1. Evaluation of the NZGG Suicide and Self-Harm Prevention Collaborative Julian King and Michelle Moss 10 September 2010 Julian King & Associates Limited www.julianking.co.nz

2. Key messages Collaborative methodologies… – are a successful method of guideline implementation and quality improvement – are resource intensive – may be undertaken again in the future Success factors – Evaluation has identified features of the approach that are thought to contribute to its effectiveness

3. The Collaborative A Collaborative is a network of people who share information, build on existing knowledge, develop expertise and solve problems for a common purpose, driven by the interest of the community involved (NICS). Local DHB project teams with support of NZGG national implementation team Using the Breakthrough methodology (www.ihi.org)www.ihi.org Undertook pathway mapping, identified gaps/ barriers/ opportunities for improving the assessment and management of people at risk of suicide Trialled & implemented small changes Measured and monitored progress toward meeting targets 2 phases – Phase 1 (2005-07) 10 DHBs – Phase 2 (2008-10) 14 DHBs (incl 9 from Phase 1)

4. The evaluation Objectives – to review: – Quality of project implementation – Impacts – Stakeholder satisfaction Methods – principally qualitative: – Interviews with all project coordinators, NZGG implementation team, consumer panel, nominated advisory group members, 6 DHB project teams – Descriptive analysis of target data (not gathered for evaluation purposes)

5. Intervention logic NZGG team Support project teams Learn Methodology DHB Project Team DHB Management Support, Facilitate access to resources Apply Methodology Improved practice Measurable improvements against targets for change Improved Mental Health Reduced significant self- harm Reduced suicide OutcomesProcesses Culturally Responsive..........Whakawhanaungatanga..........Local Flexibility (Who)(What)(Intermediate)(Long term) (How)

6. PDSA cycle ACT Implement the changes that have been proven to be effective PLAN Plan the change that is to be trialled DO Conduct a trial of the proposed change STUDY Evaluate the impact of the trial What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement?

7. Improved practice What changes did the Collaborative achieve?

8. Access Aim: people at risk of suicide get seen sooner in ED What happened in the DHBs? – Pre-existing assessment tools and templates were adapted to suit local contexts – Assessment tools were trialled to assess how well they worked in practice – Tools were implemented – Staff were trained around initial assessment

9. Access Aim: people at risk of suicide get seen sooner in ED What were the impacts? – Improved processes – Improved knowledge about self-harm and suicide – Increased skills and confidence to ask relevant questions of people at risk – Mental health issues being detected and acted on more promptly There is increased confidence of ED staff because of training and the tools. People used to be left just sitting there...there were no key processes...nurses felt uncomfortable and didn’t know how to talk about self-harm and suicide...most ED staff have the confidence to deal with this client group now, which they didn’t have before. (ED Nurse Manager)

10. Assessment: Mental Health Aim: people at risk of suicide get a timely and comprehensive mental health assessment What happened in the DHBs? – Mental Health Services were alerted and engaged with more promptly – Communication channels between ED and Mental Health were developed – Processes for mental health assessment take place prior to medical clearance – Mental Health staff increased presence in ED – Improved electronic records were introduced

11. Assessment: Mental Health Aim: people at risk of suicide get a timely and comprehensive mental health assessment What were the impacts? – Improved communication and relationships between ED and Mental Health – More prompt and thorough comprehensive assessment The relationship between ED and Mental Health is more open. ED can now say to Mental Health that they need to get to ED to do assessment quicker. (Service Manager, Mental Health and Addiction Services)

12. Assessment: Cultural Aim: Māori at risk of suicide offered timely cultural assessment What happened in the DHBs? – Collaboration between departments to develop strategies for better cultural responsiveness – More proactive efforts to offer Māori patients cultural input – Culture-specific questions included in initial assessment – Making available appropriate space in ED for cultural assessment

13. Assessment: Cultural Aim: Māori at risk of suicide offered timely cultural assessment What were the impacts? – Debate and dialogue was created – Improved collaboration between Māori Health and other departments – Connections being made with Māori providers in the community – Possibilities for collaboration were being explored – Models for cultural assessment were appearing/being developed – More of a “cultural lens” in ED

14. Discharge Aim: discharge plans always provided (to patient, whānau, others involved in their care) What happened in the DHBs? – Discharge forms developed and implemented – Mental health and ED notes included in discharge plans – Resources developed for family members to take home – One DHB designed a consumer satisfaction survey – Use of lay person’s language in discharge plans – Sending fax or electronic copies of the discharge form to GPs and other care providers

15. Discharge Aim: discharge plans always provided (to patient, whānau, others involved in their care) What were the impacts? – More people at risk of suicide and self-harm who were discharged received written discharge summary – Discharge plans contained more useful and clear information – More family/whānau received a copy of discharge plan – Better engagement with primary care

16. Follow up Aim: more timely follow up appointments post discharge, and follow up of DNAs What happened in the DHBs? – Automatically referring people at risk of suicide to mental health services – Improving IT infrastructure so that patient notes could be accessed by both MH and ED – Developing processes for people referred to MH to be contacted by that service prior to their follow up appointment – Developing as written policy that all current MH Unit clients be seen by that service after discharge from ED – Improving communication between the DHB and services in the community

17. Follow Up Aim: more timely follow up appointments post discharge, and follow up of DNAs What were the impacts? – Improved referral processes and continuity of care – Improved follow up of DNAs (in the 4 DHBs that implemented changes in this area) Follow up is better. Before, ED usually had no idea what happened once patient went to Mental Health. Now all info can be found in the notes. (ED Nurse Manager)

18. Success factors Doing a Collaborative well in Aotearoa New Zealand…

19. National implementation team Credibility to engage with clinicians and managers in relevant departments Useful mix of skills and disciplines (e.g., project management, clinical, consumer, etc.) Leadership style facilitates and models values of the Collaborative methodology (e.g., whakawhanaungatanga) Generates excitement for the project

20. Effective national support Initial training workshop – provide foundation Regular teleconferences, meetings, workshops Relevant and useful for stakeholders Accessible to local project teams Facilitate setting of achievable goals and timeframes

21. Local executive support Senior management “sign up” to core requirements of project – written EOI DHB nominate appropriate project coordinator and clinical leads from ED & MH Dedicated staff release time and resources Executive sponsors understand and champion the project at senior management level

22. Local project teams Representatives from all departments (ED, Mental Health, Māori Health, Māori Mental Health) Consumer & family/whānau advisors Mix of innovators, leaders & technical experts Whole-team ownership & commitment to change Effective mechanisms for: – Communication – Progressing the project – Overcoming logistical challenges (e.g., associated with shift work, multiple departments involved)

23. Learning the methodology Initial team-building prior to induction workshop Good representation at induction workshop Lot of new information to absorb initially; workshop needs to provide enough of a base to get started – Familiarity with methodology (pathway mapping, testing small changes, applying change methodologies) – Familiarity with underpinning values (e.g., whakawhanaungatanga: Commitment from the different services to work together with respect, aroha and share responsibility for one another) – Understanding how to access support/expertise when needed

24. Applying the methodology Pathway mapping to identify gaps, barriers and opportunities for improvement – In conjunction with Guideline – Consumer-centred approach – Ground rules (respect diversity, differences of opinion) Breakthrough methods – Defining the problem, clear and agreed aims/ goals/ measures, test changes and monitor improvement prior to implementation

25. For more information The Collaborative & implementation team: www.nzgg.org.nzwww.nzgg.org.nz Breakthrough methodology: www.ihi.orgwww.ihi.org The Evaluation report: www.tepou.org.nzwww.tepou.org.nz The Evaluators: www.julianking.co.nz | www.hoi.com.auwww.julianking.co.nzwww.hoi.com.au