The self-harm project team was established in 2016 and is comprised of senior members of the Centre for Perfect Care team, together with the ward managers and other senior clinicians from the pilot wards. The project was established to reduce incidents of self-harm on inpatient wards. Four ‘hot spot’ wards were identified (see below) and Design Thinking methodology was then employed to gain a deep empathic understanding of the issue from the end users’ perspective (in this case, staff and service users), and then to design solutions tailored to the specific needs of the end user.
Highly Commended in the MH Safety Improvement Category - #MHAwards18
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
The self-harm project team was established in 2016 and is comprised of senior members of the Centre for Perfect Care team, together with the ward managers and other senior clinicians from the pilot wards. The project was established to reduce incidents of self-harm on inpatient wards. Four ‘hot spot’ wards were identified (see below) and Design Thinking methodology was then employed to gain a deep empathic understanding of the issue from the end users’ perspective (in this case, staff and service users), and then to design solutions tailored to the specific needs of the end user. Project interventions were piloted during 2017 and achieved a 55% reduction in incidents. Interventions are now being scaled across a number of other wards in a phased approach agreed with the clinical divisions.
What makes your service stand out from others? Please provide an example of this.
The project is an international collaboration with The Risk Authority (TRA) Stanford and several other healthcare providers in both the US and the UK. It uses leading edge technology (Innovence Pulse™) and machine learning algorithms to identify key risks and hot spot areas. Design thinking is then used to understand and frame the issue from the end users’ perspective, and ensure resultant interventions are tailored to their specific needs.
How do you ensure an effective, safe, compassionate and sustainable workforce?
The project has contributed to the development of an effective, safe, compassionate and sustainable workforce in several ways: • For example, a number of project interventions have focused on addressing such issues: o Reflective practice, focused specifically on issues related to self-harm; o Training in the prevention of self-harm, including personal resilience and the promotion of alternative coping mechanisms; o Establishing and maintaining stable and consistent teams; o Training in personality disorder; o Person-centred responses to self-harming behaviour; o Safety Huddles; o A shift in focus from managing the risk to understanding the behaviour and supporting more therapeutic alternatives. • There is substantive evidence of reduced bank and agency use, lower levels of sickness absence, and reduced turnover following implementation of project interventions. • This is supported by the anecdotal evidence whereby staff describe the respective wards as calmer and more conducive environments.
Who is in your team?
The core team is comprised of: • Dr Cecil Kullu, Consultant Psychiatrist; • Steve Bradbury, Deputy Director of Improvement and Innovation (8C); • Steve Morgan, Director of Patient Safety (8D) • Dr Tim Riding, Associate Director (8D) • Claire Iveson, Consultant Clinical Psychologist (8D)
How do you work with the wider system?
Having piloted the interventions on four hot spot wards throughout 2017, interventions are now being rolled out on a number of other wards in a phased approach agreed with the clinical divisions. Those wards experiencing the highest levels of self-harm have been prioritized for phase 2 of the project and this will continue until all relevant wards are on board.
Do you use co-production approaches? If so, please illustrate how you involve individuals, families and carers to drive improvement and deliver services?
The project has utilized Design Thinking methodology throughout. This is based fundamentally on co-production. It elevates the role of the end user and seeks to gain a deep empathic understanding before moving into the design phase. During the initial phase – inspiration – a series of semi-structured interviews and observations are carried out before being synthesized into key themes and a number of insight statements. Moving into the second phase – ideation – the project team worked with end users to develop and refine interventions, working through a series of prototypes of increasing sophistication, before moving into the action phase. During the action phase, interventions continue to be refined based on a feedback from end users, until all concerned are comfortable with the finished product.
Do you share your work with others? If so, please tell us how.
We have established a ‘sharing the learning’ network for all wards in the project, using the Basecamp platform to communicate as a virtual team, and hosting bi-annual learning events. Additionally, a poster presentation has been delivered at a number of events and a paper is currently under development for publication. Case studies have also featured in the Royal College of Psychiatrists’ newsletter and the NHSi Improvement Guide
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
A range of outcome measures have been used to evaluate the effectiveness of the project: • The frequency of reported incidents was determined from the Trust’s Datix risk management database. This demonstrated a 55% reduction in incidents during the course of the pilot, when compared to the baseline (i.e. the 12 month period prior to implementation of any interventions). • A bespoke 6 item questionnaire was administered to staff before and after the pilot period. This demonstrated an overall 10 point positive shift from 71 to 81%, indicating increased clarity and consistency in the ward’s approach to managing self-harm. • Relevant items on the Trust’s Inpatient Survey Report (a ‘patient reported experience measure’) were also monitored over the course of the pilot and reflected a 7% improvement in patient satisfaction. • These two measures were also supplemented with a range of other, more informal, outcome measures in which qualitative interviews were conducted with staff and service users. Data from these interviews supported the quantitative data, adding both context and deeper insight. • An in-depth ‘return on investment’ assessment was also conducted in conjunction with TRA Stanford and indicated a return in the region of 130%. This is perhaps best illustrated in relation to bank and agency use, which fell by 37% across pilot wards during the course of the project, delivering actual savings in excess of £86,000.
Has your service been evaluated (by peer or academic review)?
The self-harm project per se has not been formally evaluated other than as described above. The service itself has been assessed by the CQC, however, and received an overall rating of good.
How will you ensure that your service continues to deliver good mental health care?
As part of the project we undertook the NHS sustainability assessment achieving an overall score of 67% (with 55% being the cut off point for a favorable sustainability rating. During the exercise two areas were highlighted to further strengthen the sustainability of project interventions, namely the engagement of clinical and senior managerial leaders. The first of these has already been addressed by involving senior clinicians on project wards. The latter is currently being addressed through our work with the clinical divisions to identify senior managers to actively support the ongoing work.
What aspects of your service would you share with people who want to learn from you?
Whilst we would be more than happy to share project interventions with others seeking to learn from us, it is the process preceding the intervention phase (i.e. the use of Design Thinking) which has arguably had the greatest impact; instilling a sense of ownership in end users and thereby promoting sustainability. We would, therefore, be more than happy to share our experiences of using this methodology.
How many people do you see?
The four hot spot wards in phase 1 of the project provide care and treatment for up to 54 service users at any one time. This will grow exponentially throughout the life of the project as new wards come on board.
How do people access the service?
People generally access our inpatient service via the crisis resolution and home treatment team which serves a gatekeeping function for inpatient services. Once an inpatient on one of the project wards the service users will automatically be able to benefit from project interventions, even if only indirectly (i.e. receiving care from staff who have undergone enhanced training).
Brief description of population (e.g. urban, age, socioeconomic status):
Mersey Care NHS Foundation Trust serves the populations of Liverpool and Sefton primarily. In addition, the high secure services based at Ashworth Hospital serve the broader catchment of the North West, Wales and the West Midlands.
Size of population and localities covered:
Liverpool and Sefton populations are in the region of 485,000 and 274,000 respectively.
