Meridian were asked to carry out a study of the Inpatient OT service across the Trust’s directorates after the successful completion of another project. The study showed that control of the Inpatient OT activities was weak, that patient treatment needs were not well managed with no strong link between care plans and type of beneficial activity and very little in the way of management controls. Although RiO was used, its use was very inconsistent across the directorates with no meaningful reports available.
A study was undertaken at Meridian’s expense to quantify the opportunity within Inpatient OT across the directorates. A subsequent improvement programme was undertaken with the Trust which significantly improved the utilisation of the OT group activities, as well aligning the way in which OT departments worked across the directorates and developing management controls to give more control over resources and drive an improvement in performance. An improvement of 36% (average across three directorates) in the utilisation of OT group activities was obtained throughout the lifetime of the project with further improvements expected as the new management controls became embedded.
To identify if there was capacity present to improve OT patient contact and therefore provide a better service to each of their service users, a 2 week study was carried out that focused on the management controls in each area, an analysis of the group sessions looking at the capacity and utilisation and an analysis of the patient experience. The study incorporated several methods of investigation, including observational studies, statistical analysis and face to face interviews with team members. Meridian expended. 9 resource days on this scoping phase.
A review of the use of the OT group activities across the directorates found that OTs were carrying out one to ones and groups for the inpatients and it was not a case of getting them to do more, but rather, making more effective use of the time that they were spending with service users. A lot of time was spent going round to the wards chasing after people who said that they would attend group activities, only to find that they had already gone to join in with an activity elsewhere or that they were not ready to go when it was an outdoors group. There seemed to be a lot of the OT time spent ‘pulling’ people into groups but with little support from other members of the MDT helping to push patients towards OT activities.
It was further found that there was no consistent reporting of activities. On RiO the data looked to be inaccurate with inconsistent reporting across the teams. In addition, there was no patient centred reporting to show what OT interventions the patients on each ward had received in any one week. In addition, only one directorate reported the attendance figures at each OT group. The overall utilisation of OT groups for the month we focused on was 34% leaving clear capacity to increase OT contacts without increasing the number of OT group activities or one to one interventions.
Through the analysis work carried out, Meridian concluded that there was sufficient opportunity to warrant the Trust taking action to improve utilisation of current OT activity as well as to develop management controls that would give the Head OTs far greater control over their resources and therefore to be better able to manage their budgets effectively going forwards. The Trust had made it clear that they were not looking to make savings from this project but that rather they wanted to ensure the effective utilisation of the OT resource across the Trust and improve the care and experience of the inpatients. On this basis, Meridian entered into an improvement programme with the Trust with the following key goals:
- To develop and install management controls across all directorates
- To define group session availability and patient access availability
- Implement a group performance format to show utilisation
- Agree and implement a ‘push’ of nominated patients into group sessions from members of the MDT working alongside the OTs on the wards
This was reinforced with a series of workshops held with the Head OTs to ensure that they had a clear understanding of the benefits of having a management control system that was in alignment across all of the teams, to agree targets, develop the new controls required and understand how to implement these with their teams. One to ones were held between the workshops to follow up on agreed actions and ensure that any local needs were taken into account.
An average 36% improvement against historically reported figures in utilisation of Inpatient OT group sessions, against a proposed 20% improvement.
The programme produced a clear set of management controls which generated transparency across the Directorates allowing the Strategic Lead for OT to receive reports across all teams that were in alignment. For the first time, all stakeholders had immediate access to the ‘true’ utilisation of the OT Group activities and the amount of Face to Face time (One to One and Group interventions) OTs were spending with patients in any given week or month.
As well as giving all important management information, the programme also had many successes in quality, behaviour change and improved system utilisation. These deliverables were as follows:
QUALITY
Utilisation of each group can now be clearly seen together with the costs per patient attending. This allows the Head OTs to make better decisions in how to spend their budgets when reviewing the OT groups.
Head OTs discussed with the Clinical Directors the need for support from consultants in encouraging patients to attend the OT groups that are recommended to them. There was a positive reception to this with the clinical directors rolling this down at their Consultants meetings so that OT activity gained more support from the consultants on each ward.
Booklets explaining the purpose and activities of each of the OT groups have been produced giving patients a clearer idea of what to expect by attending. These also allow consultants and nurses to gain a clear understanding of the different groups and ensure any recommendations are appropriate.
Clear management control provides Head OTs with accurate reports on the amount of Face to Face time each of their OTs or OTAs has spent with patients in any given week or month. These can be compared against the targets agreed to drive performance Group Availability guidelines developed in the workshops with the Head OTs give a clear framework for the provision of Group Activities whilst allowing for variances between the different directorates to be taken into account.
A ‘Rolling Needs Analysis’ shows the main OT needs for each service user, broken down by category such as Recovery, Social, Creative, Fitness, Life Skills etc. As assessed by the OTs. Having this information enables each Directorate to ensure that the percentage offering of each type of activity is in alignment with demand and so the groups reflect the provision of activities best matched to address the therapeutic needs of their patients.
Greater cooperation amongst the MDT with discussions taking place as to how groups are to be provided rather than just assuming it is the other discipline’s responsibility.
Cancellation protocols agreed and rolled out across each team ensure any cancellations are valid and that these are reflected on the timetables on display on each ward. They also put more responsibility on the OT for arranging cover for their groups when they are away.
SYSTEM
Implementation of the weekly / monthly management reports together with follow-up in the monthly Head OT meetings will help to drive improvement in OT face to face time with patients.
Ward round time is now captured on RiO in a consistent format across all teams and is included in the weekly / monthly reports. This allows the sometimes considerable variation in the amount of time spent in rounds to be taken into account and addressed with the individual consultants running the ward rounds.
The Head/Lead OTs can see the number of patients on each ward with OT referrals and the number of one to one and group interventions each patient has received each week, thereby ensuring that patients are receiving OT interventions in accordance with their care plan and highlighting where action needs to be taken.
OTs and OTAs are now more focused on their face to face time now that it is being reported, asking to see the weekly reports to ensure that they have achieved their targets each week.
Throughout the project, there were risks identified which had to be effectively managed. These risks, along with the steps taken to mitigate them, were as follows:
1. Risk – The existing culture. There had been a great deal of autonomy with people developing their own systems and ways of working within each Directorate and this had not previously been challenged. Each Directorate team was working very much independently.
Resolution – Working with the Head OTs together in group workshops to agree common practices and bring all of the directorates into alignment for reporting purposes, whilst spending time with each Head OT within their local area to ensure we were also adapting to the needs of the directorate and their service users. The workshops also created the opportunity to share best practice and created a better understanding of how they were each working.
2. Risk – Working from the patient’s perspective rather than the OT professional viewpoint. There was a tendency amongst the OTs to use patient feedback as the indicator of future demand, asking patients for their feedback on the groups that they had attended, what groups they would like to attend, what groups they feel they might benefit from and to gear future group timetables according to the groups that patients had stated a preference for. There were 2 key problems with this:
- A. The patients were giving feedback only on those groups that they had attended not on those that they hadn’t chosen to attend and some of the groups with a higher therapeutic value may by their nature not be the groups that patients are so willing to attend, especially so in the Forensics unit with groups aimed at treating specific behaviours.
- B. The patient may not be best placed to assess their needs and to know what therapies will be of the most help in moving them towards recovery.
Resolution – the Rolling Needs Analysis records the needs of the patients on each ward on a week by week basis from the OT’s professional point of view. Working with the Head OTs through the workshops this was rolled out and initially trialled in one directorate with good feedback from the OTs. Although there was initial reluctance from the Head OTs as they felt the group timetables should be dictated by patient feedback, the recognition that they are professionally trained to assess patient needs and lead them to recovery won through. The Rolling Needs Analysis feeds through the information from the OT perspective to show the demand for the various types of therapeutic group intervention. This, combined with the patient feedback is used when designing new group timetables to ensure the offering is reflective of both therapeutic need and patient preference.