Crossing boundaries with QI to improve prisoner health

Update June 2020.

This work had two key strands:

Reducing self harm at HMP Woodhill
Eradicating Hepatitis C at HMP Woodhill
In addition to this, we hoped to be able to spread learning on the use of QI methods into other prisons, particularly those where CNWL provide healthcare services.

We started our work at HMP Woodhill in February 2020 with a session for staff from across the prison and healthcare to explore the processes involved in the ACCT (Assessment in Custody, Care and Teamwork) approach across the prison (21 Feb).  ACCT is used to support prisoners who have expressed suicidal ideation or threatened to self harm.  It is intended to support the individual through a period of crisis as safely as possible.  The process has been highlighted as an area of concern following a recent inquest, and the team was keen to explore how we might improve the experience for both prisoners and staff.

A report was prepared for the Safety Committee held on 26 February outlining what we had covered at the session, and the actions that came from it.  This has been uploaded as a separate up-date on the project.  A follow up meeting with the Safety Governor and the Residential Governor was held in early March to discuss a second session with a different group of staff where we could explore their experience of the ACCT process and how we might improve it.  However, before any dates were set, the prison went into lockdown due to Coronavirus and work was suspended.

The final discussion before lock down was held on the 2 March with the lead psychiatrist in the team to discuss how we best use QI methods to support the development of a multi-tiered pathway to support mental health and well being for all men within the prison.  He agreed to set up a meeting with a number of other staff in the mental health team later in March, but again this was suspended due to lock down.

A meeting to look at processes associated with eradicating Hep C was held on the 25 February. This involved the practice nurse from Woodhill, the specialist hepatology nurse from the John Radcliffe (we are linked to JR through the ODN for these services), and staff from the Woodhill Addictions team.  (Note: CNWL provides all healthcare services at HMP Woodhill.  Primary care and mental health services are provided through Offender Care and substance misuse services are provided as a sub-contract by the CNWL Addictions team).  The key points from this meeting were:

The prison has been recatagorised as a Cat B trainer, which has meant a significant reduction in new prisoners coming to the prison each day.  In addition, all men have already been sentenced and are coming to Woodhill from another prison rather than from the courts.  The majority were coming to Woodhill having had a recent test for Hep C and other blood borne viruses (BBV) at another site.  This reduced the number of men accepting a test on arrival at Woodhill.
Best practice suggests that we should offer all patients a test every 6-12 months.  Our discussion focused on how we review our current processes to look at introducing recall for testing as standard.  We also looked at the current processes followed by Addictions.  At present, addictions staff refer any man who wants a test to the practice nurse for testing.  Previous work has suggested that this approach introduces a delay and increases the likelihood that the patient does not attend the appointment for a test.  We agreed to re-draw the Addictions process to equip their staff to carry out dry blood tests at the time they are offered.  Training would be provided for staff by the practice nurse.
Process maps were to be drawn up for discussion within the Addictions team.
The group also discussed a education/ information campaign that would use a rolling programme of wing based sessions to promote regular testing for BBVs, as well as helping men to understand the treatment pathway.  We contacted the Hep C Trust to start work on developing some patient stories and to see if we could bring them into the team to develop some peer support within the prison.
We had planned to start the rolling programme of events in late March, but this was all paused following lockdown.  At the time of writing our specialised Hepatology nurse has been redeployed into another service and we haven’t yet had any update on when services might resume.  All men who had been on Hep C treatment in the prison have now finished it and some testing is being carried out by the practice nurse team.  As lock down within the prison continues, all clinical activity is being carried out on a one to one basis on the wings – not in out-patient settings –  and no group activity is possible.

At the time of writing, 1 June 2020, the prison continues to have a restricted regime with out-patient clinics suspended, and all clinical activity taking part as required on the wings.  We have had some tentative conversations with staff in healthcare and feel there is scope to look at some new ways of working in more detail using QI approaches.  For example, the mental health team has had to cancel all group work, but are offering telephone consultations and welfare checks to the men.  There should also be scope to look at how Hep C has been managed over the past 10 weeks, and consider any lessons for the future.

Beyond these two areas of work, we had planned to carry out two sessions of bespoke QI training for staff at HMP Bronzefield and pharmacy and addictions staff at HMP Woodhill.  These were both scheduled for March/ April and were cancelled due to restrictions on numbers meeting, and pressures of work within the prisons as services responded to the Covid-19 situation.

The CNWL QI team, including the Q Project team, were all redeployed to support operational planning for Covid-19 in late March, and have only just been brought back together to bring QI approaches to bear in planning for the future of services within the Trust.  This will allow at least some of the work to start again although it may look different to what we expected when we developed the project plan in 2019.

The QI team is currently looking at re-writing its training programmes as virtual training, and we hope to be able to explore this approach with the prison teams over the next few months.

Michele Dowling, 1 June 2020.

Report to: Woodhill Safety Committee, February 26, 2020
Report by: Michele Dowling
Date: 24 February 2020
Title: ACCT Process Deep Dive – summary of activity and actions
Background and introduction
Following a recent inquest, the Coroner identified weaknesses in the ACCT process in Woodhill.  A number of actions have already been implemented to address some of these weaknesses, but to date the Woodhill team has not had the opportunity to take a full system overview of the process, thereby giving a clearer view of areas of potential delay and risk.

Funding from Q Exchange (NHS England and the Health Foundation) has provided resource to allow the prison to take a systems approach to improving prisoner health, and this includes exploring processes such as the ACCT process.

A full day’s facilitated session was held on Friday 21 February 2020.  It included staff from Safety, Residential, Envision, Psychology and Healthcare.  The purpose was to start a systems approach to improving the ACCT process by mapping the full system as it currently is, and then identifying possible areas for improvement across the full system.
Discussion of key points:

We started by identifying what the ACCT process was for.  It was agreed that the ACCT process was:

To keep people safe and alive; and

To support people through periods of crisis.

We discussed the concept of the team, and explored who was actually involved in the ACCT process.  This allowed us to think about the wider inputs to the process from across the prison.  The group used this information to prepare a systems map showing all of the groups within the prison who are involved in the process.  This is included as appendix 1 to this report.  This has highlighted the need to involve a wide range of staff from across the prison in future work to improve how we use ACCTs to support prisoners.

The majority of the day was spent exploring the processes already in place across different teams.  Occupational groups were asked to work separately to map what actually happened at the moment.  We then used this as the basis of an in-depth discussion where we talked about the different parts of the ACCT process and how they came together.  A summary of this is included at Appendix 2 to this report.  A graphic process map is being prepared and will be shared with the group and the prison SMT shortly.

The teams spoke frankly and everyone contributed to the discussions.  This allowed us to identify a number of potential issues:

This work identified:

·         Pressure within the first 24 hours for assessment and first review.

·         Multiple handovers between different staff groups.

·         Different recording systems across groups which introduces risk of incomplete information being available to any one member of the team.  This highlights the importance of ensuring MDT meetings

·         Changes in staff and staff roles across the prison highlighted the need for ongoing refresher instruction and guidance, and in particular easy access to key points for staff involved in the process.

The final part of the day explored possible areas for improvement and how we might test improvements to see if they have the impact that we need.

The group looked at the use of Plan, Do, Study, Act cycles to test change ideas at small scale, before deciding to make larger scale changes across the prison.  With this in mind there are three changes that are being proposed:

·         B4 Mental health team to attend the meeting with prisoners held by the assessor.  This will put patient confidentiality to the fore, but has the potential to work more efficiently across departments, by co-ordinating meetings/ checks carried out with the prisoner once the ACCT is opened.  Suggested this is tested for one week in early March and then reviewed for effectiveness.

·         Assessors to attend first review meetings with wing staff.  This will have the dual purpose of building capacity and confidence among wing staff as well as ensuring consistency in sharing information across the teams working with the prisoner.  This to be tested for one week and reviewed for effectiveness.

·         Quality checks to be carried out by the wing S/O each week, with any issues identified and discussed with staff as they arise.  This will give ownership of the process back to the wings, and should address quality issues in a more timely manner than currently.  This will also be tested for one week and reviewed.

Recommendations
·         That three PDSA cycles are carried out in early March, with time set aside to review the effectiveness of the changes being tested at the end of the week designated for the test.

·         That a full report of the session is prepared for the Prison SMT, including a full process map of current arrangements, highlighting areas for improvement

·         That further sessions are held with staff of varying bands and from the full range of departments identified in the systems map.  These sessions will be bespoke and are designed to encourage involvement from all staff in the ongoing process to improve how we carry out ACCTs and keep men safe at Woodhill