closing the gap in patient safety programme safer care pathways in mental health: project overview...
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Closing the Gap in Patient Safety Programme
Safer Care Pathways in Mental Health: Project Overview
Presented by Tim BrysonProject Manager
Closing the Gap In Patient Safety Programme
• The Health Foundation is an independent charity working to improve the quality of healthcare in the UK
• Two priority areas: i) patient safety and ii) person-centred care
• CtGPS - £4 million to support ten projects to implement and evaluate tested, evidence-based patient safety interventions at scale
• Substantial two year projects
Project partners
•Hertfordshire Partnership University NHS FT (lead)•All mental health trusts in East of England•Engineering Design Centre, Cambridge University•University of East Anglia•University of Hertfordshire
Safer Care Pathways in MH – Project Aims
• To address patient safety hazards and create safer and more reliable MH care pathways
• To enable sustainable learning and capacity in patient safety skills and tools
• Five project sites: one in each mental health trust in East of England
• Project sites to include dementia care pathway and adult and older adult mental health care pathways
Safer Care Pathways in MH – Project Focus
• Shifting the balance towards prospective• Focus on people, culture and systems• Avoidable deaths and harm – suicide, self-harm, falls,
medication errors, harm from aggression• Improved safety communication between staff,
service users and carers• Risk enablement
Project Intervention Package
1. Prospective hazard analysis (PHA) tool (CLAHRC – Cambridge University EDC)
2. Human factors training & implementation (L&D NHS FT/Hertfordshire University approach)
3. Service improvement methods (e.g. PDSA cycles)
Project Sites
Trust Site
NEPFT Older adults functional care ward, and dementia care ward
NSFT Dementia care ward and community team (DIST)
CPFT Dementia care ward and older adults functional care ward
SEPT Adult acute ward and CRHT
HPFT Adult acute day treatment unit and CRHT
Project Timetable
Clinical team Evaluation PeriodProject site establishment Baseline
evaluationJune 2014
Care pathway mapping Sept/Oct 2014Completed PHA process – training and diagnostic
Mid-point evaluation
November 14 to February 15
Completed human factors training and team coaching
Mid-point evaluation
March to Sept 15
Service improvement project activity Final evaluation Oct 15 to July 2016
Project Evaluation
Evaluation questions• How mature is the risk
management approach ?• What is the safety culture ?• How useful and useable are the
interventions ?• What is learnt ?• What is the Impact on patient
safety and outcomes ?
Evaluation data
• Key informant interviews• Patient safety data – risk
registers, datix and patient experience reports
• Safety culture survey questionnaire
• Training experience questionnaire• Reflective diaries
• Observations
Project Benefits
• Completed PHA for each care pathway (links to ‘Sign Up to Safety’ assessment)
• Creation of a cohort of PHA trained, and human factors trained, patient safety champions in each trust
• Implementation of a minimum of 1 service improvement project within each care pathway site
• Safety culture feedback, and strengthened safety culture in the care pathway
• Shared learning across region and nationally
Project Governance
• Project board involving all partners, and including service user and carer advisers, and EoE Strategic Clinical Network
• PID approved by project board• Six monthly and final reports to Health Foundation
More information
• Website = http://mentalhealthpartnerships.com/project/safer-care-pathways-in-mental-health-project/
• Twitter - #safercarepathways• Health Foundation – www.health.org.uk• Tim Bryson – Project Manager - 07767354620• [email protected]• Jeremy Wallman – Project Officer - 07719555412• [email protected]• Charlotte Copley – Project Administrator - 07540294317• [email protected]