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PROactive Management of Integrated

Services & Environments



We manage what we measure, this often results in a culture of doing what we count rather than doing what counts. So we often hit the target but completely miss the point. Bringing to life the story behind the key performance indicators which will help us track the improvement journey is vital. It enables a shift from a mindset that is focussed just on delivering the targets to one that sets a premium on outcomes for individual patients. Such a premium is at the heart of delivering proactive, person centred, safe and effective care and keeps goals and targets meaningful for individual frontline staff.

Often the failure to bring KPIs to life is to do with the sheer volume of targets that managers have to hit. So they are engaged in a game of endless whack a mole, just when they have got on top of one, another is lagging and the cycle continues. This barely leaves time to engage in a process by which one can translate for the frontline how a particular KPI is helping track improvements in care delivery or is helping make the case to bring in more resources for the team. So for the frontline it is an annoyance that takes away from face to face time with patients and something that they are doing as they have been told to do so. Sometimes there is an element of truth in this feeling as we measure what is measurable at the cost of neglecting what is important and perhaps quite difficult to put a number on.

Within PROMISE we have tried to take these issues into account. Time invested in administering tools must have returns that more than offset the upfront investment. Evaluation tools have to be participatory and add value to either individual recovery journeys for patients or to the learning and development of staff teams and the individuals within them. From board to ward there needs to be clear visibility of what the issues are and how one is addressing them. The latter is more complex than it sounds.

One can have metrics at an individual level, by these we mean individual incidents, individual patients, and individual members of staff. When collated they provide indices for collectives like a ward, hospital, directorate or an organisation. When combined with outputs from other organisations they provide measures for systems like the Cambridgeshire health and social care economy. For the frontline it is the tools and metrics at an individual level which matter most and getting these right is vital to any governance framework.

PROTECT (PROactively deTECT) is an easy to use tool that staff can rely on to think through at the point of admission, or for that matter at any point in the patient journey the potential for incidents during that inpatient stay. The predisposing factors can be grouped under patient, staff and environmental and can be thought through as those which are static and difficult to immediately shift, moving through the spectrum to those which are dynamic and staff can modify. The goal is not just to assess the potential for incidents but use a combination of tried and tested remedies for the risks being identified to those which will need creative and lateral thinking. The tool also focuses on opportunities that exist to influence the trajectory.

Understanding precipitating factors for near misses and actual incidents is key to avoiding similar scenarios. Often the only version of events that is available is one from the staff perspective. Obtaining the patient’s version of events provides not just a different version of reality but highlights the missed opportunities to act proactively. Perpetuating and protective factors are grouped in a similar way to predisposing (patient, staff, environmental factors), their exploration in the post incident debrief is also essential as they feed forward the next stage of proactive detection. Patient and carer led individualised support plans or distress tolerance plans will invariably be more robust. Thus it is important to re-establish the therapeutic relationship as soon as possible. Once a near miss or incident has happened another is around the corner as unresolved conflict or distress breeds more of its type. Tools like PROTECT which make a tangible difference to the recovery trajectory of patients are most meaningful at the frontline. The data gathered can feed into the PROMISE governance framework: PROGRESS (PROactive Governance for Restrictive Settings).

PROGRESS provides visibility from board to ward and includes the key metrics that allows one to interrogate the improvement trajectory by measuring against standards that are divided into essential, desirable and aspirational. At a ward level it focuses more on the qualitative information which will enable the ward team to make real time changes to individual care plans and as the information moves up the rungs of the organisation, the data becomes more quantitative and meaningful more in a monthly or quarterly cycle, so that trends can be proactively addressed. Within PROMISE the approach to decrease the use of force has been through enhancing patient experience, thus this forms a vital part of the data and is combined with the incidence of use of physical interventions and rapid tranquilisation. We also strongly advocate the sharing of this data widely and transparently with all stake holders. Encouraging patients and families to scrutinise the information and challenge the organisation to take the next step is key to making forward strides.