Learning from the NSW Mental Health system

The Clinical Excellence Commission has developed a deep understanding of NSW mental health services, the many challenges and contextual factors that patients, clinicians and teams are encountering, and the harms in the mental health system. The sources of information that have informed our understanding include:

  • Visits, structured interviews, survey of LHDs/SHNs
  • Identifying exemplary services in Australia and internationally
  • Analysis of incident data.

We were both surprised and heartened by how these separate sources of information led to a coherent understanding of the direction NSW mental health services (and indeed the whole of NSW Health) need to move in order to improve patient safety.

Our commitment is to continue to check-in with, listen to and learn from patients, clinicians and leaders in the LHD/SHNs. We will continue to test our understanding and developing the Mental Health Patient Safety Program to enable and support our work on quality and safety.

Case Study

Testing change in mental health services

In 2019-20, the clinical teams at Bloomfield Hospital Mental Health, Drug and Alcohol in Orange began a remarkable program of change in their delivery of services, supported by the CEC's Mental Health Patient Safety Program. Using improvement science, they came together to reflect on current practice and brainstorm better ways to engage with their clients. The results have been as successful as they have been innovative ranging from introduction of a pet companion to cooking up curried sausages, with each change enriching the daily experience of inpatients and in some wards reducing needs for seclusion and restraints.

Explore and Understand

A deep understanding of context and conditions is one of the foundations of the Mental Health Patient Safety Program approach to every step of our work.

The Clinical Excellence Commission conducted interviews and an online survey to explore:

  • the current capabilities of mental health staff in patient safety and quality improvement
  • points of focus and achievements regarding patient safety and quality improvement for patients and carers
  • the experiences of mental health staff working in NSW mental health services.

We collated and analysed the experiences of 134 mental health staff to ensure that we considered the local context and implementation considerations in the design of the program.

Leadership Forum

The Clinical Excellence Commission held a Leadership Forum on 9 May 2019. The forum was an opportunity for Senior Executives, Mental Health Leaders, Peer Support Workers and representatives from other NSW health agencies to contribute to the design of the Mental Health Patient Safety Program.

We had great representation from all Local Health Districts and Specialty Health Networks with a total of 89 attendees. Participants helped describe:

  • the current state of safety and quality improvement in NSW Mental Health Services
  • the future focus for creating the conditions to enable safety and quality improvement
  • key implementation considerations and actions to achieve the future focus
  • possible measures of success.