‘4 Steps to Safety’ is a system for safer inpatient mental health care. The overall aim of the project is to achieve a 50% reduction in violence and aggression by September 2017. The '4 Steps to Safety' are 1. Proactive Care, 2. Patient Engagement, 3. Teamwork and 4. Environment. These four steps are delivered in partnership with people with lived experience of inpatient services, and aims to support staff to deliver the best evidence based care to improve patient engagement and reduce violence and aggression on inpatient wards.
What We Did
‘4 Steps to Safety’ is a system for safer inpatient mental health care. The overall aim of the project is to achieve a 50% reduction in violence and aggression by September 2017. The ‘4 Steps to Safety’ are 1. Proactive Care, 2. Patient Engagement, 3. Teamwork and 4. Environment. These four steps are delivered in partnership with people with lived experience of inpatient services, and aims to support staff to deliver the best evidence based care to improve patient engagement and reduce violence and aggression on inpatient wards.Our journey to the ‘4 Steps to Safety’ Programme started about three years ago when Dr Michael Holland, the Medical Director from South London and Maudsley NHS Foundation Trust (SLaM), presented his pilot data from testing an evidence based bundle of interventions designed to reduce violence on inpatient wards at the South of England Improving Quality and Safety in Mental Health Collaborative.
In 2014, Devon Partnership NHS Trust in collaboration with SLaM were extremely lucky to be funded £500,000 by the Health Foundation to scale these interventions across both of our organisations. We have come a very long way since starting this ambitious work. The enthusiasm and ingenuity of our staff, ‘4 Steps to Safety’ team and people who use our services, has meant that this work has taken us in directions we had not expected. Co-production with people who have lived experience, supports understanding the purpose and culture change. This project is changing the conversations we are having with people who use our services and carers, as well as creating a more collaborative way of working together. We have made an amazing start, and there will be even greater benefits as we continue to test and modify our interventions.
The ‘4 Steps to Safety’ violence reduction programme commenced within our Trust in September 2015. The toolkit has now been introduced into 17 out of 20 of our inpatient wards, with the final three wards to commence by January 2017.
Whilst the programme has an overall aim of reducing violence, we have learned that it is also delivering other key benefits, such as people who use our services reporting greater feelings of engagement with staff, which is leading to them feeling safer on the unit. One team has also reported how a more proactive approach to engagement and risk review has led to a decrease in restrictive practices which has a positive impact on staffing. We hope that all wards will continue to positively implement all the interventions and feed back to the Quality Improvement Academy about their experiences, so we can inform the final evaluation of intervention effectiveness.
Project teams from Devon Partnership NHS Trust (DPT) and South London and Maudsley NHS Foundation Trust (SLaM) are working collaboratively to implement the ‘4 Steps to Safety’ Programme.
Consultation meetings and surveys were carried out prior to implementation. Real time violence and aggression baseline data were collected and fed back to teams. The clinical interventions that are part of ‘4 Steps to Safety’ are tested using Quality Improvement (QI) methodology. Teams work with QI facilitators, Lived experience representatives and Service Users to train staff and support implementation. The project plan divides wards into cohorts across two years. Using QI methodologies, Facilitators work simultaneously with a number of wards within each cohort, offering joint training sessions and implementation support. Wards allocate staff champions to lead each intervention and to embed them into day-to-day work. Patients, staff and facilitators including lived experience representatives work collaboratively throughout.
Within Devon there has been a real collaboration between the project team, staff and patients. Carers have been involved in clinical areas that already work closely with families. Alongside training and implementation, we have held collaborative events whereby presentations are given and sessions run by staff and patients. We have received feedback from those that attend, that staff prefer the opportunity to discuss implementation successes and challenges together, rather than listening to project team leaders providing presentations. Our collaborative events are very well attended and very much owned by the teams rather than the project team. The energy of the teams working together has provided real momentum and ownership of the project by those delivering the interventions on their wards. Storyboards provide data, narrative re progress, and examples of resources created by the teams.
We also share our work with the South of England Mental Health and Patient Safety Collaborative and we have been asked to support other Trust teams to implement some of the interventions. We attend and present and share our learning at events such as IHI Quality International Forum (Gothenburg 2016 and London 2017), AHSN events and recently at the Homicide conference in Taunton. There is a commitment between the project teams of both DPT and SLaM to continue our joint meetings/collaboration to continue to share and learn from each other extending beyond the length of the project.
This project was co-designed from the beginning with lived experience representatives working alongside Trust facilitators. Training and implementation, team support and collaborative working with patients was paramount with facilitated staff/patient meetings and carer meetings part of the process.
Complete process monitoring, coaching, advice and patient feedback was included in the framework. Both Devon lived experience representatives have been involved in supporting other work streams directly inspired by their own involvement/contribution within the ‘4 Steps’ Programme. Events outside of the Trust are also encouraged to share learning experience and the project as a whole.
Looking Back/Challenges Overcome
Our main challenges have been around frontline resistance, implementation as a priority, staffing impact, relevance to clinical area, stable leadership, intentional rounding and compact culture change, PDSA cycles and learning logs, process monitoring – seen as another Audit Facilitator role, time intensive.
We have overcome some of the challenges by being flexible with the teams and encouraging them to think about how they wish to implement, along with using a ‘model for improvement’ methodology to design the interventions to better suit their clinical areas.
We have encouraged managers to identify champions for the interventions, to ensure that leadership is not only from the manager/consultant but from key frontline staff.
We have begun to talk about prevention rather than reduction, as prevention is about creating the right conditions for safety and positive experience, so that we get it right all of the time regardless of service or levels of incidents.
Coaching makes up a large part of the facilitator role and conversations have been key to this work. The concept and practical experience of co-production has also been very helpful for teams as our lived experience representatives provide an insight that professionals can lack. The teams have welcomed this and have responded positively to learning from and discussing issues with our lived experience representatives. We have captured all learning from each cohort and used this to plan how we work with next cohorts, we also share the learning between teams.
Conversations, co-production and collaboration have had an impact on our changing culture. We are beginning to think about narratives to support data to help teams be able to share their data with staff and patients that will also encourage better conversations between them. We also have a plan to focus more on the interventions that require engagement change as the areas that have achieved this report more satisfaction. Our lived experience representatives are very much involved with this as their insight helps teams to see how helpful engagement and agreed mutual expectations can be to outcomes.
•Flexibility is required with training/ implementation plans.
•Early proactive leadership is essential.
•Governance reporting structures to be agreed early.
•Data processes – agreed and established very early on.
•Interventions requiring a culture change face more challenges.
•Flexibility is needed to avoid duplication of processes, as may cause resistance.
•Co-production supports understanding purpose and culture change.
•Collaboration between organisations is difficult at ward level, but is more successful at facilitator/lead level.
•Collaborative events are a positive way for teams to support and learn from each other.
•Resistance is engagement.
•Prevention rather than reduction.
•Include frontline staff early.
•Talk about data early.
•Make time to help teams understand co-production at ward level.
We have a ‘4 Steps’ Sustainability Plan – Checklist: What? How? Who? When? Outcome/Progress – following is an excerpt from this to indicate measure we have in place to ensure that our positive service continues, should those leading it move on elsewhere:
•Build QI support to ensure 4 Steps programme is embedded beyond the length of the programme.
•Business case developed for integrated project management office including additional QI staff
•Project Management Office to oversee and support all QI programmes/initiatives Inc. Trust/Directorate objectives
•Embed ‘4 Steps’ in key training programmes for staff
•Embed ‘4 Steps’ interventions in management of violence and aggression programme which is delivered to all new staff in ward environments and is updated annually.
•Training plan developed with QI facilitators supporting delivery of the plan.
•New training programme developed. Train the Tutors programme delivered incorporating ‘4 Steps’/Non-technical and Human Factors.
•Ensure new staff in inpatient wards are trained in ‘4 Steps’
•Build into induction programmes.
•Directorate management teams to agree and change induction process.
•Secure Directorate which manages cohorts 1-3 have built it into their induction programme
•All secure wards now have built into induction packs. Staff will continue to liaise with the project team to improve process and provide further training when necessary, work on-going to ensure inclusion in inpatient welcome packs.
•Ensure strategy continues as a priority for the Trust beyond the length of the programme.
•‘4 Steps to Safety’ to be included in directorate objectives for the period 2016-2020
•Directorates have built it into their Quality Improvement programmes.
•‘4 Steps’ has been agreed as a QI programme to continue within the Trust Quality Delivery Plan 2016-20.
•Include in inpatient policy, practice standards and SOP’s.
•Embed new interventions when policies etc. are reviewed.
•Supportive observation and engagement policy to include Intentional Rounding.
•Discussions commenced to review relevant policies.
•Reviewing SOP’s and practice standards to include ‘4 steps’ interventions.
•Embed 4 steps data into ward internal monitoring process.
•Triangulation of process measures, incidents and staff/patient feedback to inform wider improvement agenda.
•As each cohort takes ownership of monitoring of ‘4 steps’ processes
•Cohort 1 to 3 includes ‘4 steps’ data on agenda for monthly ward leadership meetings.
•Build ‘4 Steps to Safety’ into local and directorate governance agendas.
•Discussions ahead of pre-work with directorate and at commencement of pre-work for wards.
•Identified structure for reporting for all directorates. Included as agenda item within ward governance meetings as cohorts commence pre-work.
•QI competencies have been built into the Trust leadership framework for all staff groups.
•Signed off by appropriate Trust committee(s)
Evaluation (Peer or Academic)
An ethnographer has spent time on two Devon wards as part of the process. The evaluation team meet with facilitators etc. for qualitative feedback alongside any data analysis.
We have a measurement plan which gives details of our outcome, process and balancing measures, recording our method for collection, source, identified person for collection and collection period.
Kings College are also evaluating the project and this is on-going.
This project is still underway and ends in August 2017. Final outcomes relating to violence and aggression will be reported end of 2017/early 2018.
The use of safety crosses has identified that in Devon the severity of harm has reduced.
Accident/incident date is currently demonstrating a significant reduction in frequency in 55% of our wards.
Where engagement has consistently improved through the intentional rounding intervention, team managers have reported decreased use of restrictive practice and reduced agency spend.
We have also seen for one of our OPMH wards that although they still have high levels of risk on their ward, through better engagement they have reduced the use of increased observations, and now no longer need to use level 1 or level 2 observations. They increase engagement to manage increased risk and only use level 3 observations when the patient really needs 1-1 support.
“I feel valued and appreciated when working collaboratively”
“I get the time of day for someone to listen to me”
“It’s good; we don’t have to bother them. It’s good to chat about anything. They will help you with anything”
“I like knowing I get to see the same person and they will understand me each time”
“I like my 1:1 time I can get my feelings out”
“I think patient representatives should lead with staff on this improvement”
“Smooth transition from something which was currently taking place on the ward to now being done in a more structured way”
“Self-isolating patients now get staff time each shift”
“Continuity of day-to-day care is more effective due to improved quality of patient handover”
“Due to IR I am able to recognise when my patients are having a bad day”
“Better nursing care”
We also share our work with the South of England mental health and patient safety collaborative and we have been asked to support other Trust teams to implement some of the interventions.
We attend, present and share our learning at events such as IHI Quality International Forum (Gothenburg 2016 and London 2017), AHSN events and recently at the Homicide conference in Taunton. There is a commitment between the project teams of both DPT and SLaM to continue our joint meetings/collaboration to continue to share and learn from each other extending beyond the length of the project.
Is there any other information you would like to add?
The programme has an overall aim of reducing violence and we have learned that it is also delivering other key benefits such as people who use our services reporting greater feelings of engagement with staff – leading them to feel safer on the unit. This more proactive approach to engagement and risk review has led to a decrease in restrictive practices which has a positive impact on staffing.
The ‘4 steps to safety’ programme has led to many unexpected benefits including:
•Improved conversations about quality and safety
•Shift, for some, away from ‘just observations’ to engagement
•Consultants leading operationally
•Difficult data conversations leading to teams moving towards triangulation of own data for improvement
•Teams welcoming learning from our lived experience representatives
•Reduced restrictive practice
•Reduced agency spend
•Reduced severity of harm