2. Early Years Collaborative Improvement Adviser
Dawn Moss
NHS Borders
Early Years Collaborative Improvement Adviser
Child Protection Health Needs Assessment

3. Background
Why does it matter - long-term effects for child’s health, growth, intellectual development and mental wellbeing (NSPCC, 2010)
Primary drivers in EYC Workstreams 2 and 3: child’s physical, mental and emotional development
Child Protection Health Needs Assessment process established in 2013 – improvement needed to ensure that every child who needs it will have a health needs assessment

4. Aim Primary Drivers Secondary Drivers Specific Ideas to Test
100% of children who have an IRD will be considered for a health needs assessment; 95% of these children will get an assessment if there is an identified need by January 2015.
Reliable health needs assessment process aligned to GIRFEC
Criteria for identifying children
Operational definitions for:
- Measurement
- Criteria for judgement
Use proper measurement for data collection processes/tools (e.g. number of IRDs, number of children who have a health needs assessment)
Health Needs Assessment process
Redesign health needs assessment documentation
Standardise health needs assessment process
Develop contingency plans to deal with unexpected problems
Evaluation
Apply the Child Protection Case File Audit Tool to highlight evidence of health needs assessment within child's records
Motivated and competent workforce
Staff have the knowledge and resources
Build knowledge and skill through the delivery of briefing /Q&A sessions
Written guidance for staff

5. PDSA RAMP 1: Test data collection tool
Establish data collection process for HNA
Cycle 5: All members of Child Protection Team to take a turn in collecting and inputting data to ensure consistency.
Cycle 4: Repeat cycle 3 now that problems accessing excel spreadsheet are resolved.
Cycle 3: Senior Nurse Child Protection has responsibility for collecting and inputting data onto excel spreadsheet
Cycle 2: Senior Nurse Child Protection has responsibility for collecting data, additional information identified, Nurse Consultant inputs data onto excel spreadsheet
Cycle 1: Child Protection Team collects data at weekly Child Protection Unit Business meeting

8. PDSA RAMP 2: Test new Health Needs Assessment documentation
Improve HNA process aligned to GIRFEC
Cycle 3:Test introduction of new form as part of HNA process with one health visitor (currently underway)
Cycle 2: Test new HNA form with school nurse, no changes
Cycle 1:Test new HNA form with health visitor, changes made

9. PDSA RAMP 3: Communication with staff
Staff have knowledge and resources for HNA process
Cycle 4: Test written guidance for staff (currently underway)
Cycle 3: Test briefing/workshop format (currently underway)
Cycle 2: Test feedback form to health visitors/school nurse when HNA request (currently underway)
Cycle 1: Communication via to paediatricians re having discussion at end of weekly Child Protection Unit Meeting for all children discussed to be considered for HNA

10. Reflections Worrying about measures – I’m doing it wrong
Lots of activity but no run charts!
Not knowing what is wrong, not knowing what questions I need to ask!
Knight in shining armour.... ta-da... Brandon Bennett
Knowing your process – steps – decision points
“Moving from objective reality to belief”

12. South Lanarkshire Pioneer Site: Maximising income for pregnant women
Michelle Dowling
South Lanarkshire Pioneer Site:
Maximising income for pregnant women

13. Background
Telephone advice line (TAL) for pregnant women, funded from SL Tackling Poverty Programme
Lower than expected referrals from universal NHS midwifery services
Focus initially to increase referrals from community midwives to service
Initial tests post LS1 – one midwife in Hamilton; tested a number of change ideas

14. Phase 1 testing
Aim: to increase referrals from community midwifery services to the TAL
Measure(s): NO. of referrals from midwifery staff to TAL:
Result: initial rise; but slows. Think again
Learning from data
Cycle 2: information about service given to women as part of visit as well as discussion with midwife:
Cycle 3: case studies used to promote the service with women.
Change Ideas: midwife speaks to
women routinely as
part of visit;
use of case studies;
Are we ready to scale up?
Cycle 5: start test with another midwife in EK.
Team presentation slide for breakout.
Cycle 4: stop using case studies but feel change is embedded.
Cycle 1 : Helen in Hamilton is recruited to test new ways of promoting service. She starts speaking to women as part of routine visits. 31

15. Run chart data
Use of case studies – stopped following data protection concerns

16. Add a new site...Run Chart
Data suggests no increase in Hamilton overall and EK little or no change.

17. Secondary drivers
What changes will make a difference?
Primary drivers
Aim
Focus of current tests
Women allow midwifery staff to pass details to TAL for phone back
Staff working with ante-natal women refer clients to service
Financial advice services and information are available and accessible
Midwifery staff routinely talk to women about the TAL
FNP/First Steps staff routinely refer women to TAL or other service
Financial advice services have specialist knowledge to support pregnant women
Women get the information they need when they need it
All pregnant women on low incomes have the opportunity to maximise their incomes during pregnancy and in the first year of their child’s life
Staff member with good generic knowledge of financial issues linked to midwifery team
Opportunities for other forms of income support are available and accessible
Redesigned leaflets with input from potential and past service users increase women’s knowledge
Women take up Healthy start vouchers and vitamins
Women and their partners have access to information on training and employment schemes
Pregnant women need support to be able to budget and manage their money
Opportunities for training and education are available and accessible
Parents have access to affordable childcare

18. South Lanarkshire CPP: phase 2
Aim: to increase referrals from community midwifery services to the TAL
Measure(s): number of referrals from midwifery staff to TAL:
Result: initial rise; volume becomes an issue
Learning from data
Cycle 2: Continue to monitor Helen’s progress and a second midwife starts using the new approach :
Cycle 3: (planned):more midwives in the team use this method with women in their clinics.
Change Ideas: pass contact details to TAL who
phone back the women for
initial discussion.
Team presentation slide for breakout.
Cycle 1 : Helen starts asking women if details can be passed to TAL. Initial results seem favourable : 31

19. Run chart data

20. Reflections Complexity of testing across services and organisations
Tackling poverty (Com & Ent)
Money Matters Advice Service (SW)
Midwifery services
FNP
Local Authority
NHS
EYC

21. Reflections (2) You don’t know what you don’t know!
Scale - one eye on full scale when starting small.
Don’t make assumptions about new practice and scale too early
Don’t forget basic project management
Volume
Much work across EYC is to improve low volume activity – implications for scaling up

22. Early Years Collaborative Improvement Adviser
Sacha Will
Aberdeen City CPP
Early Years Collaborative Improvement Adviser
Improving Attachment-led Practice

23. Background
Series of multi agency training sessions held on Attachment during 2013
2014 – Early Adopters identified
Preschool settings incl. private childcare sector
AIM: Identify, by December 2014, an evidence based change package which can improve attachment-led practice within pre-school settings in Aberdeen.

24. 1⁰ 2⁰ Tests of Change Attachment Aim
Improving attendance at Ante Pre-School provision (WS3)
Attachment
Optimise development of children’s emotional well being and resilience.
Evaluate support for parents (incl. Foster Carers) Pre-birth and Beyond
Provision of Antenatal Education-universal as well as targeted
Optimise Family Relationships
Wider Communication Strategy
Promoting skin on skin/ eye contact (WS1)
Improve Maternal Health and Wellbeing
Enhancing Secondary Education PSHE
Parent/Caregiver is attuned and responsive to children’s needs.
Engagement with PEEP
Aim
Content of Ante-natal classes
Optimise Workforce Capacity to implement attachment-led practice
Development of Peer networks to reduce isolation and share knowledge & understanding
Developing Dad’s Work
To ensure that 90% of children experience positive and secure relationships with their caregiver by June 2015, when assessed
Evaluation of Attachment Training (WS4)
Engage with Private Sector
Consistent/ clear assessment of attachment/emotional wellbeing
Workforce Development and Training
Attachment Training
Access to Bumps programme
Developing Community Assets
Develop Assets to support positive and secure attachment (Co-production)
Access to support when needed.
Linking Roots of Empathy
Developing Co-production methods
Parental engagement with projects.
Early identification of Health Plan Indicators (WS1)
Early Identification of parents that need support (Inc. pre-birth)
Version 2:

26. Pre-school Setting 1 Learning from data
Aim: Introduce use of assessment tool and individual support plans to improve support provided for children’s emotional wellbeing by September 2014.
Learning from data
Cycle 2: Test use of Leuven Scale with two practitioners and small group of children
Cycle 3: Test use of Leuven Scale with three practitioners and all children.
Cycle 5: Test use of run chart to display progress for individual children
Cycle 4: Develop individual support plans for specific children
Cycle 1: Test use of Leuven Scale of Wellbeing & Involvement with one practitioner and small group of children

27. Data for Setting 1

28. Data for Setting 1

29. Data for Setting 1

30. Pre-school Setting 2 Learning from data
Aim: Introduce use of transitions worker and transitions ‘bundle’ to improve support provided for all children during settling and transitions by October 2014.
Learning from data
Cycle 2: Introduce use of ‘key worker’ system for children who are transitioning between rooms
Cycle 3: Test use of Leuven Scale for assessing children’s wellbeing during transitions
Cycle 4: Develop ‘transitions checklist’
Cycle 1: Identify areas for improvement in our transitions process

31. Data for Setting 2

32. Data for Setting 2

33. Data for Setting 2

34. Pre-school Setting 3 Learning from data
Aim: Improve ‘dropping off’ and ‘picking up’ routines for all children by October
Learning from data
Cycle 2: Share information with parents to identify new ‘drop off’ process
Cycle 1: Use Leuven Scale of Wellbeing & Involvement to gather baseline data regarding impact of interruptions during ‘drop off’ process

35. Data for Setting 3

36. Reflections
Messiness of life Making assumptions is a trap! PDSA cycles help you to pay attention to the detail Always make predictions BEFORE you start to test The value of learning from others Run Charts make life easier!

38. Early Years Collaborative: Learning Session 5
EYC Leith Pioneer Site: income maximisation and maternal & child nutrition
Graham Mackenzie
on behalf of the Leith Pioneer Site team

39. Income Maximisation Healthy Start: Food and vitamin vouchers
Benefits recipients
All pregnant women under 18 years of age
Pregnant women (from 10 weeks gestation) and children under 4 years old
£3.10 per week food vouchers

40. Aims
Improvement project: To improve uptake of Healthy Start (food and vitamin voucher scheme) to 90% of eligible participants (benefits recipients, child tax credit recipients if household income < £16,190 and pregnant women under 18 years old) in selected areas of Edinburgh (initially north east Edinburgh) by March 2015
Pioneer site: To learn lessons that can be scaled up to other areas and parts of Scotland 40

41. Project Driver Diagram41

42. Project Driver Diagram (prioritisation process)42

43. Population segmentation
5 women per week,
20% eligible
= small enough? 43

44. Woman’s antenatal care
One midwife
Timeline
6 weeks?
8-9 weeks
10 weeks
11-13 weeks
16 weeks
25 weeks
Woman’s antenatal care
Woman finds out she is pregnant
Calls central booking line
“Booking” appointment with midife
Ultrasound scan
Midwife appointment
HS process: Before
Appn form may be given at this point
Appn form completed now…
…if remember to bring it…
…or now
HS process: After
Appn form completed 44

45. PDSA Ramp (for antenatal work)
DATA FEEDBACK TO FRONTLINE STAFF: Compliance w PVC check
Scaling up: Survey with other team identified similar areas for improvement (n=7). Working with two midwives in that team to incorporate lessons from Leith team. Preparing to spread simple messages across Lothian (Further survey completed by 61 midwives).
Increased registration at antenatal booking
PDSA 7. Reinforced messages with team by collecting information in survey and fed back results at team meeting (n=19).
PDSA 6. Midwife shared simpler application process with colleagues at team meeting (n=19 midwives in team).
PDSA 5. Identified simpler application process and tested this with same midwife: no need for ultrasound as proof of pregnancy, complete midwife section of application form at booking visit (initially n=1).
(PDSA 4. Work with Health visitor team and welfare rights advisor).
PDSA 3. Time between centralised booking call and appointment was 2-4 weeks, and first 8 women were seen by 5 different midwives, so shifted to look at caseload of single midwife, with routine enquiry about eligibility for Healthy Start (n=1).
PDSA 1. The health records team identified women from two postcode sectors calling the centralised booking line. They inserted a letter and Healthy Start application form into the booking pack. Health records staff sent details to midwives who met women at booking visit. Shared data with health records team that showed that some women from postcode sectors were not being identified (PDSA cycle 2). 45

46. % antenatal bookers eligible for Healthy Start in Leith (self report)
(n=410; source Maternity Trak)
“Shift” on run chart (6+ points above median)
Universal enquiry re HS
Complete form at booking appt
Team meeting
Focus on Trak docu-mentation
Monthly data release
Monthly data release
Leith Survey Monkey
Team meeting and survey results
Median
Leith Pioneer site work started 3 March

47. Conclusions Plan small, start smaller
Deming’s Lens of Profound Knowledge
understanding variation
appreciation for a system
building knowledge
human side of change
Having an existing electronic record has
been really useful
We still have a long way to go 47