very broad focus on the care pathway through our services from
initial referral through to discharge with a desire to improve the patient experience.
•High incidence of falls and violence and aggression relative to other services in the
Trust - Decision - to focus on the DCLL inpatient services.
•Our overarching aim was to create a safer pathway for patients within the DCLL
Inpatient Services
• FOCUS Reduction of falls, major contributor to patient harm in our service,
extensions to length of stay
•FOCUS Reduction of violent incidents, high levels reported low levels of significant
harm but major contributor to patients feeling unsafe in our services.
•How could we prevent the above incidents and reduce the level of harm when
incidents do occur?
About the chosen patient safety improvement project
• The Lead for the project is the Deputy Director of Nursing.
• Key individuals identified for implementation of the project, stakeholders
identified
• Appointment of a SCP Coordinator to collate data and coordinate project
• Focus to reduce falls / harm from falls and reduce incidence of violence
and aggression decided upon.
• Meeting Schedule for project
• Leads for the three wards identified
• Beach Ward modified the role of one of it’s Band 6 nurses to drive the
project
• Safer Care Pathways embedded into Ward Staff Meeting Agendas
• SSAs for the two subjects undertaken
Project progress so far
SSAs Admission procedure, Boredom, Reactive practice, Lack of sense of
control/ coordination of shift, Environment - poor observation, dead ends,
long narrow entrance corridor frequent incidents.
•Engagement of staff, LMS, Appraisals, allocation of link roles building on
interests, constructive feedback, clarity of expectations, skills development
•Unexpected admissions – development of systems to reduce frequency
•Person centred admission procedure developed by staff
•Increased engagement with relatives – carer support group
•Ward Move – approved by Trust Board
•Introduction of SBAR communication
•Focus on increased level of Therapeutic Interventions and patient
engagement.
Project progress so far
Barriers –
•Staffing, vacancies, sickness
•E Rostering, source of discontent for staff
•Lorenzo electronic patient records, introduced the week of the ward move
•Ward having to respond at short notice transferring / discharging/ admitting patients
with little notice and little pre admission information – unpreparedness and frequent
poor communications with significant others
•Original ward environment, not suitable for people with dementia, ‘hotspots’ where
incidents occurred
•Frequent anxiety and incidents on arrival, processes and procedures especially
regarding personal possessions and clothing.
•Falls- not been a focus only one change to practice
Future plans
Project group to continue meeting
•Evaluation of the changes to the Role of Band 6
•Focus onto Falls
•Project Coordinator presenting data to project group and ward staff, regular
feedback
•Measures for Falls and V&A (including within first 72hours of admission)
to continue and monitor impact of changes. Baselines for incidents (V&A)
in the first 72 hours to be reviewed in August 2015, then 3monthly thereafter.
•Human Factors to be cascaded throughout teams by those attending training
to enable facilitation.
•Patient Safety training to be cascaded to staff by Patient Safety Champions
Early 2016.
•Embed into Hammerton Court as a whole
Key learning points from your experience of the
SSA process
Process implementation has worked splitting up the processes – original
document completed at project team level
•The project team identified at a ‘higher’ level challenges, areas for
development
•The ward team being able to modify the above and work out their own
solutions has lead to some really creative workarounds
•Removing the data collection requirements from clinicians has ensured that
the data has been collected!
•Having an identified link between the project team and ward team has
maintained the focus
•Will provide feedback for the staff of how their changes to practice have
reduced incidents, often the data is lost when incidents are prevented
General learning points about your
improvement work
Within our services the identification of a lead on the ward with a remit for
implementation of SCP has facilitated change at a much increased rate
•Engagement of key staff
•SSA meetings at project lead level then brainstorming the detail at ward
level has ensured ownership
•Staff devised workable solutions – admission procedure
•Staff want to improve their practice and the patient experience
•Implementation of other major changes throw all progress off schedule
•Demonstrable support from the Trust Board validates the efforts of staff
•Change management is hard work!
South Essex Partnership NHS FT
(SEPT)
Declan Jacob
Presented by
Safer Care Pathways in Mental Health
About the service
• Acute and Crisis Pathway
• Crisis Resolution and Home Treatment Team
(west locality)
• Mental Health Assessment Unit (Basildon
MHU)
• Recent strategic review and redesign of
service model
About the chosen risk focus
• Points of entry
• Interface with other parts of the mental
health system
• Referrer expectation
• High case loads
• Throughput and risk
• Handover
About the chosen patient safety improvement project
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Cohort of complex service users
Decision to admit
Variables and presenting risk
User led approach
Project progress so far
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SSA 1 & 2 complete
Difficulties in linking to mainstream
Need to underpin and support service teams
Revisit assumptions
Future plans
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Revalidation and appraisal
Operational focus
Quick wins
Short/medium term initiative
Workshop planned for 20th July 2015
Dedicated service user and carer event early
August.
Key learning points from your experience of the
SSA process
• Good discipline
• Structured
• Applicable to operational and clinical
processes
• Transferable
General learning points about your
improvement work
• Harnessing learning from human factors
training
• Making a difference in the workplace
• Improving efficiency and effectiveness
• Releasing time to care