Following a successful first project within this large Foundation Trust, the Executive team decided to engage in the second piece of work undertaken since October 2014.
Since delivering financial improvements of over £286,000 annualised within Specialist Nursing teams, Meridian was invited to identify operating improvements in the Trusts’ largest service area – Community and Inpatient Mental Health services in Essex.
Meridian conducted a three-week long study, working with 9 inpatient wards (Adults, Older Adults and PICU across 3 locations), and 18 Community Mental Health Teams (including Assertive Outreach and Crisis Resolution & Home Treatment), alongside Psychology, OT and other specialties. The findings were as follows:
Community MH Teams:
- A need for appropriate management controls to measure performance and enhance the structure of care delivery/activity within teams;
- Data quality did not allow for consistent calculation of productivity, and utilisation of resource was not systematically known;
- A cultural way of working and inefficient use of resource including bank and agency hours not justified through work content;
- Average F2F contacts per worked day historically 2.2 with only 20.8% of time spent in direct clinical contact by staff.
Inpatient Wards:
- Average length of stay was longer than expected for patients without clear discharge planning;
- Discharge dates were not routinely set or known by clinicians in the care pathway;
- Delays and variances were not consistently quantified and attributed to actions required by multiple teams/functions both in and out of the wards’ control;
- The definition of delays was weak and significantly understated the true position.
The current system within Community MH Teams and Inpatient MH Wards showed a lack of control over activity, expectation, and performance.
Within a 26-week timeframe, the Trust embarked on a £2.2m improvement project including over 500 WTE across 33 separate functional teams/departments.
Within Community MH Teams and Associated Therapies (Psychology and OT), we supported the development of a range of pathways in terms of intensity and frequency of contact & support, including management controls to improve targets, plans, assignments, and reporting tools.
Working closely with the Executive, Directors and front line Service Management, Meridian engaged in a collaborative manner with the Trust to set up effective methods of quantifying demand and pathways, allowing all levels of the organisation to review treatment caseloads at a team level and activity levels across all 18 Community Teams and 6 separate Psychology & OT functions, utilising clinical activity data.
Work allocation methods were developed within Community and Crisis Home Treatment teams to enable staff to plan home visits effectively across the area whilst freeing up resource for other clinical activity such as tribunal and panel hearings, and discharge planning such as ward Assessment Unit (MHAU) visits and ward rounds/MDT meetings.
Inpatient MH Wards:
- Significantly reduce the length of stay, leading to a reduction of required beds;
Through working with Matrons, Ward Managers and the Consultant body, developed a suite of tools focused on effective patient pathway planning and allocation of critical tasks to ensure the most appropriate length of stay for each patient on the ward.
Front-line management practices and behaviours were challenged with a view to taking ownership over 2 expectations on external parties to ensure the Trust manages barriers to discharge effectively.
Meridian worked with the management team within Community MH Teams and Inpatient MH Wards through a series of meetings and workshops. During these various sessions a new management control system was designed to ensure effective running of the MH Teams and Wards.
The processes introduced and implemented gave the management of the Community MH Teams and Inpatient Wards better control over the proactive governance of the booking teams, as well as visibility on a daily basis of individual and team performance. The main results of the programme are:
Community MH Teams:
- Total annualised savings of £2.2m identified through a reduction in budgeted establishment & substantive resource requirement by 2015/16;
- Weekly agency savings in the amount of 225 agency hours/ week;
- Active management and follow-up on team performance and identification gaps.
- In Psychology, session utilisation was measured systematically through evidence based reporting at the front line, enabling management to identify gaps and reduce backlog for Community Team colleagues;
- Perpetuated workshops with Senior Management ensuring that the skills necessary to identify, measure, and realise opportunities within the Community Teams are also developed and retained within the Trust.
Inpatient MH Wards:
- Total annualised savings of £439,693 from reduced length of stay
- A reduction in the average length of stay from 99.4 days for the base period to 74.7 days – this equals a reduction of 24.8% (compared to 16% planned);
- By week 26 of the project, over 20 beds free across Adult and 21 across Older Adult wards; equating to almost a third of total bed stock, enabling better care for patients in a reduced occupancy environment and care closer to home for those discharged at the right time.
- Increased throughput of patients within the system, and an increase in staff nurse-topatient ratios as a result of reduced length of stay and occupancy.
- Weekly operational management meetings with robust patient-pathway focused reports and controls from both Nursing and Medical line management, enabling focus and attention to the needs of discharge planning at the point of admission;
- A change in behaviour to maintaining the current effective pathway of inpatient care, with a positive culture communicated directly from the Executive Medical & Service Directorate to facilitate effective patient pathway management.