Prospective Risk Assessment in a Mental Heath Trust

A Study About Ways to Improve the Quality of Care in Mental Health Services

This research is a CLAHRC fellows project and the fellow is Dr Jenny Spencer.

The Project PI is Dr Terry Dickerson, Assistant Director of the University of Cambridge Engineering Design Centre.

The project Sponsor is Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) through the NIHR CLAHRC for Cambridgeshire and Peterborough.

Initial Goals

AimTo test whether two closely related methods for identifying risk prospectively (both frequently used in industry) can be efficaciously adapted to a mental health environment.

Goal 1. To verify and validate the use of these tools in a mental health setting.2. Ideally, to improve patient safety and the quality of clinical care in mental health settings.

Outcome measures

Primary – Comparison of managerial Prospective Hazards Analysis and clinical staff Quality Assurance Data Collection results.

Secondary – Change in Patient Safety Culture using MAPSAF. Change in the number and severity of reported near misses and SUIs.

Timescale Managerial PHA sessions to be held in January, April and July 2012; Clinical staff data collection to begin in February and continue through May 2012. Final data analysis to be performed July – August 2012

Aim of the Study

Hazards List

NumberBrief

SummaryDescriptio

n

Most likely worst case Consequen

ceProbabilit

y Severity

Current Layer of

protection l

Teams affected

Environments

Change required

Implemented

Hazard 001

Patients might..

Feel suicidal .. Death Likely Severe CPN, 6

years AO, Crisis Community

Hazard 002

Staff might..

assess a skin

condition ..

First aid Certain Minor Jr Dr (SHO)

Old Age, Adult Inpatient

.. .. .. .. .. .. .. .. ..

Hazards List

NumberBrief

SummaryDescriptio

n

Most likely worst case Consequen

ceProbabilit

y Severity

Current Layer of

protection l

Teams affected

Environments

Change required

Implemented

Hazard 001

Patients might..

Feel suicidal .. Death Likely Severe CPN, 6

years AO, Crisis Community

Hazard 002

Staff might..

assess a skin

condition ..

First aid Certain Minor Jr Dr (SHO)

Old Age, Adult Inpatient

.. .. .. .. .. .. .. .. ..

Compare and contrast

• Classify problems using WHO patient safety classification system

• Add or change categories as needed

Prospective Hazards Analysis Quality Assurance Data Collection

Health Services Research: Evidence Based Practice

Assess the Clinical Safety and Effectiveness of the Quality Assurance methods under study using Adequate and Appropriate Research techniques (Quantitative, Qualitative and/or Mixed Methodologies)

Main Study Flowchart (Engineering Diagram)

QA Arm - Control• Cambridgeshire North

•No Intervention• Out-of-Hours Service

• CR&HT Service

2011 2012Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

SepProject Setup• Project Protocol• QA Tool Design

• CPFT Permissions• Peer Reviews• Ethical Review Routine Quality Indicators

Setup | Collection and Monitoring

QA Arm - Intervention• Cambridgeshire South

• QA Intervention• Out-of-Hours Service

• CRHT Service

QA Arm - Control• Cambridgeshire North

•No Intervention• Out-of-Hours Service

• CRHT Service

PHA Arm• Consists of a management workshop

• Takes place early in this period

Project Reporting• Formal

• Objectives 1, 2 and 3

= MaPSaFTimings are indicative

Blinding (as far as practicable)

Blinding (as far as practicable)

Gantt Chart 1 (September 2011)AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG

Deliverables Owner Duration W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W5 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W5 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W5

Planning phase 3 w

Task I SDO application Jenny, Rv by Terry 2 w

Task II IRAS application Jenny, Rv by Terry 2 w

Task III Brief protocol Jenny, Rv by Terry 1 w

Task IV Approval of brief protocol by CLAHRC leadJennyBelinda Lennox/Prof Jones

Task VI Detailed protocol Jenny, Rv by Terry 1 w

Task VI Information sheet for participants Jenny, Rv by Terry 1 w

Task VII Consent form for participants Jenny, Rv by Terry 1 w

Team phase 7 w

Task I Review of Ethics submission by R&DJenny Steve Kelleher Rachel Kyd

1 w

Task II Approval of Ethics submission by faculty Jenny, many others 4 w

Task III Ethics submission Jenny, Terry 1 w

Task IV Introductory presentation for various committees Jenny 4 w

Task V Approval of brief protocol by faculty (sought at end of meeting) Jenny 4 w

Prototype phase 5 w

Task I Introductory presentation for out of area trainees Jenny 1 w

Task II Pilot tool with out of area trainees Jenny, out of area EoE volunteers 3 w

Task IIIPeer review of detailed protocol, information sheet and consent forms by out of area reviewers

Jenny, 2 out of area reviewers 4 w

Implementation phase 16-20 w

Task I MAPSAF 1a Cecily Morrison 1 w

Task II MAPSAF 2a Cecily Morrison 1 w

Task III MAPSAF 3a Cecily Morrison 1 w

Task IV Prospective Hazards Analysis James Ward/Terry Dickerson 1 w

Task V Application of Inclusive design toolkit James Ward/Terry Dickerson 1 w

Task VI Data collection tool design workshop forum for OOH team (Junior doctors)

Jenny? Martin Stefan 1 w

Task VII Data collection tool design workshop forum for CRHTT

Jenny? Martin Stefan 1 w

Task VIII Data collection and ongoing training for OOH team (Junior doctors) Jenny 16-20 w

Task IX Data collection and ongoing training for CRHTT ? Martin Stefan 8-12 w

Task X Weekly data analysis Jenny 16-20 w

Task XI Management workshop review of collected data Jenny, ? Others 1 w

Task XII MAPSAF 1b Cecily Morrison 1 w

Task XIII MAPSAF 2b Cecily Morrison 1 w

Task XIV MAPSAF 3b Cecily Morrison 1 w

Closure phase 5 w

Task I Comparative Risk Culture Analysis Cecily Morrison 5 w

Task II Completion of collected data analysis (mixed qualitative and quantitative design) Jenny 4 w

Task III Comparative Economic Analysis James Ward/Terry Dickerson 5 w

Annotations

Gantt Chart 2 (May 2012)

Gantt Chart 3 (Current)

Main Study Flowchart (Engineering Diagram)

QA Arm - Control• Cambridgeshire North

•No Intervention• Out-of-Hours Service

• CR&HT Service

2011 2012Oct Nov Dec Jan Feb Mar Apr May Jun Jul AugSep

Project Setup• Project Protocol• QA Tool Design

• CPFT Permissions• Peer Reviews• Ethical Review

Routine Quality Indicators Setup | Collection and Monitoring

QA Arm - Intervention• Cambridgeshire South

• QA Intervention• Out-of-Hours Service

• CRHT Service

QA Arm - Control• Cambridgeshire North

•No Intervention• Out-of-Hours Service

• CRHT Service

PHA Arm• Consists of a management workshop

• Takes place early in this period

Project Reporting• Formal

• Objectives 1, 2 and 3 = MaPSaF

Timings are indicative

Blinding (as far as practicable)

Blinding (as far as practicable)

We have additionally written a Literature Review And thoroughly researched our evaluation methodologies

Barriers to Project Completion

Is Your Project Research?

• Service Improvement Project (SIP) vs Health Services Research (HSR)

• Ethics approval, Sponsorship, Peer review, Indemnity/Insurance, Grant Contracts, Feasibility, Commercial charges, Service Support Costs, Identification of PI, Letters of access/Honorary Research contracts

Limit Growth - Project size and goals

Collaborator buy - in

Ethical approval - Appropriate venue

• University Ethics Boards vs LREC

Service Provider Buy-in as a moving target

• Changes initiated by people other than you

Hard-to-Measure Work

Learning the ropes

• Reviewing current literature

• Studying new methodologies

• Appreciating the process steps necessary for study approval

Spreading the word: Creating a positive feel for the project• Project documents (including PHA) to:

• Medical director

• Head of Service Improvement

• Clinical Directors

• Risk Assessment department

• Clinical staff who are likely participants

• Discussions at RCPsych Faculty Conferences

• Literature Review article submission to a peer reviewed journal

Suggestions for Future Projects

• Limit project scope (and supervisor enthusiasm)

• CLAHRC Resources webpage is very useful:

• Research Governance Pathway Guidance http://www.clahrc-cp.nihr.ac.uk/resources/research-governance

• Don’t forget to budget time for

• Peer Review, Letters of access/Honorary contracts for all involved, Indemnity/Insurance, Sponsorship

• As well as Ethical Approval

• Make sure you really enjoy your topic, because you will be dedicating a lot of time to it

“Design for Patient Safety” Department of Health 2003

Thank you for listening.