mental health services executive clinical leadership

Mental Health Services Executive Clinical Leadership

Program Project Overview– Running

Away Causes Delay

June 2017 Tanya Dugard

Quality Manager Mental Health Services, MNCLHD

Quality Project Overview

Reducing absconding events in CHAMHU

MHS Absconding Report, June 2017 Page 1

Table of Contents No. Page Executive Summary 2 1. Background 3 2. Aim and SMART checklist 4 3. Rationale and Purpose 5 4. Deliverables and Constraints 6 5. Work plan 8 6. Stakeholder Communication 9 7. Team Members 10 8. Resources 1 9. Evaluation 12 10. Reporting 15 11. Sustainability and Spread 15 Appendices

One – Action plan 16

Two – Driver Diagram 17 Three –Patient Stories - example 18

ABBREVIATIONS

Title Abbreviation Mid North Coast Local Health District MNCLHD

Mental Health Services MHS

Clinical Excellence Commission CEC

Ministry of Health MOH

Specialty Health Network SHN

High Dependency Unit HDU

Low Dependency or Open Area LDU




EXECUTIVE SUMMARY OUTLINE This report provides a summary of the Quality Project – Running Away Causes Delay – reducing absconding incidents in Coffs Harbour Mental Health Inpatient Unit. This was facilitated via the Executive Clinical Leadership Program Cohort 17 BACKGROUND As a result of a number of incidents of patients absconding from mental health inpatient units, a safety notice was issued to Local Health Districts and Specialty Health Networks (LHDs and SHNs) in June 2016 in conjunction with results from the MNCLHD Mental Health Clinical Incident Trending report indicated that 17% of all admissions resulted in an absconding event. Of those events Coffs Harbour mental health inpatient unit accounted for 49% of all absconding events for the July 2015 to June 2016 period. OUTCOMES TO DATE Completion of Capitol works to the Inpatient unit which included removal of trees,

raising and lowering of fences, installation of airlock facility

Multidisciplinary Team Clinical Reviews recommenced

Supervision in courtyards

Flexible Visiting Hours introduced

Leave included in Clinical Handover

Patient stories commenced

Participation in Smoke free working party – who now attend the group program

Leave procedure finalised for global consultation

Process for including alerts of absconders to be embedded into Complex care

procedure

RESULTS

21% Decrease in Absconding rates

100% of all Mental Health Consumers are involved in multidisciplinary team review

100% of all Clinical Handovers include Leave

40% visitations to the Coffs Harbour mental health inpatient unit occurred outside

of the recommended visiting hours

53% of consumers who were identified as a smoker was provided the appropriate

processes to commence smoking cessation

10% of those who absconded were repeat absconders

56% events were absconding Type 1 (directly from the unit) (50% in 2015/2016)

o 42% absconded via the courtyard (68% in 2015/16)

o 57% absconded via the door (31% in 2015/2016)




1. Background As a result of a number of incidents of patients absconding from mental health inpatient units, a safety notice was issued to Local Health Districts and Specialty Health Networks (LHDs and SHNs). Chief Executives had to ensure that a rigorous process is in place to support the safe and appropriate assessment of involuntary patients prior to the approval of leave being granted from a mental health inpatient unit. A number of tasks were allocated to each LHD which included 1. Distribute this notice to all stakeholders and all mental health inpatient units. 2. Undertake a safety audit of the physical environment of all mental health inpatient units in the LHD/SHN to identify any requirements to reduce the risk of patients absconding and report to the Ministry by 1 August 2016. 3. Review any absconding incidents to identify areas for improvement of risk management and report to the Ministry by 1 August 2016. 4. Audit and revise the current procedures for leave from mental health inpatient units with a view to reducing absconding incidents and to better assess and manage the risk of harm to self or others. This is to include a review of risk assessment protocols, including the patient’s past history of absconding and current absconding risk. This is to be reported to the Ministry by 1 August 2016. 5. Ensure that any leave decisions be considered by a multidisciplinary team, and the outcomes documented, with regard to improved management of the risk of harm to self or others from patients prior to approval by the treating psychiatrist. The patient’s leave plan must include written advice to the family/carer concerning measures to manage risks during leave, including risk of harm to self or others, and the provision of a crisis plan if difficulties arise during leave. This, and written advice and information, must be provided to the family/carer prior to the leave. As part of the project, that despite the results of each of the actions required further information would be sought by the project team to identify further innovative areas of improvement




2. Aim and SMART

SMART CHECKLIST Specific An agreed and identified problem that Mental Health Services

is trying to solve? Reducing Absconding Rates in Coffs Harbour Mental Health Inaptient Unit by 50%

Yes

Measurable How will you know if the problem has been solved? Reduction in Absconding rates

Changes to process and Balance measures

Yes

Achievable Resources allocated to address problem? Budget for capitol works $80K

Project management for smoke free

Team allocated for project

Yes

Realistic Is it likely that the desired outcome really will be achieved? Major changes to unit and processess within

Yes

Time-based Clear and appropriate start and finishing dates for the implementation of the work

June 2017

3. Rationale and Purpose Results from the MNCLHD Mental Health Clinical Incident Trending report indicated that 17% of all admissions resulted in an absconding event. Of those events Coffs Harbour mental health inpatient unit accounted for 49% of all absconding events. Further data indicated the following • 84% (n=39) of the inpatients were involuntary • 58% (n=23) were involuntary patients absconded directly from the unit (Absconding Type 1) • The most common form of absconding was over the fence 20% (n=8) including one incident where the patient absconded over the High Dependency Unit (HDU) fence. • 17% were patients on trial leave to the low dependency unit from HDU • 1% were recently transferred to Low Dependency Unit (LDU) from HDU • Out of the Five repeat absconders four patients absconded more than twice during a single admission • 30% (n=12) had noted in the incident that there was a history of absconding • 23% (n=9) returned to the unit within 48 hours • 20% of all admissions during July 2015 to June 2016 included an absconding event




4. Deliverables and Constraint CHANGES

Recommendations Endorsed by Director of reports submitted to MOH –

August 2016

Environment

Review of all fenced courtyards

Removal of trees in courtyards near the fence

Increased supervision in courtyards by staff

Reduction of access to IPU

Review of establishing an air lock in the front door

Absconding Report July 2016

Increase in supervision

Post debriefing with consumers who have absconded

All inpatient services review and explore opportunities to implement improved

smoke free activities

Patients sent out on time out of High Dependency units are to remain on

15/60 observations

Use of eMR to identify high risk absconders through alert system

Use the Trauma informed care and Practice Organisation Toolkit to assess

Mental health services commitment to Trauma informed care

Procedure Review

Mental Health Leave procedure finalised

Care level procedure to include auditing requirements of patients on care

level 3 to remain under nurse escort

Ongoing training regarding risk assessment in eMR and improvement of

documentation thereof

Management of Consumers In Mental Health High Dependency Units

completed

Clear documentation requirements pertaining to leave and care levels

Deliverables

Increased supervision of patients

More time with the patients

More patient centred care approach

Better Communication processes in the identification of high absconding

risks

Less absconding incidents

Improved Communication between clinicians and consumers

Improved understanding of rules and responsibilities in the unit

Improved insight to the reasons why consumers abscond




Other

Project Team through brainstorming via driver diagram

Meet with project team to further identify more innovative ideas to improve

Work in conjunction with Productive MH wards to release time to care

Proposed outcome is to have closer governance and engagement of patients

in their care and improve treatment plans at commencement of admission by

the provision of alerts in the Electronic Medical Record

Constraints

Reluctance by Staff to engage with increased supervision in courtyards

Enough time to implement all the recommendations as well as consideration

for new ones




5. Work Plan Through consultation, and using the resources provided by Mental Health Services the following is a rough road map to achieve the outcomes and key milestones for each step suggested. An action plan (attachment 1) to identify key persons, services and actions will be outlined.

July 2016

Development and submission of reports as per directive of MOH

Recommendations reviewed and endorsed by Director MHDA

September 2016

Commencement of environment review outlined in action

plan commenced

October 2016

First meeting with project team to complete driver diagram

Supervision of courtyards commenced

Update of action plan for environment submitted to Director MHDA

Nov 16

Project team to meet and finalise solutions

Implement PDSA on at least three primary solutions

February 2017

Review Process measures and feedback to team

Update action plan and reprioritise

June 2017

Capitol Works to doors, fences completed

Compile results and distribute to team

6. Stakeholder Communications Worksheet

Stakeholder name Communication Approach (from

Power/interest grid)1

Key interests and issues Current status

2

Desired support

3

Desired Actions Messages to convey

Action and communication

Director Mental Health, Drug and Alcohol

Monitor

Progress on recommendations Monthly reports

Advocate High Drive change

Information

Senior Executive Team Alan Pretty

Monitor

Monthly reports

Advocate High Drive Change Supply infomration action plan update on environmental changes

MHS Workforce Keep informed Supervision of consumers Care levels Provision of reports

Critic: Blocker Medium Implement change progress with project

Official Visitors Keep Satisfied Supervision in courtyards Supporter low support change Progress with Project

Facility Managers Keep informed Action plans and implementation thereof

Support High Implement Change Progress with project

Patients and carers

Keep satisfied Leave arrangements debriefing tool

Neutral low Receive /participate Change and feedback

information

Project Team Keep Informed progress of PDSA Cycles and results of data

Advocate HIGH Develop change methods

Support and implement change

Patient safety and quality Committee

Monitor Results of audits advocate High Endorse change Update on progress

1 Manage closely; keep satisfied; keep informed; monitor

2 Advocate (actively helping success); Supporter; Neutral; Critic; Blocker

3 What support do you require from them? High / medium / low

7. Team Members Project Sponsor – Alan Pretty, General Manager Mental health Services

Team Lead – Tanya Dugard, Quality Manager, Mental Health Services

Nurse Unit Manager – Coffs Harbour Mental Health Inpatient unit –

Paul Gover

Clinical Nurse Consultant level 3

(Senior MH Nurse) – Kim Edwards

Social Worker Michelle Donges

Clinical Nurse Educator

Allyson Wilson

Occupational Therapist

Jaclyn Cansdell

Health Security Assistant

Kathy Brazel

Consumer Representative

Nicholas Kosseris

Clinical Director – Dr Afraz Zaman

Clinical Educator Lynn Davies

8. Resources

Date Resources Cost

12/2016 Environmental audit conducted with recommendations and Quotes to physically change inpatient unit structure

$88K

06/2016 Participation in executive Clinical Leadership program including flights and accommodation

$10K




9. Evaluation

The following are the tools to determine the effectiveness of the work plan:

OUTCOME MEASURE (Measured at end of period September 2016 – May 2017) Total Absconding Events in same measurement period September 2016 - May 2017 and compare to previous measured period Results

A 21% decrease in absconding events measured over the same period

25 absconding events compared to 32 from the previous year % Consumers who abscond more than once in the measured time frame




PROCESS MEASURE (INDIRECT IMPACT ON AIM)

1. Number of Absconding incidents directly from courtyard

68% of consumers absconded from the courtyard in 15/16 period, compared to 42% absconding in 16/17 (45%

Reduction)

2. Number of visitations outside of scheduled visiting hours

40% of visitations occurred outside of normal visiting hours

Visitors included Official Visitors, Legal Aid, Non-Government Agencies and Volunteers

Implemented in August 2016 (Measured Sept16 – Feb 17)

3. Number of absconding Type One Incidents

50% of patient absconded directly from the unit (15/16)

56% absconded directly from the unit (16/17)

(Construction/modifications to the inpatient unit was completed at the end of May 2017)




4. Number of leave prescriptions in eMR (Measurement taken on 23/6/17) Measurements taken on 23 mental health consumers in Coffs Harbour Mental Health Inpatient unit in the open area. 100% of all consumers had a leave prescription 5. % Use of leave in clinical handover Measurements taken on 23 electronic medical records to locate clinical handover sign of mechanism. 100% had leave arrangements documented in the handover tool.

6. % of consumers who smoke offered NRT upon admission

Documentation Audit conducted in April 2017 indicated that 53% of consumers who were

identified as a smoker was provided the appropriate processes to commence smoking

cessation

7. Number of Patient stories = 2

o Themes identified – issues with not being listened to, medication not helping and

misinterpreting information due to psychosis

BALANCING MEASURE Side Effect Number of Patients readmitted within 28/7 who had absconded prior

A vast reduction in the readmission rates




11. Reporting The following table indicates the reports developed as part of the project. Report To whom Frequency Tabled Comments

MNCLHD Mental Health Services Absconding Report – July 2015 – June 2016

Chief Executive and MOH

once Operations Overview of absconding events and identification of trends

Mental Health inpatient unit Environment Report August 2016

General Manager, MHS

Once WHS assessment to highlight risk and recommendations to mitigate

Environment Report action plan

General Manager, MHS

Quarterly update on structural changes outlined in report

MOH Absconding Report MOH Monthly All absconding incidents listed identified with an absconding type

MHS Clinical Trending report

All staff Annual PS&Q Highlights absconding events

Protocol and Assessment Review

MH Executive, CE and MOH

Once PS&Q update on actions arising from SN00

12. Sustainability and Spread

Future focus will be:

Continuing updating the action plan

Education on new finalised policy/procedure

Provide project to 1A expansion project

Auditing of leave and care planning

Appendix One: Action Plan

Mental Health Services, MNCLHD

Appendix Two: Driver Diagram

Driver Diagram Template

By June 2017 the number of absconding

patients will be reduced by 50% at Coffs HarbourMental health inpatient

Unit

Outcome Measure: • Total Absconding

events• By when: June 2016

Reduce Restrictions

Process Measure: • Number of Absconding

incidents from courtyard• By May 2017

Process Measure: • Number of leave

prescriptions in Emr• By when: June 2017

Process Measure: • Number of absconding

Type 1 incidents• By when: June 2017

Secure Environment

Improve staff awareness and management re:

AWOL

Improve understanding

RE:AWOL

Process Measure: • Number of patient

stories• By when: June 2016

Increase Supervision

Improve leave arrangements

Increase contact with family/carers

Improve communication factors

Increase supervision times in courtyard

Increase engagement with consumers

Reduce opportunity to leave from exit points

Improve Fencing

Improve supervision when transitioning from HDU to

LDU

Improve understanding of consumers why AWOL

Increase access to doctors

Improve NRT Replacements

Roster for nursing and HSA for supervision times

Finalise leave procedure

Introduce preferred/flexible visiting hours

Involve carers/family in Care plann ing

Clinical Handover to include leave arrangements

Leave prescriptions

Introduce inpatient brochure

Include high absconders in Alert system

Consider Airlock facility

Restrict access to unit

Quotes for fencing

Implement HDU procedure

Develop clinical Agreement with Medical officers

Conduct patient stories

Introduce scheduled MDT meetings

Involve D&A referrals

Offer NRT for all identified smokers upon admission

Impact: High Implementation: Easy

Impact: High Implementation: Hard







Impact: LowImplementation: Easy


Impact: LowImplementation: Hard







Team Members:• Project Sponsor/s – Alan Pretty• Team Leader - Tanya Dugard• Consumer - Nicholas Kosseris• NUM – Paul Glover• CNE – Ally Wilson• CNC3 – Kim Edwards• OT – Jaclyn Cansdell• HSA – Kathy Brazel• CE – Lynn Davies• Clinical Director – Dr A Zaman

The Problem: Of all absconding events registered in June 2015 - July 2016 Coffs Harbour Mental Health Inpatient Unit accounted for 49% of all absconding events

Outcome Measure: • % patients who

abscond more than once in measured time

• By when: June 2016

Process Measure: • Number of visitations

outside of scheduled visiting hours


Process Measure: • Use of leave in Clinical

Handover• By when: June 2017

Process Measure: • % Consumers who smoke

offered NRT upon admission

• By when: june 2017

Primary Drivers Secondary Drivers Solutions Priority Solutions

Balancing Measure: • Number of patients

readmitted within 28/7 who had absconded prior


Appendix Three: Sample Patient Story

BIN

DIN

G M

AR

GIN

– N

O W

RIT

ING

FAMILY NAME MB MRN

GIVEN NAME □ MALE □ FEMALE

Facility:

D.O.B / / . M.O.

ADDRESS

Mental Health Services Post Incident Debrief Tool

LOCATION/WARD

COMPLETE DETAILS OR AFFIX PATIENT LABEL HERE

“PLEASE”- Engage/Analyse/Summarise DATE CONDUCTED = 9/3/17

E = Engage - “How do you feel about what happened?” The consumers experience of the event, from the consumers’ perspective. Provide information to the consumer and carer about the event (assisting in understanding), provide emotional support, validate the consumer’s feelings associated with the event and repair or improve rapport

Felt labelled

Freaked me out

Paranoid about telephone lines

Went over the fence and walked into town and went home and partner drove him back

Po

st In

cid

en

t De

brie

f To

ol

A - Analysis What are the triggers that causes these actions?: (What sets off the aggression/anger/disturbed behaviour?)

I told the doctor about a peodophile experience and he asked me if I thought I would become one

I was totally psychotic and could not deal with what the doctor said to me so I left the unit

What do you notice in yourself when the triggers are brought on? (What physical signals of distress are there? What is noticed by

the consumer and staff?)

More tolerant now these days

What are some strategies you can use to help you manage stress? (What are some individual and specific strategies to manage or minimise

stress)

Summarise the review Consumer Care Plan Updated in eMR

(Adapted from the PLEASE© Debrief Model iSim Centre)

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