This Yorkshire-based Foundation Trust has a number of Mental Health Services serving clients in the community, employing over 3,700 staff with an operating expenditure of £155.4m per annum. Around 115,000 people access the services provided each year.
The Trust wanted to improve the service given within their ICT and SI teams, reduce the size of the waiting list and improve the work allocation process. Meridian was invited to carry out a week-long analysis to identify causes of inefficiency, explore management and cultural behaviours and determine the main organisational needs to improve the operating efficiency of the service.
Meridian expended 14 resource days on an analysis, identifying the following key areas for improvement; – Low productivity in both services expressed as F2F contacts per clinician day (observed between 2 and 3.25 average per day (ICT vs. SI), data analysis shows 2.0 F2F contacts p/day (ICT) and 2.5 (SI); – The existing expectation of F2F contacts or targets is not fully embedded and is not a universal measure to give a true reflection of productivity;
- Lack of management control (weak team leaders/no clear direction);
- Very little planning and monitoring performance;
- Large waiting list due to expectation that current caseload cannot be discharged.
Following Meridian’s proposal, the Trust embarked on a 5-week long project to address the challenges. During this time, changes were implemented to trigger the improvement process. The project focused on designing tools and processes to improve the control within the four elements any management control system should possess: forecasting, planning, assigning and follow-up.
Management Control System elements were designed and installed throughout a series of workshops working directly with front-line clinicians and the managers as well as one-to-one coaching.
Forecast & Targets: protocols were developed to enable better patient care, discharge and note keeping/administration. Patient care targets for reasonable amount of patient-facing time per clinician were set. Norms for visit type and duration were developed and agreed.
Planning: definitions were developed for improved patient care (patient-focused needs rating, review of the rating, agreement on duration of patient contact, agreement on more focused supervision to accommodate patients on the caseload from top and bottom of need scale).
Assignment: appropriate content of patient facing time was assigned to each clinician, based on the quantity of work not number of cases on the caseload, taking into consideration patient needs, patients allocated to clinicians with inequitable amount of activity, therefore waiting list reduced.
The backlog of audits and patient reviews were brought up-to-date, with a structured and agreed process to writing and storing care notes and clinical administration, utilising the existing ICT system, and working with Information to 2 ensure the correct processes and training was given to clinicians to ensure a minimum of lost time in care-related administration and report writing activity.
Management controls were designed to enhance planning and review of care per patient and per health care professional. Daily and weekly assignment and monitoring against plan were implemented throughout the use of current (adapted) and new group meetings and individual sessions.
Follow up & reporting: management control system elements were implemented with an element of perpetuation, i.e. each level of management had set out an expectation on the next level and a review process was implemented to ensure the mechanical processes remain used and develop into full utilisation and with time become improved as the system lives and grows.
- Size of the waiting list decreased by 50% on average, decreasing within 1 team from 100 patients to just 14; – No of contacts per HCP increased by 50% in SI and 45% in ICT;
- Time spent patient facing has increased by 44% in ICT and 40% in SI as a proportion of total worked hours;
- Better control of the capacity in order to manage the demand and ordered and managed wait process has been installed in both services;
Cash benefits were also received at the end of the project, through the use of the tools and reporting methods to reduce staffing by two Band 6 WTE agency workers, without any clinical impact on care. This meets the services need to increase productivity of existing substantive staff whilst reducing reliance on agency and temporary staff.
All levels of management within the teams to Service Director have regular, structured views and evidence-based discussion regarding the admission and discharge of patients through the service on a daily and weekly basis by reviewing size of caseloads both in terms of care planning work content and clinical risk, enabling weekly admission and discharge meetings to ensure the service maintains the right level of care for the patients most in need.