Welcome GROWING A PROACTIVE CARE SYSTEM - OUR JOURNEY Main title slide page Co-brand logo here GROWING A PROACTIVE CARE SYSTEM - OUR JOURNEY Welcome

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Welcome Main title slide page Our journey began on our PICU in 2010 and it all begins with wrestling with the classic tension...   …the balance and tension between risk management and safety against patient involvement and decision-making. When working on our accreditation as a Practice Development Unit with Bournemouth University we began developing a QI program we called: ‘Debunking the Myth of a Psychiatric Intensive Care Unit.’ We saw the patient pathway through our PICU as not just merely being about the reduction of risk, violence and unpredictability but that it in fact related to the search for capacity, increased involvement, autonomy and choice. Main title for slide set Optional sub title or name Main title slide page

Model for managing risk by increasing patient involvement and searching for capacity ON ADMISSION Safety provided by restriction, and environmental containment UPON TRANSFER Safety provided by therapeutic interventions of the Team PATIENT PATHWAY THROUGH PICU Reduced patient involvement in decision making Patient involvement in decision making Our fundamental task is to facilitate the move of patients towards greater involvement and autonomy as they move towards recovery Clinical challenges: Searching for capacity and choice however reduced How do we help this individual move forwards towards greater involvement in decision making?

Welcome Main title slide page Main title for slide set Optional sub title or name Main title slide page Then following the 2008 revision to the Code of Practice in 2010 we linked de-escalation to our seclusion policy for the first time.   6.2 De-escalation and seclusion may be seen as a continuum or pathway, with movement for the patient possible in both directions along the pathway between the two. Therefore, use of de-escalation facilities in the Trust does not, therefore, always constitute seclusion. Making this link explicit for the first time gave birth to our Trusts current Proactive Care Model.

At this time we only kept data on the number of seclusions   As well as monitoring ‘segregations’, we wanted to be able to see the number of successful de-escalations that didn't end in seclusion. At this time we only kept data on the number of seclusions So, how did we know when we were doing a good job? …and how did we show the number of times we had managed V&A really well so that it required either limited or no restrictive practice? This is the conundrum - the most positive and proactive clinical work seemed to be largely invisible and immeasurable. n title slide page

In late 2012 Our Seclusion Policy – became a genuine De-escalation Pathway policy. Using PDSA cycles on our PICU we developed: The De-escalation Pathway Algorithm (A1, A2) The Patient Safety Tool, a first person, guided formulation version of the Alfred Psychiatry Tool. (handout)

Welcome Main title slide page Main title for slide set Next Winterbourne View and Minds subsequent report into prone restraint. Then 2014 – (DoH) Positive and Proactive Care: reducing the need for restrictive interventions. Our response an Executive led, Trust Positive and Proactive Care Group - Trust Action Plan against the self-assessed, 129 points of guidance! The Trust immediately ‘Sign up for Safety’ and we were given a Driver Diagram by our then Head of Patient Safety – with a goal of a 50% reduction in 3 years from 2014/15. (D1) Welcome Main title for slide set Optional sub title or name Main title slide page

Welcome Main title slide page Main title for slide set Then the April 2015 revision to the Code brought both pleasure and pain. Firstly a perplexing new definition of seclusion: 26.103 Seclusion refers to the supervised confinement and isolation of a patient, away from other patients, in an area from which the patient is prevented from leaving, where it is of immediate necessity for the purpose of the containment of severe behavioural disturbance which is likely to cause harm to others.   26.104 If a patient is confined in any way that meets the definition above, even if they have agreed to or requested such confinement, they have been secluded and the use of any local or alternative terms (such as ‘therapeutic isolation’) or the conditions of the immediate environment do not change the fact that the patient has been secluded. It is essential that they are afforded the procedural safeguards of the Code. Secondly, our three stages of the de-escalation pathway were mirrored by the focus on primary, secondary and tertiary Intervention, which the Code (Re. NICE) reinforced when it was updated. These simple intervention categories became the basis of all our thinking Welcome Main title for slide set Optional sub title or name Main title slide page

Welcome Main title slide page Main title for slide set Optional sub title or name Main title slide page We revised our de-escalation/seclusion policy and it became the ‘Proactive Care Policy’, we developed our de-escalation pathway to become the Proactive Care Pathway. (A3) Our clinical models, procedures, documentation and PMVA training now focus on understanding primary and secondary interventions and their impact on reducing the necessity for tertiary intervention rather than teaching purely tertiary level physical PMVA techniques. What we call The Proactive Care Model began to grow and spread.

Welcome Main title slide page Main title for slide set It gave us the opportunity to re-design our ‘Sign up to safety’ Driver Diagram in a way that reflected our developing model (D2) An emphasis on proactive primary, secondary and tertiary intervention. This now structures our Proactive Care QI projects. Main title for slide set Optional sub title or name Main title slide page

Welcome Main title slide page Main title for slide set Quarter 1 2016 - The inevitable… restraint figures increased consistently and comprehensively for three months! Blind panic from senior management and clinical teams! Largely due to a specific and very high risk patient who was in long term seclusion and is now in a high secure services. Importantly we realised controlling the incidence of restraint events was not going to be easy or quick. We were on a long term journey! A new Data focus on the ‘quality and qualities’ of the restrictive practice events, not merely quantitative numbers which are at times in the hands of fate and fortune. Evidence that we were improving as reporters as a result of the new systems and staffs increased understanding. Welcome Main title for slide set Optional sub title or name Main title slide page

Welcome Main title slide page Main title for slide set So, a need to re-think how we measure and illustrate our culture of Proactive Care and reducing restrictive practice. …whilst persuading our Board that we aren’t just trying to distract from not meeting our targets!   Latest revision to our Proactive Care Driver Diagram (D3) Temporarily redefining our goal, making it more qualitative, whilst we work out our new metrics. We also developed it as an ‘Always Event’ version. Welcome Main title for slide set Optional sub title or name Main title slide page

Welcome Main title slide page Main title for slide set Where we are now: Looking to present restraint data in more useful and relevant ways: Firstly by developing simple restraint categories on incident forms (handout) Display run charts of restraint comparatively with incidences of violence and aggression. The Board now receive reports in run charts Secondly in terms of duration, proportionality and necessity – was the least restrictive option utilised? (handout)   Completing the cycle of the pathway algorithm – developing a relevant model for post incident support and learning, patient and staff. Extending the Safety Tool further. Changing the emphasis of the Trust Proactive Care group to begin looking qualitatively at restrictive practice events and spread learning rather than 129 point action plans! Ongoing Proactive Care quality improvement projects (using IHI methodology): RAG Rating therapeutic observations Non-Contact Physiological Observations Tool (Shamelessly stolen from AWP!) Community Hospital Proactive Care Pathway Algorithm and Safety Tool Welcome Main title for slide set Optional sub title or name Main title slide page

Welcome Main title slide page Main title for slide set Lessons learned: We have moved from reducing restrictive practices to increasing Proactive Care. As a result we want to see a reduction in V&A, which MAY then lead to a reduction in restraint. Keep Driver Diagrams live and own them. Don’t accept hand downs! Service strategy and governance is very important but keep your QI firmly on the ground. Are your measures really showing you what you think they are IMPORTANTLY our journey has taught us that whether you are a service or a clinician you don’t just deliver Positive and Proactive care, you live it!   Welcome Main title for slide set Optional sub title or name Main title slide page