In November 2015, Meridian were invited to conduct a study across the Inpatient and Community Services within this Mental Health Trust. The study identified an opportunity within the Working Age Adult and Older Adult Community teams to improve the productivity as well as an opportunity to reduce the average length of stay on the Older Adult inpatient wards. Based on the study findings and the identified opportunity, Meridian engaged in an 18-week Productivity Improvement and Behavioural Change Programme.
Meridian delivered 61 resource days on the analysis in November/December 2015. The following key areas for improvement were identified;
- There were no daily targets or expectations for percentage clinical time, or face to face contacts for any of the teams.
- The local management control system did not identify required resource levels but was based on historic team sizes and natural evolution.
- Community teams did not routinely report their performance to senior management apart from compliance with essential regulated indicators.
- There was no clear method for discharge within the Wards to ensure the timely discharge of patients once clinically fit.
- There was no management control system that systematically managed delays within the inpatient journey.
Meridian proposed a Community Team programme predicated on setting a minimum expectation of activity for clinicians according to band and role. This process was designed to enable the Trust to accurately allocate resources, numbers and appropriate skill mix, matched to the current level of demand. This ensured maintenance of quality whilst avoiding waste of financial resource.
It was proposed that working with the Executive team, Service Directors and Managers and Team Managers/Leaders, Meridian would undertake a programme to implement significantly improved management systems and behaviours. The aim of these improvements being an increase in face to face activity by each whole time equivalent. The proposed improvement was 20% across each of the community teams. The Trust would thereby release capacity among the teams and use this to offset against their required CIP savings for the year.
Within Older Adult inpatient wards, it was proposed to develop and install a robust method of discharge management to support timely discharge. As the Trust had recently undergone a programme to reduce their bed base, there were no financial savings attached to this. The method change was designed to enhance the patient experience by preventing them being held in a ward longer than necessary.
Over the 18-week programme Meridian worked with managers and team leaders to develop the new system. They worked with different management and leadership tiers to create a management control system that allows productivity to be reviewed on regular basis. The system facilitates support and effective supervision of aid managers in their allocation of work and caseload management. The system allows the management team to fully understand demand, enable equitable distribution of work and allow accurate reporting on performance. Consequently, the service can ensure their resources are best placed, allocated according to need and skill level and thereby users of the service receive the highest quality service possible. This system was achieved by installing daily operating and variance reports to record planned and actual activity, by defining the list of activities carried out by clinicians and their expected times for completion and by creating a workload calculator for each clinician to monitor how much work was required to deliver their individual caseloads. During a series of workshops, Meridian supported managers to define clear expectations/targets for their staff and designed a formal chain of reporting to senior 2 management to ensure the new systems and controls were fully embedded by there being a need to produce productivity reports.
The work with the Inpatient wards concentrated on simplifying, where possible, the administration process at admission but also to focus on discharge from the moment of patient admission on to the ward. As many of the delays centred around agreement of care packages and the finding of suitable accommodation post admission this work included considerable engagement with external agencies who play a key role in finding and providing the necessary levels of care. A new agenda for ward handovers was created to ensure ward staff were fully sighted on the actions required during the shift to enable timely discharge, estimated discharge dates (EDDs) were set for all patients upon admission and discussed during the multi- disciplinary meetings and ward rounds and a weekly discharge conference call was given a new focus to not only concentrate on delayed discharges but also on impending ones.
In both areas, Community and Inpatients, the workshop programme focused on coaching and training front line managerial staff on not only the newly created and installed management systems but also on the necessary management behaviours required to ensure the system is a sustainable success. To achieve this managers and team leaders were involved in both group and one-to-one sessions to support them though the journey. The group work included practical decision making sessions to aid the development of new controls and also role play exercises to practise new management techniques around the requirements of a new way of working. These sessions were designed to help embed the managerial and behavioural changes with the teams.
As a result of the work Meridian carried out with the Working Age Adult and Older Adult Community teams a clear system of work allocation and equitable distribution of work was achieved. The management team now have in place a reliable system for work allocation a reporting structure which allows managers at every level to have a view on the performance of teams and individuals as required to be able to fully understand how the service is functioning. Following the installation of these systems and the ability to better understand both the demand upon and capacity of their community teams the organisation was able to identify in excess of £1.4m savings annualised. These savings will be used to meet their CIP once they have restricted their service to meet changing local demands.
The wards’ process is now better aligned from admission to discharge and the installation of EDDs and the new focus on acquiring the necessary packages of care is embedded. Ward handovers are more effective and ward staff have clearer SMART objectives upon which to work during their shift.
Following this productivity improvement programme, the Trust is currently working with their finance department to align the identified savings to individual posts. This will enable the Trust to both meet their CIP and re-direct clinicians no longer required within the community service to staff new initiatives the Trust wishes to pursue, namely the Single Point of Access Team, currently under creation, and the Recovery College.