In April 2015, Meridian Productivity carried out an analysis into a number of departments at a large, East Midlands Foundation Trust.
The Trust provides mental health (including substance misuse) service for adults across a large rural County. The departments in project scope included Crisis Resolution and Home Treatment (CRHT) Teams, Integrated Community Mental Health Teams (ICMHT), Adult Psychology Services (APS) and 3 Inpatient Wards.
Historically within these teams there had been limited link between demand and capacity. The Trusts’ Executive Team invited Meridian to conduct an analysis with the view that a new management system would ensure improved ways of working to increase efficiency.
During the initial study, Meridian carried out observations, meetings and interviews with staff and management across each department as well as exploring clinical activity data to establish the current level of productivity and working practices within the service. The analysis identified a number of key management procedures, either under-utilised or not in place. As a result, the current system showed a lack of control over activity, expectation, and performance.
Meridian proposed:
- A 20% increase in productivity in CRHT and ICMHT;
- New ways of working on inpatient wards leading to reduction in length of stay;
- A new methodology for allocating and booking new patient assessments in APS.
This proposal was accepted and a 20-week Improvement Programme commenced on Tuesday 5th May 2015.
Meridian worked closely with all levels of the organisation throughout the project. Management of each service attended a series of 5 group workshops (x4 Services incl. 4x Corporate & Operations Management workshops; 24 in total) and weekly 1:1 review meetings to ensure a smooth transition into the new ways of working.
Culture and behaviour change was necessary for team leaders to become true ‘operational’ managers for the service with the systems to help improve planning and review of clinical resources.
Effective allocation of work (mental health treatment for adults and those in crisis) across a large, rural, geographical area represented a major challenge across 8 locality teams; which was achieved through a robust understanding of the skills mix and travel requirements in the rural area.
This visibility of workload was agreed as a fundamental control which then developed through the project, taking into account risk, planned clinical interventions and care pathway including PbR clustering.
In addition, financial improvements for the Trust was crucial as the target for bottom line budgetary savings was set at £1.4m.
1:1 working with Service Managers & Clinical Directors enabled clinicians and operational managers to understand the clinical work requirements of patient caseloads and supported the service to ensure bespoke care plans, driven by an effective admission to discharge pathway.
Working closely with the Director of Performance & IMT, reports were created to provide daily activity reporting, allowing an evidence-based review of productivity. Review templates were also introduced for line management meetings with bespoke coaching on planning resource to match patient demand and agreeing expectations required in terms of service delivery.
Wards admissions & assessment paperwork was reduced by at least a third per inpatient stay through standardising documentation and agreeing templates across the service (i.e. between CRHT teams and inpatient wards), thereby streamlining admissions and improving clinician availability to inpatients.
As a result of the changes, capacity and demand tools were developed, providing management with an accurate understanding of the clinical resource requirement for each service given their individual demand profile.
The processes introduced and implemented allowed management at all levels a greater degree of control over service demands and resource availability. Daily reporting of team and individual activity encouraged management to proactively plan workload and follow up on performance where necessary.
The robust follow-up process was a significant change in the culture of the team and manner in which it was run. It has prompted faster decision making and actions to be taken to create a ‘steady state’ of the flow between referral to discharge throughout the services.
Daily and weekly review meetings further embedded a plan-and-review culture within the organisation across departments and skill levels.
In brief, the new system has helped The Trust to achieve the following results:
- Actual annualised savings (through reduction in substantive WTE) equated to £128,414 annualised by Week 15 of the project;
- Further identified savings of £1.3m between both CRHT and ICMHT teams to be realised through the next 12 months (commencing October 2014);
- By Week 14, ICMHT teams had exceeded 80% of service hours spent in treatment including clinical administration and travel;
- Implementation of the new group therapy approach in APS with a 50% reduction in 1:1 therapy and over 26% of new patients moving into groups, leading to a substantial reduction in the waiting list;
- More than 500 completed assessments in APS through the lifetime of the project, reducing the waiting list by a net 250+ patients in 18 weeks;
- Improved visibility of staff activity across all areas;
- Cost improvements through a reduction in time off in lieu (TOIL) within ICMHT;
- Cost avoidance through the closing of all vacancies within CRHT and ICMHT;
- Increased supervision of clinician work through effective caseload planning and pathway-focused team meetings with an emphasis on the right admission and discharges at the right time.