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Marlborough House

Marlborough House project

Marlborough House is a self-contained child and adolescent unit in Swindon, Wiltshire. There are 12 inpatient beds on the ward and the unit also has the capacity for six day patients. Many of the inpatients demonstrate symptoms of an emerging personality disorder or autism spectrum disorder (ASD), both of which are linked with incidences of self-harm. In addition to this, Marlborough House is involved in the treatment of eating disorders (both inpatient and day patient), which are also often comorbid with self-harm. In 2016 staff at Marlborough House had previously implemented a highly successful improvement project reducing self-harm in children and adolescents. This project saw incidents of self-harm decline by 85%, which was maintained over a period of 18 months.

Project Aim
To reduce the incidence of all types of deliberate self-harm by 25% within one year of the commencement of the project (1st June, 2019).

Project Focus
After a recent increase in the number of incidents of deliberate self-harm, which is having a substantive effect on staff morale and patient experience, the ward engaged with Oxford Health Improvement Centre (OHIC) for support to try and reduce the incidence of all types of deliberate self-harm. To date, this project aims to address the following factors:
• Disruption to the therapeutic environment of the ward
• Physical ward environment
• Staff and patient morale
• Communication and teamwork

Methodology
The project follows the methodology set out by the Institute of Health Improvement (IHI), which involves consultation between the wider ward staff (not just senior ward staff) and OHIC in order to generate ideas to help reduce the number of all types of deliberate self-harm incidents. These tests of change are implemented by the ward, with ongoing support from OHIC.

Progress
The first test of change, the introduction of a mandatory “twilight” shift which provides an extra member of staff between 3-11pm (a time during which the data indicates that there is a peak in self-harm incidents), has been implemented. The project is now in a measurement phase to assess the impact that the introduction of the twilight shift has on the number of incidents of self-harm on the ward. The ward are also planning and preparing the second test of change, which will involve having planned evening activities for the young people on the ward. This directly builds on the introduction of the twilight shift due to the availability of the extra staff member to support this.

Resources 
Andover, Pepper, Ryabchenko, Orrico, & Gibb, 2005; Hannon & Taylor, 2013; Klonsky et al., 2003; Nock et al., 2006
Iannaccone et al., 2013

Failure to return from leave project

Failure to return from leave project

On acute adult psychiatric wards, failing to return from leave from acute psychiatric wards can have a range of negative consequences for patients, relatives and staff. Positive risk taking is part of the recovery process so staff need to work to ensure that patients are as safe as possible when they leave wards on Section 17 leave or take time away. This project sought to improve the return rates at the agreed time to enhance the safety of people in their care.

Project Aim
For each adult acute ward to reduce failure to return on time from Section 17 leave or agreed time away by 50% within 12 months of the start of their project.

Project Focus
The project was initiated and lead at Oxford Health NHS Foundation Trust as part of their Improvement Programme:
Project Details

The failure to return from leave project addresses:
• Interruptions to care planning and disruption to the therapeutic ward environment
• Breakdown in working alliances
• Loss of trust
• Possible risks to the patient or others well being
• Increased workload for staff and other agencies in time spent ensuring the patients wellbeing and safe return.

Methodology
The project followed Institute for Health Improvement (IHI). The project tested a number of ideas generated by the staff and service users who worked on the pilot ward:
• Individualised Safer Leave forms for patients which capture key information and support the therapeutic planning of leave and time away from the ward
• Patient information leaflets detailing ward expectations
• The use of business cards with staff messages of care and contact numbers for the ward
• Intentional rounding
• Visual Information for staff to raise awareness of the procedures necessary to ensure leave and time away from the ward is safer.

Progress
The project is established in Oxford Health NHS Foundation Trust. At baseline, the rate for on-time return was 56.0%; this increased to 87.1% post-intervention, a statistically significant increase of 55.5%. SPC charts showed that the interventions were associated with improvements. The pilot ward is now achieving 96% return on time rate and the process is stable. The project earned the Matron Mental Health Nurse of the Year in the Journal of Clinical Nursing 2016.

Further information
• For more information, contact jill.bailey@oxfordhealth.nhs.uk or nokuthula.ndimande@oxfordhealth.nhs.uk
• The project featured in the AHSN national ‘Patient Safety Collaboratives: Making care safer for all’ report published in July 2016
• Published paper in November 2016 – Bailey J, Page B, Ndimande N, et al. Absconding: reducing failure to return in adult mental health wards. BMJ Quality Improvement Reports.

Improving clinician experience of the Electronic Health Care Record during the assessment process

Improving clinician experience of the Electronic Health Care Record during the assessment process

When new patients are referred to a mental health team at Oxford Health (OH), the assessing clinicians have multiple forms to complete on the Electronic Health Care Record (EHCR) including assessment, risk, physical health, care plan, clustering. This is in addition to producing a letter to the GP detailing the outcome of the assessment. These forms are located in different locations within the EHCR, they can be lengthy and information can be duplicated on different forms. Further, clinicians have noted that the information requested on certain forms are not aligned well with their particular service. Oxford Healthcare Improvement (OHI) were requested to undertake a project addressing these issues.

 Project Aims

  1. Improve clinician experience of using the EHCR system
  2. Reduce the amount of time required to complete an EHCR assessment
  3. Increase the use of EHCR assessment forms by clinicians in the Trust

 Methodology

Clinician focus groups were convened from the different mental health services within OH to meet with the EHCR team and develop a process map of the assessment pathway, to understand where the problems might lie in engaging with the EHCR. Following this a further meeting was arranged with the clinician focus group to discuss potential options for changes to the EHCR system.

The following changes were chosen to be tested:

  1. Adding conditional logic to the Mental Health Assessment form to tailor questions appropriately for the different services
  2. Creating an assessment team dashboard that informs the team of when forms need completing
  3. Removing duplications from forms
  4. Auto creation of GP letters

Measures

Improve clinician experience of using the EHCR system

  • Via a survey (5-10 questions) to assess clinician experience of EHCR
  • Survey will be sent out to clinicians involved in the pilot, 4 weeks before and 4 weeks after the changes are implemented

Reduce the amount of time and number of clicks to complete a EHCR assessment

  • Measured using a lab study with 6 clinicians
  • Complete forms for 3 hypothetical patients representing different services: CAMHS, Adult, and Older Adult
  • Time taken and number of clicks will be recorded pre and post

Increase the use of EHCR forms by clinicians in the Trust

  • Proportion of forms completed for the number of referrals for 2 teams in the Trust
  • 4 weeks before and 4 weeks after change
  • Calculate GP letters auto-populated for the new EHCR system

Reducing time spent on enhanced observations for service users

Reducing time spent on enhanced observations for service users

Service users admitted for care in acute or psychiatric intensive care units may be so unwell that they present a risk to themselves or others.  There is little empirical evidence to support the practice of enhanced observations although the practice is widespread in the UK (De Santis et al., 2015; Muralidharan & Fenton, 2006). Enhanced observations are commonly used to reduce the risk of self-harm, suicide and to prevent violence and aggression (Bowers et al., 2000). In some situations, enhanced observations may not enhance safety or have a negative influence on the service user’s mental state. (2008; Chu, 2016; Stewart, Bowers & Ross, 2012). In the local service, staff wish to work on reducing the time service users spend on enhanced observations through the introduction of a coached quality improvement project designed to test a number of changes in practice to benefit both patients and staff.

Project Aim

To reduce the amount of time spent on enhanced observations in Ashurst Ward, a psychiatric intensive care unit (PICU), by 15% by 1 January 2019.

Methodology

The project employed the Institute for Health Improvement (IHI) Improvement model.  The team began by taking a set of baseline measures to better understand the amount of time spent on regular and enhanced observations, as well as reasons for enhanced observations and the roles of staff who carried out enhanced observations. Patients were offered the opportunity to talk with an independent worker from the Patient Experience Team to collect their views on the current observation practices in the PICU.  Next, a driver diagram was developed to identify major issues contributing to the use of enhanced observations, based on analysis of the data, a literature review, and facilitated discussions to capture staff theories and ideas.

Progress

The team has identified their first test of change to improve the handover of information between staff who are undertaking enhanced observations and patients subject to enhanced observations.

  • Establishing the purpose of the observations being carried out for both staff and the service user.
  • Understanding the service user’s experience and preferences for making the most of time on enhanced observations.
  • Describing key lessons/points from the previous observation to ensure continuity.

 Further information
For more information, contact jill.bailey@oxfordhealth.nhs.uk, dorcas.dan-cooke@oxfordhealth.nhs.uk, or tony.perry@oxfordhealth.nhs.uk.

Reducing time spent by nurses on documentation when admitting patients on Allen Ward using keyboard-equipped iPads

Reducing time spent by nurses on documentation when admitting patients on Allen Ward using keyboard-equipped iPads

Allen ward is an acute psychiatric ward for women. The ward is working to increase the reliability of critical care processes with the aim of reducing waste, improving quality and safety. Nurses on the ward currently document admissions on paper, which is then entered into the CareNotes electronic medical record. Information is therefore documented both manually onto paper and into the electronic system. creating opportunities for error.

Project Aim

To reduce time spent by nurses documenting nursing tasks to complete formal admissions by using iPads rather than paper forms.

Methodology

The project employed the Institute for Health Improvement (IHI) Improvement model.  The team began by creating a process map to document the current process to admit patients under the Mental Health Act.   This identified several areas where entering information directly into CareNotes would save time and improve safety.  The team then created a driver diagram to identify changes that could be made including the use of iPads during face to face assessments, a review of documentation (amount of information needed and design), IT training needs and availability of information.

Progress

  • Three Clamcase keyboards were procured and ready for deployment.
  • Training sessions organised to increase confidence in use of iPads.
  • Baseline data collected to track the amount of time required to document admissions.

Reducing delays experienced by patients at the Older Adults Mental Health Services team in South Bucks

Reducing delays experienced by patients at the Older Adults Mental Health Services team in South Bucks

The Older Adults Mental Health Services team care for service users with a range of mental health needs. Service users include people with functional (mental health) and organic (dementia/memory services) needs.

The Duty Team triage referrals into the service, but many referrals are missing important details such as blood test results. Incomplete information can delay access to the right health services.

Project Aim

Reduce the proportion of incomplete or inappropriate referrals received by the Older Adults Mental Health Services team by 50% within six months of replacing the referral form.

Methodology

The project employed the Institute for Health Improvement (IHI) Improvement model.  The team began by collecting baseline data on referrals received by the service.  Information gathered included number of referrals, referral reasons, referring practices and suitability and reasons if not (e.g., missing tests).  The team found that the referral form in use was not sufficiently clear, leading to referrals with incomplete information.

Progress

  • A new referral form has been created, providing more guidance to referring GPs with supporting evidence from NICE.
  • The new referral form is now under consultation, with plans to meet with stakeholders before implementation.

Last updated: 4 October, 2018