28 th May 2018 IIMHL Sweden Shane Mills

28 th May 2018 IIMHL, Sweden Shane Mills Director of Quality & Patient Experience NHS Wales

Context q Progress Indictor Approach is for citizens in managed environments q Enacted through 3 National Collaborative Commissioning Frameworks q 1, 700 citizens in MH or LD hospitals/ care homes* (within scope of frameworks) q £ 165 million* spend *2017/18 2 Property of Shane Mills, Director of Quality & Patient Experience, NHS Wales National Collaborative Commissioning Unit -Do not reprint without express permission of the author

2011 -2014 Process q In 2011 we were focused on processes and costs Low Secure Mental Health - Male Unit Cost Elm Unit £ 350 Oak Unit £ 375 Beech Unit £ 400 Ash Unit £ 425 3 Property of Shane Mills, Director of Quality & Patient Experience, NHS Wales National Collaborative Commissioning Unit -Do not reprint without express permission of the author

2014 -2016 Process/Progress q In 2014 we changed focus to ensure primacy of quality and monitoring of ‘outcomes’ Low Secure Mental Health - Male Unit Q Rating Cost Oak Unit QQQ £ 375 Ash Unit QQ £ 425 Elm Unit Q £ 350 Beech Unit Q £ 400 4 Property of Shane Mills, Director of Quality & Patient Experience, NHS Wales National Collaborative Commissioning Unit -Do not reprint without express permission of the author

2018 Looking back q Quality indicators provide the key link between evidence -based practice and improved outcomes* q Quality is fluid and complex q Lack of clarity on placement outcomes q Lots of activity not much progress q Still focused on big steps q We count what we can, not what counts *Mc. Coll et al. , 1998 5 Property of Shane Mills, Director of Quality & Patient Experience, NHS Wales National Collaborative Commissioning Unit -Do not reprint without express permission of the author

Why not go with the flow… q It’s the citizen rather than professional/intervention q Linking intervention to outcome is complex q Outcome may differ for citizen and professional q Benchmarking across range of services is difficult q Reliant on professional expertise or experience 6 Property of Shane Mills, Director of Quality & Patient Experience, NHS Wales National Collaborative Commissioning Unit -Do not reprint without express permission of the author

2018 Looking forward, the PI approach q Minimize burden of performance management q Useful to citizen, provider & commissioner q Outcomes -Outputs -Activity q Provider quality is built on citizen journeys q Citizens voice should be loud but part of a chorus q Straightforward -simple as possible 7 Property of Shane Mills, Director of Quality & Patient Experience, NHS Wales National Collaborative Commissioning Unit -Do not reprint without express permission of the author

Standards to outcomes q Outcomes emerge from outputs-which are a product of activities Care and Treatment Planning • Each Patient’s needs in respect of mental health and wellbeing are Outcome assessed using appropriate evidence based assessment tools and processes by appropriately qualified and experienced Staff trained in their use. • Care and Treatment Plan(s) are developed in accordance with the Mental Health (Wales) Measure 2010, good clinical practice, professional standards and national and local guidance and (i) identify one or more outcomes for each identified need and (ii) identity one or more pharmacological and/or psychological / therapeutic interventions to be undertaken and / or maintained I know and to achieve these outcomes and (iii) record any needs which will remain unmet during the duration of the Care and Treatment Plan. understand what • (i) The Patient is appropriately supported to take as much responsibility for developing the Care and Treatment Plan(s) as care, support and they are able and (ii) coproduction of the Care and Treatment Plan(s) by the Patient and Staff is clearly documented and (iii) theopportunities are Care and Treatment Plan(s) is developed and composed from theavailable and use perspective of the Patient. these to help me • Carers and Local Care Team are actively involved in the development of the Patients Care and Treatment Plan(s). achieve my well- being Meaningful and Culturally Appropriate Activities • There is a broad range of meaningful and culturally appropriate activities available (i) on each Unit and (ii) for each Patient. • Each Unit shall clearly display information on all available activities and access restrictions to these activities. My voice is heard • (i) Purposely designed and designated areas are available for the undertaking of these activities (ii) these areas are available on the and listened to Unit for those unable to access external areas. • Activities are available (i) Monday to Saturday (ii) in the evenings My individual after 5 pm. • Activities support or address the Patients individual strengths, circumstances are needs, preferences and aspirations wherever possible and considered reasonably practicable. • The Patient is enabled and encouraged to participate in these activities. Outputs to be measured to support the achievement of the outcome A current, holistic, co-produced and outcome focused Care & Treatment Plan Issues that would result in a Level 1 improvement notice Issues that would result in a Level 2 improvement notice Activity that would support the achievement of the outcome (Issues impacting quality of care) Ø A Care and Treatment Plan (CTP) is developed in accordance with the Mental Health (Wales) Measure 2010, good clinical practice, professional standards and national and local guidance Ø The CTP identifies one or more outcomes for each identified need and then identity one or more pharmacological and/or psychological / therapeutic interventions to be undertaken and / or maintained to achieve these outcomes Ø The CTP records any needs which will remain unmet during the duration of the Care and Treatment Plan. Ø The Patient is appropriately supported to take as much responsibility for developing the CTP as they are able Ø Co-production of the CTP by the Patient and Staff is clearly documented and evidenced Ø The CTP is developed and composed from the perspective of the Patient Ø The CTP is customised to address the Patients communication abilities (for example no use of ‘jargon’, pictographic) Ø Where a patient lacks capacity, there will be evidence of action taken by the provider (for example consulting with family and/or best interest assessors) (Issues critically impacting quality of care and/or safety of patient) Ø An Identified need has not Ø Ø been included in CTP Ø No clear outcomes documented against one or Ø more needs within the CTP Ø Evidence interventions are temporarily not available (less than 1 month) Ø No evidence of coproduction Ø No evidence of unmet need being documented Ø No evidence of customisation to address the Patients communication abilities Ø No evidence of action for patient who lacks capacity CTP not in place Evidence interventions are not available for longer than 1 month Evidence that a range of interventions are not available 8 Property of Shane Mills, Director of Quality & Patient Experience, NHS Wales National Collaborative Commissioning Unit -Do not reprint without express permission of the author

Level 5 Level 4 Level 3 Level 2 Level 1 Safety Recent restrictive practices (within 24 hrs) required as resident is risk to self/others and requires continuous observation to prevent repeat Needs anticipated because of inability to communicate Potential risk of harm to self/others and requires continuous observation Needs anticipated through non-verbal signs due to familiarity with the individual. Potential risk of harm to self/others and requires regular observation Confused residents requiring constant supervision Residents maybe cohorted to provide continuous supervision Needs assistance to communicate their needs. Escorted community access Some cognitive impairment and reduced level of understanding Requires minimal ongoing support, reassurance or intervention Unescorted community access Has capacity Able to communicate need Activities Totally dependent for all activities of living as unable to participate in own care Requires care from minimum of 2 staff for most ADL's, manual handling, repositioning Requires assistance with most or all activities of daily living Requires assistance with personal care lasting more than an 30 mins Requires assistance with mobility, repositioning with 1 -2 staff and use of aids Requires assistance with some ADL's Residents requiring prompting with most or all activities of daily living Assistance with feeding or fluid management Enteral feeding (PEG/NGT) or Routine catheter care Residents requiring prompting with some activities of daily living Requires the assistance of one person to mobilise Self-caring/ independent Mobile, with/without use of aids Pressure area care Medication Invasive monitoring, vasoactive drugs, treatment of hypovolaemia / haemorrhage / sepsis or neuro protection Complex medication regime requiring frequent changes Complex medication or IVI regime Resident requires support to take medication (more than 30 mins) Resident prescribed antipsychotic/hypnotic PRN within last 24 hrs Assistance taking medication(reminding and/or administered by staff) Self-medicating for symptom control ü ü ü Acuity Indicators Elm Unit, Progress Care Ltd Review Date ü Patient: AC Time (24 hrs, nearest 15 mins) Safety Activities Medication 22/11/17 1315 5 5 3 17/12/17 1430 4 4 2 15/1/18 1545 3 4 2 20/2/18 1330 3 4 1 18/3/18 1245 2 3 1 23/4/18 1500 2 2 1 FR PD GH TY ü OL ü ü Progress Indicator Current AC Previous months BN Safety Acuity Snapshot 5 4 3 3 2 2 Activities Acuity Snapshot 4 4 3 3 2 2 Medication Acuity Snapshot 3 2 2 1 1 1 DC Safety Activit Medic ies ation 9 Property of Shane Mills, Director of Quality & Patient Experience, NHS Wales National Collaborative Commissioning Unit -Do not reprint without express permission of the author

Provider Progress Indicators This review date 1/5/18 Reduce/ minimise violence, aggression, behaviours that challenge Reduce/minimise/control self-harm, self-harm ideology Details Objective set 18/03/17 Measurable objective achievement estimate Variance Periodic disruptive behaviour when denied leave Incidents rate of less than 1 per month 06/05/18 5 Unescorted community leave of more than 2 hrs per week 03/04/18 -28 Regress stagnation Progress X n/a Reduce dependency and promote independence through life skills 06/07/17 Lack of social awareness, requires positive community activities Empower through hope, positive regard, psychosocial interventions 06/07/17 Poor decision making over illicit substances No illicit substance misuse after periods of leave 06/06/18 62 X Reduce/ minimise symptoms of mental illness through pharmacology 06/07/17 Reduce use of PRN diazepam requirement use of PRN Benzodiazepines less than once per week 06/05/18 5 X Achieve positive outcomes through specific psychological therapies 06/07/17 Substance misuse -support harm reduction & relapse prevention No illicit substance misuse after periods of leave 06/07/18 92 X Progress Indicator X Previous months Current Reduce/ minimise violence, aggression, behaviours that challenge Reduce/minimise/control self-harm, self-harm ideology Reduce dependency and promote independence through life skills Empower through hope, positive regard, psychosocial interventions 10 Property of Shane Mills, Director of Quality & Patient Experience, NHS Wales National Collaborative Commissioning Unit -Do not reprint without express permission of the author

Goal Based Outcomes q GBOs enable us to measure the effectiveness of an intervention across…a variety of settings and with a variety of service users* I want to be able to stay calm so that I can get out more to local shops Goal 1 10/4/17 0 1 2 3 4 5 6 7 8 9 10 baseline Goal 2 10/4/17 0 1 2 3 4 5 6 7 8 9 10 baseline Goal 1 7/7/17 0 1 2 3 4 5 6 7 8 9 10 +3 Goal 2 7/7/17 0 1 2 3 4 5 6 7 8 9 10 -1 Progress indicator Metric Does the citizen believe they are making progress towards achieving their goals? GBO [minimum 1]. Aggregate. GBO score greater than +1 is positive- indicator is GREEN. GBO Score 0 is neutral indicator is AMBER. GBO Score lower than 1 is negative indicator is RED. Refusal/non submission – Neutral submission. Report date should be 7 days prior to submission date. Does the citizen believe they are making progress across ALL goals? GBO [minimum 1]. Individual. All GBO score greater than +1 - indicator is GREEN. All GBO Score 0 -indicator is AMBER. Any single GBO Score lower than -1 indicator is RED Progress Indicator Previous months Current Citizen making general progress towards achieving their goals *Law, D & Jacob, J, GOALS AND GOAL BASED OUTCOMES, 3 rd Ed. 2013 Citizen making progress across ALL goals 11 Property of Shane Mills, Director of Quality & Patient Experience, NHS Wales National Collaborative Commissioning Unit -Do not reprint without express permission of the author

Citizen Progress Summary Progress Indicator Previous months Current 5 4 3 3 2 2 [ Activities Acuity Snapshot 4 4 3 3 2 2 Acuity Medication Acuity Snapshot 3 2 2 1 1 1 [ Reduce/ minimise violence, aggression, behaviours that challenge ] Safety Acuity Snapshot Reduce/minimise/control self-harm, self-harm ideology Empower through hope, positive regard, psychosocial interventions Provider Reduce dependency and promote independence through life skills Reduce/ minimise symptoms of mental illness through pharmacology Citizen making progress across ALL goals [ Citizen ] Citizen making general progress towards achieving their goals ] Achieve positive outcomes through specific psychological therapies Ben Brown Current Provider: ? Provider Q rating: ? Elm Unit, Progress Care Ltd, Oldham QQQ Type of care: Low secure –male – mental health Last CTP: Next CTP: 09/02/18 16/08/18 Time at current Unit: 2 years, 3 months and 17 days Cost to date: £ 275, 420 Time in Framework care: 5 years, 9 months and 22 days Cost to date: £ 1, 475, 674 Date of last reported incident: 18/04/2018 ? Date of last reported complaint: ? 09/01/2018 Date of last reported safeguarding event: 23/11/2017 ? 12 Property of Shane Mills, Director of Quality & Patient Experience, NHS Wales National Collaborative Commissioning Unit -Do not reprint without express permission of the author

Seeing the pattern Progress Indicator A Previous months Activities Acuity Snapshot 4 4 4 Medication Acuity Snapshot 3 3 3 Safety Acuity Snapshot 5 4 4 3 4 4 Activities Acuity Snapshot 2 2 2 Medication Acuity Snapshot 3 2 3 3 Reduce dependency and promote independence through life skills Empower through hope, positive regard, psychosocial interventions Achieve positive outcomes through specific psychological therapies Citizen making general progress towards achieving their goals Citizen making progress across ALL goals [ Citizen ] Citizen making general progress towards achieving their goals ] Reduce/ minimise symptoms of mental illness through pharmacology Provider Empower through hope, positive regard, psychosocial interventions Reduce/minimise/control self-harm, self-harm ideology Provider Reduce dependency and promote independence through life skills [ [ Reduce/minimise/control self-harm, self-harm ideology Reduce/ minimise violence, aggression, behaviours that challenge ] 4 Acuity 4 [ 5 ] 5 Current Acuity 5 Previous months [ Safety Acuity Snapshot Reduce/ minimise violence, aggression, behaviours that challenge Progress Indicator Current B 13 Property of Shane Mills, Director of Quality & Patient Experience, NHS Wales National Collaborative Commissioning Unit -Do not reprint without express permission of the author

Implementation q Proof of concept 120 citizens: November 2017 q Learn and modify: January-March 2018 q Testing 400+ citizens: April-August 2018 q IT system modifications: May-August 2018 q IT system testing: August-October 2018 q Provider early adopters: September-November 2018 q Diligence and retest: September–November 2018 q Information transfer protocols: December 2018 q Training: January-March 2019 q Contractual agreements: February 2018 Nice work, maybe a little more detail right here… q Commencement date: April 2019 14 Property of Shane Mills, Director of Quality & Patient Experience, NHS Wales National Collaborative Commissioning Unit -Do not reprint without express permission of the author

Diolch am Wrando Shane Mills Director of Quality & Patient Experience NHS Wales National Collaborative Commissioning Unit 1 Charnwood Court Heol Billingsley Parc Nantgarw ( (01443) 744928 Cardiff 8 Shane. Mills 2@Wales. NHS. UK CF 15 7 QZ 15 Property of Shane Mills, Director of Quality & Patient Experience, NHS Wales National Collaborative Commissioning Unit -Do not reprint without express permission of the author