Niche In-Brief Spring 2018 - Flipbook - Page 8
Conscious change
Learning across organisations to improve safety - Matt Walsh
Our own Nick Moor interviewed Matt Walsh who is the Patient Safety Lead in the Quality Governance Team for
Pennine Care NHS Foundation Trust. He is a qualified social worker with a long career in working with mental health
service users in the community before commencing this role. Matts focus now is on helping teams learn from incidents
and helping develop systems to prevent such incidents recurring by addressing the system issues to improve services.
You are really keen to look beyond learning from
recommendations towards wider transformational
solutions – what were your reasons behind that?
I think one of the things we’re interested in is getting
upstream of incidents, so actually improving care and
practice and embedding some of those changes
before an incident occurs. Making sure that learning
isn’t constrained or restricted to within a single
organisation is one of the things we are interested in
doing through the Greater Manchester Partnership
where we are putting our learning into a wider format
on both an intra and an inter organisational basis.
I think disappointingly for mental health trusts we lag
behind the whole structured review process for
learning from deaths at big acute hospitals. But we are
very much at the forefront of the journey around
mental health trust learning from deaths, along with
our local colleagues from GMMH and North-West
Boroughs after being supported in learning by Humber
NHS FT. What we’ve established across Greater
Manchester is a provider-led mortality review group,
so we could take some of the lessons from deaths,
themes and practice examples, and try and make sure
the whole population of Manchester benefits. The
other thing we’ve also established is the Greater
Manchester Provider Suicide Prevention Group.
What was your starting point?
The starting point was to get the right buy-in from the
right people at Executive Director level and below. The
mortality groups at the different trusts are established
differently, some had more medics etc. so we had to
align involvement and our individual Medical Directors
were key. One of the biggest challenges initially, was
that we had to set out to try and measure the same
data and in particular deaths, because we know that
organisations use different information data
repositories for incident recording. To do this we
established a task and finish group for the business
intelligence parts of the organisations to make sure
that we are able to review and compare equitable
data; this work remains in progress.
8
We also had an initial information governance challenge
and had to overcome some obstacles here about how each
organisation wanted the data to look and where it should
be held; we also had two systems - Datix and Ulysses - as
software platform providers for incident data management.
Ultimately, my vision is to try and get a provider-led
mortality review board live-stream out to staff and patients,
but that scenario at the moment is quite far down the line.
Beyond establishing a footprint wide mortality forum,
what are the outcomes you want that to deliver?
At the first mortality review provider forum at GMMH we
discussed outcomes, and in Pennine Care there have been
two separate studies running looking at learning from
deaths with people from COPD and drug use. So, we
brought those two studies together, and now we have a
single set of recommendations of improved practice,
improved interventions, and hopefully improving mortality
rate for that population. Secondary care mental health
service users die 27 years sooner than their standard life
expectancy, we’ve got to try and do better than that. If the
Provider Mortality Review Group can assist to close that
life expectancy gap then it will be a worthwhile exercise to
pursue.
We will also look at level 2 RCAs, and level 3 independent
investigations for mental health homicides, so that we are
able to gather the best intelligence and promote the best
opportunities for learning and development between the
respective mental health providers.
Have you got any recommendations yourself about
how to make the best recommendations?
I think in order for recommendations to be meaningful and
effective, front line staff have to be the architect of those
recommendations. This could be done through a multidisciplinary learning event where all participants feel
relaxed and able to contribute their ideas. Events should
also include the independent investigation team.
Everybody who attends the events are part of designing
the recommendations and this makes them much more
likely to stick and to have a ‘lived reality’ going forward.