Section 136: Improve phase

The Improve phase of the Section 136 case study involved proposing actions for addressing the risks, examining these actions and selecting ones to implement, and then putting them into practice. These involved several smaller steps, as follows:

Propose actions:

Generating ideas for actions

Examine actions:

Shortlisting actions
Reassessing risk
Identifying possible side-effects
Examining other considerations
Selecting actions to implement

Implement actions:

Detailing actions
Planning for delivery
Planning evaluation

Review assessment:

Reviewing the assessment
Planning a review of the system

Diagram showing the Improve phase as part of the overall SSA process. This phase involves Propose actions, Examine actions, Implement actions and Plan further assessment.

The Improve phase of the Section 136 case study

Guidance on how to do the Improve phase can be found in the Guide part of this website.

Note: All screenshots on this page are taken from the print version of the SSA Assessment Form, so that they match the Section 136 download exactly. As a result, the screenshots of the ‘Examine actions’ page differ slightly from those in the Guide. The latter use the screen version of the ‘Examine actions’ page to allow the details of the risks to be seen side-by-side with the possible actions.

Generating ideas for actions

The group conducting the Section 136 SSA brainstormed possible actions to address the risks that had been identified in the Assess phase of this SSA. These possible actions were recorded on the ‘Propose actions’ pages in the SSA Assessment Form, as shown opposite.

The group focused on the risks rated Red and Orange. Green risks were already fairly low, so most of these were not addressed by the group - the group simply advised that current measures were continued for these situations. An exception was Risk E. Although this was rated Green, the team considered it because they were keen to minimise it further. With more time available, the group could have addressed the other Green risks, to ensure they were absolutely minimised.

Due to time restrictions in the SSA meeting, there was insufficient time to consider ideas for addressing risks H and I, even though these were rated Amber. This is not ideal, but does reflect the reality of conducting an SSA in practice. Since these were not considered, they were added to the Review Assessment section as an additional task to carry out in further SSA work.

A range of measures were proposed under all five of the risk reduction categories. For example, the group conducting the SSA suggested that the ambience of the unit could be improved to reduce patients' stress and improve their comfort, in the case of a protracted wait to be seen. This is an example of a Design control. Another example of this type of measure was the proposal to increase the height of the courtyard wall to reduce the risk of a patient absconding. Another suggestion was to ban smoking entirely. This is an example of Removal of risky processes. There was also some repetition of proposed measures due to the similarity of some of the risks.

Information about how to generate a set of possible actions is provided in the Guide section: Propose actions.

Screenshot of part of the Propose actions page from the Section 136 case study. Possible measures for reducing the risks are listed in five columns corresponding to different types of measures. The columns are: Removal of high-risk processes, Design controls, Administrative measures, Monitoring and Preparation for foreseeable risks. Measures listed under Removal of high-risk processes include stop offering the 136 service and use the facility for other means, and never take staff from other areas to cover 136 Suite. Measures listed under Design controls include using an automated process to help assess young people, and locating the unit closer to the staffing area to reduce journey time. Measures listed under Administrative measures include reviewing staffing policy and implementing changes, and improving staff training to help speed up the assessment process. Monitoring measures include using CCTV in the Suite and connecting it to the nursing station. Measures under Preparation for foreseeable risks include developing plans to manage an escalating situation, and training staff on de-escalation techniques. The full assessment form in pdf is available from the Resources page.

Actions to address the risks were recorded on the ‘Propose actions’ pages.
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Shortlisting actions

In the Section 136 SSA, many initial ideas were generated. These were rapidly reviewed by the group and most were felt to be impractical, leaving only a minority that were highlighted and shortlisted for further consideration. The shortlisted actions were mainly examples of Administrative Measures, which may not be as robust as some other options. These were chosen because more information and time were needed to devise suitable actions of other types.

The shortlisted actions were recorded on the ‘Examine actions’ pages of the SSA Assessment Form.

Information about how to shortlist actions is provided in the Guide section: Examine actions.

Shortlisted actions were highlighted on the ‘Propose actions’ pages.
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Shortlisted actions were recorded on the ‘Examine actions’ pages.
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Reassessing risk

The group conducting the Section 136 SSA examined the shortlisted set of actions for reducing risk. They estimated what the new impact, likelihood and risk scores would be if these actions were put into practice.

The effectiveness of these actions would depend on their finer details. Further development work was therefore needed before the new risk scores could be calculated accurately. Nevertheless, it was possible to give preliminary estimates, based on initial ideas, and this was regarded to be sufficient. The new impact, likelihood and risk scores were recorded on the ‘Examine actions’ page in the SSA Assessment Form, as shown opposite.

It was estimated that the shortlisted actions would reduce the risk that had originally been rated Red so that it would now be Orange. Likewise, one of the Orange risks would now be rated Green. Some of the other Orange risks were also reduced, although they stayed within the Orange risk band.

Information about how to reassess risk is provided in the Guide section: Examine actions.

Screenshot of the Examine actions page from the Section 136 case study. The columns containing the new ratings for impact, likelihood and risk are circled. For example, it is estimated that a risk B could be reduced to 8 by reviewing the staffing policy and implementing changes. The full form in pdf is available from the Resources page.

New risk scores were recorded on the ‘Examine actions’ pages.
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Identifying possible side-effects

In the Section 136 SSA (as in any SSA), the shortlisted actions for reducing risk could have undesired side-effects, which may reduce their feasibility or effectiveness. For example, some of the shortlisted actions might require more staff to be recruited or further skills training to take place.

Possible side-effects of each action were identified and recorded on the ‘Examine actions’ page in the SSA Assessment Form.

One of the shortlisted actions was to improve the ambience of the unit to reduce stress and improve comfort. This could be achieved by introducing nice furniture, decoration or equipment. However, this might get broken or ruined if a patient is violent. This had happened on one unit that had bought a nice high-tech television, which was smashed shortly after purchase.

Screenshot of the Examine actions page from the Section 136 case study. The column describing side-effects of the proposed actions is circled. For example, changes to the staffing policy may result in needing to recruit more staff or do additional training. The full form in pdf is available from the Resources page.

Possible side-effects of the actions were recorded on the ‘Examine actions’ pages.
(Image shows print version of the page)
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Another proposed action was to increase the height of the courtyard wall to 9 feet to prevent patients from absconding over it. However, it was felt that this may make the courtyard feel a bit like a ‘prison’, and the architect was very reluctant to agree to such a change.

In contrast, another action suggested a smoking ban to remove the need for patients to go outside (with the attached danger of them absconding). Although there were some concerns that this might be hard to put into practice, this ban was actually introduced very successfully after a separate SSA examined the issues involved in it in more detail.

Information about how to identify possible side-effects is provided in the Guide section: Examine actions.

Examining other considerations

The group conducting the Section 136 SSA considered various other factors when examining the shortlisted actions for reducing risk. In particular, some of the actions, such as recruiting additional staff, had cost concerns, as they could be expensive. Another action was to increase the height of the courtyard wall to prevent patients from absconding over it. However, the architect was not at all keen on this as it could spoil the ‘lines’ of the building. These issues were recorded on the ‘Examine actions’ page in the SSA Assessment Form.

Information about how to examine other considerations is provided in the Guide section: Examine actions.

Screenshot of the Examine actions page from the Section 136 case study. The column for other things that should be considered is circled. For example, changes to the staffing policy may have cost considerations. Storing spare forms in the 136 Suite means that the stack of forms will need replenishing or updating periodically. The full form in pdf is available from the Resources page.

Other considerations were recorded on the ‘Examine actions’ pages.
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Selecting actions to implement

The group conducting the Section 136 SSA then considered which actions for reducing risk they would put into practice. To do this, they examined the effect the actions were expected to have on the risk ratings, any possible side-effects of the actions and other considerations (such as cost and the architect's opinions), as mentioned above.

It was very important to select at least one action to reduce the Red risk. Some actions to address the Orange risks were also preferable, if practical. The actions that were selected to take further were highlighted on the ‘Examine actions’ page in the SSA Assessment Form, as shown opposite.

The group decided to review the staffing policy and implement changes, and to review the protocol for what should happen while the young person waits to be seen. They also decided to investigate some options in more detail: improving the ambience of the unit to reduce stress and considering a smoking ban. These would need to be specified in more detail before a final decision could be made.

Information about how to select actions to implement is provided in the Guide section: Examine actions.

Screenshot of the Examine actions page from the Section 136 case study. The actions that have been chosen for implementation or to examine further are highlighted. These include: Review staffing policy and implement changes, Improve ambience of suite to reduce stress and improve comfort, and Consider a smoking ban on site. The full form in pdf is available from the Resources page.

The selected actions were highlighted on the ‘Examine actions’ pages.
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Detailing actions

The outline details of the four chosen actions in the Section 136 SSA were copied into the ‘Implement actions’ spreadsheet. However, these actions were not specified in more detail during the main SSA meeting. Notes were made to investigate some of the actions further before deciding on them.

In particular, the idea of introducing a smoking ban to the unit was complex, and it required a further meeting to consider all the issues involved with it.

Information about how to detail actions is provided in the Guide section: Implement actions.

Screenshot of the Implement actions page from the Section 136 case study. The columns for Planned actions and Further details are circled. Planned actions are: Review staffing policy and implement changes, Improve ambience of Suite to reduce stress and improve comfort, and Consider smoking ban on site - no need to send patient outside in this case. The further details column says TBC (To be Completed) in it. The full form in pdf is available from the Resources page.

Some further detail was given on the actions on the ‘Implement actions’ page.
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Planning for delivery

The group conducting the Section 136 SSA specified some practicalities to ensure that the further assessment and selected actions were implemented in practice. These included the person responsible for each action, and when it should be done by. These were recorded the ‘Implement actions’ page in the SSA Assessment Form.

In particular, the group allocated the project manager to be responsible for ensuring that all the actions were completed. However, in order to do that, she would need to continue discussions with other members of staff. Timescales were also set for her to report back on the progress.

Information about how to plan for delivery is provided in the Guide section: Implement actions.

Screenshot of the Implement actions page from the Section 136 case study. The columns for the person responsible and the timescale for each action are circled. For each action, the person responsible was listed as the Project manager, and the timescale was the 3rd December 2010. The full form in pdf is available from the Resources page.

Some practical details were recorded on the ‘Implement actions’ page.
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Planning evaluation

Little time remained in the Section 136 SSA to consider how to evaluate the effectiveness of the actions. Despite evaluation being important, for example to demonstrate cost-savings to funders, this is a common problem. In this case it was felt that staff discussions, a more comprehensive review in the new year, and a more in-depth staff questionnaire would be sufficient to monitor future risks, alongside the Trust's incident reporting system. This was noted on the ‘Implement actions’ page in the SSA Assessment Form.

Information about how to plan evaluation is provided in the Guide section: Implement actions.

Screenshot of the Implement actions page from the Section 136 case study. The column for Evaluation measures is circled. Measures listed are: Staff discussions, staff design review in January 2011, staff questionnaire and incident forms. The full asssessment form in pdf is available from the Resources page.

Evaluation plans were recorded on the ‘Implement actions’ page.
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Reviewing the assessment

Some of the risks in the Section 136 SSA required further assessment before decisions could be made about how to address them. The further assessment required was noted on the ‘Review assessment’ page in the SSA Assessment Form, as shown opposite.

In particular, it was considered important to monitor any new risks that might be introduced as a result of implementing the proposed actions.

Earlier in the SSA meeting, it had been noted to set up another brief SSA meeting to review risks H and I. As all members had access to their diaries, this meeting was set up there and then, two weeks ahead.

In addition, the proposed action of introducing a smoking ban to the unit was complex. It was decided that another SSA at the Trust was needed to investigate the issues involved in it in sufficient detail. This took place on a later date, and illustrates how one SSA can lead to another.

Information about how to reviewing the assessment is provided in the Guide section: Review assessment.

Screenshot of the Review assessment page from the Section 136 case study. The section on recommendations for further assessment is circled. The recommendations are to set up a separate 1 hour meeting to review risks H and I, to review any additional risks introduced by implementing the actions, and to conduct a new SSA to consider the risks of introducing a complete smoking ban. The full form in pdf is available from the Resources page.

Further assessment was described on the ‘Review assessment’ page.
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Planning a review of the system

The group conducting the Section 136 SSA noted that the situation needed to be monitored once the unit was actually open, with particular attention being paid to the goals for the SSA, stated on the ‘Outline assessment’ page. These included issues around the capacity of the unit.

While this is not explicit about the triggers for a review of the system, it does indicate the kind of things that should be monitored and implies that the situation should be reviewed if these cause problems.

Information about how to plan a review of the system is provided in the Guide section: Review assessment.

Screenshot of the Review assessment page from the Section 136 case study. The box headed Triggers for review is circled. It says: Monitor the situation once the unit opens, particularly as regards item I: Capacity of the unit. The full form in pdf is available from the Resources page.

Triggers for reviewing the system were noted on the ‘Review assessment’ page.
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Section 136: Improve phase

Section 136: Improve phase

Generating ideas for actions

Shortlisting actions

Reassessing risk

Identifying possible side-effects

Examining other considerations

Selecting actions to implement

Detailing actions

Planning for delivery

Planning evaluation

Reviewing the assessment

Planning a review of the system

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