To reduce antisocial behaviour on one ground floor team at a drug treatment centre to zero by June 2016

Theory of change: A theory was proposed that if we increased the therapeutic effectiveness of the clinic, we would reduce antisocial behaviour and change the perception of the clinic from being a punishment clinic to a place of therapy and treatment.

Introduction: High levels of anti social behaviour both inside and in the vicinity of our clinic led to this project1,2. Staff morale was low and there was recognition of the need to change. Patients referred to our clinic as “the punishment clinic” and staff saw it as merely a methadone clinic. We set about utilising the skill set of the multidisciplinary team in a more effective and therapeutic way, with the quadruple aim of  improving patient experience, staff experience, patient outcomes, all at lower cost3.

Methods: We recorded and analysed incident forms, producing weekly run charts and using the data to recognise our outliers. We introduced low intensity CBT interventions4,5, setting up training workshops for staff and a post Amicus intervention. We changed the format of our weekly team meetings and expanded the role of care plan coordinators.

Highlights/Outcomes: 7% of our patients are responsible for nearly 50% of incidents, and these outliers were a special cause effect and need to be managed individually and differently3. The team has an average of 150 patients and through improved work practices, we have freed up time to work in a more therapeutic way with emphasis on active key working and individualised care packages.

Sustainability and Spread: The scale-up of this project will be overseen by the Clinical Governance Committee and individual consultants.The project has been presented twice at academic meetings in the service.The results have proven beneficial to management and other clinical teams and the term “outlier” has entered the day to day lexicon in that outliers are now quickly identified and managed.

Challenges and lessons learnt: Where there is special cause variation, the need is to manage the individual rather than the service. Where there is common cause variation, a holistic service wide assessment and improvement may reduce the number of incidents of the whole population. We must understand the individual outliers.

Two factors improve a service:-reduction of variation and standardising care.

This project has demonstrated that The Art of Measurement (i.e. how we use graphs to illustrate data), is as important as The Act of Measurement3.

Reflection: This work shows the importance of data collection and measurement3.  We have demonstrated the importance of the front line staff (Microsystems), and refocused our work on patient centred care.This has been an analytic study, where action is being taken on a cause system to improve the system in the future.

Our operational definition has been:

(1)   A method of measurement-the run chart and graphs showing outliers,

(2)   A set of criteria for judgement -the generation of an incident form and therefore a breach of the patient contract.

Commitment to change is built through sharing of information and we have shared our learning and findings from the beginning of this project. The success of our service will depend on the integration of its components rather than their individual performance, (Langley G. et al 2009).

References:

1- Fahy S, Brown R, Sloan D, Keating S, O’Connor J.  An audit of violent incidents in a Drug Treatment Centre. Ir J Psych Med 2000;17(1):29-33.

2- Whitty P, O’Connor J, Violence and aggression in the Drug Treatment Centre Board.  Ir J Psych Med 2006;23(3):89-91.

3- Langley G, Moen R, Nolan K, Nolan, Clifford L. Provost LP, The Improvement Guide   Jossey-Bass, 2nd ed 2009.

4- Bennett-Levy J, Richards D A, Farrand P, Oxford Guide to Low Intensity CBT Interventions Oxford University Press 2010

5- Osborne D, Williams C, BJPsych Advances 2016;22:53-54