7 February 2014

1. Health FoundationClosing the Gap in Patient Safety ProgrammeSafer Care Pathways in Mental Health Services: Overview 7February 2014

2. HPFT is the lead partner

3. Closing the Gap in Patient Safety • 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 • CtG - £4 million to support ten projects to implement and evaluate tested, evidence-based patient safety interventions at scale • Substantial two year projects

4. Safer Care Pathways in MH – Project Aims • Aim to address patient safety hazards and create safer and more reliable MH care pathways • And 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 mental health care pathway

5. 5 4 6 3 7 2 8 1 9 Limitations Shifting the balance towards prospective Approach to patient safety: Retrospective vs. Prospective Prospective Retrospective What has gone wrong? What could possibly go wrong?

6. Focus on people, culture and systems“processes are essential but values and behaviour are critical” (DH, 2010) Review of early warning systems • Good practice relies on good systems used by good people

7. Project Summary • Intervention package • Prospective hazard analysis (PHA) tool (CLAHRC – Cambridge University EDC) • Human factors training & implementation (L&D NHS FT/Hertfordshire University approach) • Service improvement methods (e.g. PDSA cycles) • Plus regional MH patient safety collaborative approach

8. What is Prospective Hazard Analysis ? • Systematic, holistic and prospective analysis of care pathway risks • Helps teams to identify, prioritise and solve complex safety issues through redesign of pathways or interventions • Teams and team leaders trained and coached in use of PHA toolkit • Adapted from other industries: process mapping and redesign/re-engineering • Developed 2007-10, tested across Eastern region and beyond, and positively evaluated

9. What is Human Factors Training & Implementation ? • Human factors (HF) training is a well established patient safety improvement approach • HF training & implementation approach created and tested extensively at Luton & Dunstable NHS FT • Improves multidisciplinary teamwork and communication to enhance safety, patient and staff experience • Involves training & coaching change leaders and key staff in psychosocial factors and teamwork practices • Key teamwork practice interventions: • Briefings and de-briefings • SBAR • Closed loop communication • Critical language

10. Other project information • Project sponsor – Oliver Shanley • Project manager – Tim Bryson • Project set up and recruitment – February to May 2014 • Project Board will include trust involvement and service users and carers • Project will run from June 2014 to June 2016 • Project will include: • ‘Training the trainers’ • Systematic evaluation: qualitative and quantitative • Periodic learning events • Website and project comms, including discussion forum