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Paper 6
Ayrshire and Arran NHS Board Meeting Monday 7 October 2019
Scottish Patient Safety Programme – Mental Health and Improving Observation Practice Author: Gordon Hay – SPSP MH Improvement Advisor Ruth Davie – Senior Manager, Quality Improvement
Sponsoring Director: Stephen Brown – Director, North Ayrshire Health & Social Care Partnership Professor Hazel Borland – Nurse Director
Date: 17 September 2019
Recommendation The Board is asked to note and discuss the ongoing work of the Scottish Patient Safety Programme - Mental Health/Improving Observation Practice Programme within NHS Ayrshire & Arran.
Summary
This paper outlines the progress within the past six months with the SPSP MH/IOP work - highlighting the improvement activities introduced to achieve the overall aim of reducing the risk of avoidable harm to the people who receive care, the staff who deliver care and for the carers of those who use our services. The programme workstreams promote safe, high quality care and experience for those accessing Mental Health Services (MHS).
Key Messages:
Revised themes of national SPSP MH Programme
Proposed national refresh of SPSP MH Measurement Plan and reporting format
Care Partner Activity Record now recording SPSP MH fields.
Therapeutic Activity Projects in Ward 10 recognised at local and national Quality Improvement (QI) Awards.
Joint Acute/Forensic/Elderly Mental Health (EMH) project trialling use of Safety Pods in restraint.
Discrete Acute/Forensic and EMH QI Interest Groups now established - aim to share improvement methodology knowledge and skills, create a forum for discussion and to build ward level QI capacity. Community Mental Health Group proposed later in year.
Spread of SPSP MH projects in Acute, EMH, Forensic and Learning Disability (LD) Wards with key projects developing in Community.
Establishment of NHSA&A IOP Policy Delivery Group, first meeting scheduled 18th September 2019.
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Glossary of Terms AHP CAMHS CI CNM EIC EIP EMH EO GP HIS IA LD MH IA MHP MHS MDT NHS A&A QI SCN SMG SPSP MH/IOP
Allied Health Professionals Child and Adolescent Mental Health Services Continuous Intervention Clinical Nurse Manager Excellence In Care Early Intervention in Psychosis Elderly Mental Health Enhanced Observation General Practitioner Healthcare Improvement Scotland Improvement Adviser Learning Disability MH Improvement Adviser Mental Health Practitioner Mental Health Services Multi-Disciplinary Team NHS Ayrshire & Arran Quality Improvement Senior Charge Nurse Safer Medicines Group Scottish Patient Safety Programme Mental Health and Improving Observation Practice
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1. The National Programme The Scottish Patient Safety Programme Mental Health and Improving Observation Practice programme continues to be supported in NHS Ayrshire & Arran by the dedicated Improvement Adviser based in Woodland View Hospital covering all Mental Health Services within the board area. The SPSP MH IA has recently completed the Scottish Improvement Leadership course. The working relationships and channels of communication between Senior Nurses, Managers, Clinical Nurse Managers, Senior Charge Nurses and the SPSP MH IA are well established and working well. The SPSP MH IA also meets regularly with key individuals from Community Mental Health services and identifying opportunities for Phase Three rollout of SPSP MH in 2019. The overall aim of the SPSP MH IOP Programme is to reduce avoidable harm to people using MHS and to better safeguard staff working in the service. The main areas of harm have been categorised as physical, psychological, sexual and social harm. In Spring 2019 Healthcare Improvement Scotland updated the programme themes. The revised work-streams are:
Leadership and Culture [unchanged]
Least Restrictive Practice [incorporating reducing restraint and seclusion]
Physical Health [incorporating Safer Medication Management]
Communication [expanded beyond ‘at transitions’] Phase Three of the Programme aims to extend the original target service areas from Acute Inpatient Wards to include Community Mental Health Services, EMH, CAMHS and LD. 2. Local Delivery The principle focus of SPSP MH programme both nationally and locally has been in Adult Acute Admissions Wards. Review of core SPSP MH data from these wards between 1 May 2016 – 1 July 2019 now indicates improvement across all areas:
15.31% Reduction in average monthly Incidents of Violence per 1000 Bed Days from 14.52 to 12.30
7.41% Reduction in average monthly Incidents of Restraint per 1000 Bed Days from 5.28 to 4.36
50.39% Reduction in average monthly Incidents of Self Harm per 1000 Bed Days from 5.03 to 2.50
8% Reduction in average monthly number of patients per 1000 Bed Days on Enhanced Observations (EO) from 11.43 to 10.57
25% Reduction in average monthly total Hours EO from 2242.82 to 1672.30
The data above averages the core SPSP MH monthly data for Violence, Restraint, Self-Harm and Number of Patients and Total Hours on Enhanced Observations from all three Acute Admissions Wards (Wards 9, 10 &11). It compares available data from the move to Woodland View in May 2016 to May 2018 and from that point to the present. 3. Data and Reporting In addition to national revisions to SPSP MH workstreams the national team at HIS have developed a new measurement plan and new reporting schedule. The launch date is as yet unconfirmed but anticipated to begin in November 2019.
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3.1 Revised HIS Measurement Plan Outcome Measures are:
o Rate of restrictive care o Rate of restraint episodes o Days between episodes of restraint o Rate of Seclusion episodes o Days between episodes of seclusion o % of patients who have an episode of self-harm o Rate of violence and aggression episodes o Days between episodes of violence and aggression o % of patients receiving continuous intervention(CI)
Process Measures are:
o The % of patients who receive planned therapeutic interventions o A full suite of process measures is available in the ‘Safety Principles in
Mental Health’ change package
Balancing measures are: o Average length of episodes of restraint o Average length of episodes of seclusion o Average length of episodes of CI
The Board will submit quarterly data reports once these measures are initiated. 3.2 Self-Assessment Reporting The Board will also be asked to complete a six monthly Self-Assessment report detailing the Aim, Progress, Challenges, Tests of Change and Reflection and Learning Points and Plans for Next Steps relating to all QI work associated with Restraints, Seclusion, Self-Harm, Physical Violence and IOP. This reporting format will replace the existing bi-monthly submission of data and leadership reports. While much of the data collection required to support these reports is already being collected through existing methods there will be a requirement to identify some additional processes and mechanisms to collect additional data. The SPSP MH IA has a close working relationship with the national team and will consult with them and QI technical support within NHS A&A to ensure a smooth transition. 3.3 Care Partner The much anticipated update of Care Partner to version 26 has now been successfully rolled out and allows the use of In-Patient Activity Record Version 3 which includes fields for recording core SPSP MH data relating to Violence, Restraint, Self-Harm and EO/CI. The Care Partner team have indicated that a further update to include IOP data relating to therapeutic activity will follow shortly. The use of the Activity record is currently being piloted by Ward 9. The SPSP MH IA will discuss with QI Support how this data can be collected via Business Objects. These developments also link to the ongoing work on the Excellence In Care dashboard which will include SPSP MH/IOP data. The SPSP MH IA and EIC Lead maintain regular contact to progress this work.
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4. Programme Governance
The NHS A&A SPSP MH/IOP Steering Group is well established and well attended, with all work informed by national guidance and locally identified need. The SPSPMH IA is also actively involved in national IOP Leads and SPSP MH steering groups. In relation to the IOP From Observation to Intervention guidance and subsequent national policy guidance produced in June 2019 the SPSP MH IA has progressed the establishment of an NHS A&A IOP Policy Delivery Group, with membership of Consultant Psychiatrist, Ward SCN, CNM, Senior Nurse and AHP Lead: first meeting in September 2019. 5. Acute Admissions and Ward 8 Updates Please refer to charts relating to the wards most involved in SPSP MH/IOP contained within Appendix 1. These charts relate to core data of Violence, Restraint, Self-Harm and EO. Also included is a run chart comparing incidents of Violence and use of Restraint in each ward. These charts offer an opportunity to illustrate the use of de-escalation and non ‘hands on’ techniques by nursing staff in managing violence and aggression. Further analysis of this data and corresponding Datix information will inform further SPSP MH improvement projects. 5.1 Ward 9 is the Admissions ward covering the North Ayrshire geographical area. Current SPSP MH activity is focused on applying the model for improvement to support Safer Medications Management and improved routine medication administration processes. The ward is also piloting the use of the revised Care Partner In-Patient Activity Record. When both tests have concluded the ward will enhance its current system of group work to reflect the approach trialled and implemented in Wards 10 and 11. The accompanying charts illustrate that values are generally within upper control limits; where spikes have occurred the SCN was able to provide narrative to explain – for example; April 2019 violence and restraint relate largely to two patients; July 2019 Restraint is linked to a single patient. The Self Harm incidence in June 2019 relates to a patient with Autistic Spectrum Disorder. 5.2 Ward 10 is the Admissions ward that covers South Ayrshire geographical area. Current SPSP MH activity has been focused on the establishment of IOP Therapeutic Groups work. This work has proved to be very successful with the test of change resulting in a reduction in core SPSP MH measures:
• Incidents of Violence per 1000 Bed Days 9.11 to 7.53 - 17% reduction • Incidents of Restraint per 1000 Bed Days 4.40 to 2.32 - 47% reduction • Incidents of Self Harm per 100 Bed Days 6.68 to 1.67 - 75% reduction The Project was recognised by locally winning a QI Team Award and nationally winning overall Effective QI Award at the NHS Scotland 2019 Conference. The profile of these awards has attracted interest from colleagues in NHS Lothian and NHS Highland who plan visits to the ward to learn from their approach. The National IOP team have chosen the Ward to form one of three case studies to illustrate high quality QI work in support of national IOP guidance materials. Next steps in SPSP MH activity will focus on testing ways of reactively utilising the full Multi-Disciplinary Team to support continuous interventions in place of current EO practices. Ward 10 data chart spikes in June and July 2019 in Violence and Restraint are generally related to a single patient. This patient has been assessed by the National Advanced
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Interventions Service as presenting a ‘unique challenge’ and will continue to be managed with consultation from them within Ward 10 until a more suitable environment is identified. CAMHS patients regularly continue to require additional ward staff resources. 5.3 Ward 11 is the Admissions Ward that covers East Ayrshire geographical area. SPSP MH work within the ward focused on implementing the Therapeutic Groups model from Ward 10. The ward is also involved in the Joint project with Wards 6, 8 and Jura to test the use of Safety Pods in restraint, which will include deltoid Intra Muscular testing and use of post incident patient debrief tool. The accompanying charts illustrate a marked increase in violent incidents in June and July 2019 – these are directly related to a single patient. It should be noted that this increase in violence has not resulted in an increase in restraint as staff utilise alternative interventions. LD and CAMHS patients placed with Adult Admissions Wards also present challenges. 5.4 Ward 8 is the Intensive Psychiatric Care Unit for all of NHS A&A caring for the most vulnerable, unwell and volatile patients. The ward is also participating in the Pods Project. The ward has recently been reallocated to the Forensic management SPSP workstream and will participate in a development week in October 2019. The accompanying charts illustrate spikes in violence in December 2018 and June 2019 which relate directly to a single patient. This patient has recently been assessed by a Psychologist from LD re Positive Behavioural Management who will offer support to staff going forward. 6. Programme Spread The SPSP MH IA is routinely asked to become involved in a range clinical and service developments and improvement activity. Many of these projects are within Phase 3 SPSP MH and examples of these include.
Discrete Acute/Forensic and EMH QI Interest Groups now established - aim to share improvement methodology knowledge and skills, create a forum for discussion and to build ward level QI capacity. Community MH Group proposed later in year.
Early Intervention Psychosis – a CAMHS/Community Mental Health working group identifying best practice in caring for first presentation patients. Early Intervention Psychosis will be an area of development nationally and NHS A&A is well advanced in identifying scope for development and improvement.
Emotional Instability Working Group – A pan-Ayrshire Nursing/AHP/Psychology /Psychiatry working group considering new approaches to working with this client group.
GP Mental Health Practitioner Team – supporting the GP MHP team in North Ayrshire in charting impact of interventions and onward referral to Third Sector Partners.
A working group has been established to review Standard Operating Practices for managing Depot administration between Inpatient and Community to support patient discharge.
The Senior Manager for Adult Community Mental Health North Ayrshire has requested SPSP MH IA support in improvement projects with North Ayrshire Community Mental Health Team.
SCN in Clonbeith Ward to analyse and present data linked to Post Falls Communication Bundle test.
Iona/Lewis Ward to develop transition communication plans between NHS, families and Care Home prior to ward closure.
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Learning Disability Service support addressing communication issues with in-patient teams.
SPSP MH IA worked with ward staff to produce a Forensic MDT Aide Memoire and tested staff use of same.
QI support to a short life working group chaired by Susan Holland, Alzheimer Scotland Nurse Consultant reviewing the use of EO with the Acute General Hospital.
7. Safer Medicines Management The SPSP MH IA has been a member of the NHS A&A Safer Medicines Group representing MHS. Following discussions with MHS Pharmacy, Rhona Sutherland the Woodland View Head Pharmacist will take this place. The SPSP MH IA will meet regularly with Rhona to discuss any improvement work relating to Safer Medication Management and updates on the work of the SMG.
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Appendix 1: Ward Data
Ward 8
Chart 1
Chart 2
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
1/4
/17
1/5
/17
1/6
/17
1/7
/17
1/8
/17
1/9
/17
1/1
0/1
7
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7
1/1
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7
1/1
/18
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/18
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/18
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/18
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/18
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/18
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/18
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/18
1/1
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1/1
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8
1/1
/19
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/19
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/19
1/4
/19
1/5
/19
1/6
/19
1/7
/19
Rate
pe
r p
atie
nt b
ed
da
y
Rate of Incidents of Violence W8 Woodland View - U Chart
UCL
LCL0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0.16
0.18
1/4
/17
1/5
/17
1/6
/17
1/7
/17
1/8
/17
1/9
/17
1/1
0/1
7
1/1
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7
1/1
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7
1/1
/18
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/18
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/18
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/18
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/18
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/18
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/18
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/18
1/1
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8
1/1
/19
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/19
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/19
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/19
1/5
/19
1/6
/19
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/19
Rate
pe
r p
atie
nt b
ed
da
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Rate of Incidents of Restraint W8 Woodland View - U Chart
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Chart 3
Chart 4
UCL
LCL0
0.02
0.04
0.06
0.08
0.1
0.12
1/9
/17
1/1
0/1
7
1/1
1/1
7
1/1
2/1
7
1/1
/18
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/18
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/19
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/19
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/19
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/19
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/19
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/19
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/19
Rate
pe
r p
atie
nt b
ed
da
yRate of Incidents of Self Harm W8 Woodland View - U Chart
UCL
LCL
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1/9
/17
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/19
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/19
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/19
Ave
rage
Ho
urs
Average Monthly Hours Enhanced Observations W8 Woodland View
C Chart
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Chart 5
Ward 9
Chart 6
0
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Nu
mb
er o
f in
cid
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W8 Woodland View Violence and Restraint Comparison Run Chart
restraint
violence
UCL
LCL0
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Rate
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Rate of Incidents of Violence W9 Woodland View - U Chart
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Chart 7
Chart 8
UCL
LCL0
0.002
0.004
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0.012
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/17
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Rate
pe
r p
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da
yRate of Incidents of Restraint W9 Woodland View - U Chart
UCL
LCL0
0.001
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Rate of Incidents of Self Harm W9 Woodland View - U Chart
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Chart 9
Chart 10
UCL
LCL
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Ave
rage
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urs
Average Monthly Hours Enhanced Observations W9 Woodland View
C Chart
0
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Nu
mb
er o
f In
cid
ents
W9 Woodland View Violence and Restraint Comparison Run Chart
restraint
violence
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Ward 10
Chart 11
Chart 12
0
0.01
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0.061
/9/1
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Rate
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Rate of Incidents of Violence W10 Woodland View - U Chart
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Rate of Incidents of Restraint W10 Woodland View - U Chart
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Chart 13
Chart 14
0
0.002
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0.008
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0.012
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Rate
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Rate of Self Harm Incidents W10 Woodland View - U Chart
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Ave
rage
Ho
urs
Average Monthly Hours Enhanced Observations W10 Woodland View
C Chart
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Chart 15
Ward 11
Chart 16
0
5
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15
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25
W10 Woodland View Restraint to Violence Comparison - Run Chart
restraint violence
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Rate
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Rate of Violent Incidents W11 Woodland View - U Chart
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Chart 17
Chart 18
0
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Rate of Restraint Incidents W11 Woodland View - U Chart
0
0.002
0.004
0.006
0.008
0.01
0.012
0.014
0.016
0.018
1/9
/17
1/1
0/1
7
1/1
1/1
7
1/1
2/1
7
1/1
/18
1/2
/18
1/3
/18
1/4
/18
1/5
/18
1/6
/18
1/7
/18
1/8
/18
1/9
/18
1/1
0/1
8
1/1
1/1
8
1/1
2/1
8
1/1
/19
1/2
/19
1/3
/19
1/4
/19
1/5
/19
1/6
/19
1/7
/19
Rate
pe
r p
atie
nt b
ed
da
y
Rate of Self Harm W11 Woodland View - U Chart
17 of 18
Chart 19
Chart 20
0
50
100
150
200
250
300
350
1/9
/17
1/1
0/1
7
1/1
1/1
7
1/1
2/1
7
1/1
/18
1/2
/18
1/3
/18
1/4
/18
1/5
/18
1/6
/18
1/7
/18
1/8
/18
1/9
/18
1/1
0/1
8
1/1
1/1
8
1/1
2/1
8
1/1
/19
1/2
/19
1/3
/19
1/4
/19
1/5
/19
1/6
/19
1/7
/19
Ave
rage
Ho
urs
Average Monthly Hours Enhanced Observations W11 Woodland View
C Chart
0
5
10
15
20
25
30
1/6
/17
1/7
/17
1/8
/17
1/9
/17
1/1
0/1
7
1/1
1/1
7
1/1
2/1
7
1/1
/18
1/2
/18
1/3
/18
1/4
/18
1/5
/18
1/6
/18
1/7
/18
1/8
/18
1/9
/18
1/1
0/1
8
1/1
1/1
8
1/1
2/1
8
1/1
/19
1/2
/19
1/3
/19
1/4
/19
1/5
/19
1/6
/19
1/7
/19
Nu
mb
er o
f In
cid
ents
W11 Woodland View - Restraint to Violence Comparison -Run Chart
violence
restraint
18 of 18
Monitoring Form
Policy/Strategy Implications
This paper outlines improvement activity regarding the progress of SPSP MH/IOP which contributes to the delivery of Scotland’s Healthcare Quality Strategy
Workforce Implications
The QI Team provides support to build capacity and capability in service areas to deliver improved processes and patient outcomes
Financial Implications
None identified at present.
Consultation (including Professional Committees)
Mental Health Public Reference Group representatives are involved and consulted regarding programme next steps and progress, as are senior clinical and management teams including the SPSP MH Steering Group
Risk Assessment
Delivery of the SPSP MH IOP is aimed at reducing harm experienced by service users and staff in Mental Health. Non delivery of the programme may impact on provision and perception of safe service locally and nationally.
Best Value - Vision and leadership - Effective partnerships - Governance and
accountability - Use of resources - Performance management
Health Economy remain involved in seeking to identify economic impact of SPSP MH/IOP work – in particular considering cost of Enhanced Observation. Initial reports suggest a longer period of analysis is required to accurately understand the systems and evidence impact of the programme.
Reducing the potential and actual harm to patients and staff involved in MHS through improved capability, capacity and processes will contribute to a more efficient and effective delivery of service.
Compliance with Corporate Objectives
Delivering services that are clinically effective, safe, efficient and person centred.
Creating a learning organisation which is passionate about improvement and innovation.
Delivery of high quality care to every person, every time.
Delivery of efficient and effective services within budget and development of a culture of continuous improvement.
Single Outcome Agreement (SOA)
Not applicable
Impact Assessment Not required as this is an internal document.
