Project Overview (25.09.14 - Mental Health Partnerships

Closing the Gap in Patient Safety
Safer Care Pathways
in Mental Health:
Project Overview
Presented by Tim Bryson
Project Manager
Closing the Gap In Patient Safety Programme
• The Health Foundation is an independent charity
working to improve the quality of healthcare in the
• Two priority areas: i) patient safety and ii) personcentred care
• CtGPS - £4 million to support ten projects to
implement and evaluate tested, evidence-based
patient safety interventions at scale
• Substantial two year projects
Project partners
•Hertfordshire Partnership University NHS FT
•All mental health trusts in East of England
•Engineering Design Centre, Cambridge University
•University of East Anglia
•University of Hertfordshire
Safer Care Pathways in MH – Project Aims
• To address patient safety hazards and create safer
and more reliable MH care pathways
• To enable sustainable learning and capacity in
patient safety skills and tools
• Five project sites: one in each mental health trust in
East of England
• Project sites to include dementia care pathway and
adult and older adult mental health care pathways
Safer Care Pathways in MH – Project Focus
• Shifting the balance towards prospective
• Focus on people, culture and systems
• Avoidable deaths and harm – suicide, self-harm, falls,
medication errors, harm from aggression
• Improved safety communication between staff,
service users and carers
• Risk enablement
Project Intervention Package
1. Prospective hazard analysis (PHA) tool (CLAHRC –
Cambridge University EDC)
2. Human factors training & implementation (L&D NHS
FT/Hertfordshire University approach)
3. Service improvement methods (e.g. PDSA cycles)
Project Sites
Older adults functional care ward, and dementia care ward
Dementia care ward and community team (DIST)
Dementia care ward and older adults functional care ward
Adult acute ward and CRHT
Adult acute day treatment unit and CRHT
Project Timetable
Clinical team
Project site establishment
June 2014
Care pathway mapping
Sept/Oct 2014
Completed PHA process – training
and diagnostic
November 14 to
February 15
Completed human factors training
and team coaching
March to Sept 15
Service improvement project activity Final evaluation
Oct 15 to July
Project Evaluation
Evaluation questions
Evaluation data
• How mature is the risk
management approach ?
• What is the safety culture ?
• How useful and useable are the
interventions ?
• What is learnt ?
• What is the Impact on patient
safety and outcomes ?
• Key informant interviews
• Patient safety data – risk
registers, datix and patient
experience reports
• Safety culture survey
• Training experience questionnaire
• Reflective diaries
• Observations
Project Benefits
• Completed PHA for each care pathway (links to ‘Sign Up to
Safety’ assessment)
• Creation of a cohort of PHA trained, and human factors
trained, patient safety champions in each trust
• Implementation of a minimum of 1 service improvement
project within each care pathway site
• Safety culture feedback, and strengthened safety culture in
the care pathway
• Shared learning across region and nationally
Project Governance
• Project board involving all partners, and including
service user and carer advisers, and EoE Strategic
Clinical Network
• PID approved by project board
• Six monthly and final reports to Health Foundation
More information
• Website =
• Twitter - #safercarepathways
• Health Foundation –
• Tim Bryson – Project Manager - 07767354620
• [email protected]
• Jeremy Wallman – Project Officer - 07719555412
• [email protected]
• Charlotte Copley – Project Administrator - 07540294317
• [email protected]

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