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AIM: To reduce incidents of inpatient violence and aggression across two secure hospital sites by at least 30% between July 2016 and June 2018. WHY DOES THIS MATTER FOR SERVICE USERS AND STAFF? • Most significant cause of reported safety incidents (18% of 2013 total). • Immediate consequences for service users, staff and working environment. • Complex contributing factors: patient mix, secure setting • Support exists for structured risk assessment, safety discussions at ward community meetings and restrictive practices.[1,2,3] • Mental health nurses report high abuse rates: physical (80.6%), verbal (41.3%). • Lower reporting for verbal (57.9%) than physical abuse (85.6%). • Poor satisfaction: approx. half were satisfied with report outcome. • Approx. 40% did not report as they believed nothing would change.[4] • Reducing inpatient physical violence was identified as a major ELFT QI priority. METHODS: • QI methodology applied across medium and low secure sites (John Howard Centre & Wolfson House) from July 2016 – June 2018 (Fig. A). Change ideas: 1. Safety huddles (Fig. B) 2. Safety crosses (Fig. C) 3. Safety discussions in weekly community meetings • Safety crosses were a data collection tool for staff to capture incidents. • Operational definitions were developed and disseminated to ensure consistency (Fig. D). Corresponded to coloured dots used by staff to record incidents. Agreed electronic incident report system was inadequate. • Change ideas for the forensic violence reduction collaborative (FVRC) derived from Tower Hamlets violence reduction collaborative and developed through exploration of theories on inpatient violence and interventions to minimise this.[5] • FVRC launched on the four medium secure wards with highest incident rates. • Later expanded to five wards and finally to a total of eight. The latter three sought to join of their own initiative. • Operational definitions for sexual harassment were not initially used. They were developed and added to bundle following feedback from LD wards where staff reported it was not adequately being captured by usual means. Like all ELFT QI projects, it benefited from a framework ensuring close support, advice, supervision and QI coaching. Monthly collaborative meetings were attended by patient representatives, other wards and services. ELFT uses a standard approach to improvement: identifying and defining a problem, analysing causes, creating a theory of change, testing ideas and evaluating their impact on the system at regular intervals. The Model for Improvement is used to guide testing and implementation of the change bundle into clinical practice.[6] RESULTS: • Reductions of 8% and 16.6% in physical and non-physical violent incidents, respectively, were achieved and sustained per 1000 occupied bed days. • Compared to baseline, this equated to one less incident of physical and 17 less of non-physical violence per week averaged across seven wards (Fig. E). • Three wards achieved ≥30% reduction in incidents of physical violence per week. • Five achieved ≥30% reduction in incidents of non-physical violence per week. • One ward did not have complete data and was excluded from the final analysis. LEARNING: Despite the FVRC’s partial success, it brought significant improvements in difficult-to- measure areas. A cultural shift towards openness and collaborative working was experienced around ward-based violence, aggression and sexual harassment. This fostered staff and service users to take ownership in tackling it together. Locally, it led to formation of a steering group to address sexual aggression and violence with plans for increased staff training and standardised support. In 2018, national strategic direction was published on this.[7] QI can be effective in reducing inpatient violence and aggression within secure care. At ELFT, QI has become integrated into the lives of staff and patients. In developing change ideas, key emphasis is placed on service user involvement and staff input. To progress to lasting transformational change, broad organisational support is vital. OTHER ELFT FORENSIC QI PROJECTS… Improved access to employment for service users,[8] implemented self-catering meals in an LSU[9] and improved user experience at an MSU reception. Twenty active projects e.g., increasing videoconferencing use, improving ward environments for patients’ sleep and improving staff satisfaction on acute wards. The violence reduction collaborative continues to scale up across the trust. Dr Owen P O’Sullivan, Specialty Registrar in Forensic Psychiatry (1, 2) Nynn Hui-Chang, Improvement Advisor (2) Day Njovana, QI Sponsor, Head of Nursing & Associate Clinical Director (1, 2) Dr Philip Baker, Consultant Forensic Psychiatrist & Head of Forensic Services (1, 2) Dr Amar Shah, Consultant Forensic Psychiatrist & Chief Quality Officer (1, 2) 1. John Howard Centre 2. East London NHS Foundation Trust Contact: Owen.O’[email protected] Quality improvement in forensic mental health: the East London forensic violence reduction collaborative References [1] Abderhalden C, Needham I, Dassen T, Halfens R, Haug HJ, Fischer JE. Structured risk assessment and violence in acute psychiatric wards: randomised controlled trial. British Journal of Psychiatry. 2008 Jul;193(1):44-50. [2] Lanza ML, Rierdan J, Forester L, Zeiss RA. Reducing violence against nurses: the violence prevention community meeting. Issues in mental health nursing. 2009 Nov 10;30(12):745-50. [3] van de Sande R, Nijman HL, Noorthoorn EO, Wierdsma AI, Hellendoorn E, Van Der Staak C, Mulder CL. Aggression and seclusion on acute psychiatric wards: effect of short-term risk assessment. British Journal of Psychiatry. 2011 Dec;199(6):473-8. [4] Royal College of Nursing. Employment Survey 2017. Royal College of Nursing: London. 2017. [5] Taylor-Watt J, Cruickshank A, Innes J, Brome B, Shah A. Reducing physical violence and developing a safety culture across wards in East London. British Journal of Mental Health Nursing. 2017 Jan 2;6(1):35-43 [6] Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP. The improvement guide: a practical approach to enhancing organizational performance. John Wiley & Sons; 2009 Jun 3. [7] NHS England. Strategic direction for sexual assault and abuse services. 2018 [8] Beck C, Wernham C. Improving access to competitive employment for service users in forensic psychiatric units. BMJ Open Quality. 2014 Jan 1;3(1):u204182-w1821. [9] O'Reilly A. Improving ward environments and developing skills for discharge with the implementation of self-catering on a low secure forensic unit. BMJ Open Quality. 2016 Dec 1;5(1):u210929-w4509.

Quality improvement in forensic mental health: the East ... · • Change ideas for the forensic violence reduction collaborative (FVRC) derived from Tower Hamlets violence reduction

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Page 1: Quality improvement in forensic mental health: the East ... · • Change ideas for the forensic violence reduction collaborative (FVRC) derived from Tower Hamlets violence reduction

AIM: To reduce incidents of inpatient violence and aggression across two securehospitalsitesbyatleast30%betweenJuly2016andJune2018.WHYDOESTHISMATTERFORSERVICEUSERSANDSTAFF?•  Mostsignificantcauseofreportedsafetyincidents(18%of2013total).•  Immediateconsequencesforserviceusers,staffandworkingenvironment.•  Complexcontributingfactors:patientmix,securesetting•  Support exists for structured risk assessment, safety discussions at ward

communitymeetingsandrestrictivepractices.[1,2,3]•  Mentalhealthnursesreporthighabuserates:physical(80.6%),verbal(41.3%).•  Lowerreportingforverbal(57.9%)thanphysicalabuse(85.6%).•  Poorsatisfaction:approx.halfweresatisfiedwithreportoutcome.•  Approx.40%didnotreportastheybelievednothingwouldchange.[4]•  ReducinginpatientphysicalviolencewasidentifiedasamajorELFTQIpriority.METHODS:•  QImethodologyappliedacrossmediumandlowsecuresites(JohnHowardCentre

&WolfsonHouse)fromJuly2016– June2018(Fig.A).Changeideas:

1.   Safetyhuddles(Fig.B)2.   Safetycrosses(Fig.C)3.   Safetydiscussionsinweeklycommunitymeetings

•  Safetycrosseswereadatacollectiontoolforstafftocaptureincidents.•  Operational definitionsweredevelopedanddisseminated to ensure consistency

(Fig.D).Correspondedtocoloureddotsusedbystafftorecordincidents.Agreedelectronicincidentreportsystemwasinadequate.

•  Changeideasfortheforensicviolencereductioncollaborative(FVRC)derivedfromTower Hamlets violence reduction collaborative and developed throughexplorationoftheoriesoninpatientviolenceandinterventionstominimisethis.[5]

•  FVRClaunchedonthefourmediumsecurewardswithhighestincidentrates.•  Laterexpandedtofivewardsandfinallytoatotalofeight.Thelatterthreesought

tojoinoftheirowninitiative.•  Operationaldefinitions for sexualharassmentwerenot initiallyused.Theywere

developed and added to bundle following feedback from LDwards where staffreporteditwasnotadequatelybeingcapturedbyusualmeans.

Like all ELFT QI projects, it benefited from a framework ensuring close support,advice,supervisionandQIcoaching.Monthlycollaborativemeetingswereattendedbypatientrepresentatives,otherwardsandservices.ELFTusesastandardapproachto improvement: identifying and defining a problem, analysing causes, creating atheoryofchange,testingideasandevaluatingtheirimpactonthesystematregularintervals.TheModelforImprovementisusedtoguidetestingandimplementationofthechangebundleintoclinicalpractice.[6]RESULTS:•  Reductions of 8% and 16.6% in physical and non-physical violent incidents,

respectively,wereachievedandsustainedper1000occupiedbeddays.•  Comparedtobaseline,thisequatedtoonelessincidentofphysicaland17lessof

non-physicalviolenceperweekaveragedacrosssevenwards(Fig.E).•  Threewardsachieved≥30%reductioninincidentsofphysicalviolenceperweek.•  Fiveachieved≥30%reductioninincidentsofnon-physicalviolenceperweek.•  Onewarddidnothavecompletedataandwasexcludedfromthefinalanalysis.LEARNING:DespitetheFVRC’spartialsuccess,itbroughtsignificantimprovementsindifficult-to-measure areas. A cultural shift towards openness and collaborative working wasexperienced around ward-based violence, aggression and sexual harassment. Thisfosteredstaffandserviceusers to takeownership in tackling it together.Locally, itledtoformationofasteeringgrouptoaddresssexualaggressionandviolencewithplans for increased staff training and standardised support. In 2018, nationalstrategicdirectionwaspublishedonthis.[7]QIcanbeeffectiveinreducinginpatientviolenceandaggressionwithinsecurecare.AtELFT,QIhasbecomeintegrated intothelivesofstaffandpatients.Indevelopingchangeideas,keyemphasisisplacedonservice user involvement and staff input. To progress to lasting transformationalchange,broadorganisationalsupportisvital.OTHERELFTFORENSICQIPROJECTS… Improved access to employment for service users,[8] implemented self-cateringmealsinanLSU[9]andimproveduserexperienceatanMSUreception.Twenty active projects e.g., increasing videoconferencing use, improving wardenvironmentsforpatients’sleepandimprovingstaffsatisfactiononacutewards.Theviolencereductioncollaborativecontinuestoscaleupacrossthetrust.

DrOwenPO’Sullivan,SpecialtyRegistrarinForensicPsychiatry(1,2)NynnHui-Chang,ImprovementAdvisor(2)DayNjovana,QISponsor,HeadofNursing&AssociateClinicalDirector(1,2)DrPhilipBaker,ConsultantForensicPsychiatrist&HeadofForensicServices(1,2)DrAmarShah,ConsultantForensicPsychiatrist&ChiefQualityOfficer(1,2)

1.  JohnHowardCentre2.  EastLondonNHSFoundationTrustContact:Owen.O’[email protected]

Qualityimprovementinforensicmentalhealth:theEastLondonforensicviolencereductioncollaborative

References

[1]AbderhaldenC,NeedhamI,DassenT,HalfensR,HaugHJ,FischerJE.Structuredriskassessmentandviolenceinacutepsychiatricwards:randomisedcontrolledtrial.BritishJournalofPsychiatry.2008Jul;193(1):44-50.[2]LanzaML,RierdanJ,ForesterL,ZeissRA.Reducingviolenceagainstnurses:theviolencepreventioncommunitymeeting.Issuesinmentalhealthnursing.2009Nov10;30(12):745-50.[3]vandeSandeR,NijmanHL,NoorthoornEO,WierdsmaAI,HellendoornE,VanDerStaakC,MulderCL.Aggressionandseclusiononacutepsychiatricwards:effectofshort-termriskassessment.BritishJournalofPsychiatry.2011Dec;199(6):473-8.[4]RoyalCollegeofNursing.EmploymentSurvey2017.RoyalCollegeofNursing:London.2017.

[5]Taylor-WattJ,CruickshankA,InnesJ,BromeB,ShahA.ReducingphysicalviolenceanddevelopingasafetycultureacrosswardsinEastLondon.BritishJournalofMentalHealthNursing.2017Jan2;6(1):35-43[6]LangleyGJ,MoenRD,NolanKM,NolanTW,NormanCL,ProvostLP.Theimprovementguide:apracticalapproachtoenhancingorganizationalperformance.JohnWiley&Sons;2009Jun3.[7]NHSEngland.Strategicdirectionforsexualassaultandabuseservices.2018[8]BeckC,WernhamC.Improvingaccesstocompetitiveemploymentforserviceusersinforensicpsychiatricunits.BMJOpenQuality.2014Jan1;3(1):u204182-w1821.[9]O'ReillyA.Improvingwardenvironmentsanddevelopingskillsfordischargewiththeimplementationofself-cateringonalowsecureforensicunit.BMJOpenQuality.2016Dec1;5(1):u210929-w4509.

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