Dawn Moss
NHS Borders
Early Years Collaborative Improvement
Adviser
Child Protection Health Needs Assessment
Background
• Why does it matter - long-term effects for
child’s health, growth, intellectual development
and mental wellbeing (NSPCC, 2010)
• Primary drivers in EYC Workstreams 2 and 3:
child’s physical, mental and emotional
development
• Child Protection Health Needs Assessment
process established in 2013 – improvement
needed to ensure that every child who needs it
will have a health needs assessment
Aim
Primary Drivers
Secondary Drivers
Specific Ideas to Test
Operational definitions for:
- Measurement
- Criteria for judgement
Criteria for identifying
children
Use proper measurement for data collection
processes/tools (e.g. number of IRDs, number of
children who have a health needs assessment)
Redesign health needs assessment documentation
Reliable health needs
assessment process aligned to
GIRFEC
100% of children
who have an IRD
will be considered
for a health needs
assessment; 95% of
these children will
get an assessment if
there is an identified
need by January
2015.
Health Needs Assessment process
Standardise health needs assessment process
Develop contingency plans to deal with unexpected
problems
Evaluation
Motivated and competent
workforce
Staff have the knowledge and
resources
Apply the Child Protection Case File Audit Tool
to highlight evidence of health needs
assessment within child's records
Build knowledge and skill through the delivery of
briefing /Q&A sessions
Written guidance for staff
PDSA RAMP 1: Test data collection tool
A P
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AP
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Cycle 5: All members of Child
Protection Team to take a turn in
collecting and inputting data to
ensure consistency.
Cycle 4: Repeat cycle 3 now that problems
accessing excel spreadsheet are resolved.
Cycle 3: Senior Nurse Child Protection has
responsibility for collecting and inputting data onto excel
spreadsheet
Cycle 2: Senior Nurse Child Protection has responsibility
for collecting data, additional information identified,
Nurse Consultant inputs data onto excel spreadsheet
Cycle 1: Child Protection Team collects data at weekly Child
Protection Unit Business meeting
% of Child Protection IRDs where HNA
discussion takes place at weekly CPU meeting
Percentage
120%
Median
100%
80%
Weekly
meeting only
occurred 3 out
of 4 weeks,
need to change
measure
60%
40%
20%
12/1/14
11/1/14
10/1/14
9/1/14
8/1/14
7/1/14
6/1/14
5/1/14
4/1/14
3/1/14
0%
Percentage of Child Protection IRDs where
Health Needs Assessment Requested per Month
Percentage
40%
Aug 13 - Feb 14:
baseline data
35%
Data
collection
tool tested
30%
25%
Median
20%
15%
10%
5%
12/1/14
11/1/14
10/1/14
9/1/14
8/1/14
7/1/14
6/1/14
5/1/14
4/1/14
3/1/14
2/1/14
1/1/14
12/1/13
11/1/13
10/1/13
9/1/13
8/1/13
0%
PDSA RAMP 2: Test new Health Needs Assessment
documentation
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Cycle 3:Test introduction of new form as part of
HNA process with one health visitor (currently
underway)
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Cycle 2: Test new HNA form with school nurse, no
changes
Cycle 1:Test new HNA form with health visitor, changes made
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PDSA RAMP 3: Communication with staff
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Cycle 4: Test written guidance for
staff (currently underway)
Cycle 3: Test briefing/workshop format (currently
underway)
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Cycle 2: Test feedback form to health visitors/school
nurse when HNA request (currently underway)
Cycle 1: Communication via email to paediatricians re having discussion at
end of weekly Child Protection Unit Meeting for all children discussed to be
considered for HNA
9
Reflections
• Worrying about measures – I’m doing it wrong
• Lots of activity but no run charts!
• Not knowing what is wrong, not knowing what
questions I need to ask!
• Knight in shining armour.... ta-da... Brandon Bennett
• Knowing your process – steps – decision points
• “Moving from objective reality to belief”
Michelle Dowling
South Lanarkshire Pioneer Site:
Maximising income for pregnant women
Background
• Telephone advice line (TAL) for pregnant
women, funded from SL Tackling Poverty
Programme
• Lower than expected referrals from universal
NHS midwifery services
• Focus initially to increase referrals from
community midwives to service
• Initial tests post LS1 – one midwife in Hamilton;
tested a number of change ideas
Phase 1 testing
Aim: to increase referrals from community midwifery services to the TAL
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Result: initial rise;
but slows. Think
again
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Change Ideas: midwife speaks to
women routinely as
part of visit;
use of case studies;
Are we ready to scale up?
A
Measure(s): NO. of referrals from midwifery staff to TAL:
Cycle 5: start test with
another midwife in EK.
Cycle 4: stop using case studies
but feel change is embedded.
Cycle 3: case studies used to
promote the service with women.
Cycle 2: information about service given to
women as part of visit as well as discussion
with midwife:
Cycle 1 : Helen in Hamilton is recruited to test
new ways of promoting service. She starts
speaking to women as part of routine visits.
Run chart data
Money Advice Line - Pregnant Mums
no of women given info/no contacting service
blue line - no of women given info on service
red line- no of these women taking up service
Use of case studies –
stopped following
data protection
concerns
02-Sep
26-Aug
19-Aug
12-Aug
05-Aug
29-Jul
22-Jul
15-Jul
08-Jul
01-Jul
24-Jun
17-Jun
10-Jun
03-Jun
27-May
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Add a new site...Run Chart
Hamilton EK referrals
4.5
4
3.5
3
2.5
EK
Hamilton
2
1.5
1
0.5
0
29 Nov '13
13 Dec '13
16 Dec '13
20 Jan '14
31 Jan '14
12 Feb '14
Data suggests no increase in Hamilton overall and EK little or no change.
Aim
Primary drivers
Secondary
drivers
Focus of current tests
Financial advice
services and
information are
available and
accessible
All pregnant women on
low incomes have the
opportunity to maximise
their incomes during
pregnancy and in the
first year of their
child’s life
Opportunities for
other forms of
income support
are available and
accessible
Opportunities for
training and
education are
available and
accessible
Staff working with ante-natal
women refer clients to
service
What changes will
make a difference?
Women allow midwifery staff
to pass details to TAL for
phone back
Midwifery staff routinely talk
to women about the TAL
Financial advice services
have specialist knowledge to
support pregnant women
FNP/First Steps staff
routinely refer women to TAL
or other service
Women get the information
they need when they need it
Staff member with good
generic knowledge of
financial issues linked to
midwifery team
Women take up Healthy start
vouchers and vitamins
Redesigned leaflets with
input from potential and past
service users increase
women’s knowledge
Women and their partners
have access to information
on training and employment
schemes
Pregnant women need
support to be able to budget
and manage their money
Parents have access to
affordable childcare
South Lanarkshire CPP: phase 2
Aim: to increase referrals from community midwifery services to the TAL
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Cycle 3: (planned):more midwives in
the team use this method with
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women in their clinics.
Cycle 2: Continue to monitor Helen’s progress
and a second midwife starts using the new
approach :
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Measure(s): number of referrals from midwifery staff to TAL:
Result: initial rise;
Change Ideas: pass contact details to TAL who
volume becomes
phone back the women for
an issue
initial discussion.
Cycle 1 : Helen starts asking women if details can be
passed to TAL. Initial results seem favourable :
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9
7
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5
4
PDSA - midwife involved in
test
8
New Test: passing details to TAL for phone back
PDSA - phone back
number of women
allowing details to be
passed to TAL
use case studies - had to stop this for data protection
reasons
Run chart data
3
2
1
0
May '14
April '14
Mar '14
Feb '14
Jan '14
16 Dec
'13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
Reflections
• Complexity of testing across services and
organisations
Local Authority
NHS
Tackling
poverty
(Com & Ent)
EYC
Money Matters
Advice Service
(SW)
FNP
Midwifery
services
Reflections (2)
• You don’t know what you don’t know!
• Scale - one eye on full scale when starting small.
• Don’t make assumptions about new practice and scale too
early
• Don’t forget basic project management
• Volume
• Much work across EYC is to improve low volume activity –
implications for scaling up
Sacha Will
Aberdeen City CPP
Early Years Collaborative Improvement
Adviser
Improving Attachment-led Practice
Background
• Series of multi agency training sessions held on
Attachment during 2013
• 2014 – Early Adopters identified
• Preschool settings incl. private childcare sector
AIM: Identify, by December 2014, an evidence based
change package which can improve attachment-led
practice within pre-school settings in Aberdeen.
1⁰
2⁰
Optimise development of
children’s emotional well being
and resilience.
Attachment
Provision of Antenatal
Education-universal as well as
targeted
Optimise Family
Relationships
Wider Communication Strategy
Improve Maternal Health and
Wellbeing
Aim
To ensure that 90%
of children
experience positive
and secure
relationships with
their caregiver by
June 2015, when
assessed
Optimise
Workforce
Capacity to
implement
attachment-led
practice
Improving attendance at
Ante Pre-School provision
(WS3)
Evaluate support for
parents (incl. Foster Carers)
Pre-birth and Beyond
Promoting skin on skin/ eye
contact (WS1)
Enhancing Secondary
Education PSHE
Parent/Caregiver is attuned
and responsive to children’s
needs.
Engagement with PEEP
Development of Peer networks
to reduce isolation and share
knowledge & understanding
Developing Dad’s Work
Engage with Private Sector
Workforce Development and
Training
Attachment Training
Develop Assets to
support positive
and secure
attachment (Coproduction)
Tests of Change
Developing Community Assets
Access to support when
needed.
Parental engagement with
projects.
Early Identification of parents
that need support (Inc. prebirth)
Content of Ante-natal
classes
Evaluation of Attachment
Training (WS4)
Consistent/ clear
assessment of
attachment/emotional
wellbeing
Access to Bumps programme
Linking Roots of Empathy
Developing Co-production
methods
Early identification of Health
Plan Indicators (WS1)
Version 2: 120913
Supporting children’s
emotional wellbeing
1⁰
Tests of Change
Engage parents in planning for
transitions
Informed &
Engaged Parents
Aim
Improve children’s
emotional wellbeing in
4 pre-school settings
in Aberdeen by
October 2014 through
the use of an evidence
based assessment tool
and individual support
plans.
2⁰
Provide information to parents about
importance of emotional wellbeing
and early brain development
Include information on brain
development and emotional wellbeing
into parent’s information pack
Share assessment information with
parents
Introduce use of home visits to engage
parents in development of transition
planning
Engage parents in development and
implementation of support plans
Individual support plans are
developed and implemented for
children with low levels of emotional
wellbeing and for all children during
transitions
Use of evidence-based, standardised
assessment tool
Reliable
Assessment &
intervention
All children are regularly assessed
Develop ‘transitions bundle’ to
support assessment and interventions
for children during transitions
All children are assessed during times
of transition
Provide learning opportunities for
practitioners about importance of
emotional wellbeing and early brain
development
Informed &
Engaged
Workforce
Introduce evidence-based,
standardised assessment tool
(Leuven Scale for Emotional Wellbeing
and Involvement)
Provide training to all practitioners on
use of assessment tool
Provide Learning Sessions on
Attachment-led practice
Develop on-line resource on early
brain development and importance of
emotional wellbeing
Provide learning opportunities for
practitioners about strategies to
support emotional wellbeing
Version 1: 2 May 2014
Pre-school Setting 1
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Aim: Introduce use of assessment tool and individual support plans to improve support
provided for children’s emotional wellbeing by September 2014.
Cycle 5: Test use of run chart to
display progress for individual
children
Cycle 4: Develop individual support
plans for specific children
Cycle 3: Test use of Leuven Scale with
three practitioners and all children.
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Cycle 2: Test use of Leuven Scale with two
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practitioners and small group of children
Cycle 1: Test use of Leuven Scale of Wellbeing & Involvement with
one practitioner and small group of children
Data for Setting 1
Percentage of children assessed for emotional wellbeing in Setting One
100%
80%
70%
60%
50%
40%
30%
20%
Tool introduced
Next Practitioner trained
10%
Month 2014
December
November
October
September
August
July
June
May
April
March
February
0%
January
Percentage of children assessed
90%
Data for Setting 1
Percentage of children who have received individual support for emotional
Individual plans
introduced
Month, 2014
December
November
October
September
August
July
June
May
April
March
Assessment Tool
introduced
No process
February
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
January
Percentage of children with
support plan
wellbeing
(following need identifed through assessment)
Data for Setting 1
100%
90%
Target 100% by Dec 2014
80%
70%
60%
50%
40%
30%
20%
Leuven Tool introduced
10%
Month, 2014
December
November
October
September
August
July
June
May
April
March
February
0%
January
Percentage of Staff Trained
Percentage of Staff Trained in use of Leuven Scale in Setting
One
Pre-school Setting 2
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Aim: Introduce use of transitions worker and transitions ‘bundle’ to improve support
provided for all children during settling and transitions by October 2014.
Cycle 4: Develop ‘transitions
checklist’
Cycle 3: Test use of Leuven Scale for
assessing children’s wellbeing during
transitions
Cycle 2: Introduce use of ‘key worker’ system for
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children who are transitioning between rooms
Cycle 1: Identify areas for improvement in our transitions process
Data for Setting 2
Percentage of children receiving 'Transitions Bundle'
100%
Target = 100%
80%
70%
60%
50%
40%
30%
20%
10%
'Bundle' introduced
Month, 2014
December
November
October
September
August
July
June
May
April
March
February
0%
January
Percentage of Children
90%
Data for Setting 2
Data for Setting 2
Pre-school Setting 3
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Aim: Improve ‘dropping off’ and ‘picking up’ routines for all children by October
2014.
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Cycle 2: Share information with parents to identify
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new ‘drop off’ process
Cycle 1: Use Leuven Scale of Wellbeing & Involvement to gather
baseline data regarding impact of interruptions during ‘drop off’
process
Data for Setting 3
Reflections
Messiness of life
Making assumptions is a trap!
PDSA cycles help you to pay
attention to the detail
Always make predictions
BEFORE you start to test
The value of learning from
others
Run Charts make life easier!
Early Years Collaborative: Learning Session 5
EYC Leith Pioneer Site:
income maximisation
and maternal & child nutrition
Graham Mackenzie
on behalf of the Leith Pioneer Site team
Income Maximisation
Healthy Start:
- Food and vitamin vouchers
- Benefits recipients
- All pregnant women under 18 years of age
- Pregnant women (from 10 weeks
gestation) and children under 4 years old
- £3.10 per week food vouchers
Aims
Improvement project: To improve uptake of Healthy
Start (food and vitamin voucher scheme) to 90% of
eligible participants (benefits recipients, child tax credit
recipients if household income < £16,190 and pregnant
women under 18 years old) in selected areas of
Edinburgh (initially north east Edinburgh) by March 2015
Pioneer site: To learn lessons that can be scaled up to
other areas and parts of Scotland
Project Driver Diagram
Project Driver Diagram (prioritisation process)
Population segmentation
5 women per week,
20% eligible
= small enough?
One midwife
Timeline
Woman’s antenatal care
6 weeks?
Woman finds out she is pregnant
HS process: Before
HS process: After
Appn form may be given
at this point
Appn form completed
Calls central booking line
8-9 weeks
“Booking” appointment with midife
10 weeks
11-13 weeks
16 weeks
Ultrasound scan
Midwife appointment
Appn form completed
now…
…if remember to bring
it…
25 weeks
Midwife appointment
…or now
PDSA Ramp (for antenatal work)
A P
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Scaling up: Survey with other team identified
similar areas for improvement (n=7). Working with
two midwives in that team to incorporate lessons
from Leith team. Preparing to spread simple
messages across Lothian (Further survey
completed by 61 midwives).
PDSA 7. Reinforced messages with team by collecting information
in survey and fed back results at team meeting (n=19).
PDSA 6. Midwife shared simpler application process with colleagues at team
meeting (n=19 midwives in team).
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PDSA 5. Identified simpler application process and tested this with same midwife: no need
for ultrasound as proof of pregnancy, complete midwife section of application form at
booking visit (initially n=1).
(PDSA 4. Work with Health visitor team and welfare rights advisor).
PDSA 3. Time between centralised booking call and appointment was 2-4 weeks, and first 8 women were seen
by 5 different midwives, so shifted to look at caseload of single midwife, with routine enquiry about eligibility for
Healthy Start (n=1).
PDSA 1. The health records team identified women from two postcode sectors calling the centralised booking line. They
inserted a letter and Healthy Start application form into the booking pack. Health records staff sent details to midwives
who met women at booking visit. Shared data with health records team that showed that some women from postcode
sectors were not being identified (PDSA cycle 2).
% antenatal bookers eligible for Healthy Start in Leith (self report)
(n=410; source Maternity Trak)
“Shift” on run chart (6+ points above median)
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35
30
Monthly
data
release
25
Universal
enquiry re HS
Complete form
at booking
appt
Team meeting
Monthly
data
release
20
Focus on
Trak documentation
Leith
Survey
Monkey
15
Median
10
12/05/2014
28/04/2014
14/04/2014
31/03/2014
03/03/2014
17/02/2014
03/02/2014
20/01/2014
06/01/2014
17/03/2014
Leith Pioneer
site work
started 3 March
5
0
Team
meeting
and
survey
results
Conclusions
Plan small, start smaller
Deming’s Lens of Profound
Knowledge
-
understanding variation
-
appreciation for a system
-
building knowledge
-
human side of change
Having an existing electronic record has
been really useful
We still have a long way to go