The Safer Care Pathways in Mental Health project, part of the Health Foundation’s ‘Closing the Gap in Patient Safety’ was conducted over a two-year period from June 2014 to June 2016.  The project involved patient safety expertise and evaluation expertise from three universities, and worked with five mental health trusts in the Eastern region.  The project involved the implementation of an integrated patient safety programme in five project sites and across two mental health care pathways: adult acute community mental health care and older people’s mental health care.

The intervention consisted of:

  • training in and completion of a System Safety Assessment (SSA) for the care pathway
  • training in Human Factors (HF) for the clinical teams and an intensive five-day patient safety champions training for a smaller cohort of staff, to support them with implementing HF tools and techniques and
  • general service improvement tools and support.

The intervention was largely delivered as planned.  Project delivery partners included the Engineering Design Centre, Cambridge University, University of Hertfordshire and University of East Anglia.

Evaluation was undertaken by a separate evaluation team from the Engineering Design Centre and Dept of Psychology, Cambridge University.

The key learning and findings from the project

The SSA is a rigorous process of analysing and prioritising action on future risks. It supports clinical teams to look across the whole pathway and to critically evaluate the proposed safety solutions.  A web based SSA toolkit has been developed during the course of the project.

Human Factors training and coaching enables the staff culture to shift and to be more proactive and collaborative on patient safety communication and to increase situation awareness.  Human Factors tools were implemented by clinical teams. Mental health related Human Factors resources were created during the project.

Critically we learnt that the SSA and the Human Factors training have to go hand in hand, and that patient safety improvement is much stronger if these are used in combination.  Safety culture became stronger through the course of the project, and clinical team practice changed.  Clinical teams introduced novel innovations to care processes as well as strengthening known good practice.

The involvement of service users and carers throughout the project was important.  Where service users and carers were involved in co-design and co-production, the patient safety changes had more impact and clinical teams adopted more person-centred practice.

Safer Care Pathways in Mental Health video

Safer Care Pathways learning presentation

Safer Care Pathways in Mental Health project booklet

Useful resources and quick links

Article for MHLDDNLF
Human Factors Training Programme 2015 – Frontline staff
Human Factors Training Programme for PSCs
SCPMH Evaluation Final Report
Trust workshop presentations combined
Mental Health Partnerships
The Health Foundation
Clinical Human Factors Group
Follow the conversation on Twitter – #safercarepathway

Key contacts

Tim Bryson – Project Manager
Oliver Shanley – Project Sponsor
Kai Ruggeri – Evaluation Lead
James Ward – SSA Lead
Cinzia Pezzolesi – Human Factors Lead
Sarah Rae – PPI Lead

© Eastern AHSN