“zero seclusion: towards eliminating seclusion by 2020”€¦ · zero seclusion process measures...
TRANSCRIPT
“Zero seclusion: towards eliminating seclusion by 2020”The New Zealand initiative led by the Health Quality & Safety Commission
Clive Bensemann, Clinical Lead HQSC
• Why a Quality Improvement programme?
• Zero seclusion initiative
• Methodology
• Progress and challenges
• What’s next
Why the Need?• 2015 a ‘call to action’ from sector
leaders
• Safety concerns
• Variation
• Local and international examples eg Scottish Patient Safety Programme
The Programme• 5 years District Health Board (DHB) funded - July 2017
• Using Improvement science methodology: improve
outcomes, reduce harm, address inequity.
• Building sector capability
• Quality Improvement Facilitator training ( x3 annual cohorts)
• Developing leadership & Changing culture
• National learning events, workshops, visiting speakers,
relationship with Scottish Patient Safety Programme
Initial Engagement and PrioritiesHQSC hosted
• 2016 Proposal developed via 2 national meetings
• 2017 across sector engagement via 4 regional
forums
Developing partnerships: Te Pou o Te Whakaaro
Nui (Te Pou), National KPI programme
Programme Leadership• Stakeholders Group
• Ministry of Health, Mental Health Commission,
Professional Colleges, Consumers, Maori, national
NGO group, DHBs, Unions
• Leadership Group – MH&A sector wide
• Maori Advisory Group
• Commission team supporting local leadership
• Clinical, Consumer, Maori, QI & Data expertise
Prioritisation of QI topicsRegional Forums then Leadership Group
1. Strategic fit
• Improving consumer experience & equity
• Reducing harm & unwarranted variation
2. Evidence for intervention?
3. Benefits realisation – impact, timing, sustainability, ability to scale &
spread
4. Value for money
5. Available data
5 priorities
HQSC principles
• Consumer partnership
and co-design
• Partnership with Maori
• Building leadership
and improvement
capability
• Measurement
www.hqsc.govt.nz
Zero Seclusion:
towards eliminating seclusion by 2020
• National Collaborative (20 DHBs) over
18 monthsIncreases pace & visibility, shares learning & builds a
network
• To build on and accelerate the work of Te
Pou & National KPI programme
Project Aim• “Zero seclusion: towards eliminating
seclusion by 2020”
• Clarity: ‘a big audacious goal’.
• Provocation to build Will and motivation
• A clear project aim; focus on the problem you are
trying to solve and not the solution you would
want to implement.
The Six Core Strategies©
Six Core
Strategies©
1.
Leadership
2.Use of Data
3.
Workforce
Development
4.
Reduction Tools
5.
Service User
Inclusion
6.
Debriefing
Between 2009 and 2014
55%
Source: Ministry of Health. 2015. Office of the Director of Mental Health Annual Report 2014.
Wellington: Ministry of Health, p.38.
Referral with seclusion as a % of all referral during the year
(18-64 years non-forensic), by ethnicity, New Zealand July 2009 to June 2016
Percentage of tāngata whai ora who experienced seclusion by hours
spent in seclusion during referral (18-64 years non-forensic), by
ethnicity, New Zealand, July 2015 to June 2016
Referral with seclusion as a percentage of all referral
(18-64 years non-forensic), by DHB, July 2015 – June 2016
Likelihood of Seclusion 2015
Lai et al, Int J
Mental Health
Nursing, Aug 2018
Seclusion: current state• Seclusion rates have plateaued
(8% of people admitted)
• Maori 13% vs non Maori 6%
• Maori males 20-44 years 18%
vs non Maori 12%
• Seclusion 5x more likely for
Maori (likelihood of admission
plus likelihood of seclusion
(2015 MOH)
• Pacific have similar rates to
Maori
National training SPEC
Engagement Challenges• ‘Aspirational Goal’ not a target
• How is this different from previous work?
• Managing Stakeholder expectations– Staff & Unions
– DHB leadership: health & safety, resource implications?
• ‘Working with the willing’ vs national
programme? “This is about improving consumer and staff safety”
Seclusion project plan• Evidence review
• An integrated methodology over 18 months
• experience based design
• a national improvement collaborative methodology
• Learning sessions and coaching throughout the
project.
• A suite of measures to assess effectiveness
• Outcome, process, balancing measures
`
Co- design
Pathway
elements and
changes ideas
established
Pre work
Communications
Partnerships
Assemble teams
DHB teams
2018 MHA QIFS
Setting
the scene
workshop
MARCH 7
Why?
What
How
Co design
session 1
Supra regional
sessions
March
National learning sessions
Co design session 2
1) 19th June
2) 22nd June
Web
ex
1
Web
ex
2
Web
ex
3
Web
ex
11th
July
Web
ex
1st
August
A Model to support improvement
Collaborative methodology
Identify
Change
Concepts
Pre-work
LS 1
S
P
A D
LS 2
Collaborative teams
Support: emails / visits / reports / sponsors /
meetings / assessments / conference calls
P
A D
S
The Breakthrough Series: IHI Collaborative
Model for Achieving Breakthrough Improvement
LS – learning session
From Co-design LS 3 Implement
Rapid cycle testing
Key success factors
• Project team • Those who will be testing changes – staff (all disciplines)
• Lived experience – consumers, family and staff
• Q.I. capability/support
• Data support
• Engaged sponsor (support & remove barriers).
• Time & space for team to improve.
• Consistency of purpose and urgency
Zero Seclusion driver diagram example Primary pathway drivers:
System components which will contribute to moving the aim
Change ideas:
• Use of sensory modulation
• SPEC competency
• Safety huddles
• Debriefing
• Whanau support
• Peer support
• Welcoming environment
• Cultural support
• Early nicotine replacement
strategies
• Standardisation – effective
medication management
• Early crisis intervention
• Daily medical rounds
• Meaningful activities available
• 360 debriefs
Aims / Primary outcome:
Aim measure: Primary driver - Outcome measure(s): Seclusion events, hours and individuals Secondary drivers - Process measure(s):
Balance measures: Staff assaults, restraint use, PRN med use
Early Change Ideas• Implementing evidence
• Sensory modulation including a Maori approach – karakia
(prayer), miri miri (massage), kapa haka (dance)
• Debrief – implementation in new ways?
• Acute Behavioural Disturbance guidelines
• Safety Huddles
• Admission processes
• Culturally informed ‘safe space’ - use of whare hui, powhiri, kai
• Working with Police
Change Ideas• Tikanga Maori approaches to care
• Whakawhanaungatanga (established relationships)
• Manaakitanga (hospitality, kindness)
• Whanau centred care
• Peer workforce
• Increasing range of ward activities
• Supporting on call medical staff differently
Planning for spread and sustainability
This is a distinct phase in the Q.I. process
• Very reliant on leadership to ensure there is a
resourced process.
• Complexity of changes will effect ability to
spread and resource required
• Requires ongoing monitoring to maintain gains.
Maori• Maori Advisory Group Co-design trained
• Project teams & Maori participation• Co-design with a ‘cultural lens’ eg Whanau centred?
• Cultural perspective in change ideas
• Equity issues
Equity for MaoriIssues
• Institutional racism
• Unconscious bias
• Health literacy
• Cultural competence
• Maori participation
Current Challenges• Every DHB is different
• Industrial action
• National Mental health Inquiry
• Data
Data capability and capacity
Outcome, process, balancing measures• Integrate data collection into everyday practice
• A balanced set reported regularly
• Focus on the vital few (need vs nice to have)
• Plot over time on annotated graphs
• Goal of measurement for improvement is action
Data capability and capacity • Learning sessions & coaching
• Resources
• Run charts
• Spreadsheets
• On line tools
National set: Outcome & Balancing measures
Outcome meaures
1. People rate: % of those admitted
2. Duration: average hours per person admitted
3. Multiple events: average events per person admitted
Balancing measures prioritised by project teams:
1. Assaults on staff / consumers and staff injuries
2. Increased sedative use
3. Personal restraint
Still early in collection and reporting phase
National – monthly (Measure 1)Jan 2016 – June 2018 (30 months)
Median
Goal0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
Jan_
2…
Feb
_2…
Ma
r_2…
Apr_
2…
Ma
y_
2…
Jun_
2…
Jul_
20
16
Aug_
2…
Sep_
2…
Oct_
2…
No
v_
2…
De
c_
2…
Jan_
2…
Feb
_2…
Ma
r_2…
Apr_
2…
Ma
y_
2…
Jun_
2…
Jul_
20
17
Aug_
2…
Sep_
2…
Oct_
2…
No
v_
2…
De
c_
2…
Jan_
2…
Feb
_2…
Ma
r_2…
Apr_
2…
Ma
y_
2…
Jun_
2…
Jul_
20
18
Aug_
2…
Sep_
2…
Oct_
2…
No
v_
2…
De
c_
2…
Jan_
2…
Feb
_2…
Ma
r_2…
Apr_
2…
Ma
y_
2…
Jun_
2…
Jul_
20
19
Aug_
2…
Sep_
2…
Oct_
2…
No
v_
2…
De
c_
2…
Jan_
2…
Feb
_2…
Ma
r_2…
Apr_
2…
Ma
y_
2…
Jun_
2…
Jul_
20
20
Aug_
2…
Sep_
2…
Oct_
2…
No
v_
2…
De
c_
2…
National - seclusion measure #1 - people rate
Zero Seclusion launch
Secluded
as %
admitted
National – monthly (Measure 2)Jan 2016 – June 2018 (30 months)
Median
Goal0
0.5
1
1.5
2
2.5
3
3.5
4
Jan_
2…
Feb
_2…
Ma
r_2…
Apr_
2…
Ma
y_
…Jun_
2…
Jul_
2…
Aug_
2…
Sep_
2…
Oct_
2…
No
v_
2…
De
c_
2…
Jan_
2…
Feb
_2…
Ma
r_2…
Apr_
2…
Ma
y_
…Jun_
2…
Jul_
2…
Aug_
2…
Sep_
2…
Oct_
2…
No
v_
2…
De
c_
2…
Jan_
2…
Feb
_2…
Ma
r_2…
Apr_
2…
Ma
y_
…Jun_
2…
Jul_
2…
Aug_
2…
Sep_
2…
Oct_
2…
No
v_
2…
De
c_
2…
Jan_
2…
Feb
_2…
Ma
r_2…
Apr_
2…
Ma
y_
…Jun_
2…
Jul_
2…
Aug_
2…
Sep_
2…
Oct_
2…
No
v_
2…
De
c_
2…
Jan_
2…
Feb
_2…
Ma
r_2…
Apr_
2…
Ma
y_
…Jun_
2…
Jul_
2…
Aug_
2…
Sep_
2…
Oct_
2…
No
v_
2…
De
c_
2…
National - seclusion measure #2 - duration rate
Zero Seclusion launch 7 March 2018
Average
hours per
person
admitted
National – monthly (Measure 3)Jan 2016 – June 2018 (30 months)
Median
Goal0.00
0.02
0.04
0.06
0.08
0.10
0.12
0.14
Jan_
2…
Feb
_2…
Ma
r_2…
Apr_
2…
Ma
y_
…Jun_
2…
Jul_
2…
Aug_
2…
Sep_
2…
Oct_
2…
No
v_
2…
De
c_
2…
Jan_
2…
Feb
_2…
Ma
r_2…
Apr_
2…
Ma
y_
…Jun_
2…
Jul_
2…
Aug_
2…
Sep_
2…
Oct_
2…
No
v_
2…
De
c_
2…
Jan_
2…
Feb
_2…
Ma
r_2…
Apr_
2…
Ma
y_
…Jun_
2…
Jul_
2…
Aug_
2…
Sep_
2…
Oct_
2…
No
v_
2…
De
c_
2…
Jan_
2…
Feb
_2…
Ma
r_2…
Apr_
2…
Ma
y_
…Jun_
2…
Jul_
2…
Aug_
2…
Sep_
2…
Oct_
2…
No
v_
2…
De
c_
2…
Jan_
2…
Feb
_2…
Ma
r_2…
Apr_
2…
Ma
y_
…Jun_
2…
Jul_
2…
Aug_
2…
Sep_
2…
Oct_
2…
No
v_
2…
De
c_
2…
National - seclusion measure #3 - multiple-event rate
Zero Seclusion launch 7 March 2018
Average
events
per
person
admitted
Zero Seclusion Process measures
Change ideas• Sensory modulation
• Use of de-briefing
• Cultural interventions / access to cultural tools / Māori specialist
• Smoking / nicotine replacement
• Advanced directives
• Admission processes (eg. Powhiri)
• Pre admission contacts
Current Challenges
• Staff fear and perceived blameFear and blame in mental health nurses’ accounts of restrictive practices:
Implications for the elimination of seclusion and restraint. Muir-Cochrane
et al International Journal of Mental Health Nursing 2018
• Pressure on resources – facilities and staffing
• Smoke free environments?
• Methamphetamine and ‘synthetics’
Smoke Free: staff perceptionsSmoking status (PRIMHD & NMDS)
% recorded smokers within 31 days (of seclusion or inpatient activity)
% recorded smokers within 12 months (of seclusion or inpatient activity)
Secluded 57% 70%
Not Secluded 41% 50%
All Admissions 43% 52%
Smoke Free• Smoke free reduces violence and aggression
Robson et al 2017, Lawn et al 2003, 2005, el-Guebaly 2002, Quinn et al 2000
• Poor Implementation?The Review of Seclusion, Restraint and Observation of Consumers with a Mental Illness in
NSW Health Facilities Dec 2017 Recommendation 7: There is evidence of poor management of
nicotine dependence …..an immediate reinvigoration of the implementation of the NSW Health
Smoke-free Health Care Policy
• Withdrawal management vs abstinence?
• Survey re NRT use/barriers?
• NRT best practice – withdrawal managementNational Centre for Smoking Cessation and Training (NCSCT). Smoking cessation and
smokefree policies: Good practice for mental health services
http://www.ncsct.co.uk/usr/pub/Smoking%20cessation%20and%20smokefree%20policies%20-
%20Good%20practice%20for%20mental%20health%20services.pdf
• E cigarettes/‘Vaping’• MoH position statement: Vaping and smokeless tobacco 2018
• RANZCP position statement (for approval) 2018
• NCSCT 2018
NCSCT
Methamphetamine• A risk factor
• methamphetamine use a significant predictor of
restrictive intervention (odds ratio (OR): 7.83, 95%
confidence interval (CI): 2.33–26.31)Association of methamphetamine use and restrictive interventions in an acute adult
inpatient mental health unit: A retrospective cohort study. Brian McKenna et al 2016
• Survey current practice ABD guidelines
• Emergency Department interface and pathways
Improving service transitions June 2018
• Co-design-collaborative ‘Cluster’ approach
• ‘Connecting Care’
1. Inpatient - Community/NGO
2. Community/NGO - Primary care
3. Life course: Youth/Adult
2019 Priority areas
• Improving medication management and
prescribing
• Maximising physical health
• Learning from adverse events
and consumer experience
Building the QI Culture• Staff culture survey
(Nga Poutama)
• Consumer survey
Conclusions
• The Goal
• Methodology
is key
• Developing
capability
• Changing
culture
Behaviour
Leadership
Culture
Tools/Technique
Process
