This NHS Mental Health Trust provide integrated mental health and community health services for patients of all ages across three London boroughs. The project scope included 10 inpatient wards and a home treatment team treating patients in “crisis and emergency” as well as community services providing care for dementia and cognitive impairment, psychosis along with Severe and Complex non-psychotic disorders.
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 ‘over-occupancy’ of inpatient units, with the view that the new systems and processes would help ensure a consistent way of working is developed, agreed and implemented in each of the locations, resources are managed efficiently to meet the demands of the service and as a result reduce length of stay on the wards.
Meridian conducted an analysis over a 3 week period starting on 17th February 2014. This consisted of:
- 16 Day in the Life (DILO) Studies in the Community, including Crisis & emergency, Psychosis, non-psychotic and Dementia & Cognitive impairment;
- 8 Inpatient Ward Studies;
- Jonah Analysis;
- 6 Consultant Interviews;
- 14 Management Control System Analyses
- 17 weeks of activity data including all 17 categories of patient contact by every clinician in each team in Community;
- 16 Weeks of e-roster, agency & bank analysis.
The analysis highlighted huge variances between boroughs and identified the following:
- A variance of 13,268 hours on the wards. This was 11.45% over target across the ten wards with the highest variance of 29% on one ward;
- Nurses in the Triage service within crisis and emergency saw between 1.4 and 2.7 contacts per WTE day (depending on Locality) meaning between 20% and 37% of time spent in direct clinical contact;
- Staff in the Crisis Resolution Home Treatment team saw between 1.4 and 2.1 patients per WTE day (depending on Locality) meaning between 17% and 20% of time spent in direct clinical contact;
- Staff in the Dementia and Cognitive Impairment team saw between 1.5 and 3.5 patients per WTE day meaning between 16% and 41% of time spent in direct clinical contact;
- Staff in the Psychosis team saw between 2 and 4.2 patients per WTE day meaning between 16% and 41% of time spent in direct clinical contact;
- Staff in the Severe complex and non-psychotic team saw between 2 and 2.5 patients per WTE day meaning between 29% and 40% of time spent in direct clinical contact.
Consultant interviews highlighted the following:
- Private beds being utilised adding additional costs;
- Key individuals not attending meetings resulting in discharge delays;
- A perception amongst some that “nothing could be done to reduce length of stay” and “there is a lack of accommodation”;
- No evidence of a robust management control system.
Meridian proposed to install a Management Report at Trust Executive level, allowing the monitoring of costs and productivity at Service Line Level by the Trust’s Executive Team highlighting variances to targets as they occur, install a resource planning tool for all community teams to directly link activity to staff, reduce numbers of categories for using bank/agency staff.
Meridian embarked upon a 22-week programme to address all of the points from the analysis across all three boroughs.
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 three sites, meaning that for the first time utilisation could be measured in the same way across all services. Meridian quickly agreed and installed:
- The Management Report at Trust Executive level before installing the reporting philosophy down the organisation;
- Reduced numbers of categories for using bank/agency staff (down from 27 to 3) on the wards to gain clear decision making, remove confusion and highlight unrequired spending;
- A revised Jonah structure while attending consecutive meetings 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 Operations Dashboard was installed which clearly shows Service Directors, Assistant Service Directors and Clinical Directors how many contacts the Team will carry out, how many hours are required carry out the work in linking demand to capacity and eliminating expensive bank and agency staff. 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
- Weekly Schedule Review Meetings were also installed with Service Managers and Assistant Service Directors to evaluate the Operations Dashboard in order to take corrective action.
1 Ward Manager in each borough was made responsible for reviewing staff availability across all 3 boroughs and to change rostering daily to ensure the efficient use of staff and eliminate unnecessary Bank/Agency shifts.
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 led the Trust to be significantly over budget year on year, and gave the Trust the tools to identify and deal with them quickly.
Additional pay hours identified through the work allocation tool within the Home Treatment Team in Crisis and Emergency Service were used to create a Rapid Response Team on the Wards. This group are dedicated to making sure patients are discharged according to plan.
The elements of the new system addressed the “additional shifts” on the wards saving 815 hours in the final week of the project.
In Crisis and Emergency, the number of hours used has reduced from 3,313 to 2,410 per week while the number of contacts seen has increased from 893 to 1,187 per week. In the severe complex and non-psychotic service, hours used has dropped from 1,679 to 1,467 per week. In the Dementia and Cognitive Impairment service, the hours used has reduced from 1,326 to 1,008 while the number of contacts seen has increased from 340 to 392 per week.