This NHS Health Board provide integrated mental health and community health services for patients of all ages across East Central Scotland. The project scope included 7 inpatient wards and a home treatment team treating patients in “crisis and emergency” as well as Adult, Children and Adolescent Community services providing care for a range of patients with mental health issues.
Prior to the project, there was no systematic way of measuring productivity, and the method for calculating productivity varied according to the service.
The Executive team invited Meridian in to conduct an analysis focusing around the productivity of those community teams and the inpatient wards; number of contacts with service users, impact on waiting times, variances across sectors, discharge protocols, length of stay and care packages.
Meridian conducted an analysis over a 3 week period starting in July 2015. This consisted of 73 resource days, including specific observations with:
- 119 patients on the wards for a full shift across 7 wards
- 73 members of staff working on their ward for a full shift
- 6 Community Mental Health Team (CMHT) staff members for a live study
- 4 Primary Care Mental Health Team (PCMHT) staff members for a live study –
- 2 Intensive Home Treatment Team (IHTT) staff members for a live study
- 2 Community Rehab staff for a live study
- 2 Managers for Time Management Studies
Alongside the observations, the Meridian team analysed system data for a 13 month period for all Mental Health Practitioners.
The analysis highlighted huge variances between teams and identified the following;
- 1.5 contacts per WTE Day within the CMHT
- 1.6 contacts per WTE Day within the PCMHT
- Rising numbers of waiting patients
- Rising number of 18 weeks waits
- Average 409 contacts per week across the service – Between 20% – 30% of community mental health worker time being spent face-to-face with patients
- No visibility for management of performance and productivity indicators within the services
- Inconsistent care plans on the wards
- Only a handful of Estimated Discharge Dates (EDD) across all patients
- Poor compliance and usage of the TRAK system in community and wards.
Meridian proposed to install a Management Report at Health Board Senior Management level, allowing the monitoring of costs and productivity at Service Line Level by the Senior Management Team highlighting variances to targets as they occur, install a resource planning tool for all community and inpatient teams to directly link activity to staff.
Meridian embarked upon a 16-week programme to address all of the points from the analysis across the district.
Working with management through workshop sessions, they set and agreed minimum level of contacts/WTE along with targets and norms for types of visits and interventions in the community.
A new management control system was developed and installed across all teams, meaning that for the first time utilisation could be measured in the same way across all services. Meridian quickly agreed and installed:
- Dashboard Reports at a team and individual level across the service which allowed managers to see clearly how their team, and its individuals, were performing against the agreed targets.
- The Management Report at Senior Management level before installing the reporting philosophy down the organisation;
- A revised meeting structure to make sure the new structure focusing on the proactive management of activities required to ensure patients were discharged on time instead of reacting to patients already overdue their discharge date.
An electronic planning and allocation system was installed to work alongside the Health Board’s core PAS system which clearly shows Service Leads, Senior Managers and Executive Leaders how many contacts each team will carry out, how many hours are required carry out the work in linking demand to capacity. The actual activity is also shown in order to review the plan against actual and necessary adjustments can take place.
A daily/weekly work allocation tool in the community teams allowing Team/Shift Leads to allocate work to staff equally and productively in line with set targets, this is then reviewed at the end of the day to follow up on any variances in order to eliminate avoidable variances.
- Weekly Schedule Review Meetings were installed with Team and Service Managers to review the work allocation tool and evaluate team’s performance in relation to the set targets.
- Daily and Weekly rundown meetings on wards were restructured to measure performance against the plan, helping to ensure that patients were receiving the appropriate quality of care in order to facilitate their recovery and discharge.
The main benefits in the organisation put a spotlight on to what has previously not been a priority such as productivity and resource planning according to the needs rather than budget.
A robust follow-up process where management assessed the team’s performance daily was a significant change in the culture of the team and manner in which it was run. This control system identified variances which had led the Health Board to be over budget year on year, and gave them the tools to identify and deal with them quickly. Information helped to underpin management decisions on service redesign and prioritisation.
The inpatient wards now had a system with which to plan the right resource to meet the demands of their patients while management of patients’ proposed discharge dates saw a rise in compliance with those measures. These changes resulted in a 21% reduction in the LoS of the acute patients on the wards during the time of the programme.
In the CMHT the volume of contacts being seen per WTE day rose from 1.5 to 2.3 contacts per day during the 16 week programme. In the PCMHT the contacts rose from 1.6 to 2.4 contacts per day within the same period.
The ability to see more patients within the same amount of resource saw the number of weekly contacts rise from 409 to 736 per week.
By increasing the productivity of the existing workforce the cost per contact dropped by approximately 30% which meant a cost saving of £1.4 million per calendar year.
This change, in turn, saw the waiting lists begin to reduce for the first time in 18 months; the number of people waiting within 18 weeks, and those waiting longer, were reduced during a period which saw the continual rise of referrals into the service.
Alongside these benefits was an identification of further spare capacity within the service of 18 WTE. By better understanding the needs of the service, including the capacity and demand within each of their local teams, the Senior Management then had the opportunity to develop the various services, create dedicated resource teams to further benefit patient care and make budgetary savings accordingly.