Risk Assessment and Improvement Methodology

Risk Assessment and
Improvement
Methodology
Dr Ian Clarke
9th May 2014
SBAR


Situation,Background,Assessment,
Recommendation
Focus.
Situation





Why are we here today?
Scottish Patient Safety Programme- ‘Risk assessment and
safety planning’
Quality of risk assessment prior to suicide and homicide: a
pilot study. NCISH, 2013.
The Psychiatric Bulletin. April 2014
Are we still unsure of what to do about risk?
“The Scottish Patient Programme is without
doubt one of the most ambitious patient safety
initiatives in the world – national in scale, bold in
aims, and disciplined in science. It harnesses the
energies and wisdom of Scotland’s health care
leaders – NHS executives, QIS experts, clinical
professionals, civil servants, and more – all aligned
toward a common vision, making Scotland the safest
nation on earth from the viewpoint of health care.”
Don Berwick
Programme Objective
To:
(1) systematically (2) reduce harm experienced by people using
mental health services in Scotland, (3) by empowering staff to
work with service users and carers (4) to identify
opportunities for improvement, (5) to test and (6) reliably
implement interventions, and (7) to then spread successful
changes across their NHS Board area
Background






Risk reading lists
Assessing and managing risk- MRCPsych course
Critical incidents
Patient Safety
Suicide Review Network
Suicide Reporting and Learning System
The Glasgow Risk Screen (GRS)
Introduced 2004
 To support more
Transparent, systematic
and multidisciplinary
approach to risk
Complete on:
 Admission
 Engagement
 Transfer
2005 Practitioner survey

“…indicated that the Glasgow Risk Screen should be retained
as the foundation risk screening tool for use in mainstream
adult and elderly mental health services in both inpatient and
community settings.”
Report on the Glasgow Risk Screen; Clinical
Record Audit-2006

Random audit of 143 patient records
Results







GRS completed – 96.5%
Evidence in nursing notes of identified risks/needs being
addressed in the planning of care/treatment – 9%
GRS findings reviewed in a multidisciplinary team context –
9%
GRS findings used to influence decision making – 5%
Evidence in the medical notes of identified risks/needs being
addressed in the planning of care/treatment – 5%
Evidence of patient involvement in decision making – 2%
Evidence of carer involvement in decision making - <1%
Risk assessment of psychiatric in-patients: audit of
completion of a risk assessment tool. Masson et al 2008.


Completion improved from 60% to 81%
Clinical implications- Audit coupled with a simple
educational intervention can improve the completion of risk
assessment forms by medical and nursing staff.
Review of Significant Clinical Incidents- 2010


Evidence from review of SCIs in GG&c 2010 is that in
approx 80% of cases a risk assessment (RA) in some form
was carried out in the period prior to the SCI, but overall the
GRS was used prior to less than 20% of incidents.
Ruth Ward.
Assessment

A tool is not sufficient on its own for the
purposes of risk assessment and management.
Recommendation


A reliably applied ‘bundle’ of measures
around risk assessment AND management.
‘Culture’ change.
Improvement Methodology- key ingredients



Unhappy with the status quo
Leadership
Meaningful and sustainable change
Improvement Methodology






Bottom-up process
Facilitative management
To improve outcomes you need to work on the process
An environment of purposeful design achieved through small
stepped experimentation and measurement
Test small and then spread (1-> 3 -> 5 ->all)
The purpose of measurement in Quality Improvement work is
for learning not judgment.
Driven by desire for change.
Improvement Methodology
A systematic narrative review of
quality improvement models in health care
AE Powell, RK Rushmer, HTO Davies
NHS QIS 2009.
What are you trying to accomplish?

Your aim should be time-specific and
measurable; it should also define the specific
population of patients that will be affected.
How will you know your change is an
improvement?

Use quantitative measures and qualitative
learning to determine if a change actually
leads to an improvement.
What change can you make that will
result in an improvement?

All improvement requires change, but not all
changes result in improvement.
Testing change

The PDSA cycle is shorthand for testing a
change in the real work setting by planning it,
trying it, observing the results and acting on
what is learned.
Act
Plan
• Objective
• What changes
• Questions and
are to be made? predictions (why)
• Plan to carry out the cycle
• Next cycle?
(who, what, where, when)
• Plan for data collection
Study
• Complete the
Do
• Carry out the plan
analysis of the data • Document problems
• Compare data to
and unexpected
predictions
observations
• Summarize
• Begin analysis
what was
of the data
learned
Repeated Use of the Cycle
Changes That
Result in
Improvement
A P
S D
A P
S D
Hunches
Theories
Ideas
Examples of PDSA Cycles
Separate flows for
people and bags
will reduce delays
at security stations
Eliminate the
Queue
A P
S D
Cycle 5: Implement new process
Cycle 4: Test with all passengers for 1 day
A P
S D
Cycle 3:Test system with every 10th passenger
Cycle 2: Test system with one passenger at all stations
Cycle 1: Test system with one passenger at one security station
Example of Testing
Multiple Changes
Aim: Eliminate
queues at airport
security
Use separate
flows for people
and bags
Match
capacity &
demand
Use visual
reminders
Use self-scanners
as pre-check
Principles into practice


Does it work in a mental health setting?
In-patients and CMHT.
The Process









June 2011
The ‘list’
SBAR
Bin the GRS!
Measurement (the process- what about the outcome?)
Ask staff
Protected time on a weekly basis
Multidisciplinary input
Safety planning
(SPSP-MH) Outcome measures








Rate of violence and aggression
Percentage of patients engaged in violent and aggressive
behaviour
Rate of patients being restrained
Percentage of patients being restrained
Percentage of patients who experience one or more episodes
of seclusion
Percentage of patients who experience self harm
Days between in patient suicide
Percentage of patients who have emergency detention or
nurses holding powers.
Risk assessment/Management Plan Meeting - DATE
-----/-----/----
Keyworker name
1. Preparation
Keyworker prepares brief summary of
relevant background information to
present to the team
Yes/No
2. Preparation
Main risks present for that particular client
are emphasised
Yes/No
3. MDT
Discussion
Risk Management Plan (revised Glasgow
Risk Screen) used to frame MDT
discussion
Yes/No
4.
Documentation
Draft GRS/management plan completed
and summarised at the end of the meeting
then passed to admin for typing
Yes/No
5.
Documentation
Draft revised GRS is filed appropriately
(electronic shared drive and section 4/5 of
the clients case-notes)
Yes/No
6. Discussion
with
Client/Carer
A keyworker reviews completed revised
GRS with the client, and relative/carer, as
appropriate
Yes/No
7. Safety plan
Revised GRS used to develop a
collaborative Safety Plan with the client
and relative/carer, as appropriate
Yes/No
8. Overall
Bundle
Compliance
Total of ‘yes’
Comments
COMMENTS
NHS GGC Rutherford Ward Overall % Risk Assessment compliance Mar 2013 to October 2013
100%
90%
80%
Medical staff reminded of protocol
Service user w ithheld consent
70%
Patient transfered to A&E
Overall % com pliance
60%
50%
40%
30%
20%
10%
0%
Medics not onboard
15
15 April
March
2013
2013
15 May
2013
15 June
2013
15 July
2013
Date Data Collected
15
August
2013
15 Sept
2013
15th
Oct
2013
The ahh- buts







Working with an unclear and contested evidence- base.
Setting measurable yet deliverable aims within a context
where little is known about what actually works to reduce
harm/risk.
Components of bundles lack an evidence base
‘real’ culture change
Not possible given our management culture
Fashion
Measurement! Measurement! Measurement!
Parachute use to prevent death and major trauma related to gravitational
challenge: systematic review of randomised controlled trials
Gordon C S Smith, Jill P Pell. BMJ 2003;327;1459-1461



Aim: To determine whether parachutes are effective in preventing major
trauma related to gravitational challenge.
Design: Systematic review of randomised controlled trials
Results: Our search strategy did not find any randomised controlled trials
of the parachute.
Parachute use to prevent death and major trauma related to gravitational
challenge: systematic review of randomised controlled trials
Gordon C S Smith, Jill P Pell. BMJ 2003;327;1459-1461
Conclusion:
As with many interventions intended to prevent ill health, the
effectiveness of parachutes has not been subjected to rigorous evaluation
by using randomised controlled trials.
Advocates of evidence based medicine have criticised the adoption of
interventions evaluated by using only observational data.
We think that everyone might benefit if the most radical
protagonists of evidence based medicine organised and participated
in a double blind, randomised, placebo controlled, crossover trial of
the parachute
Take away messages




This is about doing things differently
If you are not part of the solution then you are
part of the problem.
It calls for real trust between clinicians and
managers
It requires time and patience.
Thanks for listening.

Download Report