In June 2018, VAHI released the state’s first dedicated mental health quality and safety report to Victoria’s 18 designated mental health services. Inspire: mental health was a special edition of the Inspire report series, which has been distributed to health services since July 2017. Inspire was developed for clinicians to make it easier to identify variations in practice across health services and use this information to drive quality and safety improvements.
The Inspire: mental health report presented results across a range of measures including consumer experience data, use of restrictive interventions, self-harm and readmission to hospital. This means for the first time mental health services are able to see how their results compare with similar services.
Services always strive to make improvements but if they see in the report that one of their results is below that of their peers, they can choose to focus attention on that area.
The data presented in Inspire: mental health can act as a starting point for important conversations about quality and safety of services provided. In addition to the results, the report includes clinician-focused information and advice from the Chief Psychiatrist to support clinicians in taking the next steps. This information guides clinicians to relevant resources and provides practical advice on how to drive improvements across different aspects of the service.
Data drives changes at Peninsula Health
After reviewing the Inspire: mental health report, the team at Peninsula Mental Health Service found that while their overall results were positive, there were some areas where their results didn’t match up to some of their peers. The team identified three areas to focus their attentions on: restraint, falls and ECT.
Use of restraint
Reducing or, if possible, eliminating restrictive interventions such as bodily restraint is a national safety priority.
After deciding to focus on reducing use of restraint, the Peninsula Mental Health team went through series of steps to gather information and identify strategies. This included setting up a committee, talking to staff in different parts of the hospital with relevant expertise and discussing the issue with nursing staff. The team took a holistic approach, looking at factors ranging from the environment, such as noise levels and how make the ward less stimulating for some patients, to setting up behaviour management plans more consistently.
A key part of the approach was also putting in place ongoing monitoring to ensure the initiatives were maintained. After just a few months, Dr Carmel Peavey, Aged Inpatient Consultant Psychiatrist, Peninsula Health Mental health service says, ‘I'm pleased to report that our restraint numbers have really greatly reduced.’
A second focus area for Peninsula Mental Health is reducing falls. The aged mental health ward tends to have a frail population, often with severe behavioural and psychological symptoms of dementia. While the team had a good review process following falls, they realised there was more they could do for prevention.
Again, the approach they took looked at the big picture. They began by setting up a falls committee and undertook research including a literature search regarding medication and falls. They also visited other services to see how the issue was being addressed elsewhere.
The staff feel that small changes they have made to environmental factors, such as increasing the lighting, have had a big impact. Using behavioural management plans and reducing use of the medications most likely to cause falls have also been important. The ward now has a champion of falls prevention and there are weekly falls rounds to mitigate risks that could lead to a fall.
Dr Peavey says, ‘We are aiming for zero falls. We’re still in an analysis phase so it’s too soon to say if statistically we have been able to make a change but certainly anecdotally, we have.’
Use of ECT
Continuation or maintenance electroconvulsive therapy (ECT) is usually administered on an outpatient basis, and with increasing intervals between treatments, with the intention of preventing relapse.
Prior to receiving the Inspire: mental health report, the Peninsula team had identified that they could make some practice improvements in their use of maintenance ECT. The report confirmed to them that they were on the right path and there was an opportunity to lower their rate of ECT.
The team recently was visited by Deputy Chief Psychiatrist, Professor Daniel O’Connor and other staff from the Office of the Chief Psychiatrist (OCP) for a regular audit review of ECT practice. ECT is a highly regulated procedure and is overseen by the OCP. The OCP’s role includes providing guidelines and regulations for ECT and supporting clinicians with complex cases.
Dr Peavey said the suggestions and recommendations from the OCP review were invaluable. ‘It was really good for us to review all of our ECT practices and we really took on board that we want to have the best program we possibly can, and we want to demonstrate that to the OCP. The visit was so wonderful for morale,’ said Dr Peavey.
Professor O’Connor also felt very positively about the visit.
‘Peninsula Mental Health have demonstrated how services can use the ECT audit as an opportunity to collaborate with the OCP to drive improvements in their practice. We were impressed by the passion of the team and commitment to ongoing improvement, ’ he said.
The Peninsula team have made some changes to their processes relating to maintenance ECT, such as including a proposed end date for treatment in the patient’s treatment plan. They have put in place a process to signal reviews at certain points and have made a more formal program as a result, which gives the staff more direction.
A team effort
A vital part of Peninsula Mental Health’s response to Inspire: mental health is how engaged the staff have been. Team members at different levels have reviewed the report and sought to understand what it was showing them about their service. There has been a coordinated effort that has seen buy in from executives and nursing staff alike. Dr Peavey stressed the importance of the nursing staff needing to have a sense of ownership of the initiatives for them to be implemented successfully.
She is proud of the team’s achievements so far and the positive impact it is having for patients: ‘It’s a better way, a smoother way. It’s better for the patients. It’s always about the patient and aiming to make the best possible practice.’
But the work doesn’t stop here, explains Dr Peavey. ‘We will review it and then re-evaluate. If it hasn’t worked, we’ll look at what else we can do.’
Daniel O'Connor, Deputy Chief Psychiatrist says ‘we were delighted to hear that the Inspire: mental health report prompted Peninsula Mental Health into action. We hope that all mental health services will take the opportunity to review the report carefully and stop and reflect on how they can best make improvements. The OCP are happy to work with services to identify how practices can be improved.’
Following positive feedback from the sector, VAHI has committed to producing Inspire: mental health every six months. The second issue will be distributed to mental health services in February. Dr Peavey is pleased that the report was not a one off. ‘We all have areas we can improve on. We just want to have that identification that spurs us on to continuous improvement,’ she said.
We encourage clinicians to review their results each time they receive a report from the Inspire series. If they find an unfavourable result for a particular measure, this can be an opportunity to investigate internally to understand what may have caused it. In addition to internal review, clinicians can also reach out to peers from other health services to see how their practices differ. Health services can also contact Safer Care Victoria – email@example.com – or, in the case of Inspire: mental health, the Office of the Chief Psychiatrist – firstname.lastname@example.org – for advice and support on making quality and safety improvements.