A marked and sustained improvement in the numbers of psychiatric patients returning on time from leave has been achieved by a project led by the Oxford AHSN Patient Safety Collaborative. A 50%+ rise in punctuality has been recorded consistently at the growing number of wards taking a new approach – three trusts have adopted it so far. Fewer patients returning late from leave has many benefits including improved patient safety and less staff and time diverted to search for missing patients.
The project has also prompted a policy change – the incorporation of a ten-minute search period. There are now clear procedures for absconding with increased adherence to policy. Patients feel more empowered too – conversations about leave have moved from primarily concerning rules and sanctions to open discussions about the purpose and value of being away from the ward.
Challenge / problem identified
Service users absconding from acute psychiatric wards is a significant safety issue. In some instances, the consequences of absconding can be catastrophic: between 2003 and 2013, 22% of inpatient suicides in England occurred following an incident of absconding from mental health wards. Service users who fail to return on time are also at greater risk of self-harm, self-neglect, missed medication and interruptions to treatment plans. Absconding incidents can also cause relatives and staff distress and anxiety and can lead to deterioration in the relationship between staff and relatives.
Absence from a mental health facility without permission includes both leaving the ward without permission and failure to return at an agreed time. Absconding and failure to return disrupt the ward’s therapeutic environment with staff diverted onto searches.
Each psychiatric ward typically manages 20-25 periods of leave a day – that number is rising due in part to the smoking ban. There is no universally agreed definition for absconding. In this project late return was defined as “any inpatient, detained or informal, who fails to return to the ward later than 10 minutes over the leave period that was agreed and documented by ward staff, and has not made contact with the ward to agree a later return time”.
The aim was to improve rates of safe return for detained and informal service users taking planned leave from acute psychiatric wards. The project began on one ward and has so far spread to three NHS trusts.
The programme aims to reduce the number of inpatients who fail to return to the ward at the agreed time. All acute psychiatric wards aimed to improve their return-on-time rates by 50% in one year.
The focus was on changing patient perceptions of the leave planning and management process from seeing it as restrictive to a compassionate part of their care.
The ward teams were educated in Institute for Healthcare Improvement (IHI) quality improvement methodologies. Training sessions were coordinated by the Oxford AHSN Patient Safety Collaborative. Staff received fortnightly coaching and collected weekly data.
New measures introduced included:
- Books for signing in and out
- Patient information leaflets
- Pre-leave forms
- Business cards with messages of care
- Impacts / outcomes.
Impacts / outcomes
From an initial pilot on a single ward, the first trust to take this approach has now extended it across seven adult acute and recovery wards. The return rate rose from 52% to 88% between May and October 2016, an improvement rate of 69%, well above the target of 50%. The reduction in the number of patients returning late from leave has led to a significant reduction in staff time on searching for missing patients.
The project has also prompted a policy change – the incorporation of a ten-minute search period. There are now clear procedures for absconding across the organisation with increased adherence to policy. Where patients have failed to return from leave or time away from the ward, staff have been shown to have followed the new procedures.
Staff report more discussion about leave with patients and colleagues, and that patients feel more empowered to discuss their leave. Patients’ attitudes to leave have changed, now seeing it as an important, compassionate part of their care which they are involved in negotiating and agreeing. Conversations about leave have moved from primarily concerning rules and sanctions to open discussions about the purpose and value of being away from the ward, inquiries about support while away and how to access help and support when difficulties arise.
Modern matron Nokuthula Ndimande received the 2017 Mental Health Nurse of the Year award from the British Journal of Nursing for her work on this project.
The project was featured in the 2016 PSC Impact Report and in a BMJ Open article. It was also highlighted at a number of national patient safety events.
“Through its understanding and passion for patient care and safety, and its drive and support for our teams, Oxford AHSN Patient Safety Collaborative has enabled the wards to achieve excellent success in implementing, maintaining and sustaining the safe return of mental health patients from leave using quality improvement methodology.”
Nokuthula Ndimande, Matron, Oxford Health NHS Foundation Trust
Plans for the future
Work is continuing to sustain the improved return rates and spread the approach to more wards and organisations within and beyond the Oxford AHSN region.
Which national clinical or policy priorities does this address?
- Care and Quality
- Funding and Efficiency
- Health and Well Being
- Driving Economic Growth.
Start and end dates
2014 – Ongoing
Contact us for help and advice
Amanda Garner, Senior Programme Support Officer, Oxford AHSN Patient Safety Collaborative
T: 01865 784969
M: 07825 195 888
Martin Leaver, Head of Communications, Oxford AHSN
T: 01865 784944
M: 07966 174183