1. ‘One Year on’ – Project Learning Event Project team presentations Safer Care Pathways in Mental Health Project Thursday 2 July, 2015

2. Oliver Shanley Project Board Chair

3. Aims of the event To provide an overview of project progress ‘One Year on’, To hear about the baseline evaluation findings To share the learning and progress from all of the project sites on their safety improvement work to date To provide an opportunity for all project stakeholders to work on planning the next phase of the project up until June 2016, including service user and carer involvement

4. Programme 9.30Welcome and aims for the event – Oliver Shanley and Tim Bryson 9.45One Year On – Project Progress Overview System safety assessments – James Ward Evaluation findings – Kai Ruggeri Patient safety measurement – Jane Carthey Questions and discussion 10.30‘Sharing the Learning’ session – Trust project site leads A: Older peoples care workshop – CPFT, NEPFT, NSFT. B: Acute adult care workshop – HPFT, SEPT. 11.15Refreshments 11.30Service user and carer involvement in patient safety – Sarah Rae, and Sue Vincent 11.45Project site safety improvement planning - Table Workshops 12.45Plenary and closing summary – Tim Bryson and Project Team 13.00Close: lunch and networking

5. PROJECT OVERVIEW TIM BRYSON, PROJECT MANAGER

7. Project progress overview Click to edit Master text styles Third level ProcessOutput Launch event and immersion eventEngagement and project establishment Care pathway mappingFocus and map for SSA process System safety assessment 1Identified and prioritised risks System safety assessment 2Evaluated safety solutions for key risk Human factors training (in progress): champions and front line staff Skills and tools for embedding safety communications changes Baseline evaluationAnalysis of pre-intervention status

8. How did it go so far ? High lights Enthusiastic and energetic project team and project sites Collaborative approach Stages of work largely completed on time and with good participation Clear focus from project sites on patient safety outcomes Wllingness to flex and be creative Learning and feedback on tools and approach Low lights External factors (e.g. CQC and organisational change) have caused delays and discontinuity Service user and carer involvement has been variable Medical involvement low

9. Next project phase Continuing supported work on patient safety improvement projects in each project site Completion of human factors training programme by end November 2015 Mid-point and end-point evaluation Project write up from January 2016 onwards Preparation of bid for continuation funding

10. https://www.youtube.com/watch?v=JwCZwIz 0v0o

11. System Safety Assessment (SSA) Review Dr James Ward Principal Research Associate, Healthcare Dr Terry Dickerson Assistant Director, Healthcare

12. “Immersion Event” – 23 October 2014 12

13. Nov-DecJan-MarMar-Jun SSA – parts 1 and 2 13 SSA1SSA2 HF Implementatio n Process Mapping and Baseline Data SSA 1 – What can go wrong? What could go wrong? Why? How likely? How bad? Should I do anything? SSA 2 – What shall we do? Expand options Analyse options Decide on solution(s) to implement

14. 14 1 Recap of SSA1 – for each Group in each Trust

15. 15 Recap of SSA1 Risk score 1 Risk 1 Solutions to Risk 1

16. SSA2 outline 16 Establish the context Generate possible solutions Analyse possible solutions

17. SSA2 outline 17 Select desired solutions Develop implementation plan

18. SSA1: 5 Trusts 9 Groups 55 Staff 57 risks (figures in italics are approximate) SSA results – headline figures 18 SSA2: 5 Trusts 7 Groups 49 Staff 109 initial ideas, 42 shortlisted, 13 analysed

19. SSA summary 19

20. General observations on the SSA process 20 Participants. Good turnout and engagement. Ideally more service users and medics. Just one issue for SSA1. Time gap = some changed priorities (Issues). Need to maintain engagement. CQC! Readdressing some SSA1 work. Just one risk for SSA2. Challenging sections: Prioritisation of issue(s) to focus on. Clear problem statement. Criteria for success. Completing the form, e.g. “Options Evaluation” Hard work. Steep learning curve.

21. General observations on SSA2 process 21 hard work “The second time was much faster and we were getting into the flow.” Language and concepts “hard to get head round” “We got quite focussed.” “Hard going but really helpful.” “It’s full-on” “You can apply this to the mental health setting.” “I think there’s huge potential in SSA” “I’m really pleased with what we got done” “We didn’t get caught [up in] your paperwork.”

22. SSA2 – next steps Other meetings arranged with Terry / James But mainly it’s over to you! Implementation – Planning – Development of ideas – Development of evaluation plan – Implementation planning – Sustainment planning And now it really is over to you… at 10:30! 22

23. What you’ve told us Presented by Evaluation Team Lead – Dr Kai Ruggeri

24. Evaluation overview What you’ve provided  Baseline templates  Workshop feedback  Patient Safety Culture Questionnaires  Interviews  Reflective diaries

25. What are we aiming for? What is the context? What are the key positive and negative factors? What specific issues could be addressed? What has worked? What has not worked? For today: What have we learned so far?

26. What we’ve learned: Baseline Templates Feedback and conclusions on summary  In general, all trusts make use of extensive risk matrices and frameworks, risk descriptions, information from patients and carers, quality improvement projects (e.g. human factors training)  There is no abnormal spread of risks across the different types of risk categories  Most reported incidents were minor or non- incidents  Proactive vs reactive

27. What we’ve learned: SSAs Feedback and conclusions on summary  Generally positive about topics discussed  Some felt a positive improvement by the end  Perhaps would’ve liked more guidance in practice

28. PSCQ Descriptives SEPTNEPTHPFTCPFTNSFTTotal MSDSEMSDSEMSDSEMSDSEMSDSEMSDSE Teamwork Within Units 3.91.51.143.82.49.084.06.48.143.87.51.103.40.77.143.77.60.06 Supervisor/Manager Expectations & Actions Promoting Patient Safety 3.68.46.123.82.70.123.96.66.194.10.53.103.48.71.133.80.67.06 Organizational Learning - Continuous Improvement 3.64.44.123.78.35.063.65.39.113.85.50.103.35.72.143.66.54.05 Management Support for Patient Safety 3.64.59.163.30.77.133.22.80.233.60.80.152.98.78.153.32.79.07 Overall Perceptions of Patient Safety 3.34.50.133.34.78.133.21.77.223.56.66.132.74.67.133.23.75.07 Feedback & Communication About Error 3.88.64.173.46.58.104.00.45.134.14.71.143.44.72.143.72.70.07 Communication Openness 3.74.72.193.63.58.104.03.54.163.80.80.153.35.58.113.65.68.06 Frequency of Events Reported 3.95.58.163.831.03.173.031.06.314.04.85.163.60.85.163.76.94.09 Teamwork Across Units 3.16.65.173.35.62.103.29.44.133.69.57.113.08.71.133.34.65.06 Staffing 2.58.71.192.89.78.132.66.72.212.85.55.112.25.48.092.67.69.06 Handoffs & Transitions 3.20.62.172.88.73.123.00.75.223.37.64.122.90.45.093.05.66.06 Non-punitive Response to Errors 3.24.55.153.05.79.133.00.85.253.22.77.152.79.81.153.04.78.07 Patient Safety Grade* 2.14.53.142.15.64.112.17.72.212.04.59.112.96.58.112.32.70.06 Number of Events Reported* 2.261.16.312.021.09.182.07.92.272.561.08.213.271.29.242.481.22.11 *All scales are low/negative to high/positive except those with *

29. PSCQ Totals

30. Asking your help! What we’d like  Reflective diaries  Interviews were a great source  More would be ideal!  Assessment plans  Check emails tomorrow!

31. Presented by Dr Jane Carthey Human Factors and Patient Safety Consultant www.janecarthey.com EMAIL: jane@janecarthey.com Measuring and Monitoring Safety

32. Professor Charles Vincent Dr Jane Carthey Ms Susan Burnett

33. . Past harm Reliability Sensitivity to operations Anticipation & preparedness Integration and learning Has patient care been safe in the past? Are we responding and improving? Will care be safe in the future? Is care safe today? Are our clinical systems and processes reliable?

34. Has patient care been safe in the past? Ways to monitor harm include: mortality statistics (including HSMR and SHMI) record review (including case note review and the Global Trigger Tool) staff reporting (including incident report and ‘never events’) routine databases. Are our clinical systems and processes reliable? Ways to monitor reliability include: percentage of all inpatient admissions screened for MRSA percentage compliance with all elements of the pressure ulcer care bundle. Is care safe today? Ways to monitor sensitivity to operations include: safety walk-rounds using designated patient safety officers meetings, handovers and ward rounds day-to-day conversations staffing levels patient interviews to identify threats to safety. Will care be safe in the future? Possible approaches for achieving anticipation and preparedness include: risk registers safety culture analysis and safety climate analysis safety training rates sickness absence rates frequency of sharps injuries per month human reliability analysis (e.g. FMEA) safety cases. Are we responding and improving? Sources of information to learn from include: automated information management systems highlighting key data at a clinical unit level (e.g. medication errors and hand hygiene compliance rates) at a board level, using dashboards and reports with indicators, set alongside financial and access targets. A framework for the measurement and monitoring of safety Source: Vincent C, Burnett S, Carthey J. The measurement and monitoring of safety. The Health Foundation, 2013

35. Mental health safety thermometer Enables teams to measure harm and the proportion of patients that are 'harm free' from: – self-harm, – psychological safety, – violence and aggression, – omissions of medication and restraint (inpatients only). http://www.safetythermometer.nhs.uk/i ndex.php?option=com_content&view=a rticle&id=4&Itemid=109

36. GP retires: New GP Red buses & restaurants: Advertisem ents Outbursts per week Voices telling her to only use her right hand Friends/ communit y pharmacis t/ dentist./ hairdresse r Keeping track of a complex repeat prescriptio n with 11 medication s on it

37. Your safety improvement work How are you measuring whether the change leads to improvement? Do you use a combination of measures from the 5 dimensions? How are you capturing the service user and carer’s perspective in your measurement plan?

38. Service User and Carer Involvement in Patient Safety – Presented by: – Sue Vincent - Carer Advisor – and – Sarah Rae - Service User Advisor

39. Learning from the project All the trusts have found service user and carer involvement challenging Capturing service user and carer views takes time There are specific structures and factors to consider Service users and carers often feel more able to contribute in a dedicated session Their input has influenced the development of the HPFT interventions.

40. “We met yesterday for our project meeting and clearly thought about shaping our actions form the service user point of view. For example, we had planned a discharge algorithm for the MDT (Multi-Disciplinary Team) to use to make discharge safer, we are now planning to make it a shared document that is worked on and discussed together with the SU so that they feel informed and involved in the discharge plan, they would then have information to take with them to their next professional and GP that would hopefully help the transition from acute care to community feel less uncertain”. “No, not surprised but really excited about how useful the information we stumbled across was. It was a really important element that needed to be dragged in”. Sarah Biggs (HPFT) Learning from the project

41. Involving the carer Advantages Disadvantages

42. Over to you Finding ways to amplify the voice of service users and carers has been difficult What can we do to work further in their area? What might some of the issues be?

43. Patient safety improvement plan – review questions Project goals – Are we agreed ? Are they clearly stated ? How realistic ? How ambitious ? Key milestones – Are these set out ? (SMART ?) Safety outcome measures –Have we established safety outcome measures or proxy measures ? How will we make sure data is collected ? Involvement and communication – How well are we involving service users and carers ? How well are we involving staff ? What could we do to strengthen involvement and communication ? Next steps – Who is doing what by when ? Are we clear about planned project actions ? Support – do we need any additional support from within the Trust ? Do we need any additional support from the project team ? Three key points to feed back.