Aim: To pair together TRA Stanford’s leading edge proprietary software – Innovence Pulse™ – and Design Thinking methodology to identify and mitigate key clinical risks within the organisation. The programme commenced in 2016 with analysis of various risk-related data sets – Datix and Ulysses incident reports, claims, complaints, investigations etc. – spanning the previous five years, and generation of a ‘risk identification’ report. Two distinct areas emerged from the analysis: self-harm on inpatient wards in Secure/Local divisions, not least because of an increasing trend over the period in question; and assaults against members of staff in the Specialist Learning Disabilities (SpLD) division, primarily because of the sheer volume of incidents and the division’s outlier status in NHS Protect and NHS Benchmarking figures.
Method: Having identified these as the key areas to address, two distinct project teams were established to employ Design Thinking methodology and develop a deep empathic understanding of the issues from the end user’s perspective (staff, patients and service users) before moving on to generate and test appropriate solutions. Self-Harm project, the approach was piloted on 4 ‘hot spot’ wards – Arnold and Poplar (Secure), and Dee and Harrington (Local) – during 2017, each of which implemented bespoke packages of 2-3 interventions. Violence Reduction project the approach was piloted separately on both male (Secure - cohort 1) and female (Secure - cohort 2) wards within the SpLD division, with the former aiming to strengthen preventative strategies in PBS plans – through enhanced de-escalation training and development of a summary PBS plan to facilitate rapid sharing – and the latter seeking to implement restorative practice subsequent to all reported assaults.
Results: The self-harm project set out to achieve a 20% reduction in reported incidents of self-harm across the wards in question, and exceeded this with an overall reduction of 55% on conclusion of the pilot. The greatest reductions were seen on Harrington and Dee wards (91% and 63% respectively), with Arnold and Poplar wards actually reflecting a slight upward trend. It’s important to acknowledge the differing patient profiles across the two divisions though, and the skewing effects of a small number of patients on Arnold and Poplar who experienced unsettled periods particularly towards the end of the pilot. Staff moves were also cited as a barrier to further progress on these two wards.
Before and after measures indicated a positive shift of 10% in staff perception of their approach to self-harm, and this was supported by the anecdotal evidence. Project interventions were noted as “absolutely central” to the improvements observed and one ward proudly described themselves as having become a “self-harm helpline” offering advice to other wards and even to another Trust. Changes in patient perception were more equivocal when considered against relevant items on the Inpatient Survey Report, however, the anecdotal evidence again reflected more of a positive experience.
The violence reduction project set out to achieve a 32% reduction in reported incidents of assault against members of staff within a two year period, and exceeded this with an overall reduction of 50% on conclusion of the pilot; cohort 1 interventions appearing likely to have achieved greater impact than cohort 2. Interventions achieved credible levels of acceptability with 90% of delegates rating de-escalation workshops as beneficial to practice and achieving their objectives. Summary PBS plans were quoted as “1,000,001% better [than the full PBS plan]”. Formal evaluation of restorative practice did not prove possible, although anecdotal reports indicate both staff and service users found it to be a positive and beneficial experience where restorative meetings had proved possible to facilitate. The inpatient survey report reflects a slight upward trend on relevant items over the course of the pilot.
The Return on Investment (ROI), completed in conjunction with TRA Stanford, returned a favourable outcome for both projects. The self-harm project was in the range of 89% to 158% with a likely return of 130%. The most tangible benefits observed being in relation to reduced bank costs, with three of the four wards achieving savings of the magnitude of £12,333, £30,147 and £44,192 respectively. For the self-harm project the ROI was in the range of 99% to 252% with the most likely return being in the region of 203%. And whilst a number of the anticipated benefits were delivered – such as reduced staff turnover and flattening of an increasing trend of work-related sickness absence – other outcomes (most notably reduced length of stay) were not, and so the figures must be treated with caution.
Next Steps: The P4P2 programme has now been assimilated into the overall Reducing Restrictive Practices programme. With regard to self-harm, the approach is being rolled out across an additional 6 wards (4 of these had already been identified with relatively high frequencies of self-harm, and an additional 2 in accordance with the Quality Account targets for 2018-19 to reduce by 20% ligature incidents and physical restraint associated with self-harm). With regard to violence reduction, restorative practice has been discontinued as a formal project intervention, though de-escalation training has been incorporated into the mandatory programme, and summary PBS plans are being rolled out across other relevant areas within the division.
Detailed evaluation reports for the two projects are available below:
Click here to access more information about the P4P2 project including: What we're doing with our findings, How we're doing it, How we will measure success, plus some case study examples.