Following a successful first project in the Trust, Meridian embarked on an analysis in the Learning Disabilities department within the same Trust. The department operates in two different locations, offering mostly community services as well as bed-based support. There are 29.94 WTEs spread over five professions which each work under a clinical lead. There has been a steady build-up of waiting lists in all of the professions, with as many as 390 clients on one list.
Despite the extra resources that have been allocated to the service to increase capacity, there has been no change in this situation. A relatively recent split of the service from social care had some leftover expectations in the ways of working which were never intended to continue after the separation.
The lack of common ways of working and standardised processes made it hard for management to determine the cause of this state and deal with it effectively. Management has been finding it increasingly difficult to move forward in spite of an effort to redesign the system and update the reporting software used.
A thorough three week analysis took place, conducting a comprehensive review of the management control systems in place, behavioural studies and data examination. This produced the following findings:
- Despite sharing office space to facilitate collaboration and in many occasions offering interventions to the same clients, the five teams were working in silos and without a clear image of each other’s capabilities, resulting in inappropriate referrals;
- The myriad of specialties and multitude of part-time employees exacerbated the situation by frequent miscommunication which often caused duplication of work.
- The system itself was not clear in the expectations set to the employees, the demand of the clients’ needs unknown, resulting in insufficient planning and reporting.
- Each team had adapted processes to suit best its own functions and what data was available could not be readily used at the scale of the whole department.
- Management could not employ internal resources to gather, format and study the data to get a clear, overall picture of the department’s performance.
The programme sold was a 16-week long project aiming to increase the activity of the teams and eliminate the waiting lists.
Meridian worked closely with all levels of the organisation to comprehend every aspect of the operations and then design a bespoke management control system to improve the identified areas. Extensive support was also provided in the form of 1:1 sessions, workshops and regular review meetings to ensure the successful progress of the project.
By week 8 of the project, numerous developments had already taken place in the service.
The first development in the project was the unification of the five separate waiting lists into a shared template, which could display information about the length of time on a caseload, the priority for each client, set target days and the plan for treatment.
After a detailed examination of the clients on the system, the identification of ‘hidden’ waiting list became apparent. Each team had members who were trained on sub-specialisms, such as dementia and autism, and subsequently there was a large number of clients sitting on 4 additional lists that were shared among those specialists.
As a result it was extremely difficult to keep track of those clients on the system or identify the input and level of care they required from the service. Those lists were examined and eventually incorporated to the common template.
To clarify the expectations of the Trust, the job plans have been updated by the clinical leads and targets were produced for every individual. Those targets represent the capacity to serve the client demand and it immediately became evident that they were under utilised. The action taken to rectify this situation was the development of a 4-week planning tool, which 2 set a more structured way of working and created a means of measuring the performance of the teams. Additionally, the tool identified the extra capacity for each individual on a rolling basis, taking into consideration annual leave, training and other factors.
The department had recently established a Clinical Review and Allocation meeting, attended by the clinical leads to process the new clients drawing on the experience of each profession. Through the increased utilisation of clinical time by the 4-week plan it became possible to allocate clients straight from the waiting lists to the clinicians who had identified capacity. A weekly management report was developed and installed with the aim of monitoring actual against planned activity. It incorporated the targets of teams and individuals and displayed their attainment.
Through this tool there is a formal review on a weekly basis which identifies the capacity of the system and prompts action in line with under/over-performance of individuals and teams.
A caseload report has also been produced, displaying every client’s data on the system in relation to the individual clinician. This allowed for a purification of the system, as some clients had not received visits for a long time and others were forgotten on waiting lists due to unsuccessful prioritisation.
The teams also utilise a daily variance report, which outlines all the causes of lost effort and time, thus linking plan with actual. Monitoring this information has already provided insight in regards to the trends of issues obstructing the smooth operation of the department.
The processes introduced and implemented delivered a common daily way of working over all teams ensuring the standards of care were similar across all professions.
- A change in the whole system, establishing robust forecasting, planning, assignment and reporting processes, implementing and delivering a common way of working across all professions;
- A behavioural change, acknowledging the urgency to restore timely service to the clients and raise the standards of care;
- The element of planning introduced in the daily routine assists in coordinating efforts among professions and individuals, reducing duplication of work;
- As a result of capacity identified in the Clinical Review and Allocation Meeting through the 4-week plan meeting, Clinical Leads can now proactively allocate clients in a systematic way resulting in increased productivity and continuous reductions in the waiting list;
- Re-introducing the hidden lists to the system and reviewing the caseload reports has allowed management to better evaluate the needs of the clients and redeploy resources according to the new data;
- Reflecting this change the waiting list had been reduced so far from 390 clients (excluding hidden lists) to a total of 128 clients (by Week 8);
- The review of the management report introduced a higher level of transparency and control over clinical work.
- Increased activity accomplished the targets of cost avoidance resulting in significant financial improvements. Half-way through the project, direct cost per contact had decreased from £223.04 to £123.09;
- Finally, the early financial cumulative gain for the first 5 weeks equalled £52,982.