IMPROVING PRACTICE – QUALITY IMPROVEMENT Improving Practice on Springbank Ward Lee Davies Clinical Nurse Specialist 02 July 2017

Outline Background to Springbank Ward Key initiatives The current situation

Background Crisis Leadership – high turnover Philosophy – risk containment, MHA, observations Patients – institutionalised Staffing – vacancies, burn-out and recruitment problems Incidents – record levels

Incidents Average 88.2 incidents per month 2.9 per day Up to 6.6 per day (October 2015)

Context

Mind shift Before After Rules Institutionalisation Risk containment Fire fighting Status quo After Values Discharge planning Positive risk taking Nurturing environment Ongoing change (Revolution!)

From Rules to Values Ward opens -> incident happens -> some rules -> incident happens -> people get into trouble -> new rules -> new incidents….

The (unwritten) Rules Smoking hours - 9:30am (if all awake) - 11:00pm Leave: Returning to the ward from leave by 9pm No leave after 11pm No leave at crazy hours No holidays Rooms are locked in daytime hours. Plastic cutlery and crockery No alcohol No drugs

The (unwritten) Rules Smoking hours - 9:30am (if all awake) - 11:00pm Leave: Returning to the ward from leave by 9pm No leave after 11pm No leave at crazy hours No holidays Rooms are locked in daytime hours. Plastic cutlery and crockery No alcohol No drugs

Values Respect Recovery Safety

Respect, Recovery, Safety Patients attend the ward programme (70%) Developed electronic attendance monitoring systems Patients co-produce the ward programme We listen to their feedback Fobs for patients (if attending) Drink responsibly (if appropriate) Don’t do drugs

Respect, Recovery, Safety Patients decide what type of leave is appropriate Walk at 2am Strawberry Fair Cambridge Beer Festival Greek islands and Tenerife! Patients given the responsibility to behave appropriately When coming back from leave When smoking at night Patients influence their environment Decorating Gardening Patients set discharge dates

Positive risk taking Removal of long-term observations Resisting pressures from ‘above’ to avoid risk. Removal of sections of the MHA Allowing patients to leave the ward at any point Constant team discussions

Prejudice Staff Patient Manipulative Annoying Hopeless “Hospitals make it worse” “Not really ill” “Psychological illness” “Drugs don’t work” “Social construct” Patient Bad Worthless Hopeless “Not really ill” “My fault” “Your fault”

Nurturing environment Staff support Clinical Supervision Reflective Practice Case discussions Educational activities Away days Change in staff attitudes and values Impacts patient behaviour As a result: Increased recruitment Increased retention Recovery workers Peer support worker Only 3 vacancies 2 apprentices 1 recovery worker

Before… Averages 88.2 incidents per month 2.9 per day Up to 6.6 per day (October 2015)

…and after. Averages 36.2 incidents per month (skewed) 1.2 per day 12 months of the lowest figures since the ward opened.

Context

and after…

Physical Intervention Data available from 21/2/12 till 10/08/16 234 incidents of PI 143 required rapid tranquilization Last rapid tranquilisation 25/06/15

Physical intervention Year Physical intervention Rapid tranquilisation 2012 52 36 2013 57 45 2014 59 44 2015 64 18 2016 3 2017

The Future? Self-medication Outcome measures Research Therapeutic community? Ongoing change…

Any Questions?