Safer Wards: reducing violence on older people's mental health wards

Abstract

Through the Safer Wards project we aimed to reduce the number of incidents of physical violence on older people's mental health wards. This was done using quality improvement methods and supported by the Trust's extensive programme of quality improvement, including training provided by the Institute for Healthcare Improvement. Violence can be an indicator of unmet needs in this patient population, with a negative effect on patient care and staff morale. Reducing harm to patients and staff is a strategic aim of our Trust.We established a multi-disciplinary group who led on the project on each ward and used a Pareto diagram to establish the focus of our work. We established a dashboard of measures based on our incident reporting system Datix, including number of incidents of violence, days between incidents, days of staff sickness, days between staff injury, use of restraint, and use of rapid tranquilisation (the last two being balancing measures in the reduction of violence). Each team identified factors driving physical violence on the wards, under headings of unmet patient needs, staff needs and staff awareness, which included lack of activity and a safe and therapeutic environment.Using driver diagrams, we identified change ideas that included hourly rounding (proactive checks on patient well-being), the addition of sensory rooms, flexible leave for patients, and a structured activity programme. We also introduced exercise to music, therapeutic groups led by patients, and focused on discharge planning and pet therapy, each of which starting sequentially over the course of a one year period from late 2013 and subject to a cycle of iterative learning using PDSA methods.The specific aim was a 20% decrease in violent incidents on three wards in City and Hackney, and Newham. Following our interventions, days between violent incidents increased from an average of three to an average of six. Days between staff injury due to physical violence rose from an average of eight (one violent incident resulting in staff injury every eight days) to 22 (one incident every 22 days). Incidents of physical violence reduced from 63 in 2013 to 39 in 2014. We were also able to quantify reduced costs associated with reduction in violence.The success of this project in our view lay in the involvement of ward staff in understanding the problems and generating local solutions which were also broadly evidenced based. Patients were also closely involved in generating ideas. We are currently incorporating much of this work into routine practice in order to sustain improvement, as well as continuing to generate new ideas for further improvement while using the skills learnt in this process to address other problems.

Low stimulus environments: reducing noise levels in continuing care

“…This data was measured continuously over a period of two years from early 2014 onward with each incident plotted, following a drive to record each incident of violence and aggression whether physical or verbal on incident reporting, and is published separately. [1]…”

“…The ward was involved prior to this project in improvement work to reduce violence and aggression. [1]…”

“…The ward was involved prior to this project in improvement work to reduce violence and aggression. [1] The ward is home to ten inpatient beds. It is a continuing care ward for patients with severe dementia which is complicated by challenging behaviour that cannot be managed in other care environments.…”

“…Staff absence rates also reduced by almost 40% over the same period, based on monthly reports from Human Resources, and plotted monthly, using the same rules for shifting the average. This data was measured continuously over a period of two years from early 2014 onward with each incident plotted, following a drive to record each incident of violence and aggression whether physical or verbal on incident reporting, and is published separately [1]. See supplementary file: ds6946.pptx -"Average dB levels Jan -Sept 2015"…”

Building the business case for quality improvement: a framework for evaluating return on investment

“…A 36% reduction in number of incidents of violence led to a 49% reduction in costs associated with violence. 9 A similar economic analysis of a reduction in physical violence on acute adult mental health wards showed that there was a saving of £181,296 attributable to a 40% reduction in violence over six wards (Supplementary files 4 and 5). 10 Improving safety and staff experience at work is likely to lead to a reduction in staff absence from work, as the above two case examples have quantified.…”