Quality improvement in forensic mental health: the East London forensic violence reduction collaborative

Abstract

Ward-based violence is the most significant cause of reported safety incidents at East London NHS Foundation Trust (ELFT). It impacts on patient and staff safety, well-being, clinical care and the broader hospital community in various direct and indirect ways. The contributing factors are varied and complex. Several factors differentiate the forensic setting, which has been identified as a particularly stressful work environment. Staff must constantly balance addressing therapeutic needs with robust risk management in a complex patient cohort. ELFT identified reducing inpatient physical violence on mental health wards as a major quality improvement (QI) priority. The aim was to use a QI methodology to reduce incidents of inpatient violence and aggression across two secure hospital sites by at least 30% between July 2016 and March 2018. Collaborative learning was central to this project. It sought to foster a culture of openness within the organisation around violence and to support service users and staff to work together to understand and address it. A QI methodology was applied in medium and low secure inpatient settings. A change bundle was tested for effectiveness, which included: safety huddles, safety crosses and weekly community safety discussions. Operational definitions for non-physical violence, physical violence and sexual harassment were developed and used. Reductions of 8% and 16.6% in rates of physical and non-physical violent incidents, respectively, were achieved and sustained. Compared with baseline, this equated to one less incident of physical and 17 less of non-physical violence per week averaged across seven wards. Three wards achieved at least a 30% reduction in incidents of physical violence per week. Five wards achieved at least a 30% reduction in incidents of non-physical violence per week. This collaborative brought significant improvements and a cultural shift towards openness around inpatient violence.

Quality improvement at East London NHS Foundation Trust: the pathway to embedding lasting change

“…Using QI to empower staff and service users to work together to address this issue has been a source of inspiration for other wards within our service. This violence reduction collaborative has since been scaled-up considerably across the Trust and, indeed, into other psychiatric sub-specialities such as forensic mental healthcare (O'Sullivan et al, 2020).…”

Prevalence of Physical Violence in the Medical-Forensic Approach in the Years 2015–2020 in City and Neighboring Municipalities: Perspectives from Poland—Poznań Study

“…Particularly noteworthy is the analysis of the phenomenon of domestic violence in six European countries, in which Costa et al (2015) proved that both men and women are equally likely to become victims and perpetrators of domestic violence [ 27 , 28 ]. However, it is worth noting that men are increasingly admitting to being victims of domestic violence, which is probably related to cultural changes and breaking taboos [ 29 , 30 , 31 ]. A similar analysis by Lindert et al (2011) of seven European cities found that women are more likely to be victims of violence in the older population (60–84 years) but significantly more likely to be psychological and economic rather than physical [ 32 ].…”

Influencing a Culture of Quality and Safety Through Huddles

“…9 The ability to use a safe, supportive place to articulate concerns is essential to build high expectations and standards within a culture of transparent error disclosure so that safe health care can be provided. 9,15 For example, Sullivan et al 4 found an 8% to 16.6% reduction in physical and nonphysical violent incidents in psychiatric wards over 2 years after implementing collaborative learning and huddles.…”

“…2 Other patient populations, including those with psy-chiatric conditions, have unique patient safety issues, such as risks of self-harm, restraint injuries, or violence that may be preventable if organizational safety strategies are employed. [3][4][5] In the United States, 115 out of every 1000 hospitalizations result in a preventable safety event, with a cost to payers averaging $8000 per admission. 6 A systematic review and metaanalysis across a range of health care settings globally estimated that about one in 20 patients experience preventable harm related to health care.…”

“…While there have been efforts to address this safety concern, health care organizations struggle to sustain results due to complex structures and rigorous efforts and extensive costs needed to implement changes 2. Other patient populations, including those with psychiatric conditions, have unique patient safety issues, such as risks of self-harm, restraint injuries, or violence that may be preventable if organizational safety strategies are employed 3–5. In the United States, 115 out of every 1000 hospitalizations result in a preventable safety event, with a cost to payers averaging $8000 per admission 6.…”