Table 4

Illustrating the social conditions for motivating change—a case example from Healthcare Improvement Scotland

What change was implemented?Who were the key stakeholders?
The Scottish Patient Safety Programme for Mental Health (SPSP-MH) aims to systematically reduce harm experienced by people using mental health services in Scotland by empowering staff to work with service users and carers to identify opportunities for improvement, test and implement interventions and spread successful changes in their area.SPSP-MH is part of the Scottish Patient Safety Programme initiated by the Scottish Government to reduce harm in acute psychiatric inpatient wards. The programme was designed nationally with input from service user and carer representatives, inpatient ward staff, clinical leaders and service managers. Although this was a national programme, participation was voluntary (services could choose whether to get involved). All 12 NHS Boards that had acute psychiatric inpatient units engaged from the beginning.
How did we use leadership to create a flow of trust between stakeholders?How did positive peer pressure shape motivation for change?
We used a systematic improvement approach and co-designed the programme with all key stakeholders including clinical leaders, service users, carers, inpatient ward staff and service managers. The programme leadership built in mechanisms for ongoing adaptation in response to both quantitative data and qualitative feedback from clinicians, practitioners, service users and carers about what was and was not working.
A small national team supported the implementation of SPSP-MH, which included a part-time psychiatrist in recognition of the importance of engaging clinical leadership. Close links were also established with the national mental health nursing network, in recognition of the vital role of mental health nurses. SPSP-MH also had strong political and leadership support, with regular input from politicians and senior leaders across the healthcare system in face-to-face learning sessions.
SPSP-MH had a strong focus on engaging service users and carers from the start. Their involvement in the design of the programme included the development of a Patient Safety Climate Tool, which helps wards, units and boards collect qualitative and quantitative data about what needs to be changed and what is working well from the perspective of those receiving care. This helped to build trust with patients, staff, carers and others.
The positive impact already seen in the wider SPSP in acute hospitals created a context where mental health services were keen to join an already successful initiative.
We brought staff and leaders from the NHS Boards together on a regular basis (face to face or via webinar) to share learning about what was and was not working and to enable front-line staff to share their successes and challenges. This peer-learning network was critical for success and created a genuine sense that those delivering it are directly shaping its ongoing development.
Data, evidence and expert opinion (from both health professionals and people with experience of acute mental health issues) were combined to produce driver diagrams which outlined which interventions were most likely to reduce harm at a ward level.
We co-designed with stakeholders a standard set of outcome measures, the majority of which were not routinely collected prior to SPSP-MH. Making the current harm in the system more visible through measuring and reporting it fostered the will for change. The use of a consistent set of outcome measures also meant that we had data to identify where impact was happening (and where it was not). Initially the emphasis was on whether individual wards were improving against their own baselines. However, over time, comparative data were also used to support learning and motivation.
We have also developed a strong social media presence, with over 2700 followers on twitter @SPSP_MH to date.
How did we deal with infectious negativity?How did we harness constructive resistance?
We stayed alert to the possibility of infectious negativity and put in efforts from the start to prevent this. We did this by viewing any potential negativity as a critical message from the system that we should listen to and use constructively (as described in the next box).Significant concerns were raised in the initial design of SPSP-MH by some clinicians and service users. They worried that it could result in an overly cautious approach to risk that would impact negatively on individuals’ recovery. We addressed positive risk-taking directly and also developed ‘balancing measures’ to monitor any unintended consequences on positive risk-taking that is, average length of stay and levels of one-to-one observation.