Forensics violence reduction celebration – John Howard Centre July 2018

Staff and service user representatives from the Forensics violence reduction collaborative wards shared what they are proud of as a result of the violence reduction work, and why they felt it is important to make Forensics a safer environment. Hear it directly from them in the video recorded during the celebration event. Subtitles are available for this video. Read more about their journey here.

What were the key ingredients for enabling QI work in Forensics?

All QI projects at ELFT are supported by a QI sponsor. Their main role is to champion improvement projects, and help the project teams to unblock challenges. Hear it from Day Njovana, QI Sponsor for the violence reduction work in Forensics, in conversation with Improvement Advisor Nynn Chang. He reflects on his role, challenges in getting the work started and top tips for overcoming the barriers. Day Njovana is Head of Nursing and Associate Clinical Director of Safety. Subtitles are available for this video.

Project story: Improving satisfaction of staff and stakeholders in forensic receptions

Reception staff at John Howard Centre, a specialist forensic psychiatric services provider in East London, have been working on improving satisfaction levels for service users, visitors and staff. Below is an overview of their journey so far. Words by project lead Mohammad Ramjany.

Our Quality Improvement project has been working towards increasing staff satisfaction, which in turn has impacted positively on all stakeholders experience in reception. Team meetings happen every Fridays at John Howard Centre and will now also happen at Wolfson House (a low secure unit in North London) on some Fridays.

So far, we have managed to increase our standard of competence by ensuring that all staff were fully trained starting from the induction process all the way to maintaining other necessary training i.e. Customer care. We have also been able to come up with staff charters, which are agreements of how to communicate with stakeholders via telephone and face to face together as a team, which now shape our practise. We have professionally engaged with all our stakeholders which in turn gave us a sense of team spirit, good working environment and a positive shift in our reputation.

We are listening, we are caring and we are taking steps to improving our customer care service. We have also generated scenarios based on the feedback that we have received from our stakeholders and turned them into training materials for future use. Directorate Management Team members have stationed themselves in reception control room to observe staff in action.We have introduced a satisfaction huddle after which we generate plans to avoid dissatisfaction.

If you are part of ELFT, you can learn more about the details of this project on LifeQI. Project code: #107169

Service user ownership: lifestyle improvement project on Woodberry Ward

Learn more about how service users take the lead in this lifestyle improvement project in the video below. introduction by Courtenay Gilchriest, Support Staff.

Read more about it here.

The role of Occupational Therapy in Quality Improvement and transforming catering services in Forensics

Please learn more about this completed ELFT QI project from the adjacent poster.

ELFT staff, service users and carers can access full details of this project on QI Life.The project code is 101001 please log onto your QI Life account before clicking the logo below.

How having a solid QI strategy can help teams persevere

Charles Kennedy-Scott QI Coach – Forensics

QI Coach Charles Kennedy-Scott was involved in the Improving Access in City and Hackney Adult Mental Health project, which aimed at allowing 95% of patients to be given a face-to-face appointment by April 2017. In this blog, Charles reflects on how having a solid QI strategy in place can help teams persevere.

In 2015-2016 the biggest struggle with the QI meeting seemed to be consistency. The attendees varied from week to week and there was no fixed nor rolling agenda, so items discussed and agreed one week were often discussed and agreed (differently) the next week by a different set of attendees.

The enthusiasm to keep going seemed to remain though, and this meant that, though slightly haphazardly, progress began to be made. Some of this was due to decisions that were made outside of the QI group. Decisions that had to be made for business reasons, but little by little, progress resulted from ideas put forward by the group. Around this time, more emphasis began being placed on consistent attendees and recording of actions.

When we had QI coach involvement, the project also progressed forward more strongly than when it was absent. The coach provided a focus for the group and she persuaded the group to think clearly and focus on goals and purpose. Whether the group realised it or not, the introduction of measures and tests began to have a positive effect.

The project continued. It was one that had to succeed as it was trying to achieve a strict target set on the Trust. Interestingly, without QI I think it is unlikely that the group would have continued to meet every two weeks over such a long period. But the QI backbone provided structure and almost ‘enforced’ a reason to continue meeting. This was positive. The persistence paid off, and by now good results were being achieved. But not only this, they were being understood better than had they been imposed or simply implemented, as would be usual in an absence of a quality improvement methodology.

At the beginning, with the group and project somewhat in disarray, success seemed far off and unlikely. But the group had to learn and did learn. Not giving up, continuing to meet, brought real and sustained success.

Read more about the project by clicking on the image below:

Forensics: an honest conversation about failure and what we’ve learnt as a directorate

The Forensic Service has an active and diverse QI Programme, which has enjoyed many notable successes. Some projects don’t succeed though. We recently spent some time thinking about the learning we could take from those, and how to keep enthusiasm and momentum within the group of people who have invested their time and energy.

Learn more about overcoming obstacles in this blog written by the Forensics QI Sponsors, QI Coaches and Improvement Advisor.

“Project team disengaged”

“Project has lost momentum”

These are the two most common forms of feedback we hear during the Projects’ Progress Update in the Forensics monthly QI Business Meeting and Breakfast QI Forum. At least half of the projects in the Directorate’s portfolio are in a similar state, month-on-month. Undoubtedly, it is frustrating to see a once great idea and an enthused project team with a promising improvement project grinding to a halt. It is not the outcome that had been envisioned, especially after witnessing how some excellent QI projects have flourished, and bought about significant improvements to our service such as the Self-Catering by Service-Users and The Bridge Club to name a few.

We have plenty of goodwill as the local QI team (QI Sponsors, QI Coaches and Improvement Advisor) to help re-energise these inactive projects. Unfortunately, the actual uptake of this help by project teams has been low. As a result, we felt stuck with forging ahead constructively to help restart these inactive projects. An instinctive outcome would be to instruct closure but instead, we saw this as an opportunity for us, as the local QI team to better understand what was failing these project teams, and share some honest reflections on project viability and their importance.

Our analysis started with an honest conversation on ‘why do viable QI projects struggle or become a non-starter?’ We structured our reflection and thinking by using the Cause and Effect Diagram. What was immediately evident was that current culture of the workplace interconnected with many other causes identified. For example, ‘lack of personal sense of agency’, ‘no shared belief’, ‘doing QI is not part of job plan, it is outside of staff’s day-to-day work’, and ‘QI is held by the project team ’.  Therefore, culture is one of the biggest barriers towards the chances of a project succeeding.

On the other hand, the leading enabling force for carrying out a QI project is ‘reliance on goodwill’ and special interest of the Forensic Staff. It was clear to us that the starting point and change formula would be to effectively manage and support the goodwill and passion from staff to lead on change, and foster a shared vision that all staff have a role to play in QI to deliver continuous improvements for the directorate.

We had a timely visit from the Institute for Healthcare Improvements (IHI) to Forensics, where we had the pleasure of obtaining guidance from Executive Director Pedro Delgado. He suggested we could champion the importance of all QI projects to the service as this can help to create the shared vision cascading down to the front line staff. Also, “Where we succeed, we celebrate. Where it doesn’t work, we learn”. We need to be open and transparent with unsuccessful projects. There is valuable new knowledge in each of them that we can all learn from. We should also take time to thank our project team for their time and energy for running a QI project even if it was an unsuccessful attempt.

Since the discussion with Pedro, we have taken on these valuable lessons to refine our processes for project closure. We have refined the forums on how we can share the learnings from unsuccessful projects. Systems have also been developed to manage the closure process to ensure project teams are recognised for their efforts and contributions to continuous improvements for the service. We will certainly be running our Plan, Do, Study, Act (PDSA) cycles to ensure the processes are building into the culture.

It took Thomas A. Edison 1000 attempts to create the lightbulb but he recognised that he had not failed but just found 1000 ways that don’t work. We feel that we are on a similar journey of discovery. We have not failed, but we have certainly learnt what structures and processes are needed in order for QI to be sustainable in Forensics in the long run. We were able to persevere and do so because we stayed connected to our core intention that is we truly believe in our staff, their QI projects, and the benefits it can bring to the service and our service users. As Dr Paul Gilluley summarised in his tweet:

“@NHS_ELFT sometimes you need to look back and recognise how far you have come before you look up push on with the climb #forensic #QI”

This is the start of our climb, and we look forward to the coming months learning as a service how best to deliver, enable, and better support staff in doing QI.

Read some of our QI Sponsors and QI Coaches personal reflections on what helped them to stay connected:

“QI could have been another failed NHS change that would soon fizzle out with time. It takes time to grow on you, once bought into the idea and seen the scope for continuous change and challenging the norm (this is how we do things here), you realise that the gift is in our hands to improve the quality of service for staff and patients. I am particularly pleased by the adoption of QI as a way of working rather than an added extra to the role. The changes have been slow, at times painful, disheartening, tiring and you realise early on that this is a long haul flight.”  – Day Njovana, QI Sponsor for Forensics

“I’m all for change and improvement, that’s why I got into coaching. It’s not a good feeling when projects don’t go as far as you envision. In the beginning you get a feel of a project and can project a potential outcome, especially when there are people who are invested. So to see a project halt or teams become disengaged, is not an expected outcome. I don’t like to give up. I look at the reasons behind why a project or idea was suggested in the first place and see whether it could have brought about a change. This is a driving factor for me wanting to continue and forging on. My hope and vision is to see the project do what it was created to do and hopefully more.” – Kimalee Foster, QI Coach for Forensics

“I felt very frustrated for the team that the project was not starting up. I wanted the team to feel the benefits of starting something worthwhile, a project that hopefully would improve their working days and their customers’ experiences. I didn’t want to give up on them or the project. Previously there hadn’t been clear and coherent acknowledgment on the part of the service of this project’s importance, now there was. This helped the team to really believe that their project was worthwhile on a wider scale than they’d maybe realised before. They now began and quickly the project came to life. On reflection, this has been the case with many of the successful projects, and I now realise a key factor to look out for in a project’s early days is the explicit support of the service the project takes place in.” – Charles Kennedy-Scott, QI Coach for Forensics

Violence Reduction on Adult Inpatient Units; what has been achieved so far at ELFT?

Between 2012 and 2015, Tower Hamlets Adult Mental Health inpatient wards reduced violence by over 40% and by 60% on the acute admissions wards, using a Quality Improvement approach.  Since then we have scaled up the work to City & Hackney in early 2016 and Newham in mid-2016. Forensics also launched its own Collaborative in late 2016, testing the extent to which ideas developed in general adult units is effective in Forensics, as well as developing their own ideas.

Overall, violence reduction work across ELFT has meant that we have seen a 42% reduction in incidents of physical violence across our East London services since 2013 (see figure 1).

Figure 1

The change ideas that have helped in general adult settings work on 2 main drivers:

1. Increasing teams ability to identify and predict risks of violence and to take action proactively as a team. Two change ideas work on this; Safety Huddles and the Broset Violence Checklist
2. Creating a culture of much greater openness and transparency around the issue of violence with the whole ward community, including service users. Two ideas work on this: using Safety Crosses and having proactive discussions around violence and safety in ward community meetings. (See articles on City & Hackney and Newham Adult Mental Health Services)

For more information about these ideas see the other articles in this newsletter and this article, published in February 2017 in the Journal of Mental Health Nursing>>

Local reductions

Since the beginning of the work, local collaboratives have achieved the following reductions:

Tower Hamlets has reduced violence across all 6 wards by 40% and restraints by 60%, using Datix data. There has been a 57% reduction in violence and a 77% reduction in restraints across the acute wards.

In City & Hackney, violence has reduced by 40% across the unit and upwards of 60% on the acute wards, according to Datix data. Gardner Ward and Joshua Ward in City and Hackney have sustained 65-75% reductions in violence for 6-9 months. There has also been a 54% reduction in use of restraint on Conolly Ward and there are early signs of reduction on Bevan Psychiatric Intensive Care Unit (PICU).

In Newham , Topaz Ward has seen a reduction of 66%, Emerald Ward has seen a reduction of 74% and Sapphire has seen a reduction of 84%. Jade Ward are also seeing very positive signs of change, with no incidents at all between 30^th September 2016 and 12^th January 2017.

Forensics has just seen early signs of a 51% reduction in physical violence across Bow, Broadgate, Clerkenwell, Shoreditch and West Ferry wards. Shoreditch and Bow have seen individual reductions of 82% and 51% respectively.  For more information see our article – Perspectives from Forensics; Early signs of reduction and an exciting journey ahead for further specific detail on the directorate’s journey for far and the impact this work has had.

In 2017-18 we will be looking at extending the work to Luton and Bedfordshire and focusing dedicated work on restricted practices, as well as consolidating the work in existing Collaboratives and developing a Quality Control strategy (see this article).

For any queries get in touch with Jen Taylor-Watt, QI Lead for City & Hackney & IAPT  and Lead Improvement Advisor for Violence Reduction and/or Andy Cruickshank, Associate Director of Nursing for QI and Senior Improvement Advisor for Violence Reduction.

Forensics: First steps, early signs of reduction and an exciting journey ahead!

By Nynn-Hui Chang, QI Lead for Forensics and Improvement Advisor to the Forensics Violence Reduction Collaborative & Day Njovana, Lead Nurse for Forensics & Lead for the Forensics Violence Reduction Collaborative

Forensics is a unique setting in that the majority of patients are admitted following a violent index offence in the context of their illness, which differs greatly from the general adult wards.  For this reason, we were unsure if the bundle of ideas, developed on the general wards would help us to reduce violence in Forensics. It’s been important therefore, for us to take it slowly; exploring and understanding how the issue manifests itself in our setting and the dynamics of how we are responding to it.

Something that we realised early on was that we had particular issues with sexual behaviours, particularly on our learning disabilities wards. We’ve created a different coloured dot to record this on our safety crosses, so we can keep track of the frequency of this, and we’re continuing to work to understand the drivers of these behaviours so we can address them.

Meeting together as a learning Collaborative gave us a chance to reflect on the change package from the general wards. Although we need to continue to understand things specifically in Forensics, we felt that it was worth testing a number of elements of the change package. Although there are differences between Forensics and non-Forensics settings, we too need to ensure we are communicating as effectively as possible and to try to predict risks before they occur – so we thought it was worth seeing if Safety Huddles could make a difference. As already noted, we also agreed that using Safety Crosses would help us to understand frequency of violence and share this across the service.

The fantastic news is that we’ve already seen a 51% reduction in violence across the group of wards involved in the work to date (Bow, Broadgate, Clerkenwell, Shoreditch and West Ferry) through using these ideas. Three more wards have now been inspired to join the Collaborative; Clissold, East India & Ludgate.

Shoreditch and Bow Wards have also seen individual reductions of 81% in physical violence and 54% in non-physical violence, respectively.

We asked project leads from Shoreditch & Bow what was the impact they noted from the violence reduction work. Here is what they said:

It’s been a great start. There is lots of energy and enthusiasm around this work in Forensics to stop violence and aggression being an accepted part of work.

Staff and patients are reporting that they feel safer on the wards. Safety crosses are starting to be discussed in community meetings on the wards, so that staff are working together with the patients to improve understanding and patients’ experience.

We’re really looking forwards to where the next year might take us!

“For me the Violence Collaboration has meant that we have started to address the unspoken , unchallenged ideas .  The dirty word “violence”. Never has there been a focus in forensic services on this one main driver for staff and patient satisfaction.

The early results have been encouraging for staff and mainly our service users.  It has given staff the basis to pre-plan, support and engage with service users in times of distress.“

 

Day Njovana, Lead Nurse for Forensics &

Lead for the Forensics Violence Reduction Collaborative

Reducing Handcuff Usage in Medium Secure Services

Project Lead – Graham Manyere

In April 2016, staff from several wards in the Forensic service came together to focus on reducing handcuff usage by 50% by December 2016.

The use of handcuffing was normal safety protocol, mainly used for when transporting patients to and from the secure unit such as to appointments or to court. However, staff felt uncomfortable with these practices. They felt that these procedures were highly invasive and detrimental to the therapeutic relationships with their service users, who also reported feeling stigmatised by them.

In addition to this, transferring patients in this way was costly, as secure transfers were needed and potentially police services too.

The service was keen to find alternatives to try and limit the use of handcuffing where possible. In April 2016 staff from Westferry, Broadgate, Ludgate and Shoreditch ward came together to explore their existing protocols and share ideas about how it could be changed.

The team focused on six key areas of their existing system to focus on to reduce handcuffing:

• Risk of violence
• Electronic Monitoring
• Information & Monitoring
• Service Culture
• Lawful decision making
• Least restrictive practice

At the early stages of their project, the attended a national restrictive practice conference, which allowed them to share learning from other services and develop different ways of less restrictive approaches.

The team met every week to discuss and generate various ideas. Listed below are the change ideas they tested:

1. See, Think, Act-Relational Sec Training
2. Structured Risk Assessments
3. Escort Destination Risk Assessment
4. Robust Monitoring Of Handcuff Usage & Requests
5. Regular Reviews Of Authorisations
6. Management To Approach Of Least Restrictive Practices
7. Video Conferencing With Courts
8. Compliance With CoP: ‘Mechanical Restraint’
9. Electronic Monitoring

Once in the testing phase, they began to run PDSA cycles, introducing different change ideas at each cycle. They continued to use their weekly meetings to discuss learning from their PDSA cycles to refine and drive their project forward.

From testing their change ideas, they found that handcuffing incidents had reduced from 4.66 per week to 1. This was a sustained reduction of over 79%!

Within seven months of commencing, the project had met its intended target aim. Change ideas have been embedded in to routine operational practice and their systems have been established and are now in place to hold gains.

The team are continuing to learn from their experiences and have highlighted some important points for others undertaking a QI project:

• “It was helpful to have a very hands on sponsor, as this allowed the project to always have focus and continue to be on track”.
• “Weekly short project meetings were helpful in allowing the project to remain on track and at the core of our practice”.
• “It’s important to involve patients and staff and get their viewings as this can shed light on the impact the project has on them”.
• “The project allowed for greater questioning of certain procedures and allowed leaders to review some practices”.

The QI project shared their learning and successes at the 2017 Annual QI Conference in London. View their poster by clicking the image below.

Lifestyle Improvement on Woodberry Ward…

Staff and service users on Woodberry ward, in the forensics directorate at ELFT are working on a quality improvement project to promote a healthier lifestyle for service users. A  healthier lifestyle combines  physical activity, mental and social well-being.

Click on the picture below to read what has been happening so far…

Active QI Projects – June 2019

This is the monthly report generated from Life QI, showing all active projects within all the directorates.