Closing the Gap in Patient Safety –
Making sure patients are safe
Safer Care Pathways
in Mental Health:
What the project looks like
Care Pathway: the plan to manage a patient’s care
across different services.
Presented by Tim Bryson
Project Manager
Closing the Gap In Patient Safety Programme
(CtGPS)
• The Health Foundation is a charity working to make
healthcare better in the UK.
• It works on 2 main things:
1. Keeping patients safe.
2. Making sure the patient comes first. This is called
person-centred care.
• CtGPS has £4 million for 10 projects. The projects
will put into place new ways to keep people safe and
test how well they work.
• They will be big projects lasting 2 years.
Project partners
•Hertfordshire Partnership University NHS FT (lead)
•All mental health trusts in East of England
•Engineering Design Centre, Cambridge University
•University of East Anglia
•University of Hertfordshire
Safer Care Pathways in Mental Health
Project Aims
• To look at what can stop patients being safe.
• To create safer mental health care pathways that people
can trust more than they did in the past.
• To make sure staff have good training which they can
use to keep patients safe.
• 5 project sites: 1 in each mental health trust in East of
England
• Project sites to include:
 Dementia care pathway.
 Adult and older adult mental health care pathways.
Dementia: A set of symptoms that may
include problems with memory,
planning or organising, language, how
people see things, mood or behaviour.
Safer Care Pathways in Mental Health
What the project is looking at in particular
• Thinking less about what has gone wrong in the past.
Thinking more about how we can make services safer
for the future.
• People, how things work and the systems used.
• Deaths and harm that should not have happened due
to: suicide, self-harm, falls, mistakes with medication,
aggression.
• Better communication about safety between staff,
patients and carers
• Risk enablement: Allowing patients to take some risks
safely.
Project Intervention Package
1. System Safety Assessment
A tool for working out how safe a service is.
2. Human factors training & implementation
Communication training for teams, so that
they work together more safely.
3. Service improvement methods
Support for teams to make changes that will
be better and safer for patients.
Project Sites
Trust
Site
North Essex Partnership
NHS Foundation Trust
(NEPFT)
Older adults functional care ward, and dementia care ward
Norfolk and Suffolk NHS
Foundation Trust (NSFT)
Dementia care ward and community team (Dementia and
Intensive Support Team)
Cambridgeshire and
Peterborough NHS
Foundation Trust (CPFT)
Dementia care ward and older adults functional care ward
South Essex Partnership
University NHS
Foundation Trust (SEPT)
Adult acute ward and CRHT (Crisis Resolution and Home
Treatment)
Hertfordshire Partnership
University NHS
Foundation Trust (HPFT)
Adult acute day treatment unit and CRHT (Crisis Resolution
and Home Treatment)
Project Timetable
Clinical team with doctors and
nurses
Evaluation – how well
the project is working
Dates
Start project on site
Where we are at the
start
June 2014
Decide care pathways
Sept/Oct 2014
Completed System Safety
Assessment
What we have
achieved so far
November 2014 February 2015
Completed communication
training
What we have
achieved so far
March 2015 –
Sept 2015
Activity to make the service
better
Final evaluation
Oct 2015 - July
2016
Project Evaluation
How well the project has worked
?
Evaluation questions:
•
Does the service have an
effective way of managing risks?
•
How do staff work safely?
•
How useful are the new ways of
working? And how easy are
they to use?
•
What have people learnt?
•
How has patient safety been
affected?
Information used to do the
evaluation:
• Interviews.
• Patient safety information –
risk registers and patient
experience reports.
• Safety questionnaire.
• Training questionnaire.
• Diaries kept by staff with their
thoughts about the work.
• Observations.
Project Benefits
• Completed System Safety Assessment for each care
pathway.
• Creation of a team trained in System Safety
Assessment and communication who are Patient
Safety Champions in each trust.
• At least 1 big change that will make the service better.
• Leaders and teams in the service acting more safely
and communicating better.
• Learning shared across the East and UK.
How the project is run
•



Project board with:
All partners.
Service user and carer advisers.
East of England Strategic Clinical Network
(which works on mental health and learning
disability services).
• Project Plan approved by project board.
• Reports every 6 months and final report to
Health Foundation.
More information
• Website = http://mentalhealthpartnerships.com/project/safercare-pathways-in-mental-health-project/
• Twitter - #safercarepathways
• Health Foundation – www.health.org.uk
• Tim Bryson – Project Manager - 07767354620
• tim@brysonconsultancy.co.uk
• Jeremy Wallman – Project Officer - 07719555412
• Jeremy.wallman@ntlworld.com
• Charlotte Copley – Project Administrator - 07540294317
• charlotte@brysonconsultancy.co.uk
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