Closing the Gap in Patient Safety – Making sure patients are safe Safer Care Pathways in Mental Health: What the project looks like Presented by Tim Bryson Project Manager Care Pathway: the plan to manage a patient’s care across different services.

Closing the Gap In Patient Safety Programme (CtGPS) The Health Foundation is a charity working to make healthcare better in the UK. It works on 2 main things: 1.Keeping patients safe. 2.Making sure the patient comes first. This is called person-centred care. CtGPS has £4 million for 10 projects. The projects will put into place new ways to keep people safe and test how well they work. They will be big projects lasting 2 years.

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

Safer Care Pathways in Mental Health Project Aims To look at what can stop patients being safe. To create safer mental health care pathways that people can trust more than they did in the past. To make sure staff have good training which they can use to keep patients safe. 5 project sites: 1 in each mental health trust in East of England Project sites to include: Dementia care pathway. Adult and older adult mental health care pathways. Dementia: A set of symptoms that may include problems with memory, planning or organising, language, how people see things, mood or behaviour.

Safer Care Pathways in Mental Health What the project is looking at in particular Thinking less about what has gone wrong in the past. Thinking more about how we can make services safer for the future. People, how things work and the systems used. Deaths and harm that should not have happened due to: suicide, self-harm, falls, mistakes with medication, aggression. Better communication about safety between staff, patients and carers Risk enablement: Allowing patients to take some risks safely.

Project Intervention Package 1.System Safety Assessment A tool for working out how safe a service is. 2.Human factors training & implementation Communication training for teams, so that they work together more safely. 3.Service improvement methods Support for teams to make changes that will be better and safer for patients.

Project Sites TrustSite North Essex Partnership NHS Foundation Trust (NEPFT) Older adults functional care ward, and dementia care ward Norfolk and Suffolk NHS Foundation Trust (NSFT) Dementia care ward and community team (Dementia and Intensive Support Team) Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) Dementia care ward and older adults functional care ward South Essex Partnership University NHS Foundation Trust (SEPT) Adult acute ward and CRHT (Crisis Resolution and Home Treatment) Hertfordshire Partnership University NHS Foundation Trust (HPFT) Adult acute day treatment unit and CRHT (Crisis Resolution and Home Treatment)

Project Timetable Clinical team with doctors and nurses Evaluation – how well the project is working Dates Start project on siteWhere we are at the start June 2014 Decide care pathwaysSept/Oct 2014 Completed System Safety Assessment What we have achieved so far November February 2015 Completed communication training What we have achieved so far March 2015 – Sept 2015 Activity to make the service better Final evaluationOct July 2016

Project Evaluation How well the project has worked Evaluation questions: Does the service have an effective way of managing risks? How do staff work safely? How useful are the new ways of working? And how easy are they to use? What have people learnt? How has patient safety been affected? Information used to do the evaluation: Interviews. Patient safety information – risk registers and patient experience reports. Safety questionnaire. Training questionnaire. Diaries kept by staff with their thoughts about the work. Observations. ?

Project Benefits Completed System Safety Assessment for each care pathway. Creation of a team trained in System Safety Assessment and communication who are Patient Safety Champions in each trust. At least 1 big change that will make the service better. Leaders and teams in the service acting more safely and communicating better. Learning shared across the East and UK.

How the project is run Project board with: All partners. Service user and carer advisers. East of England Strategic Clinical Network (which works on mental health and learning disability services). Project Plan approved by project board. Reports every 6 months and final report to Health Foundation.

More information Website = care-pathways-in-mental-health-project/Website = care-pathways-in-mental-health-project/ Twitter - #safercarepathways Health Foundation – Tim Bryson – Project Manager Jeremy Wallman – Project Officer Charlotte Copley – Project Administrator Easy Read version of presentation by