Understanding Patient Safety Issues In Mental Health

The complications of getting to the root causes of mental health safety issues are generally well-known:

• Is the issue due to staffing levels, staff vacancies, and the use of banks and agencies? Perhaps affected by the seniority and longevity of ward and team managers?
• Is it an issue of clinical practice pertaining to the therapeutic model of care e.g., the use of restraint or the use of drug therapy as a single modality?
• Is it an issue of a closed culture that has allowed such practices to go unchecked? This may be impacting incident reporting, resulting in safety flags not being raised.
• Are there much softer issues that can potentially be explanatory, such as a lack of MDT working, the absence of nurses in MDT meetings, poor staff survey results, or a lack of service user engagement? Do these softer issues all point towards a problematic care environment resulting in poor patient safety?

Of course, it could be all of these. To truly understand patient safety within services, one must be able to ‘join the dots’ to understand what has gone wrong when an issue is highlighted and, more importantly, be able to identify when safety could be compromised to allow for earlier intervention. This is the fundamental premise behind the development of the Niche Integrated Trigger Tool, which has been developed to help Trusts and commissioning bodies in assessing safety issues at a macro level (to alert) and a micro level (to effectively and promptly drill down into concerns).

Our Intelligence-Led Approach

The model below shows how we work, using a range of approaches depending on existing local awareness of a problem, and existing understanding of causes and solutions. Different services and issues are likely to fall into different boxes in this quadrant, and we will apply a mix of qualitative and quantitative work to address each in the way required, with the trigger tool driving the bulk of the quantitative analysis.

Knowledge Conversion Quadrant

The knowledge conversion quadrant will be used to identify where each service sits, with the aim being to move all services and issues gradually towards the upper right quadrant. In doing so, knowledge of both the nature and scale of problems, a clear plan for improvement, and a system to provide assurance that improvement will be available for all services. For some high-performing services, this approach will also provide a framework for excellence. Here, organisations with services which are known to be of high quality — and where it is properly understood why they are of high quality — will have a basis for spreading good practice within that organisation, in ways most likely to be locally relevant and accepted.