17 October 2019

Flip the triangle – Award winning QI work

Last week Shoreditch ward were winners at the Positive Practice in Mental Health National Awards.


Flip the Triangle award winning team

Shoreditch is a 14 bed male Learning Disabilities ward in the trust’s Forensic medium secure unit. They have worked very hard for over two years as part of the Forensics’ violence reduction collaborative aiming to reduce seclusions by 50%. The team are rightly proud of their candour and what they had done so far.

During a breakfast meeting, the team were encouraged by the Associate Clinical Director for safety and security and head of nursing of the hospital (who then became QI coach of this project) to try and think differently: What about the people who are not going to seclusion? Is this project helping them? What if your project aim was not in terms of seclusions but in terms of positive things they were doing for their service users. Could the team measure themselves against that instead?

The team recognised that by focusing on seclusions they were addressing symptoms not causes. In an act of what author Howard Marks calls second-order thinking, they flipped the focus of their project to how they proactively support people to stay well. The team changed their aim to increasing and maintaining proactive interventions to a rate of 95% by January 2020 and the project took on a new name – ‘Flip the Triangle: Positive Behavioural Support in Action’.

The measurement of proactive interventions became an intervention in itself. Staff put up light blue and deep blue dots and in doing so are able to reflect on the care they are giving to patients and encourage and support each other. Service users put blue dots on a wheel that was developed through co-production with service users based on what care they experience and value. Staff then use the wheel to reflect on how service users experience their care and which areas of care are important to them. Staff then respond with the care we provide and offer.

Safety huddles changed from planning how someone might need restraint or seclusion to brainstorming what positive things they could do instead. If there was upcoming bad news for a service user, rather than preparing to manage their response, could someone go with them to the café to support them in advance? How can we change the tone of language so recipients feel more dignified and the staff are more relatable? They have strived to create an inclusive, equal culture. For example, the ward introduced pedometers for service users and staff and friendly step count competitions emerged, creating rapport between service users and staff, giving opportunities to congratulate one another and encouraged both to get out more.

Not only did seclusions reduce but people no longer felt unsafe so staff overspend from observations also reduced. Now staff are busy being proactive and can spend the savings on doing activities with service users rather than monitoring seclusions.

Hearing the team speak, there is such a sense of joy in the caring and forward looking community that has grown from this work. Their positive response to challenge and creative solution finding are very inspiring. Many congratulations to the ward!!

The Flip The Triangle project can be found on LifeQI 118921.

As well as Shoreditch Ward the Tower Hamlets Mental Health Liaison Team were highly commended in the All Age Crisis and Acute Care category while City and Hackney Community Rehabilitation and Recovery Service were highly commended in the Specialist Mental Health Rehabilitation category. Finally Tower Hamlets Mental Health Liaison Team won in the category of Integration of Physical and Mental Healthcare. Find out all about what was a fantastic award ceremony here.


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