1. Closing the Gap in Patient Safety Programme Safer Care Pathways in Mental Health: Project Overview Presented by Tim Bryson Project Manager

2. Closing the Gap In Patient Safety Programme The Health Foundation is an independent charity working to improve the quality of healthcare in the UK Two priority areas: i) patient safety and ii) person- centred care CtGPS - £4 million to support ten projects to implement and evaluate tested, evidence-based patient safety interventions at scale Substantial two year projects

3. 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 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

4. Safer Care Pathways in MH – Project Aims To address patient safety hazards and create safer and more reliable MH care pathways To enable sustainable learning and capacity in patient safety skills and tools Five project sites: one in each mental health trust in East of England Project sites to include dementia care pathway and adult and older adult mental health care pathways

5. Safer Care Pathways in MH – Project Focus Shifting the balance towards prospective Focus on people, culture and systems Avoidable deaths and harm – suicide, self-harm, falls, medication errors, harm from aggression Improved safety communication between staff, service users and carers Risk enablement

6. Project Intervention Package 1.Prospective hazard analysis (PHA) tool (CLAHRC – Cambridge University EDC) 2.Human factors training & implementation (L&D NHS FT/Hertfordshire University approach) 3.Service improvement methods (e.g. PDSA cycles)

7. Project Sites TrustSite NEPFTOlder adults functional care ward, and dementia care ward NSFTDementia care ward and community team (DIST) CPFTDementia care ward and older adults functional care ward SEPTAdult acute ward and CRHT HPFTAdult acute day treatment unit and CRHT

8. Project Timetable Clinical teamEvaluationPeriod Project site establishmentBaseline evaluation June 2014 Care pathway mappingSept/Oct 2014 Completed PHA process – training and diagnostic Mid-point evaluation November 14 to February 15 Completed human factors training and team coaching Mid-point evaluation March to Sept 15 Service improvement project activityFinal evaluationOct 15 to July 2016

9. Project Evaluation Evaluation questions How mature is the risk management approach ? What is the safety culture ? How useful and useable are the interventions ? What is learnt ? What is the Impact on patient safety and outcomes ? Evaluation data Key informant interviews Patient safety data – risk registers, datix and patient experience reports Safety culture survey questionnaire Training experience questionnaire Reflective diaries Observations

10. Project Benefits Completed PHA for each care pathway (links to ‘Sign Up to Safety’ assessment) Creation of a cohort of PHA trained, and human factors trained, patient safety champions in each trust Implementation of a minimum of 1 service improvement project within each care pathway site Safety culture feedback, and strengthened safety culture in the care pathway Shared learning across region and nationally

11. Project Governance Project board involving all partners, and including service user and carer advisers, and EoE Strategic Clinical Network PID approved by project board Six monthly and final reports to Health Foundation

12. More information Website = http://mentalhealthpartnerships.com/project/safer-care- pathways-in-mental-health-project/ Website = http://mentalhealthpartnerships.com/project/safer-care- pathways-in-mental-health-project/ Twitter - #safercarepathways Health Foundation – www.health.org.ukwww.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