Commitment 27: Healthcare Improvement Scotland will work with NHS Boards to deliver the Scottish Patient Safety Programme (SPSP) - Mental Health
Cultivating learning amongst those delivering and in receipt of care, and using that knowledge to improve safety are core values of the Scottish Patient Safety Programme for Mental Health. Through collaboration and innovation from staff, service users and carers and the use of quality improvement/improvement science over the last three years, we are now starting to see significant reductions in self harm, violence and aggression, and restraint across a number of areas in Scotland.
The Programme, established in August 2012, is a four year programme with an overarching aim of reducing the harm experienced by individuals in receipt of care from mental health services. This currently entails a focus on adult psychiatric inpatient units (and forensic inpatient units), including both admission and discharge processes. Simply put, the programme states the aim should be that: 'Patients are and feel safe, Staff are and feel safe'.
Phase one of the programme, from August 2012 - September 2013, saw a high level of engagement from NHS Boards, with pilot sites working on five workstreams across Scotland. NHS Orkney and NHS Shetland are engaged in the programme, although not in a position to report against the outcome measures as they have no inpatient beds, bringing the total number of participating boards to 15 (14 territorial NHS boards plus The State Hospitals Board for Scotland).
Patient and Carer and Staff Involvement
Over 1,300 delegates have attended five national learning sessions between August 2012 and March 2015. Two regional learning sessions have included a further 530 attendees with over 350 delegates registering during this September 2015. There was positive feedback regarding direction of travel of the Scottish Patient Safety Programme Mental Health National Learning Session 5 (March 2015) with 92 per cent % of responders agreed or strongly agreed that the event had helped create a greater focus on safety work within their organisations.
Service users and carers themselves reported increased awareness of patient safety, for exampel according to one service user representative: "Users feel happier that these things are even being considered... just questions being asked has made them feel safer. For instance the survey [patient safety climate tool] that's being rolled out... people even feel more positive, knowing these issues are on the agenda".
Recognising the pivotal role that service users and carers as well as the third sector have in the SPSP-MH programme of work has ensured that they have been involved in every step of the process. An example of this is the Patient Safety Climate Tool (PSCT) that has been developed by mental health service users and carers. Over 400 patients across Scotland have had the opportunity to participate in this facilitated survey. It is a Scottish innovation that is leading the way in person centred safe delivery of care. The tool is designed to enquire about environmental, relational, medical and personal safety.
Examples of themes from completed Patient Safety Climate Tool's have included the requirement for more information about medication and possible side effects, and positive comments about staff and their ability to deconstruct and help explain and support to interpret difficult situations such as being restrained or witnessing a restraint. Furthermore over 2000 staff across the country have also taken part in the staff safety climate survey. A senior charge nurse from a psychiatric intensive care unit (IPCU) described that, following the use of the safety climate tool with patients, practice was changed to respond to female patients' concerns about safety at night:
"For the first time anywhere in the world we have a tool that measures mental health inpatients' perception of their own safety. This tool was designed by mental health service users and, after an extensive pilot phase, is now being rolled out across Scotland. This will ensure that work to improve safety focuses on the things that matter the most to the patients on the wards." ~ Gordon Johnstone, Director of Voices Of eXperience (VOX)
Outcome Data and Safety Principles
The Scottish Patient Safety Programme - Mental Health are developing 26 Safety Principles in Mental Health where there are a number of interventions and processes that are either being reviewed and tested with the view that all or a combination of these will contribute to reduction of harm measurable through the SPSP-MH Outcome Measures. There are examples of reductions in restraint of up to 63 per cent, reduction in the percentage of patients who self harm of up to 57 per cent and reduction in the rates of violence of up to 54 per cent. The nationally aggregated data that now exists gives a baseline and a route to comparison but it is the individual ward data that is showing real improvement.
There are a number of references in NHS Boards to suggest that the use of the programme is supporting cultural and attitude changes. There is work looking at prescribing and administration practice of psychotropic as required medication. The culture of its use, its efficacy and its review is being challenged with good practice of its use and monitoring from across the country. How restraint is viewed and how challenging behaviour is managed is also beginning to change. There are examples, such as that quoted, where restraint isn't considered as a 'first line' response to challenging situations. Instead, there is an examination of practice; can this be avoided? What factors are contributing to this that can be mitigated? Can the environment be adapted and is there appropriate activity? Do people have the appropriate training and does that training have the right balance of physical intervention and skills for de-escalation? These questions, and questions like these, have also contributed to the development of all of the safety principles:
"It's made me more aware of my practice in relation to patient safety. The other perspective is regarding the ward I work in; when I started working there a few years ago there was quite a pessimistic vibe within the ward. That had come as a result of certain incidents that occurred before I started, three years down the line having the Scottish Patient Safety Programme at the core of what we do I can see a culture change and that has been seen trust wide. That encapsulates everything as once patients and staff feel positive it makes practice better and safer."
"In terms of collecting data about what we are doing and changing the way we do things especially with regards to medication and post incident reviews and moving things forward so situations don’t occur again. It's an important thing to be part of and we can continue to ensure things improve."
"The introduction of huddles has improved communications. Before we'd respond to alarms in other wards not knowing what we would be going into. The introduction of therapeutic activities into the unit has reduced our levels of violent incidents; I honestly can't remember the last time I restrained which is one of the main goals."