Aim

Primary DriversSecondary Drivers

To deliver a reduction of harm within mental health and learning disability services from incidents involving : • Self harm• Violence &

aggression • Slip, Trips, Falls• Medications errors

by Dec 2012

Leadership and Safety Culture

Clinical Care 95% reliable

Supportive infrastructure

Service user and family-centred care

Effective risk assessment Robust care planning

Promoting choice, dignity & respect

Information giving

Effective working between teams

Sound evidence based practice

Clear clinical leadership

Education and Training

Active patient/carer involvement

Clinical supervision / Mentoring/Preceptorship

Access to therapeutic interventions

Safe clinical environments

Effective learning safety culture

Access to equipment

Operational systems/ policies

Meaningful activities and engagement

Learning from patient/carer feedback

Visible/ ongoing Executive support

Promoting physical health including nutrition and hydration

In Mental Health & Learning Disabilities the QIPP workstream is focused onto 4 main harms : Self harm, Violence & Aggression, Slips, Trips & Falls and Medication errors

SAFE Care - ‘Safety Express’ – Mental Health & Learning Disabilities

The QIPP Safe Care workstream is an improvement programme designed to help organisations reduce harm. In Acute Services Safe Care tackles 4 major harms in the NHS; Falls, VTE, Pressure Ulcers, Catheter Acquired UTI by 50%,

QIPP Safe Care – Acute Settings

50% reduction in in-patient physical assaults each year until 2012

Measurement

Leadership

Communication (SBARD)

Reliable risk assessment

Collateral information

Aim

Primary drivers

Standardised care

Supportive eRecord

Local feedback

Training

Secondary drivers

Michael.sykes@nhs.net

© 2010 AQuA 4

Aim

A reduction in incidents of violence&

aggression by 20% in the STAR Unit

during 2012/13

Care Planning

Environment

Workforce

A. Raise awarenessB. Introduce a SU advanced statement re management of V&A.

A. Post all records (agreed actions) of the community meetings in a central area.B. Post a weekly activity programme at a central point on the ward.

A. Develop a formal process regarding the planning of social & therapeutic activities.B. Introduce a community meeting.C. Redesign role of staff member – activity co-ordinator.

Driver Diagram - STAR Unit

Primary drivers are the systems changes which will contribute to

achieving the Aim outcome measure.

Secondary drivers are interventions associated with primary drivers. They

can be used to create projects or change packages that will affect the

primary driver.

A. Review and compare data – make data easily available to staff..B. Identify specific times/places/ personnel involved in V&A. C. Provide poster for staff comments re new PDSAs.D. Provide staff with written updates re V&A to inform staff on return from days off.E. Recruit permanent staff to vacant posts.

Therapeutic

Interventions

Primary DriversSecondary Drivers

PRIMARYOUTCOME(Measure)

Sustained reduction I the frequency of the three most common

types of incident each year (20% annually for

each year over five years from April 2011)

Incidents are:-Falls, -Violence and Aggression -Self Harm

Balancing MeasureEnsure other types of incidents are not neglected and increase as a result of targeted intervention.

Governance Structure•Report to H&S bi-monthly actions and incident data•Executive lead Kim Crowe to report to board•Tony Crumpton to report to H&S

Leadership•Identify and inform Stakeholders •Engage early implementers•Identify strategic and clinical leads

Monitoring•Policy compliance•Incident data•Implementation strategies

Secondary Drivers- Identify reporting lines- Strategy Lead and clinical leads (x1 for each harm)-Identify external groups Safety Express to develop comparison data

BC

Secondary Drivers- Engage AQuA in supporting the process--Identify with CBU’s wards / units for implementation- Support unit managers in adopting change process-identify change champions

BC Secondary Drivers- Implement measures based on PDSA cycles- Share good practice / share successes- Share / report findings-Develop sensitive measures / baseline data

-Identify and support clinical champions

CPrimary drivers are system components which will contribute to moving the

primary outcome

Secondary drivers are elements of the associated primary driver. They can be used to create projects of change packages that will affect the primary driver

Trust Harm Reduction Strategy Driver diagram Definition: A driver diagram is used to conceptualise an issue and determine its system components which will then create a pathway to get to the goal

AimTo reduce physical assaults to staff by 20% in one year on the 2011-12 Trust baseline

Safe Environment

Staff Experience

Communication

Handovers

Patient Experience

Primary drivers describe the systems / larger components which will contribute to achieving the overall aim. Each usually has an associated measure

Secondary drivers are elements of the associated primary driver. They are interventions which can be used to create projects or change packages that will affect the primary driver.

Driver diagram

Aim50%

reduction on numbers of

detained patients

absconding from acute Inpatient wards by Dec 2012

Evidence based policy and guidance that is implemented

Therapeutic milieu

Person Centred approach

•Audit of baseline •Develop understanding of existing literatiure

RA to include risk of AWOL, staff trained

Identifying and dealing with patients concerns

Risk assessment, profiling and management

• Patient activities Safe and appropriate environment

Primary drivers are systems components which will contribute to moving the primary outcome.

Secondary drivers are elements of the associated primary driver. They can be used to create projects or change packages that will affect the primary driver.