Dawn MossNHS Borders

Early Years Collaborative Improvement Adviser

Child Protection Health Needs Assessment

Background• Why does it matter - long-term effects for child’s

health, growth, intellectual development and mental wellbeing (NSPCC, 2010)

• Primary drivers in EYC Workstreams 2 and 3: child’s physical, mental and emotional development

• Child Protection Health Needs Assessment process established in 2013 – improvement needed to ensure that every child who needs it will have a health needs assessment

Aim Primary Drivers Secondary Drivers Specific Ideas to Test

Cycle 1: Child Protection Team collects data at weekly Child Protection Unit Business meeting

Cycle 2: Senior Nurse Child Protection has responsibility for collecting data, additional information identified, Nurse Consultant inputs data onto excel spreadsheet

Cycle 3: Senior Nurse Child Protection has responsibility for collecting and inputting data onto excel spreadsheet

Cycle 4: Repeat cycle 3 now that problems accessing excel spreadsheet are resolved.

Cycle 5: All members of Child Protection Team to take a turn in collecting and inputting data to ensure consistency.

PDSA RAMP 1: Test data collection tool

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PDSA RAMP 2: Test new Health Needs Assessment documentation

Cycle 1:Test new HNA form with health visitor, changes made

Cycle 2: Test new HNA form with school nurse, no changes

Cycle 3:Test introduction of new form as part of HNA process with one health visitor (currently underway)

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PDSA RAMP 3: Communication with staff

Cycle 1: Communication via email to paediatricians re having discussion at end of weekly Child Protection Unit Meeting for all children discussed to be considered for HNA

Cycle 2: Test feedback form to health visitors/school nurse when HNA request (currently underway)

Cycle 3: Test briefing/workshop format (currently underway)

Cycle 4: Test written guidance for staff (currently underway)

Reflections• Worrying about measures – I’m doing it wrong

• Lots of activity but no run charts!

• Not knowing what is wrong, not knowing what questions I need to ask!

• Knight in shining armour.... ta-da... Brandon Bennett

• Knowing your process – steps – decision points

• “Moving from objective reality to belief”

Michelle Dowling

South Lanarkshire Pioneer Site: Maximising income for pregnant women

Background• Telephone advice line (TAL) for pregnant

women, funded from SL Tackling Poverty Programme

• Lower than expected referrals from universal NHS midwifery services

• Focus initially to increase referrals from community midwives to service

• Initial tests post LS1 – one midwife in Hamilton; tested a number of change ideas

Phase 1 testing

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Result: initial rise; but slows. Think again

Learning from data

Cycle 2: information about service given to women as part of visit as well as discussion with midwife:

Cycle 3: case studies used to promote the service with women.

Cycle 1 : Helen in Hamilton is recruited to test new ways of promoting service. She starts speaking to women as part of routine visits.

Aim: to increase referrals from community midwifery services to the TAL

Measure(s): NO. of referrals from midwifery staff to TAL:

Change Ideas: midwife speaks to women routinely as part of visit; use of case studies; Are we ready to scale up?

Cycle 4: stop using case studies but feel change is embedded.

Cycle 5: start test with another midwife in EK.

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Money Advice Line - Pregnant Mums

no of women given info/no contacting service

blue line - no of women given info on servicered line- no of these women taking up service

Run chart data

Use of case studies – stopped following data protection concerns

Add a new site...Run Chart

Data suggests no increase in Hamilton overall and EK little or no change.

Financial advice services and information are available and accessible

Aim Primary drivers Secondary drivers

What changes will make a difference?

Staff working with ante-natal women refer clients to service

Opportunities for other forms of income support are available and accessible

Opportunities for training and education are available and accessible

All pregnant women on low incomes have the opportunity to maximise their incomes during pregnancy and in the first year of their child’s life

Financial advice services have specialist knowledge to support pregnant women

Women get the information they need when they need it

Women take up Healthy start vouchers and vitamins

Women and their partners have access to information on training and employment schemes

Parents have access to affordable childcare

Redesigned leaflets with input from potential and past service users increase women’s knowledge

Women allow midwifery staff to pass details to TAL for phone back

Midwifery staff routinely talk to women about the TAL

Staff member with good generic knowledge of financial issues linked to midwifery team

FNP/First Steps staff routinely refer women to TAL or other service

Pregnant women need support to be able to budget and manage their money

Focus of current tests

South Lanarkshire CPP: phase 2

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Result: initial rise; volume becomes an issue

Learning from data

Cycle 2: Continue to monitor Helen’s progress and a second midwife starts using the new approach :

Cycle 3: (planned):more midwives in the team use this method with women in their clinics.

Cycle 1 : Helen starts asking women if details can be passed to TAL. Initial results seem favourable :

Aim: to increase referrals from community midwifery services to the TAL

Measure(s): number of referrals from midwifery staff to TAL:

Change Ideas: pass contact details to TAL who phone back the women for initial discussion.

Run chart data

Reflections• Complexity of testing across services and

organisations

Tackling poverty (Com & Ent)

Money Matters Advice Service (SW)

Midwifery services

FNP

Local Authority NHS

EYC

Reflections (2)• You don’t know what you don’t know!

• Scale - one eye on full scale when starting small.

• Don’t make assumptions about new practice and scale too early

• Don’t forget basic project management

• Volume

• Much work across EYC is to improve low volume activity – implications for scaling up

Sacha WillAberdeen City CPP

Early Years Collaborative Improvement Adviser

Improving Attachment-led Practice

Background

• Series of multi agency training sessions held on Attachment during 2013

• 2014 – Early Adopters identified

• Preschool settings incl. private childcare sector

AIM: Identify, by December 2014, an evidence based change package which can improve attachment-led practice within pre-school settings in Aberdeen.

Linking Roots of Empathy

Evaluation of Attachment Training (WS4)

Consistent/ clear assessment of attachment/emotional wellbeing

Engage with Private Sector

Enhancing Secondary Education PSHE

Access to Bumps programme

Attachment Training

Promoting skin on skin/ eye contact (WS1)

Evaluate support for

parents (incl. Foster Carers) Pre-birth and Beyond

Developing Dad’s Work

Provision of Antenatal Education-universal as well as targeted

Content of Ante-natal classes

Attachment

Developing Co-production methods

Aim

1⁰ 2⁰ Tests of Change

Parent/Caregiver is attuned and responsive to children’s needs.

Wider Communication Strategy

Develop Assets to support positive

and secure attachment (Co-

production)

Early Identification of parents that need support (Inc. pre-birth)

Parental engagement with projects.

Developing Community Assets

Workforce Development and Training

Version 2: 120913

To ensure that 90% of children

experience positive and secure

relationships with their caregiver by June 2015, when

assessed

Optimise Family Relationships

Optimise Workforce Capacity to implement

attachment-led practice

Engagement with PEEP

Improve Maternal Health and Wellbeing

Optimise development of children’s emotional well being and resilience.

Early identification of Health Plan Indicators (WS1)

Access to support when needed.

Development of Peer networks to reduce isolation and share knowledge & understanding

Improving attendance at Ante Pre-School provision (WS3)

Engage parents in planning for transitions

Supporting children’semotional wellbeing

Aim

1⁰ 2⁰ Tests of Change

Provide information to parents about importance of emotional wellbeing and early brain development

Reliable Assessment & intervention

Share assessment information with parents

Version 1: 2 May 2014

Improve children’s emotional wellbeing in 4 pre-school settings

in Aberdeen by October 2014 through the use of an evidence based assessment tool and individual support

plans.

Informed & Engaged Parents

Individual support plans are developed and implemented for children with low levels of emotional wellbeing and for all children during transitions

All children are assessed during times of transition

Use of evidence-based, standardisedassessment tool

Provide learning opportunities for practitioners about importance of emotional wellbeing and early brain development

Informed & Engaged

Workforce Provide learning opportunities for practitioners about strategies to support emotional wellbeing

Include information on brain development and emotional wellbeing into parent’s information pack

Introduce use of home visits to engage parents in development of transition planning

Introduce evidence-based, standardised assessment tool(Leuven Scale for Emotional Wellbeing and Involvement)

Develop ‘transitions bundle’ to support assessment and interventions for children during transitions

Provide Learning Sessions on Attachment-led practice

Develop on-line resource on early brain development and importance of emotional wellbeing

All children are regularly assessed

Engage parents in development and implementation of support plans

Provide training to all practitioners on use of assessment tool

Pre-school Setting 1Aim: Introduce use of assessment tool and individual support plans to improve support

provided for children’s emotional wellbeing by September 2014.

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Learning from data

Cycle 2: Test use of Leuven Scale with two practitioners and small group of children

Cycle 3: Test use of Leuven Scale with three practitioners and all children.

Cycle 1: Test use of Leuven Scale of Wellbeing & Involvement with one practitioner and small group of children

Cycle 4: Develop individual support plans for specific children

Cycle 5: Test use of run chart to display progress for individual children

Data for Setting 1

Percentage of children assessed for emotional wellbeing in Setting One

Tool introduced Next Practitioner trained

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Data for Setting 1

Percentage of children who have received individual support for emotional wellbeing

(following need identifed through assessment)

Assessment Tool introduced

Individual plans introduced

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Pre-school Setting 2Aim: Introduce use of transitions worker and transitions ‘bundle’ to improve support

provided for all children during settling and transitions by October 2014.

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Learning from data

Cycle 2: Introduce use of ‘key worker’ system for children who are transitioning between rooms

Cycle 3: Test use of Leuven Scale for assessing children’s wellbeing during transitions

Cycle 1: Identify areas for improvement in our transitions process

Cycle 4: Develop ‘transitions checklist’

Data for Setting 2

Percentage of children receiving 'Transitions Bundle'

'Bundle' introduced

Target = 100%

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Pre-school Setting 3Aim: Improve ‘dropping off’ and ‘picking up’ routines for all children by October 2014.

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Learning from data

Cycle 2: Share information with parents to identify new ‘drop off’ process

Cycle 1: Use Leuven Scale of Wellbeing & Involvement to gather baseline data regarding impact of interruptions during ‘drop off’ process

Data for Setting 3

ReflectionsMessiness of life

Making assumptions is a trap!

PDSA cycles help you to pay attention to the detail

Always make predictions BEFORE you start to test

The value of learning from others

Run Charts make life easier!

EYC Leith Pioneer Site:income maximisation

and maternal & child nutrition

Graham Mackenzieon behalf of the Leith Pioneer Site team

Early Years Collaborative: Learning Session 5

Income Maximisation

Healthy Start:

- Food and vitamin vouchers

- Benefits recipients

- All pregnant women under 18 years of age

- Pregnant women (from 10 weeks gestation) and children under 4 years old

- £3.10 per week food vouchers

Aims

Improvement project: To improve uptake of Healthy Start (food and vitamin voucher scheme) to 90% of eligible participants (benefits recipients, child tax credit recipients if household income < £16,190 and pregnant women under 18 years old) in selected areas of Edinburgh (initially north east Edinburgh) by March 2015

Pioneer site: To learn lessons that can be scaled up to other areas and parts of Scotland

Project Driver Diagram

Project Driver Diagram (prioritisation process)

Population segmentation

5 women per week,

20% eligible

= small enough?

One midwifeWoman’s antenatal care

Woman finds out she is pregnant

Calls central booking line

“Booking” appointment with midife

Ultrasound scan

Midwife appointment

Midwife appointment

Timeline

6 weeks?

8-9 weeks

10 weeks

11-13 weeks

16 weeks

25 weeks

HS process: Before

Appn form may be given at this point

Appn form completed now…

…if remember to bring it…

…or now

HS process: After

Appn form completed

PDSA Ramp (for antenatal work)

Increase

d

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booking

PDSA 1. The health records team identified women from two postcode sectors calling the centralised booking line. They inserted a letter and Healthy Start application form into the booking pack. Health records staff sent details to midwives who met women at booking visit. Shared data with health records team that showed that some women from postcode sectors were not being identified (PDSA cycle 2).

PDSA 3. Time between centralised booking call and appointment was 2-4 weeks, and first 8 women were seen by 5 different midwives, so shifted to look at caseload of single midwife, with routine enquiry about eligibility for Healthy Start (n=1).

PDSA 5. Identified simpler application process and tested this with same midwife: no need for ultrasound as proof of pregnancy, complete midwife section of application form at booking visit (initially n=1).

PDSA 6. Midwife shared simpler application process with colleagues at team meeting (n=19 midwives in team).

PDSA 7. Reinforced messages with team by collecting information in survey and fed back results at team meeting (n=19).

Scaling up: Survey with other team identified similar areas for improvement (n=7). Working with two midwives in that team to incorporate lessons from Leith team. Preparing to spread simple messages across Lothian (Further survey completed by 61 midwives).

(PDSA 4. Work with Health visitor team and welfare rights advisor).

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% antenatal bookers eligible for Healthy Start in Leith (self report)(n=410; source Maternity Trak)

Monthly data

release

Monthly data

release

Leith Pioneer site work

started 3 March

Universal enquiry re HSComplete form

at booking appt

Team meeting

Leith Survey Monkey

Team meeting

and survey results

Focus on Trak docu-mentation

“Shift” on run chart (6+ points above median)

Median

ConclusionsPlan small, start smaller

Deming’s Lens of Profound Knowledge

- understanding variation

- appreciation for a system

- building knowledge

- human side of change

Having an existing electronic record has

been really useful

We still have a long way to go