Presentation on theme: "SAFE Care - ‘Safety Express’ – Mental Health & Learning Disabilities"— Presentation transcript:
1 SAFE Care - ‘Safety Express’ – Mental Health & Learning Disabilities In Mental Health & Learning Disabilities the QIPP workstream is focused onto 4 main harms : Self harm, Violence & Aggression, Slips, Trips & Falls and Medication errorsAimPrimary DriversSecondary DriversTo deliver a reduction of harm within mental health and learning disability services from incidents involving :Self harmViolence & aggressionSlip, Trips, FallsMedications errorsby Dec 2012Leadership andSafety CultureClinical Care 95% reliableSupportive infrastructureService user andfamily-centred careEffective risk assessmentRobust care planningPromoting choice, dignity & respectInformation givingEffective working between teamsSound evidence based practiceClear clinical leadershipEducation and TrainingActive patient/carer involvementClinical supervision / Mentoring/PreceptorshipAccess to therapeutic interventionsSafe clinical environmentsEffective learning safety cultureAccess to equipmentOperational systems/ policiesMeaningful activities and engagementLearning from patient/carer feedbackVisible/ ongoing Executive supportPromoting physical health including nutrition and hydration
2 QIPP Safe Care – Acute Settings The QIPP Safe Care workstream is an improvement programme designed to help organisations reduce harm. In Acute Services Safe Care tackles 4 major harms in the NHS; Falls, VTE, Pressure Ulcers, Catheter Acquired UTI by 50%,
3 50% reduction in in-patient physical assaults each year until 2012 MeasurementLeadershipCommunication (SBARD)Reliable risk assessmentCollateral informationAimPrimary drivers50% reduction in in-patient physical assaults each year until 2012Secondary driversLocal feedbackStandardisedcareTrainingSupportive eRecord
5 Trust Harm Reduction Strategy Driver diagram PRIMARYOUTCOME(Measure)Sustained reduction I the frequency of the three most common types of incident each year (20% annually for each year over five years from April 2011)Incidents are:-Falls,-Violence and Aggression -Self HarmBalancing MeasureEnsure other types of incidents are not neglected and increase as a result of targeted intervention.Governance StructureReport to H&S bi-monthly actions and incident dataExecutive lead Kim Crowe to report to boardTony Crumpton to report to H&SLeadershipIdentify and inform StakeholdersEngage early implementersIdentify strategic and clinical leadsMonitoringPolicy complianceIncident dataImplementation strategiesSecondary Drivers- Identify reporting lines- Strategy Lead and clinical leads (x1 for each harm)-Identify external groups Safety Express to develop comparison dataBC- Engage AQuA in supporting the process--Identify with CBU’s wards / units for implementation- Support unit managers in adopting change process-identify change championsB C- Implement measures based on PDSA cycles- Share good practice / share successes - Share / report findings-Develop sensitive measures / baseline data-Identify and support clinical champions CPrimary drivers are system components which will contribute to moving the primary outcomeSecondary drivers are elements of the associated primary driver. They can be used to create projects of change packages that will affect the primary driverTrust Harm Reduction Strategy Driver diagramDefinition: A driver diagram is used to conceptualise an issue and determine its system components which will then create a pathway to get to the goal
6 AimTo reduce physical assaults to staff by 20% in one year on the Trust baselineSafe EnvironmentStaff ExperienceCommunication HandoversPatient ExperiencePrimary drivers describe the systems / larger components which will contribute to achieving the overall aim. Each usually has an associated measureSecondary drivers are elements of the associated primary driver. They are interventions which can be used to create projects or change packages that will affect the primary driver.
7 Aim50% reduction on numbers of detained patients absconding from acute Inpatient wards by Dec 2012Evidence based policy and guidance that is implementedTherapeutic milieuPerson Centred approachAudit of baselineDevelop understanding of existing literatiureRA to include risk of AWOL, staff trainedIdentifying and dealing with patients concernsRisk assessment, profiling and managementPatient activities Safe and appropriate environmentPrimary drivers are systems components which will contribute to moving the primary outcome.Secondary drivers are elements of the associated primary driver. They can be used to create projects or change packages that will affect the primary driver.Driver diagramDriver diagrams are a type of structured logic chart with three or more levels (see example below). These would include:1. a goal or vision 2. the high-level factors that you need to influence in order to achieve this goal (called ‘primary drivers’) 3. specific projects and activities that would act upon these factors We decided upon 2 projects initially – Audit of baseline Develop semi structured audit tool – in red This information lead us to complete a PDSA ..