The Scottish Patient Safety Programme (SPSP) is part of Healthcare Improvement Scotland's Improvement Hub supporting improvement across health and social care. This is a unique national programme that aims to improve the safety of healthcare and reduce the level of harm experienced by people using healthcare services. SPSP aims to support National Health and Wellbeing Outcome 7: People using health and social care services are safe from harm.
The aim of the Scottish Patient Safety Programme for Mental Health is People are and feel safe.
SPSP Mental Health is working the Scottish Government and partners to deliver the "Mental Health Strategy: 2017 - 2027"
Cultivating learning among those delivering and in receipt of care, and using that knowledge to improve safety are core values of the Scottish Patient Safety Programme for Mental Health (SPSP-MH). Through collaboration and innovation from staff, service users and carers and the use of quality improvement and improvement science over the last 6 years, we are now starting to see significant reductions in self harm, seclusion, violence and aggression, and restraint across a number of areas in Scotland.
The latest quarterly data is showing an increasing number of wards and units are showing improvements in rates of violence and restraint, seclusion and percentage of individuals self harming. There are examples of reductions in restraints of up to 60%, a 28% reduction in the percentage of patients who self-harm (overall reduction across 20/39 acute admission wards) and a reduction in the rates of violence of up to 80%.
Our work programme initially centred on five work-streams:
In late 2017 the programme expanded to include:
It should be noted that these areas are not exclusive and should there be a particular area that would benefit from the application of quality improvement methodology to support harm reduction then this should also be considered, As such SPSP Mental Health is currently concentrating on Physical Health Collaborative with 3rd sector partners and Seclusion Review Collaborative with the Mental Welfare Commission for Scotland along with the above workstreams.
Human Rights Based Approach
Healthcare Improvement Scotland is the national organisation which drives improvements in the quality of healthcare people receive in Scotland. The SPSP Mental Health programme has undertaken a Human Rights Based Approach delivery and further details can be found here Please watch the below video to see the importance of undertaking a rights based approach to delivery.
- Learning sessions and events
Learning Sessions are an opportunity for the programme to come together with the aim of capacity building and are based upon Quality Improvement techniques. The sessions disseminate new ways of working, have introduced techniques to monitor patient safety and allow for networking, thus encouraging the sharing of methods and initiatives to improve patient safety in mental health. Approximately 1500 delegates have attended the 5 national learning sessions with 1360 delegates attending the regional learning sessions.
Regional Learning Sessions - January to March 2018
The fifth round of regional learning sessions for SPSP-MH included the Scottish Patient Safety Programme - Improving Observation Practice. These events took place between 31 January and 27 March 2018 they focused on the local priorities and the work being undertaken by the participating NHS boards with the agendas being co-designed. A report on the learning events, which includes the agendas, can be seen below.
Going Beyond Harm - June 2017 to February 2018
Following the Going Beyond Harm event held in Glasgow on 31 August 2016, we committed, with Carers Trust Scotland, to hold regional versions of the event in remote and rural communities. The aim of these events were to capture the views and experiences of carers and professionals about mental health services, to share this learning and to engage with carers and professionals, supporting carers.
Events were held in Oban (26 June at The Coran Halls), Dingwall (5 September at Dingwall Community Centre), Perth (24 October at the Dewars Centre) and Galashiels (5 February at The Volunteer Hall). A report on each event was created, with a final report summarising the themes from discussions across the events in relation to improving mental health services for remote and rural areas.
In it together: Child and Adolescent Mental Health Services - building partnerships - November 2017
This was the second event co-hosted with the Mental Health Access and Improvement Support Team (MHAIST) in 2017. The aims of the event were:
- Ensuring that service users and carers are at the center of all Child and Adolescent Mental Health Services
- Celebrate and share practical examples of improvement projects, hearing from teams that have reduced harm/ are continuing to reduce harm in health and social care services across Scotland and beyond (reducing harm) and where teams have increased access to mental health services across Scotland and beyond (mental health access)
- Networking across communities to learn from their experiences of person centred care, reducing harm and using quality improvement in mental health services (network)
- Have an increased knowledge and understanding of quality improvement methods and how these can be applied to mental health services (Quality improvement)
Regional Learning Sessions - February 2017
The fourth round of regional learning sessions were held in February with a focus on the work being undertaken by the participating NHS boards. Attendees also had the opportunity to attend world cafe sessions to discuss Recovery, Relationships, Principles and Equally Fit. A report on the regional learning sessions will be available in due course.
North Regional Learning Session agenda
East Regional Learning Session agenda
West Regional Learning Session agenda
Scottish Patient Safety Programme for Mental Health presentation
North Regional Learning Session Board presentations
East Regional Learning Session Board presentations
West Regional Learning Session Board presentations
Development and Improvement Day for Child and Adolescent Mental Health Services (CAMHS) - January 2017
This event was co-hosted with the Mental Health Access and Improvement Support Team (MHAIST). With the aim that delegates will have an increased understanding of how they can work at a local and a national level, using quality improvement methods, to ensure CAMHS are Safe, Timely, Effective and Person-Centred by drawing on the support from each other, national teams and the ideas and innovations shared at this event. The delegates included representatives from Health and Social Care, third sector organisations, service users and carers, families. A report on the event is available below.
Going Beyond Harm - August 2016The event was organised with Carers Trust Scotland and was aimed at carers of people (adults, children or young people) with mental health problems who have, or may have, used mental health services, such as inpatient services or community health service. The event brought together carers and staff from mental health services throughout Scotland.
The aim of the event was to gather carers' and staff views on how their involvement in services can help improve safety for service users, staff and carers within mental health services and, ultimately, share the learning with each other to support improvement and avoid harm. Following the event a report was shared with the attendees.
Going Beyond Harm Agenda
Going Beyond Harm Event Report
Phase 2 - Safety Principles in Mental Health and Phase 3 - Scoping Future Activity - March 2016
Meetings were held to allow workstream development groups to review, discuss and feedback on the safety principles as a whole. Attendees at the Phase 3 meeting also looked at gathering information on expanding into new areas and shaping the future programme.
Regional Learning Sessions - September 2015
The third round of regional learning sessions were held in September with a focus on the safety principles and overarching themes. Attendees had the opportunity to share learning, future plans and network. Feedback from the learning sessions will be published here in the coming weeks. To see tweets relating to the sessions please click here
A sample agenda can be found here
To follow the story on twitter click here
Learning Session 5 - March 2015
Learning Session 5 of the Scottish Patient Safety Programme for Mental Health was held on the 4th of March. The event marked a period of time in the life of the programme where a number of areas across Scotland are showing reductions in restraint, violence and aggression and self harm.
The day was around what processes, attitudes and cultural aspects that have contributed to the same. Karen Martin from the Carers Trust addressed the delegates describing the Triangle of Care and her role as a carer. This was followed by a Programme Update from the SPSP-MH Clinical and Programme leads detailing work to date. Workshops were themed around the development of the key elements or ‘essentials’ in mental health that collectively contribute to a reduction in harm for those in receipt of care.
The event was closed by Paul Gray and preceded by a mix of service users, carers, governance and front line staff completing the sentence – ‘patient safety in mental health matters to me because....’
Regional Learning Sessions - September 2014
The second round of regional learning sessions were held in Aberdeen, Edinburgh and Glasgow. Following on from the successful introduction in 2013 of this format the focus of these sessions was boards sharing tests of change, learning, future plans and networking with world cafés again being run. These centred on: The importance of data and the model for improvement, Climate tools (Patient and staff), service users and carers involvement, remote and rural issues. There were also breakouts for each of the change packages.
Sample Regional Learning Session agenda
To view a sample presentation from the days please click here
International Initiative for Mental Health Leadership (IIMHL) - June 2014
SPSP - Mental Health were asked by the International Initiative for Mental Health Leadership to host a workshop on the subject of "Patient Safety including trauma informed care and usage of seclusion and restraint". The aim of the event was to highlight the work being carried out across Scotland and offer the opportunity to network and collaborate with partners from across IIMHL to discuss these as themes taking into account the view of those who receive and deliver mental health care.
A sample presentation from the day can be found here
Learning Session 4 - March 2014
Learning session 4 had a focus on workstream development, sustainability and spread within the SPSP-Mental health programme, in addition to sharing and learning from the work that had been carried out to date. The day started with a compelling carers story and moved onto a programme update and a presentation on the role of human factors within mental health settings and then a patients story. Boards teamed up to showcase work that had been happening in each change package and in addition to breakouts for each workstream there were additional groups for data and measurement and introduction to improvement science and Patient experience and service user engagement. The day was closed by Paul Gray, Director General Health and Social Care, Chief Executive of NHS Scotland.
Learning Session 4 Agenda
To view presentations from the day please click here
To view pictures from the day please click here
Regional Learning Sessions - November 2013
The SPSP - Mental Health team introduced regional learning sessions as a test of change to increase participation from service users, carers and front line staff in comparison to our national Learning Sessions. The learning sessions were located in Inverness, Edinburgh and Glasgow. The focus was on sharing tests of change, future plans and learning and each board was asked to give a 15 minute showcase on a driver diagram that they had been working on with tests of change supported by data. This was also the first time we used the world café format with data measurement, remote and rural issues, phase 2, Patient Safety Climate Tool, Service user and carer engagement and transfers between boards as the subject matters.
Sample regional learning session agenda
To view a sample presentation please click here
Learning Session 3 - June 2013
Learning Session 3 focused on person-centred care within the SPSP-Mental Health programme with plenary presentations introducing the Patient Safety Climate Tool and on compassionate leadership combined with service user and carer involvement and engagement. Breakout sessions included all 5 workstreams and service user engagement in safety, data and measurement, introduction to improvement science and understanding the patient experience.
Learning Session 3 Agenda
To view a plenary presentation from the day please click here
To view pictures from the day please click here
Learning Session 2 - February 2013
Learning session 2 started with a patients perspective and included a general programme update from Scottish Government and SPSP-MH. In the spirit of sharing knowledge news from the pilot wards was presented and a structured networking session and board planning session also occurred. Breakout sessions were held for the 5 workstreams and 'Introduction to Improvement Science'. Storyboards were again used to allow boards to demonstrate local tests of change and learn from others.
Learning Session 2 Agenda
Learning Session 1 - August 2012
As the introductory learning session presentations explaining the colloboratives grounding in Quality Improvement were made by representatives from Scottish Government. Service users and carers were also involved from the start with presentations on 'A Carers View' and 'A Clients Journey' with positive feedback from delegates. An introduction to improvement science session was given with delegates keen to learn more about this. Storyboards were introduced to allow boards to share and learn about best practices that already existed.
Learning Session 1 Agenda
To view presentations from the day please click here
- Tools and resources
Below you will find links to tools and resources relating to the Mental Health programme.
Clozapine Handy Guide
The SPSP Mental Health team are piloting a handy guide for Clozapine. View the guide (PDF)
The SPSP Mental Health programme work is not just testing how to implement changes that reduce harm but also:
- what part of the system needs changing to reduce harm
- what specific changes will lead to a reduction in harm, and
- what measures can be used to reliably measure levels of harm.
For further details, read the measurement plan below.
NHS Boards across Scotland are using the Patient Safety Climate Tool with over 800 patients being given the opportunity to have a say about their care and treatment using this tool.
It is a Scottish innovation that is leading the way in person centred safe delivery of care. The tool is designed to enquire about environmental, relational, medical and personal safety. Cultivating learning among those delivering and in receipt of care, and using that knowledge to improve safety are core values of the Scottish Patient Safety Programme (SPSP).
Patient Safety Climate Tool
Patient Safety Climate Tool - Guidance
Staff Safety Climate Survey and Analysis Tool
Organisations working to develop or improve a culture of safety need a reliable measure to monitor the success of their initiatives. Using a Safety Climate Survey developed for the SPSP Mental Health programme, teams can gain information about the perceptions of front-line clinical staff about safety in their clinical area and management’s commitment to safety.
The survey can also provide information about how perceptions vary across different departments and disciplines. As the participating team tests and implements changes to improve the culture, it can repeat this survey periodically to assess the impact of those changes.
Here is the SPSP-MH Staff Safety Climate Survey, Guidance and an Excel Analysis Tool which has dummy data entered to illustrate its functionality. Please download them for use within your teams, and let us know how you get on!
- Staff Safety Climate Survey - Analysis
- SPSPMH - Safety Climate Survey - Guidance
- Staff Safety Climate Survey - Questionnaire
Improving monitoring of as required 'prn' psychotropic medication
A poster displaying the work around the monitoring of as required 'prn' psychotropic medication was shown at the 6th Annual International College of Mental Health Pharmacists Conference, 9th - 11th October 2015 in Bristol.
View the poster here
Webex calls are a means of SPSP Mental Health providing support to individual boards. The Mental Health team hold WebEx calls and provide an opportunity for participants to ask questions, as well as keeping participants up to date with progress across boards, and within the SPSP MH collaborative.
If you wish to join the distribution list please contact us here
- Data collection
Data provides rich, valuable information that allows us to understand variation in our system. Data collection is fundamental in quality improvement and there are many types of data that are helpful in supporting changes that result in improvement, including continuous measurements and counts of observations.
The Mental Health programme published the revised measurement plan in February 2014. We have set a bi-monthly reporting schedule together with a bi-monthly cycle for leadership reports for NHS boards. Data is collected at ward level, with collated measures across the board submitted by programme managers to the national team. Learning from data is key and supports staff to implement the changes required to achieve the aims of the programme. Feedback reports of data assessment are agreed in collaboration with programme managers.
Data submission dates
3rd September 2018
1st November 2018
7th January 2019
Leadership report submission dates
1st August 2018
1st October 2018
3rd December 2018
- Useful links
Joint partnership with Suicide Reporting and Learning System (SRLS)
This piece of work is focused on translating learning from adverse event reviews into service improvement.
For more information visit Healthcare Improvement Scotland
Service User and Carer Organisations:
Acumen is an advocacy organisation that covers Argyll & Bute, East Renfrewshire, Inverclyde, Renfrewshire and West Dunbartonshire. Its philosophy is to maximise service users and carers involvement in all areas of service provision this ensuring a quality of service is received which, in turn, improves the individuals quality of life.
For more information visit Acumen
Carers Trust (Scotland)
Carers Trust Scotland (formerly The Princess Royal Trust for Carers) has been operating in Scotland since 1991. They are the largest provider of comprehensive carers support services in Scotland, reaching around 40,000 adult carers and more than 3,500 young carers from all groups and communities, through a unique network of independent carers centres and young carers services (Network Partners) throughout Scotland.
They work with partners to improve support, services and recognition for carers in communities across Scotland.
For more information visit Carers Trust Scotland
Carers Trust Scotland has developed a guide to raise awareness of carers' needs amongst healthcare professionals and to recognise carers as partners in care. The Triangle of Care: A Guide to Best Practice in Mental Health Care in Scotland is an alliance between service user, carer and staff member that promotes safety, supports recovery and sustains wellbeing.
For more information visit Triangle of Care
HUG - Highland Users Group
HUG is a network of people with experience of mental health problems. Their main aim is to improve the way in which users of mental health services are treated by campaigning to improve the rights, services and treatment of people with mental health problems, and to challenge stigma and discrimination. Launched in 1996, HUG now has around 350 members and thirteen local branches across the Highlands.
For more information, visit HUG.
LAMH - Lanarkshire Association for Mental Health
LAMH is a charity and provider of a range of services to people with mental health difficulties. They develop and provide support services in partnership with people who experience mental health difficulties, their carers and other agencies. They also provide training to businesses around the mental health awareness information and how to support employees with mental health issues.
For more information visit LAMH
Mental Health Foundation
In Scotland the Mental Health Foundation focuses on social justice and inequality in mental health, raising awareness of mental health with the public and working in partnership with community organisations, policy makers and researchers.
Their programmes link together policy, research evidence and practice, helping people and polciy recognise the role mental health plays in life.
For more information visit Mental Health Foundation
SAMH - Scottish Association for Mental Health
SAMH is a charity that works to ensure that people are talking about mental health and this is done in the following four ways:
- Community based services for people with mental health problems
- National programmes
- Policy and campaigning work
- Raising funds to ensure that their work can continue
For more information visit SAMH
See Me is Scotland's Programmed to tackle mental health stigma and discrimination. They are funded by Scottish Government and Comic Relief and are managed by SAMH and the Mental Health Foundation.
For more information visit See Me
UCI – User and Carer Involvement
User and Carer Involvement is a Scottish charity operating across the Dumfries and Galloway Region. Their mission is to ensure that people who have mental illness, dementia or learning disabilities, and their carers have a representative voice and, as a result, see positive changes in their service provision.
For more information, visit User and Carer
VOX – Voices Of eXperience
VOX is a National Mental Health Service User-Led organisation, working in partnership with mental health and related services to ensure that service users get every opportunity to contribute positively to changes in the services that serve them and wider society. VOX supports individuals and works with members to ensure that their views are listened to. Mental health service user-led groups are also able to become members of VOX, thus ensuring that VOX represents a range of views and work together with groups who have a great deal of local or specialist knowledge and information.
For more information, visit VOX
For links to all our partner organisations please see our 'Resources' page
- Contact the team
To contact a member of the Mental Health team, please click on the relevant name below.
David Hall Clinical Lead Steven Robertson Programme Manager John Holligan Senior Project Officer Sandra Ross Project Officer Hana Barvik