1. Introducing facilitated reflection in root cause analysis
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Introducing facilitated reflection in root cause analysis
Laura Smith- Dorset HealthCare University NHS Foundation Trust

2. Situation
Welcome
Within the Trust a Root Cause Analysis is completed for all instances of prone restraint, rapid tranquilisation and seclusion.
Reflection with patient safety and ward manager identified whilst we were completing these and learning, this could be improved.
A co-produced 2 stage RCA form was developed. The aim was to understand what led to the event and what could have been done differently from the patient’s perspective, and then from the staffs perspective. This is then reviewed and discussed in the ward reflective space to understand what can be done to prevent the same course of action in the future
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3. Background
The idea stemmed from Trust work following the Department of Health publication related to ‘Positive and Proactive: Reducing the Need for Restrictive Interventions’
Baseline data and reflection with staff identified that there was a need to do something different as there were high numbers of incidents and use of restrictive practices on the Acute Admissions Unit.
We acknowledged that patients were coming into the unit acutely unwell, however felt that we needed to understand circumstances leading to events and incidents more clearly to prevent them reoccurring.
Welcome
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4. Welcome Background Main title for slide set Optional sub title or name
The Acute Admissions Unit (Seaview) in the East of the County was an outlier for high numbers of restrictive practice usage.
The team were committed to reducing this but were struggling to identify ways to do this.
Peer workers were engaged on the ward, facilitating groups, education sessions and 1:1 time.
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5. Welcome Benefits to patient and staff Aimed for:
Patient voice being heard and their understanding of incidents being reflected to staff involved.
Reduction in restrictive practices
Better therapeutic relationships as less conflict and containment.
Calmer work environment
Increase in staff wellbeing
Increased patient outcomes
Reduced medication usage
Shorter admissions
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6. Welcome Assessment Main title for slide set Optional sub title or name
AIM PRIMARY DRIVERS SECONDARY DRIVERS
Safe Staffing levels
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Environmental assessment and PIT Systems
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Therapeutic environment
Implementation of Safe wards interventions
Clear expectations between staff and patients
1:1 time facilitated
For 100% of consenting patients
receiving restrictive interventions to participate in the review process
De-escalation and therapeutic engagement training occurs.
Behaviour support plans are updated and relevant
Staff and patients have a mutual understanding of the “triggers”, situations and experiences that may lead to the need for restrictive interventions.
Shared awareness of de-escalation techniques that have been helpful in the past
Peers are trained in facilitating reflective discussion and reviews
Learning from review process
Existing ward culture of reflecting and providing feedback to be embedded in the review process
Tends to be shared at RRI Steering Group

7. Welcome Measurement Main title for slide set
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ward identified as an outlier for use of restricitve practices
Co-produced RCA pilot developed

8. Update
RCA template was co-produced with peers from Dorset Mental Health Forum.
RCA training for peer workers facilitated by Patient Safety advisor resulted in changes to process charts and RCA template
Robust supervision process has been identified for peer workers facilitating RCA and reflective discussions
Staff have been motivated to learn, reflect and make changes to practice
Commencement of the project has been coupled with a reduction in incidents and need for the use of restrictive practices
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9. Welcome PDSA Testing Ramps for facilitated RCA by peer workers.
DATA FEEDBACK TO FRONTLINE STAFF
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Cycle 1G: Collate information and review PDSA
Cycle 1F: Pilot expanded to complete follow up conversation on treatment wards.
Cycle 1E: Changes to communication process made after data review
Cycle 1D: Changes to communication process made after data review
Cycle 1C: Changes to form made- boxes made wider and patient name added instead of Ulysses number
Cycle 1B: Form trialed within RCA training for peer workers
Cycle 1A: Form and process flow chart devised by patient safety advisor, ward manager and senior peer from Dorset Mental Health Forum.

10. Welcome Recommendations
Patients being moved from acute admissions unit to Psychiatric Intensive Care Units (PICU) are too unwell to participate in a timely manner
All team members need to be aware of the process to ensure that it is followed
Ward culture and team honesty combined with ability to reflect has enabled open discussion and feedback
Robust supervision and debrief process needs to be in place for peer workers.
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11. Identify an area for improvement and it improves itself
Key improvement message learnt
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Identify an area for improvement and it improves itself