Effective and Efficient Community Mental Health Services

Transcription

1 Effective and Efficient Community Mental Health Services Toolkit Version 1 May 2014 We are keen for this toolkit to represent all of our experiences across Scotland (and wider) on how to deliver Effective and Efficient Community Mental Health Services, so if you have comments on the contents or additional ideas that you think should be included we want to hear from you. We will credit any individual/team whose comments we include, so please do get in contact and help us to co-produce a document that pools the extensive knowledge that exists across Scotland. We are also keen to include more brief vignettes about teams who have successfully implemented the approaches outlined in this toolkit. So please do let us know about any work you ve done locally that you think would make a good example for any sections of this toolkit. You can feed any comments back by contacting us on quest@scotland.gsi.gov.uk. If you put Effective and Efficient CMHTs in the header it will help ensure your gets through to the right person, first time.

2 Version 1 May 14 2

3 Contents Section One Background and Introduction Background Introduction to the toolkit Section Two The Change Process Conditions for Change Change Curve Section Three Effective Practice Reliable implementation of evidence based care Effective team working Relapse Prevention Section Four Understanding and Managing your Capacity & Activity Introduction to capacity and activity Optimising capacity reducing DNA and CNA Optimising capacity skill mix Optimising capacity effective meetings Optimising capacity removing non-value adding work Optimising capacity reducing sickness rates Optimising capacity information for referrers and patients Optimising capacity clinical admin Section Five Understanding and Managing your Demand Introduction to demand Managing demand set clear eligibility criteria Managing demand goal setting, case review and caseload management Section Six Undertaking a full DCAQ Analysis Why carry out a DCAQ Analysis Practicalities of a DCAQ Analysis DCAQ Analysis Examples Section Seven Telehealth Telehealth/Telecare in the Context of Improving Services Page Section Eight Tools 107 Version 1 May 14 3

4 Version 1 May 14 4

5 Section One Background and Introduction Version 1 May 14 5

6 Version 1 May 14 6

7 Background In 2012 the Mental Health Pathway Efficiency and Productivity Report was released. The aim of the report was: To highlight key opportunities for delivering efficiency savings across mental health services whilst maintaining or improving the quality of care. To provide an assessment of the productive opportunities attached to each issue. To highlight the key actions needed to release the productive opportunities To identify any additional work that is needed nationally. This report highlighted the potential quality and efficiency opportunities attached to community mental health services and identified a range of issues attached to ensuring that these services are doing the right things and doing those things in the most efficient way. The work sat within the wider context of the Quality strategy which puts people at the heart of everything the health service does. It establishes our commitment to ensuring that the way in which people receive health care is as important as how quickly they receive it. The strategy outlined three quality ambitions. Care should be: person centred, meaning that there will be a mutually beneficial partnership between service users, their families and those delivering healthcare services. safe, with no avoidable injury or harm to people from healthcare services and the environments will be appropriate clean and safe. effective, with the most appropriate treatments, interventions, support and services `provided at the right time to everyone who will benefit and wasteful or harmful variation will be eradicated. In August 2012 the Scottish Government also launched the Mental Health Strategy The quality ambitions have been central to the development of this strategy, which aims to ensure that people with mental illness and their carers and families receive high quality, effective, safe, person centred care that is delivered as efficiently as possible. This toolkit sits within this context and seeks to provide practical guidance to enable community mental health teams to meet the quality and efficiency challenges ahead. Version 1 May 14 7

8 Introduction to the toolkit Why has the toolkit been developed? There are a whole range of resources that already exist to support services to meet the challenge of delivering better quality community mental health services with the same or less resource. However, the range of resources can feel overwhelming and leave services wondering where to start and what to use when. This toolkit has been developed to pull the key resources together in one place and provide guidance on which resource to use when. It aims to provide support and guidance to community mental health services to deliver effective and efficient mental health services and to assist them in identifying and delivering productive opportunities. It also supports the achievement of the three quality ambitions as outlined within the NHS Quality Strategy and will support services to deliver the ambitions outlined within the Mental Health Strategy. It identifies a wide range of tools already in existence and pulls these resources together that can then be used by community mental health services to support the release of the high impact opportunities. The programmes and tools which were reviewed for inclusion in the toolkit include: Quality Improvement Hub Service Improvement Tools Releasing Time to Care Resources Scottish Recovery Indicator (SRI2) Integrated Care Pathways (ICP s) QuEST Mental Health DCAQ resources Mental Health Collaborative - Improvement toolkit (MHC) Mental Health Improvement Game (MHIG) Resources Choice and Partnership Approach (CAPA) Research Papers You may have additional ideas that we could include in the future versions and we are keen for this toolkit to represent all of our experiences across Scotland (and wider) on how to deliver effective and efficient community mental health services. So if you spot something we ve missed, let us know and we can look at adding it in. We ll reference any individual/team whose comments we include in this and subsequent versions. You can feed any comments back by contacting us on quest@scotland.gsi.gov.uk. If you put Effective and Efficient CMHTs in the header it will help ensure your gets through to the right person, first time. Version 1 May 14 8

9 How to work with the toolkit The toolkit has been presented in sections to help break the work down into manageable steps. It provides guidance and ideas on how to take work forward. Some of these resources (such as relevant modules from the productive series) have copyright restrictions which mean we can t reproduce them here. Other resources are simply too large to reproduce in full within this toolkit. In these cases we provide hyperlinks over to relevant websites. Please note that a license is in place which allows all NHS Scotland staff to access the productive resources online. We hope the guidance is relatively easy to follow, however implementing the ideas requires skilled facilitation and management of change. The toolkit assumes that those using it will have a basic background knowledge on how to use and present data to inform improvement work, how to map processes and how to test change ideas at a small scale prior to full scale implementation. Therefore, if you do not have those skills in your team you may want to seek some input from your local improvement team. Ideally, you want to start with the effective practice section as this underpins all the other work. However, the reality of the current workload and financial pressures is such that you may need to do other things first to create some capacity to then start looking at your care processes and outcomes. What probably matters more is that you start somewhere that makes sense to you, given the issues you are facing locally. Within each section, the toolkit encourages you to start by assessing your current state and then use this information to inform where you direct your improvement work. This means that data, both qualitative and quantitative, underpins the approaches recommended in this toolkit. You will almost certainly need some analytical support to help you with the data presentation. In particular, we recommend that you don t start any new data collection work unless you are clear who will analyse the data. It is really demoralising for staff to put effort into collecting data and then find that nothing is done with it. Once you ve assessed your current state you should then have some useful information to guide your improvement work. Each section then goes on to provide you with ideas/guidance on addressing some of the more common issues that occur. However, we know there are more ideas out there so please do let us know if you think we ve missed anything significant. When using this toolkit please note we recognise that there is no agreed terminology for referring to individuals with mental health problems who are using mental health services. For ease of reading this document we use the terms service user and client. We hope this does not cause offence to those who prefer different terminologies. Version 1 May 14 9

10 Version 1 May 14 10

11 Section Two The Change Process Version 1 May 14 11

12 Version 1 May 14 12

13 Conditions for Change In order for a change to be successful you need to have created the conditions for change. There are tools which can help you asses the current conditions for change and point to ways to improve the conditions so that your change will succeed. These are: Force Field Analysis Skill, Will, Ideas model Force Field Analysis What is Force Field Analysis? A useful tool which can support services to analyse the feasibility of change is a force field analysis like the one outlined below. This was first developed by Kurt Lewin in the 1940 s. Equilibrium Driving Forces Present Restraining Forces Equilibrium is your present position. If the situation is static, i.e. not changing, it is because the forces inhibiting or restraining change are equal to the forces that are driving the change. Version 1 May 14 13

14 When you are describing the various driving and restraining forces it often helps to assess their relative strengths (represented by the thickness of the arrows) and to cluster them under different headings. Some useful ones, with examples, are: Driving Force Restraining Force Personal Ability to learn new skills Loss of specialist skill Intergroup Interface amongst professional groups within the team Interface amongst professional groups within the team Technological The patient administration system newly implemented has reduced the clinical admin workload significantly The new computer system allows clinical outcomes to be recorded and analysed but is complicated to use Financial Budget restrictions are limiting professional development opportunities Organisational The structure of the organisation or physical location makes joint working between two departments uncomplicated Environmental A forthcoming European Union directive will require changes in employment practices Climate for change Resources Why use Force Field Analysis? There is a skilled champion of change in the work group, The structure of the organisation or physical location makes joint working between two departments difficult A forthcoming European Union directive will require changes in employment practices The last change in the work group did not go well. The work group has too much work at the moment. Resources are inadequate This simple approach can be applied to many situations at an individual, Community Mental Health Team and organisational level and can be used in two ways: To assess the feasibility of the change and whether to go ahead or not To improve the chances that your change will be a success How to use Force Field Analysis? Assess the feasibility of the change and whether to go ahead or not o Are there too many restraining forces which will stop or stall progress? Improve the chances that your change will be a success o Improve or strengthen the driving forces behind the change o Reduce or minimise the restraining forces against the change Skill, Will & Ideas Version 1 May 14 14

15 What is Skill, Will & Ideas model? A further useful tool for assessing the conditions for change in your system is the Skill, Will, Ideas model proposed by the Institute for Healthcare Improvement (IHI): Ideas ideas about alternatives (changes to team / service processes) Will will to improve (make the change) Execution (Skill) make it real (changes in skill requirements) In other words, people need to be dissatisfied with status quo, perceive a better alternative AND have the ability to action the change. A way of illustrating this model is, in August 2012 a parishioner (Cecilia Gimenez) had the idea of restoring a prized Jesus Christ fresco. Cecilia was reportedly upset at the way the fresco had deteriorated and took it on herself to "restore" the image; she took her brush to it after years of deterioration due to moisture. Cecilia had the will, however, she lacked the skill to restore the fresco and the result was not good Version 1 May 14 15

16 Why use Skill, Will & Ideas? The model can help understand why there may be resistance to change in relation to whether teams are dissatisfied with the status quo, perceive a better alternative and have the ability to action the change. How to use Skill, Will & Ideas? Will will to improve (make the change) o If there is no dissatisfaction with the status quo it will be difficult to motivate teams to look at ideas of change. o You will need to create the conditions for change by creating dissatisfaction with the status quo. You could do this by: Ideas ideas about alternatives (changes to team / service processes) o If the team are finding it difficult to generate ideas or perceive a better alternative it will be difficult to implement change Execution (Skill) make it real (changes in skill requirements) o If the team do not have the ability to implement the change if will be difficult to take forward, test or implement any changes There are a few things you can do in order to create dissatisfaction with the status quo, generate ideas and implement change: Analysing qualitative or quantitative data to understand the current state Demonstrating changes which have made in other areas of the service or in other services and the impact they have had Version 1 May 14 16

17 The Change Curve Periods of change can be difficult for everyone involved, this is why it is vitally important for change agents, people experiencing change and leaders to be aware of the potential impact of change and how to manage this. The Change Curve (originally developed by psychiatrist Elisabeth Kubler-Ross) What is the change curve? Why use the change curve? There are a number of stages people and teams can go through whilst experiencing change as can be seen in the image above. If these stages are not managed appropriately selfesteem can be adversely impacted and change programmes can fail as a result. How to use the Change Curve? Denial & Anger Stage It is at this stage that the reality of the change is hitting home and key at this stage is communication. People implementing the change need to communicate frequently and clearly about what is happening, how it will happen, what impact it will have and how this will be managed. Version 1 May 14 17

18 People impacted by the change need to know where to go for further information or clarity if they require it. Practical tip - So if you were planning to relocate a number of community mental health services to another building you would need to have a clear communication plan which set out what, how and when your messages would be communicated and identify where staff can access further help. Confusion, Depression & Crisis Stage As people start to react to the change, they may start to feel concern, anger, resentment or fear. This can manifest itself in a number of ways such as: quietly worrying about the change or actively voicing issues. Key at this stage is emotional support to ensure self-esteem of the people involved does not remain at a low. Practical tip a stakeholder analysis would help you understand who the stakeholders are in the change and what interest and influence they would have. Therefore helping you to identify ways to engage with and manage the stakeholders expectations. This will also help you identify objections and plan to minimise and mitigate any problems that people will experience. Acceptance Stage This is the tipping point for individuals and for the organisation. Key at this stage is direction and guidance to ensure the change is implemented sustainably and staff have an opportunity to get used to the change and for it to become business as usual. Practical tip being on hand at this stage to provide clarity as needed for people affected by change and to provide encouragement as required. New Confidence Stage This is when the change becomes business as usual and everyone involved will start to see the benefits. The journey may have been rocky, and it will have certainly been at least a little uncomfortable for some people involved. Everyone deserves to share the success. What's more, by celebrating the achievement, you establish a track record of success: Which will make things easier the next time change is needed. Version 1 May 14 18

19 Practical tip celebrate the success you have achieved at this stage, perhaps by putting a poster in the team meeting room with some analysis of where you were and where you have gotten too. Perhaps the change has been that service users are seen within 4 weeks instead of 8 for assessment, this could be illustrated on a run chart and displayed for the team to be proud of. Practical Hints and Tips Readiness to change PDSA cycles can help support tests of change, please see Section Eight for more detail. The Model for Improvement consists of two parts. The first part contains three fundamental questions that need to be considered before you do any improvement work (though you can answer them in any order). 1. What are you trying to accomplish? Improvement work requires clear aims that will guide the work and keep your efforts focused. Ideally you want to be able to measure whether you have achieved your aim and for it to have clear timescales. For instance, you might be working in a service with a high Did Not Attend (DNA) rate for follow-up appointments, which means that a lot of time, is spent waiting for people who never turn up. You might decide to work on this issue and set yourself an aim to reduce the level of DNAs for follow-up appointments from 15% to 10% by October How will you know that a change is an improvement? We live in a constantly changing world, but how much of that change leads to actual improvements? And how will you know if the changes you are making are actually resulting in an improvement? Is it possible they ve made things worse? We know it s not always easy to measure the impact of what we do and all measures have their limitations. However, used appropriately, data can be really helpful. And what s the alternative keep making changes in the absence of any measurement about whether they work? 3. What changes can you make that will result in improvement? So now you know what you are trying to achieve and what data you will collect to know if you have achieved it. The next step is to think about what actual changes you are going to make to deliver those improvements. Ideally, you want to involve everybody who might have to make the change in generating ideas for change. You might also want to look at what has worked elsewhere. However, it is often difficult to know in advance what the impact of a change will be and even if something has worked in one area it doesn t mean it will work for you. This lack of certainty about whether a change will work, and a fear of the consequences if it doesn t, can lead teams to just talking over the same issue again and again and again. One way through this is to use Plan Do Study Act (PDSA) cycles to initially test the change at a small scale. Version 1 May 14 19

20 Version 1 May 14 20

21 Section Three Effective Practice Version 1 May 14 21

22 Version 1 May 14 22

23 Reliable implementation of evidence based care Why is this important? Highly efficient services that are doing the wrong things are not productive. Therefore a vital part of delivering productive community mental health services is ensuring that services are designed to meet the needs presenting using the best possible evidence. Understanding your current state Use clinical outcome data Ideally services should be routinely collecting, analysing and using clinical outcome data to identify opportunities for improvement. Clinical outcomes should be used and discussed routinely in individual practitioners supervision sessions and NHS Boards should be looking at the variance between different team s clinical outcomes and then understanding whether that variance is warranted (i.e. based on different case-mix) or is indicating opportunities for improvement (i.e. may highlight skills/training issues) In reality, very few services are in a position to do this at the moment. However, it s important for the longer term to put a plan in place as to how you will get to the point where you are routinely collecting, reporting and using clinical outcome data. Assess your current pathways against agreed standards/pathways Every service should have agreed local integrated care pathways against which you can assess current practice. If you haven t already completed work locally to develop pathways then you could assess practice against the national ICP standards which can be found in the Mental Health Integrated Care Pathway Toolkit. There are two main options here: Routine reporting analysis The ideal we are trying to reach is that any variance from agreed pathways is routinely reported and coded so that services can understand why the variance is happening. In some cases the variance will be for clinical reasons and may in fact be driven by the specific and unique needs of the service user (warranted variation). In other cases the variance will be because of service factors that need to be addressed such as the evidence based therapy not being offered because it is not available locally (unwarranted variation). Random audits However, very few services are routinely recording data that enables this type of analysis. Therefore the other option is to select a random sample of individuals discharged over a given time period and then map their journey against an agreed pathway, identifying any variance. You then need to understand whether the variance is warranted or unwarranted. For unwarranted variance, an action plan should be agreed and implemented to address it. You will need to repeat the audit on a regular cycle so that you can start tracking whether improvements are happening. Version 1 May 14 23

24 Please note we do not recommend that you assess your current state purely by mapping what staff members think happens to individuals. Whilst this can be a valuable part of assessing your current state, you need to test this against what actually happens to individuals Assess the recovery focus your services by using SRI2 When assessing your current state, it is important to get a sense of how recovery focused your services are. The SRI2 tool provides a way of assessing your current state in relation to the recovery focus of your teams/services. It provides the opportunity for people who provide the service, and people who use the service along with their carers, to rate aspects of the service against ten recovery indicators. This results in stimulating and reflective conversations, leading to an action plan which is then fed into the web based tool. The resulting service improvements can be recorded and celebrated, and the next SRI 2 scheduled, thus ensuring continuous improvement and service development. Delivering reliable implementation of evidence based care If your current state analysis has identified opportunities for improving your delivery of evidence based care, you then need to put a plan in place to address these. Approaches that you may find useful are: Using the Model for Improvement to test ideas at a small scale prior to then rolling out those that are successful. Routinely auditing a random selection of case notes to identify whether you are managing to reduce unwarranted variation. Using run/control charts to identify statistically significant changes. Using project management techniques to ensure actions are followed through. Ensuring discussions on outcome data are routinely included as part of clinical supervision. You will find more information on the first four of these approaches in Section Eight. Please note, due to the overlap in the actions you need to take to assess your current state, we recommend that you take forward this work in parallel with work to remove duplication and non-value adding steps (see page 41). Version 1 May 14 24

25 Effective team working Why is this important? Research has shown that when decisions and actions made within a CMHT have the participation and involvement of all team members, including service users and carers, the care which is delivered is of a higher quality than those decisions and actions made by an individual or by one discipline. 2 Understanding your current state Team questionnaires can be a really useful tool to assess your current team working and identify opportunities for improvement. Recent research funded by the National Institute for Health Research 3 has led to the development of tool to assess the effectiveness of team working in Mental Health. A copy of this for information only (this is a copyrighted tool) is included in Section Eight. This tool is based on the Aston Team Performance Inventory (ATPI) and 20 item CMHT effectiveness scale. The ATPI can currently be completed online for a flat rate of and more information can be found at The Aston Organisational Development Ltd is currently deciding whether to make CMHT version of the ATPI available to a wider audience. Please see Section Eight for more information. 2 West M, Alimo-Metcalfe B, Dawson J, El Ansari W, Glasby J, Hardy G, et al. Effectiveness of Multi-Professional Team Working (MPTW) in Mental Health Care. Final report. NIHR Service Delivery and Organisation programme; As above 4 Price quoted at 8 October 2012 Version 1 May 14 25

26 Ideas for improving the effectiveness of your team working The following points have been lifted directly from research carried out by Michael West et al. 5 The research was funded by the National Institute for Health Research and was carried out in three stages, it involved: Establishing the characteristics of Multi-Professional Team Working. This involved a range of key stakeholders including services, service users and carers. A survey of 135 teams from 11 trusts within England. The survey included the 100 item Aston Team Performance Inventory (ATPI) and 20 item CMHT effectiveness scale Ethnographic studies and observation of team meetings across 19 teams taken from stage two of the study. The research found that the following areas impact on team effectiveness and should be considered when teams are analysing what they need to focus on in order to become more effective. The following are listed in the order of priority identified in the research: 1. Clarify purpose and function of CMHT s Clear specification of purpose and team objectives was found to be a key area for good team design. When these are clear, team members can shape and develop clear roles and ways of working interdependently and effectively. Where local needs assessment reveals a need for a more generic service, particular attention will need to be given to clarifying team objectives. 2. Provide good leadership Good leaders continually clarify vision, purpose and team objectives and help team members clarify their individual roles and objectives. They also manage the organisational context; negotiate for appropriate resources; lead inter-team cooperation and manage change effectively. They have an engaging leadership style; ensure time and space for away days and reflection space; manage meetings effectively; and manage intra and inter-team conflict; they involve users and their supports; and value diversity within teams. The findings from the research reveal the central importance of honest, trusting and respectful relationships at all levels: between users and team members, between team members, between team members and their managers, and between team members from different teams. 3. Actively manage team composition and processes Team members knowledge, skills, experience and, as importantly, values and attitudes, must fit well with the demands of the team task. Team processes should also be designed to ensure that practitioners receive constructive and useful feedback, through clinical review meetings, peer support, supervision and appraisal. 5 West M, Alimo-Metcalfe B, Dawson J, El Ansari W, Glasby J, Hardy G, et al. Effectiveness of Multi-Professional Team Working (MPTW) in Mental Health Care. Final report. NIHR Service Delivery and Organisation programme; 2012 Version 1 May 14 26

27 Diversity within teams is an asset where there is a norm of positive attitudes to the value of diversity for team innovation and effectiveness. Of most importance is ensuring information on outcomes and experience of end users continuously informs team improvement. 4. Promote inter-team working This involves having structures and processes in place that reduce inter-team conflict, as well as protocols for transfer of individuals to other teams that promote cooperation. Organisations must encourage inter-team meetings, and promote strong, positive identification with the wider aims of the organisations. 5. Ensure reflection and adaptation Teams require opportunities for reflection in order to develop their skills, improve their processes and continuously improve their productivity and the quality of care they provide. They should have sufficient autonomy to innovate within safe boundaries. Leaders should help teams to create space for reflection on team objectives and processes. Such time must be defended and factored into considerations of team capacity to meet local demand. 6. Hold effective team meetings We recommend that all mental health teams ensure their meetings are effectively chaired and structured around a clear written agenda tightly linked to team objectives. Service for users should be the central theme of most meetings. The usefulness and effectiveness of meetings should be regularly reviewed. More guidance and related tools can be found in the section: Understanding and Managing Your Capacity; Optimising Capacity Effective Meetings on page 55 of this toolkit. Clinical Supervision Research has also shown that having access to regular clinical supervision and having the opportunity to reflect on practice can enhance the effectiveness of clinicians and team members. It can reduce staff burn-out, increase job satisfaction and increase staff morale. Staff within the team need to have access to supervision which supports them with clinical work and team development. They should have access to supervision which is reflective of their caseload mix and the interventions they are delivering. (Onyett, S. R. Revisiting job satisfaction and burnout in community mental health teams. Journal of Mental Health. 2011;20: ) Role Clarification A Community Mental Health Team is made up with a range of professionals groups. Each discipline will deliver specific interventions which are role specific and there are individuals who will have roles other than clinical within the team, for example they will provide a managerial and or leadership role to the team. Research has shown that conflict can exist within teams if team members are unclear about each other s roles and this can impact on the environment and climate of the team. It is suggested that time is allocated to look at the human dimensions within a MDT. There are a range of techniques which will facilitate this and your organisational development department should be able to support you with this work. Version 1 May 14 27

28 Relapse Prevention Why is this important Community Mental Health Teams (CMHTs) should be working towards maximising the recovery of individuals and should be working with individuals to develop plans which will help them to stay well and prevent a relapse. The care which is delivered should be person centred and teams need to work collaboratively with service users and carers in the design of care packages. Relapse prevention work can support teams to achieve the above. It is an important intervention because it empowers the individual; it involves them in the planning of their care and it can act as an educational tool for both the individual and the care provider as both will develop a better understanding of the illness. This includes the triggers which may increase the likelihood of relapse, the strategies which can be implemented to prevent relapse and the potential need for crisis in-put or admission. It is also important for the clinician because it can support them in their decision making and discharge planning Relapse prevention work should be part of routine practice within CMHT s. Having a plan which has been developed by the individual which is then shared with key people is evidence of an effective and efficient community health team. Understanding your current state Assess current relapse prevention practice across the team: Carry out a case note audit to identify evidence of relapse plans. Carry out a skills analysis to identify training needs The aim of this is to provide the team with a clear picture of who is doing what with regards to relapse prevention work and how it is being delivered. This exercise will act as a method for identifying current skills and practices and where there may be gaps in both knowledge and skills within the team. It is also important that community mental health team identify what current practice is across their board area. There may be areas of good practice which teams can learn from and adopt. There are examples of relapse prevention guidelines and campaigns which teams may find useful to improve and guide practice. Version 1 May 14 28

29 Delivering Relapse Prevention Practice IRIS, Early Intervention in Psychosis have developed a suite of guidelines for the care and support of people experiencing a psychosis in early life, one of the guidelines is about having a relapse prevention strategy in place. The Think Twice campaign developed by SANE provides a step by step guide on why relapse prevention work is important to the individual and to their carer s, it also provides a template which can be completed and used by the individual and can be shared with those involved in the provision of care and support. The British Journal of Psychiatry also published a report, Enhanced relapse prevention for bipolar disorder by community mental health teams: cluster feasibility randomised trial, The outcome of the study was that training community mental health practitioners to deliver enhanced relapse prevention interventions for people with Bi-polar disorder improved the outcomes overall for those individuals compared to those who received treatment as usual. Version 1 May 14 29

30 Version 1 May 14 30

31 Section Four Understanding and Managing your Capacity and Activity Version 1 May 14 31

32 Version 1 May 14 32

33 Introduction to capacity and activity What is capacity and activity? Capacity is the total resource you have available to do the work. This includes staff with the right skills and any equipment needed (such as rooms). Activity is the actual work done. It is different from capacity as you may have the ability to see 12 service users in a week but only see 10 of them as 2 of them do not attend (DNA). So your capacity was 12 but your activity was 10. This section provides guidance on understanding how the team currently spend their time and provides ideas for actions you can take to optimise the time available for client work. However, in mental health, there are times when the problem is not lack of staff but lack of rooms to see people in. Hence you may also need to do work on assessing and maximising room utilisation rates. Why look at capacity and activity? By looking at and analysing your current capacity and how it is being used (activity) you can: identify opportunities to increase the amount of time spent in clinical work improve staff morale. Practitioners don t enjoy wasting time on activities which aren t adding any benefit to the quality of service they deliver and prefer spending their time either in client work, developing the service or their own skills. analyse whether the service has enough staff to cope with the current workload. ensure you are making effective use of your current staff resources. If you have too much work to cope with then demonstrating that you are making effective use of your current resource is a vital part of making a legitimate case for more resources. work more efficiently as a team. If your team spend 50% of their time on clinical work (not unusual for a CMHT) then every additional hour you can redirect to clinical work is the equivalent of 2 hours if you bought it in as new staff time. Why is that? Well, let s say you ve worked out that your team needs 20 hours more clinical time. You couldn t just employ someone part time for 20 hours as you know that 50% of a staff member s time is spent on non-clinical work; so you would have to employ 40 hours more time to get the 20 hours of clinical work. However if you can create that 20 hours by stopping doing something else, then you only need to find 20 hours. Version 1 May 14 33

34 Measuring capacity and activity When assessing your current capacity and activity we recommend that you break it down into three broad categories: Direct Client Contact time spent with clients doing assessments, interventions, group work or time in case conferences where the client is present. Indirect Client Contact includes clinical administration duties, clinical meetings and clinical supervision. Supporting Activities covers all other activities such as travel, business meetings, training etc. Using job plans to measure capacity Ideally, you want to use a job planning system to identify how a staff member should split their time over the week. A job plan should clearly identify how much time is available for direct client contact. Further, to enable effective management of the service you need to know how much of that time should be spent seeing new assessments and how much is allocated for follow-up work. The DCAQ tool (see Section Eight) will undertake these calculations for you but a rough ratio can be worked out by looking at your average new to follow-up ratios across your team (see Section Eight for more guidance on calculating these). An example of a job plan in mental health is shown below. am pm Mon Assessments / follow-ups Clinical supervision Tues *MDT Case Discussions Meetings / Project Work Wed Assessments / follow-ups Assessments / follow-ups Thur Receiving clinical supervision / Assessments / follow-ups clinical admin Fri Assessments / Follow-ups Duty * Multi-disciplinary Team Time for writing up case-records is built into the assessment/interventions sessions at the end of every appointment. Three service users can be seen per assessment/intervention slots. Of the fifteen in total per week, two of these will be new assessments and thirteen will be follow-ups. Job plans are already routinely used by consultant psychiatrists (they are a mandatory requirement of the consultant contract and the categories/advised splits in time are laid out in national guidance). Many psychology services in Scotland have moved to using job plans and some community psychiatric nursing services are now implementing them as well. For CAMHS services, most teams have moved to using job planning as it is part of the CAPA model. Entire team completing job plans [provides information to effectively calculate how much time is allocated for direct client work, indirect client work and supporting activities. Version 1 May 14 34

35 However, to work out how time is actually being spent you will need to feed in some further information and adjust for sickness, annual leave and special leave. Measuring capacity without job plans If you don t have job plans then you can still work out your team s capacity for client work by collecting the data outlined in Table 1. By taking the total time available and subtracting all of the indirect client contact and supporting activities identified in Table 1, you will find out how much time is left for direct client contact. This is the approach used in the Capacity Calculator and Mental Health DCAQ Tool. So, if you enter this information into either of these tools they will automatically work out for you how much time you have available for client work. For more information on how to access these tools please see Section Eight. Table 1: Data for capacity analysis for a whole team What information do I need? Number of Staff Annual Leave (average days per person) Where can I get it from Your team s budget statement should tell you how many whole time equivalents (WTE) you have. Some services refer to these as Full Time Equivalents (FTEs). You can work this out accurately by adding up everyone s individual annual leave entitlement and then divide it by the number of Whole Time Equivalents. Special Leave (percentage) Special leave covers leave such as carer s leave, parental leave and compassionate leave. Sickness Absence (percentage) Time spent travelling per week (average hours per staff member) Alternatively you can estimate knowing that the maximum for staff on A4C is 41 days. You should be keeping records of special leave as it is recorded as part of most departmental payroll returns. So you may be able to get a figure from your HR or payroll department. If not, you could trawl local staff attendance records to work it out. Alternatively you can use an estimate as an interim though we would recommend that you do start recording and analysing this. You should be keeping records of sickness absence. Achieving sickness absence rates to 4% or below is a HEAT target so every board will have this data. Hopefully your Boards data systems will let you see this figure at a team level. If, not your line manager or local IT administrator for guidance If you don t have a way of monitoring this for your team monthly you need to put a system in place. Some teams collect actual data on amount of time spent travelling if you do then this will be the most accurate figure to use. However, if you don t record this then there are other ways of working it out for those who drive. If the majority of your staff use motor vehicles, then the simple way to work this out is using the formula from the Wiseman Workload Version 1 May 14 35

36 What information do I need? Average days spent in training per year Average hours spent at meetings per week Average hours spent at supervision per week Average hours spent on clinical admin Average hours spent on other This is the catchall for any regular commitment that is not captured in any of the above. Where can I get it from Management Tool. We suggest you take 3 months worth of completed travel expenses for the team and from this work out the total mileage. Then divide this by the number of staff. This will give you the average per staff member for those 3 months. If you then divide that by the number of weeks in your 3 month period (will be around 12 weeks). This will give you average miles per staff member per week. Average miles covered each hour by community staff are 36 (see WWM Tool for further info). So you take your total weekly mileage and divide it by 36 and this will tell you on average hour many hours a week are spent travelling. If staff spend a lot of time using public transport then you will need to do an audit of how much time is spent travelling. A months worth of data is probably good enough. You should have good enough training records to be able to work this out. This is probably best collected through a diary audit on how staff spend their time over a minimum of a month. If you have set supervision arrangements then you can take a fairly accurate estimate from this (e.g. you might have an agreement that every staff member has 2 hours supervision a month). Alternatively a diary audit of how staff are spending their time will tell you this Please note that the DCAQ Tool asks you to estimate how much clinical admin is associated with each client contact and then automatically works out how many hours per week you have for seeing clients. The Capacity Calculator asks you to input an estimate for the total time each week spent on clinical admin and then works out how many hours you have left for seeing clients. Work out the total other commitments per week for all of the staff and then divide this by the number of WTEs to get your average per staff member. Version 1 May 14 36

37 Doing Capacity Sums Now you need to use the information you have collected to work out how much time you have available to do clinical work. The easy way is to use the QuEST Mental Health DCAQ Tool. You enter the data; it does all the sums for you, and gives you the answer at the other end. Information on how to access this is available at: However, we know that some of you will want to know how to do the sums yourselves, so we ve included the following example. Example Application Step 1 Write down a list of all your clinical staff and how many hours they work. Name Professional Hours Harry CPN 37.5 Sally Psychologist 18.5 Step 2 Ask each member to keep a record of their work for two weeks. Use this to work out the amount of time (in hours) spent on direct clinical work. Also record: meeting time, clinical admin, supervision, CPD/training, travelling and any other relevant categories (for instance if you spend a couple of hours a week doing a piece of improvement work). For example, Harry, who is contracted to a 37.5 hour week, spends two weeks keeping a record of what he does. He allocates hours spent to a few main categories as follows: Harry s record of work Hours (2 weeks) Average hours spent per week Direct clinical work Clinical admin 12 6 Training/CPD 4 2 Supervision 2 1 Referral meeting 4 2 Team meeting Travel 10 5 Totals Step 3 Adding it all together to get the teams capacity. The following table shows the results of all team members record of their average weekly time allocation. Harry Sally Thelma Louise Totals Direct clinical work Clinical admin Version 1 May 14 37

38 CPD Supervision Supervising Referral meeting Team meeting Travel Totals To calculate your capacity you first need to take into account annual leave, sick leave and special leave. On average one day per week is already accounted for by annual leave and sickness (no one works 52 weeks a year). It can help to remember this when you are thinking about your capacity: a full time staff member is only there for an average of 4 days a week, not 5 days. We will do all our calculations in the following examples based on a 42 week year as we ve made the following capacity assumptions: 8 weeks leave and 2 weeks sickness (4%) per annum. At its simplest, the team s clinical capacity is the sum of the clinical hours. So using our example above, we have 64 clinical hours per week which equates to 2688 a year (64 x 42) and 224 hours a month (2688/12). If the average number of appointments per case is 8 and each appointment takes 1 hour then the average demand per case is 8 hours. This means we have a total team capacity of 28 new cases a month (224/8). HELP! That sounds complicated Let s break that down then step by step Each referral is seen an average of 8 times for one hour a time. This means in total each referral has 8 hours (8 x 1) of clinical contact time. You ve got 224 hours a month of staff time available to see patients (you ve already adjusted for time spent doing other things). So to work out how many new cases you can see a month simply divide the total amount of clinical time you have (224) by the total number of clinical hours you spend with each referral (8). This equals 28 new cases a month. HELP! That still sounds complicated We ve already mentioned the new DCAQ tool that will help you with this, all you need to do is to enter the data you have collected and it will do all the sums for you. Version 1 May 14 38

39 Supporting Activities Indirect Client Contact Direct Client Contact Understanding how time is actually spent (activity) If you don t use job plans then you will need to find a way to find out how staff are currently allocating their time. If you do use job plans, you will still need to check if what is actually happening is the same as what you think should happen. You can measure direct client contact time using an activity audit or undertake an analysis of activity data from your IT system. This will enable you to get a more in-depth understanding of the breakdown of direct client contact time. Further, you can customise the activity tracker to also pick up additional information such as intensity levels for those in therapy etc. which can provide useful information for work on skill mix. Ideally you want to get to a position where your routine activity data provides this level of information and hence you can get activity analysis reports directly from your information systems. However, at the moment most community mental health services can only pick up this level of information through doing an activity audit. The following graph illustrates the kind of information you can get back from an activity audit. We recommend that each staff member completes the analysis for 10 working days. A more detailed analysis can be found on the QuEST website by following this link. Figure 1: Example of analysis into how staff capacity is split Percentage of average hours per week by activity - All Staff Nurses Individual Follow-up Other Assessment 5% 4% 18% Case Review with Client present Group Therapy Clinical Admin Other Clinical Meeting Attendance 1% 0% 7% 10% 25% Telephone - other agency Supervision Case Review without Client present Travel Non-clinical Meetings 5% 1% 1% 3% 15% Other Non-clinical Admin Training CPD 1% 1% 1% 0% 5% 10% 15% 20% 25% 30% Percentage of hours per week In addition to looking at how staff are spending their time, you will also want to look at how many client sessions are not used due to DNAs and CNAs. This is such a major issue for mental health services that we have included an entire section on this later on in this toolkit. Version 1 May 14 39

40 Tools to support your capacity and activity analysis There are a number of different tools you can use to help you in assessing how your team currently spends its time, depending on the level of detail you want to go into. The capacity calculator and the DCAQ tool are set up so that, if you enter the relevant data, they will then automatically tell you how much time you have available for direct client contact. The Mental Health Activity Tracker requires you to also collect information directly on client contact time. Tool Purpose of Tool Example of how could be used. QuEST Mental Health Activity Audit This tool provides a detailed snapshot audit of how staff are currently using their time and: 1. identifies opportunities for releasing time from activities which don t add value back into clinical time. 2. collects the following key data fields to help set the assumptions for a full Demand and Capacity analysis: Average length of clinical contact time and clinical admin for new assessments Average length of clinical contact time and clinical admin time for follow-up assessments Average length of clinical contact time and clinical admin time for group work Time spent in case conferences Time spent travelling Time spent in meetings Time spent giving/receiving supervision Time spent in allocation meetings Other (Please note that a number of these fields can also be collected in other ways please see the Data Summary for DCAQ work in Mental Health for further information) One team audited their time and found that 7% of it was spent in non-clinical meetings and 25% on clinical admin. This then led the team to do a more detailed review of meeting activity both in terms of who was attending what but also how effectively meetings were being run. It also highlighted that further more detailed work needed to be done around the amount of time spent on clinical admin. The team identified a range of activities that staff were doing that could have been done by dedicated admin and calculated that 0.5 WTE of Band 3 admin investment would release 0.75 WTE of Band 7 clinical time. When some additional hours became available in the clinical budget these were moved over to fund admin which resulted in a net overall increase in clinical activity. The team also used the data from this audit to help populate the DCAQ tool. Using the scenario function on this tool they identified that if they managed to reduce DNAs from 25% to 10% then they should be able to cope with the demand presenting. They then went on to apply Version 1 May 14 40

41 QuEST Mental Health Capacity Calculator Wiseman Workload Measure Would expect this to be used approximately every 6 months for a 10 day sample audit. A comprehensive sample analysis is available on the QuEST Mental Health website. The capacity calculator is a simple spreadsheet tool that enables you to do a quick estimate of how individual staff members are spending their time. It is useful for highlighting just how much time is lost to non-direct clinical care work. It allows an individual staff member to enter estimates for the time spent on different activities in units that make intuitive sense (e.g. training is days per year whilst meetings is hours per week). The tool then converts everything into hours per week. Further the time taken for all other activities is subtracted from the overall time available to derive the amount of time available for direct client contact time. This tool is focused at an individual practitioner level and enables individual staff to better understand and manage their current workload. It is designed to be used on a recurrent basis within the context of individual line management supervision. known techniques for reducing DNAs and managed to successfully reduce DNAs to 6%. This meant they were now able to cope with the demand presenting. A one off investment enabled them to clear their waiting list and they were then able to keep on top of the on-going workload. One team used the tool to estimate the amount of time they had available for direct client contact. The estimate showed on 30% of their working week was spent on direct client work. This really surprised them. They weren t sure whether their estimates were accurate but now they were motivated to do a more detailed activity audit to find out how they were actually spending their time. One team who started to use the WWM on a regular basis found that it significantly improved the quality and focus of the discussions within the line management supervision process. Because it adjusts for dependency levels it highlighted that a couple of staff had caseloads that were too high, even though on pure numbers alone they had looked ok. It also highlighted that one nurse whose caseload looked high on numbers actually had spare capacity due to the low dependency levels. Six months after introducing the team sickness levels had reduced and staff reported that they felt less stressed, more in Version 1 May 14 41

42 Job Planning QuEST Mental Health DCAQ Tool Job Planning is a well-established mechanism for planning the use of consultant psychiatrist time. A number of areas are now rolling this out across psychology, AHP and nursing services. Job plans recognise that an individual clinician will have a mix of activities including appointments with clients; time spent in supervision, time in meetings and in some cases will also carry project management roles. A job plan simply spells out what % of time is expected to be spent in each key area of activity. This may be different to how much time is actually spent in practice on different activities (which the activity audit will tell you). For staff whose division of time is planned in advance, it identifies where they are on any given day (e.g. Monday morning ward round, Monday afternoon clinical admin and supervision etc.) This tool helps teams to look at their overall demand and consider whether they have the enough capacity to meet this demand. It also enables teams to model the impact of changes at a team level such as sickness levels, DNA rates, how often clients are followed up and how much work is seen individually or in groups. Depending on the quality of the data used and whether you have managed to appropriately segment client groups there may be large margins of error. However, even in these situations the scenario modelling function is useful for identifying the higher impact issues to address. control of their workload and that their manager better understood the challenges they were facing. Where job plans exist these will give you the capacity for face to face client work as they should indicate how many hours per week are allocated to this. This may be different to actual time spent in face to face client work (which is the activity). A mismatch between capacity and activity indicates an issue for further investigation and may be due to other duties infringing on the client time or may be due to issues such as high DNA rates. Please see DCAQ Tool Guidance Resource for example of how used. Version 1 May 14 42

43 This tool is still in prototyping test phase and is available on request from QuEST Mental Health Team. Ideally, we would want all the tools used in capacity analysis work in mental health to align and use the same categories. Unfortunately this has not been possible for a range of reasons. However, Table 2 shows how the Consultants job planning categories and the Mental Health Activity Tracker map across to each other. As the Wiseman Workload Measure is also used by a number of community teams to help with managing caseloads and use of individual staff time, we have also highlighted how the categories used in this align with the other two approaches. Version 1 May 14 43

44 Table 2: How the different tools used for capacity work in Mental Health align Category Consultant Job Planning Activity Tracker WWM Guidance New Assessments Direct Clinical Care (DCC) Direct client contact (new Direct Care assessment) Follow-up contact Direct Clinical Care (DCC) Direct client contact (followup) Direct Care 6 Group Therapy Direct Clinical Care (DCC) Direct client contact (group) Direct Care Direct contact with carers Direct Clinical Care (DCC) Direct client contact (carers) Indirect Care including telephone conversations Case reviews where client Direct Clinical Care (DCC) Direct client contact (case Indirect Care is present review) Clinical Admin including telephone to other agencies Direct Clinical Care (DCC) Indirect client contact -clinical admin Indirect Care Multidisciplinary Team Meetings about client care e.g. case reviews where client not present Clinical Supervision Direct Clinical Care (DCC) Indirect client contact - clinical meetings Indirect Care Direct Clinical Care (DCC) Indirect client contact clinical Role Agency Tasks (check) supervision Travel for clinical work Direct Clinical Care (DCC) Supporting Activities - Travel Travel Travel for supporting professional activities work Supporting Professional Activities (SPA) Supporting Activities - Travel Travel Receiving Training/CPD Delivering Training/CPD Audit Appraisal Research Clinical Management Clinical governance work Non clinical admin Non clinical meetings Supporting Professional Activities (SPA) Supporting Professional Activities (SPA) Supporting Professional Activities (SPA) Supporting Professional Activities (SPA) Supporting Professional Activities (SPA) Supporting Professional Activities (SPA) Supporting Professional Activities (SPA) Supporting Professional Activities (SPA) Supporting Professional Activities (SPA) Supporting Activities Training CPD Supporting Activities Training CPD Supporting Activities - Other Supporting Activities - Other Supporting Activities - Other Supporting Activities - Other Supporting Activities - Other Supporting Activities non clinical admin Supporting Activities non clinical meetings Role/Agency Tasks Role/Agency Tasks Role/Agency Tasks Role/Agency Tasks Role/Agency Tasks Role/Agency Tasks Role/Agency Tasks Role/Agency Tasks Role/Agency Tasks Sickness Not included Sick Leave Not included Annual Leave Not Included Annual Leave Not Included Other Leave Not Included Other Leave Not Included 6 The MH Activity Tracker allows for this category of work to be broken down further either into intensity of psychology therapy as per the matrix or into categories set locally by the relevant team. Version 1 May 14 44

45 Version 1 May 14 45

46 Ideas for making better use of your current capacity Your current state assessment will give you information on how much time you currently have available for client work and how staff are currently spending the rest of their time. This will help you identify where you might want to focus some more detailed work to release time for client work. The key issues that tend to come up from undertaking an analysis of current capacity are: Time spent in meetings and the need to streamline who attends which meetings and improve the effectiveness and efficiency of meetings. The amount of time clinical staff are spending on administrative tasks, some of which could be performed more efficiently by administrative staff. The amount of time spent on non-value adding activities such as un-necessary travel, un-necessary data collection and process steps that add no value to patient/staff experience or deliver no organisational benefit. Sickness levels and the impact these have on your capacity Level of DNA and cancellation rates. Questions about whether the current skill mix of the team is right. The following sections provide some more detailed guidance on how to assess the level of productive opportunities under each of these headings and some ideas on actions you can take to release/resources back for clinical work. Version 1 May 14 46

47 Example of application - NHS Borders In an analysis of time spent on various activities, the time spent travelling was raised as an on-going issue. When working in rural areas, travel becomes a necessary part of clinical work, but there are ways to minimise travel through effective job planning. The monthly miles travelled per staff member were extracted from the electronic expense claims. The raw data figures and average miles travelled per month were presented to the team in a table along with an estimation of time spent travelling. As no interest was sparked with the data displayed in such a way, the map was created to give team members a concrete comparison of distance covered each month. In the average month a team member can travel the equivalent of base to Amsterdam. This observation can have a stronger effect than the figure of miles travelled; 683 miles on average for one clinician. The graphic generated an immediate chain of s between managers and senior clinicians discussing the perspective that this image brings and requesting a graphic to be created for other teams. In response to the image, the team involved have embarked on an evaluation of job plans and clinic space. New team members are being encouraged to consider the division of clinics and necessity for home visits. Further analysis will be carried out in the near future to assess the impact of these changes. Jane McLachlan - Jane.McLachlan@borders.scot.nhs.uk Version 1 May 14 47

48 Optimising capacity - reducing DNA and CNAs Why is this important? A large proportion of appointments in mental health are lost each year due to service users not attending or cancelling their appointments. Whilst many staff use this time to catch up on clinical admin, s or other work, as you cannot predict when it will happen and therefore it is not the most effective way to manage time and can actually put additional stresses in the system when service users don t DNA (if for instance the staff member was hoping to use some DNA time to pick up an urgent issue). Further, not all staff will have access to the resources they need to make the best use of the time when a service users DNAs (e.g. , relevant case notes etc.). Finally, you are occupying a clinical room unnecessarily that a colleague might otherwise be able to make use of. Understanding your current state Calculating your DNA rate You need to know as a service how many appointment slots were offered over a specified period of time and how many slots were not attended. You then work out the number of DNAs over that period of time as a percentage of the total appointments offered (total number of appointments that were not attended in time period /total number of appointments offered in time period). % DNA Rate = Number of appointments not attended in the time period Number of appointments offered in the time period X 100 Splitting out New and Follow-up DNA rates You need to split out new and follow-up DNAs as they often require different solutions to address them (the reason someone doesn t attend a first appointment can be very different to the reason they don t attend follow-up appointments). Ideally you want to convert your DNA rate back to the average face to face time lost and number of additional service users who could have been seen. Focusing on follow-up DNA s initially is usually more productive, even though the DNA rate for new appointments is generally higher. This is because a 1% reduction in DNAs across five appointments (follow-ups) will release more time than a 1% reduction in DNAs for one appointment (new assessments). It is also generally considered an easier area for interventions as the individuals are known to the service. The following table taken from the Lothian DCAQ Early Implementer Phase 1 Report highlights this. Version 1 May 14 48

49 % DNA Table 3: Average hours lost per week to DNAs, East Lothian Psychological Therapy Services, June November 2010 Did Not Attend (DNA) East Lothian Psychology East Lothian Therapists 1 st Assessment DNA rate 15.5% 19% Average hours lost per week due to 1 st Ass. DNA Follow-up DNA rate 11% 12.2% Average hours lost per week due to follow-up DNA Average hours lost per week to DNAs Tracking DNA rates over time Depending on the throughput in your service you will want to track DNAs on either a weekly or monthly basis. DNA rates will naturally vary over time so you need to put the data into a run chart so that you can easily identify statistically significant changes (see Figure 2 and Section Eight, SPC Charts). You need to annotate these charts so that you can see when you are making changes. Ideally you want to put the data into a control chart so that you can identify whether you have any special cause variation impacting on your system (see Section Eight, SPC Charts). For improvement work, you need to look at the DNA rate at an individual team level. For most services, this data will already be available from your information department and all you need to do is to get an arrangement in place whereby you receive regular reports and make sure the data is presented in the appropriate graphical format. Figure 2 - Example of run chart of % of first appointments where service user DNAs Team Somewhere CMHT (May 09 - Nov 11) Introduction of Full Booking System %DNA Median Introduction of Text Reminder May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Month/Year Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Version 1 May 14 49

50 Undertaking a more detailed assessment The basic assessment will tell you whether DNAs are a significant issue for you and which teams have the biggest problem. However, if you are testing some of the ideas suggested further on and there is no impact on your DNA rate, then you will need to start looking at it in more depth. As part of this more detailed assessment you may want to consider: What reason are service users giving for their DNA. It can be really useful to conduct a survey of service users who DNA to understand why and from this you may also identify opportunities for improvement. This can be a great project for one of your trainees/students. Are DNA s higher at a specific time in the day or day of the week? How do DNA s vary over diagnostic groups? Is it in fact the problem for which the service user was referred which is preventing them from attending, has this been considered? To do this assessment on new referrals you could split the referrals into clinical categories using the reason for referral from the referrer as this may be the only information you have, if you have a provisional diagnosis from the referrer then use this. This will help you identify if there is a specific service user group who are more likely to DNA and you can then start to target your improvement work appropriately. How do your first assessment DNA rates vary across referrers? If there is significant variation, is this due to differences in demography, or does it indicate the need to do some targeted work with those referrers attached to high DNA rates. In rural areas is there a connection between DNA rates and public transport times? Where in the treatment pathway are service users not attending? Are people using DNA to self-discharge? If your DNA rate goes up near the end of treatment then the DNA maybe a form of self-discharge. You may need to review case notes for these service users to identify if service users were nearing discharge or if discharge had been discussed to identify if the reason for the DNA is that service users are self-discharging. Where and when appointments are offered may also be having an impact on your DNA rates. Collect data for new and follow-up appointments; identify the location for the appointment slot and the time offered. Is there a pattern emerging? Is there an administrative process which is impacting on service users receiving appointments on time and hence resulting in service users missing appointments? For teams which have a low DNA rate is there anything they are doing that you could spread to other areas? If this information is not available from your information department then you may need to carry out a retrospective audit of: Referrals for new assessments Case notes for follow up appointments. Version 1 May 14 50

51 Ideas for reducing DNAs The following are provided as ideas for you to test. We recommend you do this within the Model for Improvement Framework. This enables you to test it at a small scale. We would also encourage you to use creative approaches with your team to generate further ideas locally for testing. What matters is getting an understanding of why people DNA and then generating sensible ideas that address that root cause and testing these in practice to see if they work. Ideas for approaches you can implement to reduce DNA s are: Introducing a text reminder service where the service user receives a text two days before their appointment. This approach is currently being rolled out across NHS Greater Glasgow and Clyde Mental Health Services. Offer full booking, which means service users are asked to phone in and book a time that is convenient to them. Offer a choice of appointment time, day of the week and location. This has been shown to have a positive impact on reducing DNA rates. Display the time lost to DNA this month/week in a prominent place where service users will see it. When a service user calls to cancel an appointment, ask if there is a particular reason and capture the information so it can inform your improvement work on this topic. Ensure the service has a well-defined DNA and CNA policy and that staff know the detail of the policy and how to apply it. Fully explain your DNA policy and CNA policy to those who have been referred to the service in order that they understand what will happen if they DNA or CNA. Review your administrative processes, for instance are appointment letters being sent out to give the service user enough notice of the appointment. Version 1 May 14 51

52 Optimising capacity - skill mix Why is this important? Skill mix has a role to play in improving organisational and team effectiveness and quality of care. Skill mix can refer to the mix of posts in the team, the mix of employees in post and/or the combination of skills available at a specific time. It can be looked at with specific staff groups, across the whole team and across various care groups. It is often seen as being purely cost driven. However, this should not be the case, it is about analysing the quality and competence of staff required to deliver high quality care in an efficient and productive way. Understanding your current state Understanding the skills and current utilisation of your staff can help you identify areas where work load can be shifted to other professionals and where there are skills deficits/gaps. It will also help you identify the training needs of the staff working within your service. There are various methods for determining skill mix across teams. You can: Analyse the tasks carried out within the team against the grade of the individual doing them. One way of doing this is to complete a skills matrix for the whole team. The skills matrix, which can be found within the Productive GP Series (requires registration), should be reflective of all the tasks and interventions required to meet the demands on the service and the needs of those who are receiving care from the team. The main purpose of this tool is to map the staff in the team against the skills/interventions and tasks required to facilitate an efficient and effective community mental health service. Analyse the activity of the team, for instance using the Mental Health Activity Tracker but customising this to pick up relevant information that will help you to assess complexity of interventions against grade of staff. Review caseload mix, as you would expect higher graded staff to carry a more complex caseload. Interview staff to assess their professional judgement, carry out job analysis interviews and focus groups More detail and guidance can be accessed using the following link: As services start to collect more reliable information about the demand for their services this is likely to highlight further issues around the current skill mix of teams. NHS Boards and Health and Social Care Partnerships need to have systems in place to enable staffing decisions to be based on need and not the historical allocation of budgets between professional groups. Version 1 May 14 52

53 Optimising your skill mix Many services across Scotland have already completed work around the skill mix of their community services (see the NHS Scotland Efficiency and Productivity Mental Health Case Study Summary Report for more info). To maximise productive opportunities it is vital that this work is completed on a cross-professional basis rather than just a uni-disciplinary basis. Completing a skill mix analysis will allow you to consider the following: For the tasks that a number of different professionals are doing across different grades, is this appropriate? Or is there an opportunity to redesign to a more efficient skill mix? Is there an appropriate match between the grading of a team member and the tasks being carried out? Or is there an opportunity to redesign to a more efficient skill mix? Are there any key skills gaps that indicate a need for targeted training and/or a change in skill mix? In conducting a skill mix review, a key area to look at is the amount of time that clinical staff are spending doing administrative tasks. Some of the administrative duties could be more efficiently performed by administrative staff, though services report significant challenges in ensuring appropriate levels of admin are funded. The following table shows the cost of different grades of staff spending 5 hours a week of their time on admin and the potential productivity release if this was transferred to an admin professional. Table 4: Comparison of costs for different grades of staff spending 5 hours on admin AfC Banding Annual cost of 5 hours per week Annual savings from using 5 hours weekly of Band 3 admin rather than 5 hours of clinical time ( ) Annual savings from using 5 hours weekly of Band 4 admin rather than 5 hours of clinical time ( ) a b c d NB These savings are not cash releasing unless resources are being moved from vacant posts. Annual savings from using 5 hours weekly of Band 5 admin rather than 5 hours of clinical time ( ) One of the concerns that teams have about transferring resources from clinical budgets to admin is that the admin resource will then be targeted at a later stage for savings or there will be an admin review which results in some of their admin resource being moved to another team who is not as well resourced. If a team has higher levels of admin because they have moved resources out of the clinical budget to fund this then clearly redistributing their admin to other teams without also considering the numbers of clinical posts, is considered unfair. If you are going to transfer resources from clinical to admin to improve overall efficiency then you will need to address these concerns, otherwise the service could Version 1 May 14 53

54 end up being worse off overall in the longer term. This also highlights the need for any reviews of staffing to be done on a multidisciplinary basis. As Community Mental Health Teams work as a team, looking at any profession in isolation (including admin) and redistributing resources on the basis of a profession only analysis is rarely appropriate. Version 1 May 14 54

55 Optimising capacity - effective meetings Why is this important? A number of activity audits with community mental health teams have shown that meetings feature significantly in the use of time. It is often necessary for community mental services staff to attend a range of meetings which can be both clinical and non-clinical. However, in order to optimise your capacity for clinical work, the function and effectiveness of meetings within your service should be reviewed. Understanding your current state You need to know as a team and as a service what capacity (time) is currently being spent in meetings. In order to understand your current state you may wish to consider the following questions: What meetings are currently held within your service and are they all necessary? What function/purpose do the meetings serve? Is there a clear terms of reference and remit for the meeting? Who currently attends the meetings? Who needs to attend? Have you considered a different method for doing business, for example could you consider a different method for screening and allocating referrals? How are outcomes/actions shared and communicated with the whole team? Is there a system in place to monitor the effectiveness of the meeting on an on-going basis? What amount of capacity (time) is being used through staff attending meetings out with the team/service? Mapping out this information over a month will allow you to identify how much time is being spent attending meetings. It will provide you with a clear picture of what meetings are currently being held and the purpose of each meeting, as well as who attends from the team and what their role is. You can then consider whether there are ways in which the capacity which is currently being used in meetings can be released into delivering direct clinical care. Version 1 May 14 55

56 Delivering Productive Meetings Some meetings are necessary for teams to function effectively. The Productive Leader and RTC have modules which address this area in detail. In order to access the various resources you need to register with the Knowledge Network and request to join the Community of Practice. The tool will support you in the four stages of productive meetings which are: Plan Prepare Participate Pursue The meetings module is based on best practice guidance and will challenge you to consider whether you really need a meeting, alternative ways of running meetings and provides guidance on running effective meetings. It includes guidance on managing behaviours in meetings and how to define objectives for meetings and hence tailor approaches appropriately. Version 1 May 14 56

57 Optimising capacity - removing non-value adding work Why is this important? Time spent doing things that add no value is time wasted that is no longer available for seeing clients, developing skills or developing services. In many NHS services, team processes have evolved over a long period of time and hence they contain redundant steps that are not actually needed or adding any value. Understanding your current state Process Mapping Mapping your current processes is a great way of highlighting visually what happens and enables you to identify un-necessary steps and duplication. Please see Section Eight for guidance on process mapping. When you process map you must get the perspective of the people using the service, otherwise you may just end up mapping what people think happens rather than what actually happens. Ideally you want to map a couple of individual s actual experience of using the service and ask them for their opinions about what did and didn t add value. Once you have mapped your processes you then want to start challenging yourselves on whether the step actually adds value. Please see Section Eight for more detailed guidance on this process which is called value streaming. To help you think about the type of activities that happen in mental health that don t add value please also see the Mental Health Waste Spotters Guide (Section Eight). You may also want to pick up a couple of cases where you have multiple individuals involved from different agencies and do an analysis of the different roles and contributions to understand whether there is duplication or indeed whether some of the different interventions are actually contradictory. Activity Audit Undertaking an activity audit will also provide you with information on how staff are currently using their time and can help you identify opportunities for releasing time back into client work. Please see page 25 for more information on this. A couple of activity audits in community mental health services have shown approximately 25% of clinician s time being spent on clinical admin. Work to streamline clinical admin processes and make better use of technology should release time for clinical work, though this needs to be tested in practice. Meetings also feature significantly in the use of time, indicating the need to review the function and effectiveness of meetings. Please see page 39 of this toolkit for more advice on this. Version 1 May 14 57

58 There may be other issues that come up from an activity audit, the value of doing this locally is that you will identify the issues that are relevant in your area. Delivering a reduction in work which doesn t add value Redesigning your processes If your current state process map identifies duplication and waste then clearly you will want to redesign your processes to address this. You need to agree an ideal state map and then agree a plan on how to get there. You may not be able to move to your ideal state in one go, what matters is that you put a plan in place to progress from your current state to the ideal state, ideally using PDSA cycles to test changes as you go. Each cycle of the PDSA should be supported by data collection to inform if the change has been an improvement. Have you achieved what you set out to do? Allocation Meetings A number of services have moved from allocating new referrals through a meeting to direct allocation and this shows considerable productive opportunities. Western Isles released 576 hours of clinical time a year by moving to direct allocation and one team in Lothian released 312 hours of clinical time per year by moving to direct allocation. One of the problems with allocation meetings is that they can result in an unfair distribution of workload, with the most conscientious in the team taking more work on. Therefore, another advantage of allocating directly is that it ensures referrals are allocated fairly on the basis of individual s capacity. If the team does not already have a process in place for multidisciplinary discussions of cases where the worker is struggling then you may want to use some of the time released for these types of discussions. Version 1 May 14 58

59 Optimising capacity - reducing sickness rates Why is this important? Evidence shows that work is generally good for your health and that often going back to work can actually aid a person s recovery. On the other hand, staying off work can lead to long-term absence and job loss with the risk of isolation, loss of confidence, mental health issues, de-skilling and social exclusion. If there is a significant issue with sickness absence within a team or service it is difficult for that team or service to plan and manage the workload, especially if the sickness and absence is short term and unpredictable. There are also significant costs associated with people being absent from work, both in funding cover arrangements for critical posts and the time spent managing sickness and absence within teams and services. Understanding your current state As an employer or a manager within a team or service you need to have an understanding of rates and reasons for sickness absence. You can achieve this through a review of sickness and absence records which will help you to identify your rate of sickness absence. The most common measure of absence is lost time rate and this can be worked out using the following equation: Lost Time Rate = Total absence (hours or days) in the period Possible total (hours or days) available in the period X 100 There are a range of areas you can look at and review to assist you in diagnosing the factors which are likely to influence absence levels and these include: Role and organisational factors Work and role design Workload and stress Organisation and team size Occupational sick pay Organisational culture and climate Medical factors Lifestyle factors Persistent and recurring conditions External and social factors Travel difficulties Version 1 May 14 59

60 Delivering effective sickness management There are six key elements to effectively managing sickness and absence and return to work, these are: Recording of sickness and absence Keeping in contact with the employee who is off sick Planning and undertaking work place adjustments for the individual Using professional and other advice and treatment Agreeing and reviewing a return to work plan Co-ordinating the return to work process A toolkit has been developed by the Chartered Institute of Personnel and Development in conjunction with ACAS and the Health and Safety Institute. The toolkit will support managers and leaders to conduct a systematic review of absence issues and what they can then do to address these issues. Fundamentally you need to: Collect data on absence within your team This data should be available through the SSTS system which can provide reports on sickness and absence within your team. If this system is not in use then you need to ensure that you have a local system for collecting sickness and absence data. You need to be able to categorise the nature of the absence to be able to identify patterns or trends. You need to analyse your data and identify patterns or trends across the team and for individuals. The toolkit will provide you with a range of approaches which will assist you in analysing and addressing sickness and absence within your team. In July 2012 General Practitioners started to use the Fit Note. Developed and introduced by the Department of Work and Pensions, the fit note replaced the sick note which GP used to use. This was introduced to use with employees who had been out of work for seven days or more and was established to support employees return to work as it allows the GP to describe the conditions which would support the employee returning to work. Version 1 May 14 60

61 Optimising capacity information for referrers and patients Information about the service is essential for referrers to know what clinicians do and for patients to know what to expect. In both cases, information can be used to help inform, guide and shape behaviour. A psychological therapy service will know the most about what alternative resources are available, including having an expert opinion on self-help resources such as books and websites. Does your service have the following? self-help leaflets, book lists or book prescribing, a list of contact details and referral criteria for other agencies, or a website? If so, does anyone outside the service know? Can a member of the admin team be allocated as a first point of contact for the dissemination of resources? Can a member of the admin team be tasked with keeping this information up to date? Do you routinely send this information out to people who have been referred to the service? Information for referrers could include: Clear referral criteria Advice on information needed for referrals Details of alternative services for people who don t meet your criteria Links to self-help resources A description of how referrals are dealt with The Did Not Attend (DNA) and Could Not Attend (CNA) policies Details of the process from the patient point of view Descriptions of the psychological therapies offered Clarity on what will be expected of the patient Information for patients could include: Details of additional complementary services Links to self-help resources. Sending out the appropriate information early to referred patients allows them to start therapy earlier Clarity on what patients can expect from the service i.e.: o The Did Not Attend (DNA) and Could Not Attend (CNA) policy o Details of the process from the patient point of view o Descriptions of the psychological therapies offered o Clarity on what will be expected of the patient Most services have an information booklet that they include with acknowledgement or first appointment letters. Version 1 May 14 61

62 Optimising capacity - clinical administration Every service will have clinical administration processes which are performed by a range of staff within the service. Good clinical administration involves a joint working approach, with clinicians working closely with administration staff to ensure the system runs smoothly. Administrative support for clinical work is a crucial part of the service. How the service is administrated will have a significant impact on clinical demand and capacity. Understanding how much clinical administration is performed and by who can help services identify duplication, waste and opportunities to release capacity to undertake other work. There should be appropriate administrative support for clinical staff. To have routine administration being done by clinical staff is a waste of clinical capacity and is an inefficient use of resources. This section looks at ways of running the administration system to increase efficiency. There are a number of simple procedures that can have an effective impact, without increasing the administrative workload. If there is not enough administration time to implement the ideas discussed in this guide, a demand and capacity model can be applied to the administration work to inform the service about appropriate levels of staffing. The Administration Steps Who does the following steps will depend on local arrangements. We have suggested the usual allocation of duties indicated by A for administration, C for clinician. When is also a local issue, but generally it makes sense to do each step as soon as is possible. Not to do so is adding an unnecessary delay. For services with no waiting list, some of the following steps will not apply. Referral Arrives 1. Check all essential information provided, including contact information. (A) 2. Basic screen for eligibility. (A) 3. Clinician screens and allocates. (C) a) If not appropriate, rapid reply with specific information on more appropriate services b) If appropriate, identify useful additional resources to include with acknowledgement or appointment letter. First Contact with Patient What happens here will depend on whether there is a waiting list. Version 1 May 14 62

63 Waiting List 1. Letter to patient acknowledges referral, advises on approximate waiting time. (A) 2. Include: a) Service information; (A) b) Targeted resources (C) provides, (A) sends; c) Contact details form;* (A) d) Advice that short notice appointments may be offered. (A) No Waiting List 1. Letter to patient acknowledges referral, offers appointment or provides information on who to contact to book appointment (see First appointments). (A) 2. Include: a) Service information; (A) b) Targeted resources (C) provides, (A) sends; c) Assessment questionnaires (A), these could include space for patients to note issues and questions for their first appointment. First Appointments Partial booking is a system that allocates a slot or two for the first appointment but requires contact from the patient confirming they will attend before the clinician s diary is filled. This greatly reduces first appointment DNA rates and allows for reallocation of unconfirmed first appointment slots. Administration Tasks (A) 1. Inform patient that they are being offered a first appointment, providing partial details such as date. a) Be specific about limitations regarding clinic days/locations. 2. Ask that they contact your service to choose/ confirm the appointment. a) Ideally there will be a choice of appointment times available. b) The letter needs to be clear that if the date offered is not suitable they can phone to agree an alternative date. 3. Specify a response time, after which you will reallocate to another patient. 4. When patient contacts service, make full appointment, confirming by letter, or text. Clinician Tasks (C) 1. Identify new patient appointment times. 2. Provide admin staff with at least two weeks notice. 3. Allow admin access to diaries. 4. Identify new patients to be booked in: a) Identify a minimum of 2 potential patients from waiting list for each appointment time; b) Attach relevant specific information to be sent with appointment letter. Version 1 May 14 63

64 Full Booking Full booking is a system that allows the patient to phone and choose their appointment slot. This greatly reduces first appointment DNA rates and improves patient satisfaction by giving them choice over the appointment times. It also reduces the risks of a patient turning up for an appointment that they failed to confirm (as they won t get a time until they phone up). To speed the process up, some areas get GPs to fax the referral over (or send via clinical ) and the patient leaves the GP surgery with the phone number to call to arrange the appointment. For this system to work, you need to have agreed in advance who can see first assessments and have agreed new assessment slots allocated in the diary. Keeping the Clinics Full A main priority of admin should be to keep the clinicians working hard! That is, no one likes empty clinic slots because they are a waste of resource and a frustrating gap in a clinical day. A system that records appointments offered and confirmation cut-off dates is beneficial as once this is in place, if someone has not responded to their appointment offer in time, another waiting patient can be selected. Often there will not be enough time to write another letter to offer a short notice appointment to another waiting patient. Using the contact information slips, working through the list supplied by the clinician, admin staff can telephone patients to offer the vacant slot. It can seem a lengthy process phoning and chasing up, but an hour spent filling a clinic slot is another patient into the system and an hour less of clinic time wasted. Remember as well to call the patients who have waited the longest first (unless there is a clinical reason to prioritise someone waiting for less time). Did Not Attend (DNA) Policies / Could Not Attend (CNA) Policies DNA / CNA policies will set out standard practice for services however clinical decisions must be allowed to override routine policy, especially for patients for whom attendance problems are part of their clinical presentation. Did Not Attend (DNA) Policies Referrers, clinicians and patients should be fully aware of how non-attendance will be handled. An explicit policy will help all concerned and can be designed to reduce wasted time. There will need to be a policy for DNA and cancellations both at the beginning (access) and during therapy (treatment). Once a patient has started therapy, the therapist should give clear, explicit details of the DNA policy. Version 1 May 14 64

65 This may include: Counting non-attendance that has not been informed in advance as part of the initially contracted number of sessions. Identifying poor attendance as a crucial aspect of case review. Some services offer text, or phone reminders of coming appointments and this may help reduce DNA rates. However clinical decisions must be allowed to override routine policy, especially for patients for whom attendance problems are part of their clinical presentation. Could Not Attend (CNA) Policies A CNA policy will be similar to a DNA policy. It is good practice to discuss cancellations with patients so that they understand the local policy and the reasons why, if they can t make an appointment, it is important to let you know as soon as possible (so the appointment can be reallocated). Problems with variable attendance should be discussed with patients as part of the therapy process. When taking messages about cancellations, admin staff need to be clear about whether or not the patient actually wants another appointment. Ideally, with open diaries, this can be allocated at the time of the patient s call. Make it easy for the patients to let you know they can t attend There should be a number of ways that the service can be contacted. Text, and phone messaging should all be available. This will allow people to advise easily if they are unable to attend. The more notice there is, the more chance an empty clinic slot can be used. Be aware of communication needs Referral forms/information should include space for the referrer to advise of specific communication issues. For instance, English may not be the patient s first language or they may need large print or Braille. Diary Management Tips Allow admin staff to book directly into clinicians diaries The ideal diary system allows admin staff to have full access to clinicians diaries. Clinical staff need to allocate new and follow-up slots as far in advance as they can. If they know that they have contracted for a number of sessions with a patient, they may prebook these slots. If clinical staff give full access and booking permission to admin staff, then patients contacting the service can be responded to immediately. This provides a better service for the patient and reduces the wasted admin time having to contact the patient (which can sometimes mean multiple phone messages) once they have the information to hand. Version 1 May 14 65

66 When new appointments are being offered, the admin staff will have immediate access to the options available. Cancelled follow-up appointments can be reallocated at the time of cancellation. Make effective use of electronic diaries Where clinicians are working peripherally and booking their own appointments, there is a danger of both the clinician and the administrator filling the same slot. In this situation, clinicians should be allocated IT equipment, such as mobile phones with internet access, which will update the main diary remotely. This enables both the clinician and the administrator to book directly into the diary without the risk of double bookings. Work out the ratio of new to follow-up slots that are needed When planning clinics, it is good practice for clinicians to differentiate between new and follow-up appointment slots. This is vital if they do not wish to end up with too many cases and if they allocate more time to an initial assessment than a follow-up. Further information on this can be found in Section Eight. Plan the diary against your job plan A well planned diary means more efficient working. If you identify your patient appointment times for each clinic in advance you will never end up with too many people to see in a clinic. The number of patients you see in a clinic will be determined by your job plan. Some people allocate their time to allow for immediate admin; others, especially if clinic rooms are scarce, allocate more slots in a clinic and do their admin out with clinic times. Whatever your approach it is important that clinical admin is done as close to the patient contact as possible. The following checklist will help you decide whether the administration of your service is helping you to deliver an efficient service. Rather than a simple yes/no choice you can select partly, as we recognise that most services will be in the process of looking more closely at what they are doing. If you can answer yes to every question in this checklist, then you probably have an efficiently administered service. If you answer no or partly to questions, then this indicates an area where you could do further work. Administration for Psychological Therapies Yes Partly No Is there clear service information for referrers? Is there clear service information for patients? Are partial first appointment booking systems in place? Is there a system for recording appointments offered and cut off dates for responses? Is there a clearly stated Did Not Attend (DNA) policy? Version 1 May 14 66

67 Is there a clearly stated Cancellation Policy? Is the service easily contactable for patients (phone, or text)? Does the service hold comprehensive contact information for patients? Do admin staff have full access and booking permission for clinic diaries? Do clinicians identify appointment slots in each clinic in advance? Do clinicians differentiate between new and follow up slots in diaries? Is there a system in place to allow unused appointment slots to be filled quickly? Is short notice booking a priority for administration staff? Is there an admin team member allocated to disseminate resources? Version 1 May 14 67

68 Version 1 May 14 68

69 Section Five Understanding and Managing your Demand Version 1 May 14 69

70 Version 1 May 14 70

71 Introduction to demand What is demand? Services often refer to demand as the number of referrals received. But it is not that simple. Demand is better defined as the total resources needed to undertake the service required. For mental health, each referral is a request for clinical input so demand can be measured as the total time needed to respond to that request. As different types of referrals require different inputs that last for different periods of time, using referrals as a proxy for demand can lead to under/overestimating the resources needed. For example the following teams both receive 100 referrals a quarter but the amount of resource needed to respond is very different. No of Referrals Average no of hours clinical input per referral Team A Team B ,500 Total no of clinical hours needed to respond to referrals Put simply, demand is the total resources needed to respond to the referrals you receive. Why look at demand? Demand is multifaceted and something we can influence by our actions. It is not simply a never ending stream of people coming through our doors that we have no control over. We know therapeutically that identifying the nature and extent of a problem is a good first step to looking for solutions. The same applies when thinking about the systems we work in, understanding your current demand is an important step in then finding ways to influence it. Understanding demand is important because: If we know what our service demand is, it is easier to quantify what we need to do to meet that demand. It allows us to consider what we can do differently to reduce the demand. We know that one of the biggest contributors to stress is lack of control. Understanding that there are ways to influence demand can give teams back a sense of control; leading to increased morale and better working lives. Inevitably, this will then translate to better service user care. When we combine understanding our demand with understanding our capacity we can see if there is a match between the two. If not, and you are running the service as effectively and efficiently as possible, being able to demonstrate the difference is vital for putting together a case for additional resources. Measuring demand Version 1 May 14 71

72 Demand can be broken down into the following categories: Actual Demand What your service is asked for Failure Demand What you have to do again because it was not done right the first time Created Demand Demand which is created because of how your service responds (e.g. seeing people more times than they need to be seen) Hidden Demand Demand is there but us not currently presenting Breaking demand down in this way is useful as it highlights that services can release productive opportunities if they focus on reducing both failure demand and created demand. Some other definitions you may find useful are: Total Demand = actual demand + failure demand + created demand + hidden demand Current Demand = actual demand + failure demand + created demand Current demand is the total resources currently needed to respond to the referrals you receive. To measure your current demand you will need to collect a number of different pieces of data, some should be routinely collected on an on-going basis (Table 5) others can be picked up through a one off audit or estimated (Table 6). Table 5 also highlights how the DCAQ Tool (See Section Eight) supports you in analysing the data. Table 5: Data you should be collecting routinely that will feed a demand analysis What information do I need? Why do I need it? Total number of referrals received. For Mental Health Services, demand is the We recommend using a years worth of number of hours needed to respond to the data. If you don t already collect this referrals received. So unless you know how information, you won t want to wait a year many referrals you are receiving, you can t to use the tool. However, we recommend calculate the demand. you work with a minimum of 12 weeks worth of data as you need this time to We recommend recording referrals daily so smooth out some of the peaks and troughs. you can then start to analyse variations in 12 weeks should provide a reasonably demand. You d probably do this weekly and robust average, but this will depend on monthly to begin with but recording daily what is happening at a local level. Putting means you can drill down to this level if you the data into a run chart (using weekly need to. figures) will help you to assess the stability of your current referral rates and hence the It is really important that you track how extent to which using a 12 week average is many referrals you receive. Otherwise, if reasonable. your demand increases, how will you prove this? The best way to track your referral data is to put it into a Statistical Process Control Chart (SPC) Chart (See Section Eight). This will enable you to see when there is a statistically significant change to your referral patterns and will stop you wasting time looking into changes in Version 1 May 14 72

73 What information do I need? Opt Outs Some services run an opt-out system. This means they write to the person who has been referred and either: a) Give the appointment in the letter but ask them to phone and confirm or; b) Ask them to make contact to book an appointment. Both approaches can reduce DNAs. Referred elsewhere as inappropriate for team Some services forward referrals without seeing or making telephone contact with the person. Some services return referrals to the GP as inappropriate without seeing or talking to the person. We recommend caution with this approach, as the referrer has sent it to you because they are unsure what to do. However, it is sometimes clear from the referral information that another service would be better placed to respond. Did Not Attends New and Follow Up These are people who failed to turn up for an appointment and didn t let you know in advance. Could Not Attends New and Follow-Up If you have a high level of cancellations at short notice (and hence you are not able to offer the appointment slot to someone else) then you will need to consider these as well. Why do I need it? referral levels that are not significant. As demand is the amount of time needed to respond to the referrals received you need to know how many referrals don t require any intervention because the person opts out. As demand is the amount of time needed to respond to the referrals received you need to know how many referrals don t require any intervention because the person is immediately referred on. If you record the source of the referral and where it was forwarded onto, you can then start to analyse this for trends. This analysis might indicate the need to do some work with particular referrers to try and ensure it goes to the right place first time. We split the new and follow up rates as most services have a higher DNA rate for new appointments than follow-ups. DNAs represent unused yet available capacity for client contact. We recognise that some clinicians make effective use of this time to catch up on other issues such as s and paperwork. However, a well-run service will seek to minimise DNAs as high rates inevitably lead to wasted time and frustration. The DCAQ tool tells you how much direct client contact time you lose per week because of DNAs. If your appointment slots for new and follow-up are different lengths of time then you need to split the cancellation figures by new and follow-up. Version 1 May 14 73

74 What information do I need? If you do group work the total number of people who go into group work. If you do group work then you need to know: a) How many people went to group work b) How many people went to individual work (and remember some people might be included in both lines as they go through both) c) On average how many sessions each group runs for d) On average, how many people are in a group. Why do I need it? Short notice cancellations, where you don t have the time to offer the appointment to someone else, represent unused yet available capacity for client contact. Ideally you need to put systems in place to offer cancelled appointments to other clients so that you minimise the numbers of unused slots. Where clinically appropriate, using groups can be a much more efficient way of managing demand. The scenario element of the DCAQ tool allows you to look at the impact of moving work from individual sessions into group sessions. If you run lots of different groups which take different numbers of people and run for different lengths of time then you will need to work out the demand for each type of group separately. Average number of follow-up visits per new client. Please see the guidance on calculating new to follow-up ratios in Section Eight for further information on working this out. How often you see clients has a big impact on your demand. We are not recommending seeing people less times than is necessary but we all know of people in teams who are reluctant to discharge and continue to see clients who are well, just to keep an eye on things. Sometimes this is necessary, but other times it would be just as helpful to discharge them but give the client direct access back to the team if they start to find themselves deteriorating. An audit across one community mental health area showed that differences in waiting lists between teams were up to 5 Version 1 May 14 74

75 What information do I need? Why do I need it? times more likely to be connected to what they did with each case (i.e. differences in number of sessions and duration) than the number of referrals the teams received. When doing work around demand and capacity there is a lot more you might want to do around new to follow-up analysis including looking at this by diagnostic groupings, by individual clinicians and looking at the distribution. Please see Section Eight for further guidance on New to Follow/Up Analysis. The DCAQ tool enables you to look at the impact of changes to new to follow/up ratios. Some services already collect the above information electronically; ask your information department to provide it. If you can, look at the most recent 12 months worth of data. However, before you use it, you do need to sense check it to see whether it is accurate. Experience of doing work with CMHTs is that often the first step involves clarifying and simplifying data collection processes to ensure that accurate data is collected. If you don t already collect this information, you will need to put a system in place to do this. This is vital information for the management of your service, so we recommend that you continue to collect it on an on-going basis. There are limitations to using historic data to predict future demand. Some people refer to this as being similar to trying to drive your car by looking in the rear view mirror. If your demand is relatively stable, it is not a problem. To assess this you need to put the data into a run chart or ideally, a SPC Chart. If you have growing demand you will want to adjust your data to look at predicted demand over the next year. There are techniques for doing this that are not covered in this guidance, so if you are not sure, then do seek further advice from your information department or your improvement team. The following table highlights the information you will need for the demand analysis that you can either estimate or establish through a one off audit. Version 1 May 14 75

76 Table 6: Data for demand analysis that you can estimate or establish from a one off audit What information do I Why do I need it? need? Average time take per new As demand is the number of hours needed to respond to the assessment. referrals received, we need to know, on average, how long This should include both each new assessment takes. face to face client contact time and clinical admin such You probably allocate a given time slot for new assessments. as preparation, telephone Most services allocate 1 hour. We recommend you work on calls etc. the basis that each hour of face to face work has a ½ hour of clinical admin attached. This has been tested through the Wiseman Workload Management Tool and appears fairly consistent. Average time taken per follow up assessment. This should include both face to face client contact time and clinical admin such as preparation, telephone calls etc. Alternatively you might want to sample a number of new cases and audit how long they take you. As demand is the number of hours needed to respond to the referrals received, we need to know, on average, how much time you spend at each follow-up visit. You probably allocate a given time slot for follow-up visits. Most services allocate between 30 mins to 1 hour. We recommend you work on the basis that each hour of face to face work has a ½ hour of clinical admin attached. This has been tested through the Wiseman Workload Management Tool and appears fairly consistent. Alternatively you might want to sample a number of followup visits and audit how long they take you. Ideally you want to split your referrals into different types of problems, as this will enable you to undertake a more detailed analysis. There are different ways to do the grouping and, as with all attempts to group unique individuals, they will all be flawed to some extent. Paul says bananas take less time to peel than apples. So one way to split your referrals is by the time needed to treat. For the purpose of demand measurement, this is a good way forward. The following is an example from the Matrix, with patient groups and the associated levels of intensity of therapy. This has been expanded to include the typical demand on time for each level. Version 1 May 14 76

77 Table 7: Patient groups and the associated levels of intensity of therapy Level of Therapy Patient Group / Severity Treatment delivered TYPE OF DEMAND TYPE OF DEMAND TIME DEMAND Low Intensity Common Mental Health Problems (1 to 3 hours) stress/anxiety/depression Severity: Mild/moderate, with limited effect on functioning High Intensity Common Mental Health Problems Severity: Moderate/severe with significant effect on functioning. (6 to 16 hours) High Intensity - Specialist Highly Specialist Moderate/Severe mental health problems with significant effect on functioning-specialist areas E.g.: Schizophrenia, Personality Disorder, Bipolar Disorder, Eating Disorders, Substance Misuse etc. Severity: Moderate/Severe with significant effect on functioning Complex, enduring mental health problems with a high likelihood of co-morbidity, and beyond the scope of standardized treatments. Severity: Highly Complex (16 to 20 hours) (20 + hours) Some types of referrals are relatively easy to quantify in terms of the time needed, i.e. intellectual assessments and fixed programmes such as Beating the Blues or a Core CBT skills group programme. As you collect data on case types and hours needed to treat, you may find you can refine your estimate. However, this is only one way of splitting referrals; you may come up with better ways. Also, you don t need to split referrals down into type to get started with work around Demand, so don t get too hung up on this point. You can do really useful work just by thinking about referrals into your team as a whole. Doing the demand sums You can probably see from the number of data fields collected that working out your demand is not a simple calculation. Demand for New Assessments Demand for Follow-Ups* = = (total no of referrals opt outs referred elsewhere) x length of new assessment slot (new assessments people who drop out via DNA/CNA) x length of follow-up slot x average no of follow-ups per new assessment~ * This calculation only covers individual follow-ups, not group work. ~ Please note that your average no of follow-ups per new assessment needs to include follow-up DNAs. Version 1 May 14 77

78 Example Brian from Borders had to estimate demand for a pilot of his primary care ICP for depression. In total, 90 patients had been diagnosed with depression for a 12 week period in the pilot practice. He estimated that 31% would choose/require psychological therapy which was a total of 28 people. Using the evidence base he allowed 8 clinical contacts per patient and he allotted one hour for each contact. Total number of patients requiring therapy 28 Average number of appointments 8 Total number of appointments 224 (28*8) Length of appointment 1 hour Total face to face time 224 hours (224*1) However, he knew that he also needed to build time in for record keeping and telephone calls. He estimated 3 hours in total per patient. Total clinical administration time per patient 3 hours Total clinical administration time for 28 patients 84 hours (3*28) So he estimated the total demand as 308 hours over 12 weeks ( ). Because he had done work around capacity, he knew that only 50% of his staff member s time was available for clinical work (the rest was spent travelling, in meetings, on leave etc.). So, in total he needed to employ 616 hours over 12 weeks (308*2) which equates to 1.4 Whole Time Equivalents (WTE). He advertised and only managed to recruit 0.9 WTE. Worried he would grow a waiting list, he carried on collecting data on referrals, contacts and outcomes. Six months later he analysed the referral, contact and outcome data for the new psychological therapist. This showed that referrals were less than predicted, average contacts per completed case were 4 (not 8) and that outcomes were good with clinically significant changes on the PHQ-9. So, his revised estimate is now 0.8 WTE and this is the figure he has fed into the planning process. Alternatively, you can use the DCAQ Tool (see Section Eight) which is set up to automatically do the sums for you (once you enter the relevant data). This includes the group work sums. In addition the DCAQ tool will enable you to do some scenario modelling to see the impact of changes to key fields such as reductions in DNA rates, changes to the new to follow-up ratios etc. Version 1 May 14 78

79 Ideas for influencing your demand There are three key areas to think about when looking to influence your demand: Your eligibility criteria are you doing work that someone else could do, or work that does not need to be done? Failure demand - are you creating unnecessary demand by not doing things right first time and then having to do them; or not doing something at all which means the person then presents at a later stage in their illness with more acute needs? Key issues to look at here are covered in the effective practice section of this toolkit. Created demand - are you creating unnecessary demand by having steps in your processes that don t add value? This includes seeing people more times than they need to be seen? Key issues to look at here include goal setting, case review and caseload management. Version 1 May 14 79

80 Managing demand - set clear eligibility criteria Why is this important? It is crucial to have clarity about what the service will and will not do. Whilst acknowledging that every referral will be different, there will be limits at the upper and lower tiers. All areas will have other services that work with mental health and related issues; as well as having inpatient units and crisis teams. Recent research into effective multi-professional team working (MPTW) in Mental Health Care 7 highlighted that clarifying the purpose and function of CMHTs is a cornerstone for good team design and was their highest priority recommendation for developing effective teams. Understanding your current state To assess whether or not there are any issues around eligibility criteria for your team you can look at the following: Is there clear, documented eligibility criteria? Simply, can you put your hands on a document that clearly specifies what the team does? Is it understood? o To assess whether it is understood by referrers you can look at how many referrals you receive that you then send on elsewhere without seeing. You will want to break this data down by referrer to see whether it is a bigger issue for some referrers. If you are doing this, remember to adjust the data for the size of the practice population otherwise you may end up wrongly identifying a practice as an outlier simply because it covers a bigger population. If you find there is an issue with particular practices then you will want to do some work with them to understand why this is happening and agree jointly a solution. o You will also want to see whether team members have a similar understanding of eligibility criteria. You can do this via a discussion or by asking how they would respond to particular case scenarios 7 West M, Alimo-Metcalfe B, Dawson J, El Ansari W, Glasby J, Hardy G, et al. Effectiveness of Multi-Professional Team Working (MPTW) in Mental Health Care. Final report. NIHR Service Delivery and Organisation programme; 2012 Version 1 May 14 80

81 Is it appropriate? o The team may have clear eligibility criteria but these could be set either too tightly or too loosely. You may want to consider whether you are doing things that other services could do more effectively and efficiently. o Another indicator that there is a problem with eligibility criteria is when a lot of time is spent debating who should see someone and referrals end up getting passed from team to team. This is a clear signal that either teams are not clear or the system as a whole has been badly designed leaving individuals who need a service that no team provides. Either way, it indicates that work needs to be done. The amount of time that can be wasted by teams disagreeing on who should pick up a case should not be underestimated and it can also carry significant clinical risks if it leaves someone with complex needs falling between the net. This is often a particular issue around individuals with both mental health and substance misuse problems. Delivering clear eligibility criteria There is no point in making your demand more manageable if you simply move it to someone else who also doesn t have the capacity to meet the needs. So any changes to your eligibility criteria need to be agreed across the whole system and should be based on who is best placed to meet the need. The assessment of who is best placed to meet the need will need to consider the skills and hence grading/type of profession required. The following list provides some guidance on how to go about reviewing your eligibility criteria. 1. Be clear on what other resources exist. There will be many service providers in your area who respond to issues related to your service users. It is essential that your service knows what else is available and has up to date information on their contact details and referral procedures. There are a number of local examples of this, mainly web-based. By their nature such sources of information can quickly go out of date. It is useful to allocate someone to check the accuracy of the information on a three monthly basis. 2. Write down your current eligibility criteria. Clarify what you do and do not do, and what other services are available to respond to work you don t cover. 3. Define your priority criteria. a. Be explicit about what will happen and when for priority referrals. b. Ensure referrers know your priority criteria. c. Don t have more than two priority streams as the more you sub-divide the work, the more complications you are adding, and the longer your waiting lists will become. 4. Having defined your criteria, inform referrers about them. Version 1 May 14 81

82 a. Ensure they know the information you need with a referral to allow allocation to the most appropriate treatment. b. Agree that, if after assessment it is felt that your service is not appropriate, you will refer onwards and give feedback to the referrer about why you did this. c. Encourage referrers to phone you if they are uncertain about whether to refer someone. d. Consider using an e-referral process to ensure that you receive the minimum data you need to make informed decisions about the referral. If taking this route, you will need to consult with your GP colleagues and involve them in agreeing the final data set. 5. Make it easy for referrers to send people to the right place. a. Referrers are often busy and not sure where to send referrals. Clarifying what type of referral should go where, and making close links with partner agencies, will ensure a smoother journey for the service user. It will also reduce duplication and wasted effort when responding to referrals. Some services provide referrers with referral criteria and contact details for other agencies in writing or on the web. b. If there are Tier One services such as book prescribing or websites, be clear about when these could be considered as a first intervention before referral to you. 6. Aim to assess and allocate by direct contact. a. The ideal way of ensuring referrals meet your criteria and are allocated to the best treatment option is by direct screening. This will only work if you have a short waiting time. b. The referral screening should be a dynamic process with clear, rapid feedback to referrers. c. Avoid bouncing back to referrers. Re-direct to the better matched service, letting the referrer know why. d. Be careful about using the term inappropriate referral. Remember the referral has been made because the referrer is not sure what to do and is looking for advice. Your advice may be that they don t need your service and are better matched to another service. This doesn t mean the referrer was wrong to ask for your advice and the challenge for you is how you help them to know where to send future similar cases. e. Check every referral against new criteria. Keep a note of those that do not match any current service, this is un-met need and will inform future service planning. If you have the skills to see and meet the needs of these individuals then you may need to expand your own eligibility criteria to cover them. If they represent significant numbers of referrals then this should be discussed through your management processes to agree whether it is a priority for you to expand the teams remit. If you don t have the skills to meet their needs then you need to highlight this gap in service provision to the relevant individuals in your organisation together with data on how many individuals are being referred. Version 1 May 14 82

83 7. If you experience on-going issues with people being referred to your service who do not meet your eligibility criteria then you need to do further work to understand why. a. If there is another service in place that the referrals should be going to then you need to talk to your referrers to find out why they are still sending them to you. This should be done from an attitude of genuinely exploring the reasons why and seeking to agree together how you make sure they go to the right place first time. b. If there is no other service in place that meets their needs then see point 6e above. Version 1 May 14 83

84 Managing demand - goal setting, case review and caseload management Why is this important? Goal setting, case review and caseload management are crucial aspects of managing demand in community mental health services. In any service it is important to be clear about the goals of the intervention. They need to be achievable and should match as closely as possible both the identified needs of the service user and their expectations. Improving our ability to set appropriate treatment goals, building in case review and reviewing existing caseloads will notably improve the efficiency of our service and the treatment of our clients. Understanding your current state Goal Setting You can use both supervision sessions and random audits of case notes to assess the extent to which staff are routinely setting appropriate treatment goals which then guide their interventions. Goal setting and case review are crucial aspects of managing demand in psychological therapies services. In any service it is important to be clear about the goals of the intervention. They need to be achievable and should match as closely as possible both the identified needs of the patient and their expectations. Improving our ability to set appropriate treatment goals, building in case review, and reviewing existing caseloads will notably improve the efficiency of our service and the treatment of our patients. Some may say that the goal setting approach only works with a CBT treatment model. Certainly, the method and language used fit well with a CBT model, however all therapeutic interventions could reasonably be expected to set clearly defined and measurable goals, albeit using a different framework or language. It is not unusual for people to be referred for psychological therapy when the identified need may not be best met by therapy. For example, someone whose psychological distress is the result of notable debt problems may need help from a specialist debt advice service. Often people have high and unrealistic expectations of what can be achieved with psychological therapy. Understandable and normal reactions to events such as bereavement are not likely to need, or benefit from, psychological therapy. A person s goal of not experiencing a feeling of loss would not match the likely outcome of psychological therapy. It is also important to consider the expectations of referrers and patients with respect to the goals of different levels of service. A brief guided self-help programme with a limit of three Version 1 May 14 84

85 sessions, a stress control class of 4 sessions, six brief counselling sessions, and sixteen High Intensity CBT contacts would all have their own limits on what was achievable. SMARTER Clinical Work 8 One way of considering clinical interventions is to be SMARTER. For each patient we can ask ourselves a number of questions about the goals of the intervention. S M A R T E R Are the treatment goals specific? Are the therapist and patient able to measure whether they are meeting their goals? Are the goals set, achievable and attainable? Can you realistically achieve the goals with the resources you have? (This will include therapist and patient resources, as well as the impact of external factors). Have you set a time for achieving the goals? How will you measure if the goals are effective? How will you ensuring the goals are reviewed? Starting SMARTER The best place to start SMARTER working is at the first assessment interview. This allows more accurate matching to the referral criteria for your service(s) than using referral letters. The initial assessment could have a solution focused aspect to it, building in discharge planning from the start. This may include: Clarifying problem areas; Setting SMARTER treatment goals; Agreeing what is expected of therapist AND patient; Identifying supporting activities that the patient can undertake in addition to the therapy; Identifying and addressing potential barriers to progress. SMARTER Matching If you are working with a matched/stepped care model then it will be easier to be SMARTER. Once a case has been assessed it should be matched to the level of service most appropriate. This matching needs to include patient characteristics. For example, if guided self-help will involve reading and record keeping, a level of literacy will be required. SMARTER Reformulation It is not uncommon for the initial formulation to be revised in the course of therapy. This may lead to revised SMARTER treatment goals and may mean that the patient should be transferred to another therapist or service where there is a better match between competency and need. In a stepped care model, this would be a transfer to a more intense / longer duration psychological therapy or a step down to guided self-help or practical support rather than active therapy. 8 Links to SMARTER objectives from NHS HIS around reviews Version 1 May 14 85

86 SMARTER Stepping Stepping up or down should be arranged within a service and should happen as seamlessly as possible, without the need for a further referral that could lead to another wait for the patient. Case Reviews You can assess the effectiveness of your current case review procedures by looking at the following issues: Do you have a clear process in place for case reviews? How effective do staff think the review process is? In particular you may want to consider: o Is the process perceived as non-threatening, supportive and used to inform the individual and the service about clinical issues that arise? o Does the process allow recording of information that will help in the planning of training? o Does the process allow the practitioner to gain input from other disciplines. One of the benefits of multidisciplinary working is that different professional groups can often bring a different perspective to the problem that might help, particularly when the clinician feels stuck. What does your data tell you about how often people are being seen for? o Looking at new to follow-up ratios can be very informative and can identify situations when teams or individuals are outliers in terms of how long they see people for. However, there are significant risks of over-interpreting or misinterpreting this data. This is particularly the case once you break the data down to individual levels and hence great care needs to be taken when looking at data at this level. Further, the data should be used to identify areas where you want to do some more qualitative work with teams or individuals to ensure effective caseload management systems are in place, rather than using it to make judgements about practice that may then turn out to be based on an overinterpretation of the data. For more information on calculating new to follow-up ratios and interpreting this information please see the QuEST MH New to Follow- Up guidance in Section Eight. Version 1 May 14 86

87 Delivering effective goal setting, case review and caseload management Goal Setting One way of considering clinical interventions is to be SMART. For each service user we can ask ourselves a number of questions about the goals of the intervention. SMART stands for: Treatment goals should be specific Clinician and service user should be able to measure whether they are meeting their goals Are the goals set, achievable and attainable? Can you realistically achieve the goals with the resources you have? (This will include therapist and service user resources, as well as the impact of external factors). Have you set a time for achieving or reviewing the goals? When setting SMART goals you will want to consider the following: What is a realistic amount of improvement? It is worth considering what % improvement is realistic and possible, 80% improvement may well be enough to allow the service user to move forward. Is it worth trying for a possibly unrealistic 100% improvement? Are there significant factors that serve as barriers to progress? For some, the role of external factors and social stressors may act as a significant barrier to the intervention you are considering. In such cases you may want to ensure these factors are addressed prior to then progressing to other interventions. In some cases supporting the person to address these external factors will be the main intervention. Do the service user and therapist share the goals? Shared goals can be considered, regardless of the therapeutic model, to be important. Active participation in the therapeutic process is an important variable. Thus a shared view of goals and methods of treatment can be seen as essential to the establishment of a sound therapeutic alliance. Is the service user ready to change? Change is a process that unfolds over time. For some interventions, the service user needs to be ready to make changes and undertake the work required to make progress. In these situations a lack of readiness means you are unlikely to succeed, and may be a significant cause of drop-out. Case Reviews Monitoring and reviewing cases is an important part of our work as psychological therapists. It allows us to monitor progress towards a good outcome and check that our input/competency matches the needs of the patient. In practice many clinicians, especially the less experienced, greatly appreciate the learning they gain from regular case review. For case review to be effective: Version 1 May 14 87

88 the process should be non-threatening, supportive and used to inform both the individual and the service about clinical issues that arise; occur in supervision, as well as forming part of a psychological therapist s individual reflective practice; allow the recording of information that will help planning of training. From the operational point of view, there is a need to monitor the demand generated by each case and to compare this with predicted demand. There is also a need to monitor fit with service/ team criteria. Regular recording and collation of service use information should be an integral part of the service manager s role. The following is an example of a checklist that could be used by clinicians on their own, or in supervision. The language used may not suit the therapy model, and not all points may be relevant. It is the concept of a systematic, goal orientated review that is important. A checklist will work best if the clinical staff in the service have contributed to its development. Different levels and types of services will require different review checklists. Does the case meet service criteria? What are the aims of therapy? Are they SMART? Will you know when they have been achieved? Have you checked progress against aims? If aims met but problems remain, have you reformulated? Do they need your level of skill? Could someone else do the work? Do they still need the service? Is there a follow-up appointment if yes is it necessary? Could the follow-up be by phone? Are there dependency issues? Are you worried that they have nothing else? Are there attendance problems? Is the DNA policy clear to the patient and is it being applied? Yes/No Action Planned By Whom By When The following checklist will help you decide whether you are making effective use of your current capacity. Rather than a simple yes/no choice you can select partly, as we recognise that most services will be in the process of looking more closely at what they are doing. If you can answer yes to every question in this checklist, then you are probably doing everything you can to make the most effective use of your current capacity. If you answer no or partly to questions, then this indicates an area where you could do further work. Version 1 May 14 88

89 Goal Setting and Case Review Yes Partly No Are all cases checked for match to service criteria? Does the service use a goal setting approach? Are the goals of therapy explicit? Are the goals S.M.A.R.T.? Is there a seamless system for stepping up/down to services that best match goals? Is there a system of case review built into supervision? Do you regularly review caseloads against treatment and service goals? Do you regularly check progress against aims? Is there a good match between level of skill and identified needs? Are there flexible arrangements possible for follow-up appointments? Are there systems to deal with dependency issues? Is the DNA policy clear and is it being applied? A healthy community mental health service has a system that automatically builds case review into a service user s journey. This would include: Ensuring new cases meet referral criteria; Building in discharge from the outset; Where appropriate, contracting an initial number of sessions. For services working with individuals with complex needs this may not be appropriate. Setting a review date; Revising aims and reformulating if needed; Not routinely offering check-up appointments, but instead putting in place systems to allow individuals to self-refer if they need additional support; Routinely monitoring and measuring caseload activity. There are a range of approaches to embedding caseload reviews into your service. The following are provided as ideas that have been used by community mental health teams: Regular multidisciplinary meetings where individuals bring cases that are not achieving good outcomes or seem stuck, for discussion. You may also want to initiate a process whereby all cases which exceed a given number of appointments are reviewed at this session. The number of appointments will depend on the type of service. For instance a primary care mental health team have a process where anyone exceeding 6 sessions is discussed at a MDT meeting. A CMHT may set a higher number of sessions before the case is routinely brought to the MDT meeting. CAPA (see Section Eight) highlights the need to be clear on why you are offering each and every appointment and promotes an approach of no follow-up unless there is a specific reason. CAPA also promotes an approach where the person who does the assessment is not necessarily the person who provides the intervention. This creates a useful accountability within the system. The assessor has to work with the client to agree a clear intervention goal to hand over to the person providing the intervention. It enables them to pick the person in the team best skilled to provide the specific intervention. It Version 1 May 14 89

90 also helps with effective planning of new and intervention sessions as this is done on the basis of referral volume rather than having to try and cope with an unpredictable amount of follow-up activity at an individual practitioner level. This then enables a fair distribution of work and effective management of workload levels. Other services have put in place a process whereby the service user is asked at the end of the session whether they feel another appointment would be useful and if so, when do they want to be seen. Clearly there is a small group of individuals where this approach is not appropriate, but this shouldn t prevent you from using it with those where it is appropriate. Caseload Management In addition to having a mechanism for reviewing cases, teams also need to have a way of ensuring the fair distribution of work between individual team members. The Wiseman Workload Measure (WWM) is a tool that can help staff to better understand and manage their current caseload. It is designed to be used on a recurrent basis within the context of individual line management supervision and can also help with identifying staff who may have too much work and those who may have capacity for additional work. This tool includes a turnover and time on caseload monitor. The WWM is completed by individual practitioners but can be aggregated to represent team and service total activity and total capacity. A spreadsheet has been developed which automatically aggregates individual clinician data up to a team level. See Section Eight for further info. The Choice and Partnership Approach (CAPA) is another system for enabling effective workload management. As identified above, by separating out the person doing the assessment from the person providing the intervention, it enables effective planning of new and intervention sessions as this is done on the basis of referral volume rather than having to try and cope with an unpredictable amount of follow-up activity at an individual practitioner level. This then enables a fair distribution of work and effective management of workload levels. There are also other caseload management systems in place. You need to ensure that the team has an approach to caseload management that ensures a fair and reasonable distribution of work. This means the system must adjust for dependency levels and frequency of contact, as two staff with the same level of individuals on their caseload could actually be experiencing very different workloads depending on frequency and length of contact. Supporting Discharge Sometimes practitioners hold onto people for too long because they don t feel safe to discharge. For instance, they may be worried about what happens if the individual relapses and hence they keep seeing the person just in case. Methods to support discharge include: Discussion within supervision so the practitioner has the opportunity to talk through any concerns and work through ways to manage these Version 1 May 14 90

91 Direct access re-referral. Some CMHTs operate a system whereby individuals who have previously received a service from the team can directly self-refer back in if necessary. This removes the barrier of the individual having to go back through the GP and empowers the individual client to self-manage. Relapse planning. If the individual has previously relapsed then doing work to identify early warning signs and agreeing jointly the response to these can again provide the security on both sides to enable discharge.(see Section Three) Version 1 May 14 91

92 Version 1 May 14 92

93 Section Six Undertaking a full DCAQ Analysis Version 1 May 14 93

94 Version 1 May 14 94

95 Why carry out a DCAQ Analysis Processes not people Demand, Capacity, Activity and Queue are all process measures. That is to say they measure the steps around the journey of the client, not the personal outcomes of the client or the personalities of the staff involved in their care. Therefore we can take these measures logically and look at the relationships they have with each other, and what effects change would have on the overall system. It is important to ensure throughout that the changes you make based on the process measures do not have a negative impact on the outcomes for the client of the health or morale of the staff. Demand vs. Capacity Demand is the amount of time being requested of our team and capacity is the amount of time our team has available. o If demand is equal to capacity then we will be able to treat all demand at current levels, if activity matches capacity, the queue will stay the same. o If demand is higher than activity then there will always be a shortfall and our queue will grow. o If demand is lower than activity then there will be capacity to take patients from the queue more quickly and the queue will reduce over time. The following diagram demonstrates this principle. Every time demand is higher than capacity the queue increases, and every time capacity is higher than demand the queue decreases. Therefore if we understand our demand, capacity, activity and queue we can see whether we have capacity in the team to manage the demand (with or without improvements to our processes) or whether we need to increase capacity. If there is sufficient capacity there might be need for a one-off time limited allocation of resource to reduce the queue. However without a detailed DCAQ analysis any impact on such waiting list initiatives may be reversed a short time afterwards. Version 1 May 14 95

96 Benefits and limitations One of the benefits of doing a demand and capacity analysis is that, in addition to highlighting any mismatches that might lead to growing queues or available capacity, it allows services to identify opportunities for improving the management of demand and ensuring effective use is being made of existing capacity. The aim is that the data then generates discussions that lead to changes in practice. Another benefit is being able to model scenarios of what would happen if demand or capacity changed, for example you could look at the impact of moving work from individual sessions to group sessions, or the impact of changes to sickness rates and the impact of changing how much time is spent on direct client care. The limitation of a DCAQ analysis is that it is only as good as the data you put in. This can be a major problem for some teams as the data that is immediately available is not always appropriate to use for a DCAQ analysis. However, the more you use data the better the quality the data becomes. There will be some data that can be used by your team as a starter for DCAQ work, which can in turn lead to further improvements in data. Even with accurate data, however, modelling demand and capacity for psychological therapies involves making assumptions and taking averages. Therefore there is an inherent margin of error built into any results and they need to be interpreted in that context. Nonetheless, averages and approximate figures are a considerable improvement on having no idea at all! This does mean though that considerable care should be taken before making decisions on the basis of the analysis. Version 1 May 14 96

97 Practicalities of a DCAQ Analysis Setting up the Project At the outset of the work, it is important to obtain a clear understanding of what the service delivers and how it s currently set up, prior to obtaining data. If there are different parts of the service that have different processes for handling referrals then there may need to be an analysis for each part of the service. In addition to mapping the service processes, we also recommend undertaking a process map of the data flows. This can help identify the data that is already available, whether it is of use, and if there are any gaps that you will need to gather data for the analysis. Please see the guide to info flow mapping produced for a national dementia event. The principles are the same for psychological therapies. Gather an understanding of the issues that the team would like to address what are they dissatisfied with? Where do they feel there are opportunities to improve their service? Set expectations around the DCAQ work with this in mind; DCAQ may address some problems and not others. With all the above intelligence gathered it is important to establish a project team and associated documentation. There is a template on the QuEST website for a project initiation document that can help you with this. This will ensure everyone understands the same reasons for undertaking the DCAQ analysis and what their part in the project is. Sufficient resource needs to be made available for the analysis, including DCAQ expertise, project management, analytical (both for interrogation of the system and data analysis) and improvement resource. Version 1 May 14 97

98 Approach The following flow chart outlines the steps taken in running most DCAQ projects: 1. Project initiation document prepared and signed of by Project Sponsor 2. Project Team identified and roles assigned 3. Obtain high level process map of service in order to understand what the data should reflect 4. Assess data required for DCAQ analysis against data available in local system(s) Clarify definitions and data flow for existing data If using historical data, consider whether definitions have changed in time period Is there a standard process for collecting data? If not, decide whether possible to move on with analysis with current data collection issues or to implement new process before continuing Identify gaps in data available in relation to what s needed for analysis Consider how best to fill gaps for this analysis and how to address for ongoing analysis of demand and capacity More than one information source? Compare data sources to determine which is more robust. Analysis may require a combination of sources 5. Agree work required to address issues identified, inclusive of clear timescales and responsibilities Identify and act on immediate opportunities to manage Demand and extend Capacity 6. Do initial analysis of DCAQ 7. Meet service leads to discuss initial results and to clarify any perceived data quality issues 8. Refine data where necessary 9. Redo analysis 10. Discuss results with service and scenario model changes to current processes to identify opportunities for improvement 11. Agree tests of change from analysis and timescales for revisiting analysis to assess impact of changes made Version 1 May 14 98

99 Identifying improvement opportunities Opportunities for immediate improvement in the management of demand and capacity will emerge almost as soon as the work commences. Indeed considerable progress can be made in some areas without looking at any data. There needs to be a system in place which clearly identifies how these opportunities will be captured, who will take them forward, how action will be taken and in what timeframes. There is an example action plan here. The team may already be involved in, or have recently concluded, a change programme. This needs to be considered, inclusive of changes that are being or are about to be implemented. DCAQ work needs to be integrated into that work wherever possible. Using the DCAQ tool QuEST have developed a tool to assist teams with DCAQ analysis. As mentioned earlier any calculation of DCAQ uses averages and takes assumptions, therefore before gaining access to the tool we ask users to agree to terms of use. For more information and access to the tool please contact QuEST@scotland.gsi.gov.uk putting QuEST MH DCAQ Tool in the subject heading to ensure it reaches the appropriate person. The table in section six, table 5 shows the data requirements for the tool DCAQ Analysis Examples There are reports available on the QI hub which details some DCAQ work undertaken in NHS Ayrshire and Arran and NHS Lothian, you can find both reports here: Version 1 May 14 99

100 Version 1 May

101 Section Seven Telehealth Version 1 May

102 Version 1 May

103 Telehealth / Telecare in the Context of Improving Services You may wish to consider the use of telehealth / telecare to improve efficiency and / or effectiveness of care. The use of Information Technology (IT) in healthcare provision is growing. Any view to using telehealth / telecare to provide healthcare or support to someone at home should be considered in three regards: Cost effectiveness Clinical effectiveness and Person centredness In the following sections we look at definitions of telehealth and telecare and examples of their application. Contact details are given for each example for further information to be sought. National Context In January 2013 The Scottish Government published A National Telehealth and Telecare Delivery Plan for Scotland to 2015: Driving Improvement, Integration and Innovation. The delivery plan outlines definitions of telehealth and telecare and sets out commitments to investing in and implementing technology to deliver services to patients at home and allow people to live longer and fuller lives. The delivery plan is set against six work streams: Improve and integrate health and social care Enhance wellbeing Empower people Improve sustainability and value Support economic growth Exchange learning, develop and embed good practice The delivery plan acknowledges Technology plays an increasing role in our everyday lives. The ehealth Strategy for Scotland reaffirms the pivotal role of telehealth and telecare technologies to radically transform the way health and care for people of all ages is delivered across Scotland. Deployed thoughtfully and appropriately as part of service redesign, telehealth and telecare can: Support people to have greater choice, control and confidence in their care and wellbeing; Enable safer, effective and more personalised care and deliver better outcomes for the people who use our health, housing, care and support services; Version 1 May

104 Help generate efficiencies and add value through more flexible use of our workforce capacity and skill mix and by reducing wasteful processes, travel and minimising access delays. Telehealth Definition of Telehealth For the purposes of this toolkit, we will assume telehealth is the provision of a health service using information technology. Telecare Definition of Telecare For the purposes of this toolkit, we will assume telecare is the use of information technology to support staying at home. Delivering the Productive Opportunity Delivering the productive opportunity through telehealth and telecare was previously outlined in the Mental Health Pathway: Efficiency and Productivity Report. The report outlined a number of productive opportunities related to telehealth and telecare: Telehealth: Use of video conferencing (VC) facilities to reduce time spent travelling and to improve access to specialist mental health services Better use of the telephone for client contact and meetings Use of SMS technology to issue appointment alerts to reduce DNAs Better use of technology to streamline administrative processes Better use of technology to enable self-management, peer to peer support, selfassessment, self-referral and co-delivery of care Telecare: Community alarms which enable people to call for help when they need it by pressing a push-button pendant Enuresis sensors which alert carers or support staff when someone has had an episode of incontinence Door contacts of passive infrared beams which alert carers that the person has gone outside Electronic location devices which can be used to locate a person with dementia who may have left their home and become lost or disorientated Temperature, smoke, carbon monoxide and flood detectors Devices to stop sinks and baths overflowing Medication reminders which use alarms as prompts Fall detectors which can be attached to clothing and are activated if the person falls Version 1 May

105 Please see the Telecare and Dementia report for more information. Issues to be Considered Staff awareness of potential opportunities Costs associated with video conferencing Cultural barriers Potential Measures to Evaluate Impact Cost Effectiveness o Staff time spent travelling to see service users o Staff time spent travelling to meetings o Staff travel costs o Patient travel costs o Staff time spent in meetings o Number of avoidable admissions to care homes due to better use of telecare / telehealth and savings delivered through reduced use o Number of days spent in care homes due to better use of telecare / telehealth and savings delivered through reduced use o Number of unplanned admissions and readmissions to hospital due to better use of telecare / telehealth and savings delivered through reduced use o Number of occupied bed days due to better use of telecare / telehealth and total value of this reduction Clinical Effectiveness o Did not attend rates Person Centredness o Service users and carers experience with service provided Environmental o CO2 emissions Version 1 May

106 Version 1 May

107 Section Eight Supporting Tools Version 1 May

108 Version 1 May

109 CONTENTS The following tools and resources can be accessed in this section. Some of the tools are presented within the toolkit. Others can be accessed using the inserted hyperlinks, either because they are too large to include here or because copyright restrictions mean we are not able to reproduce them in this format. Generic Improvement Tools This is not a comprehensive list. We ve included the ones you are most likely to use for this work but for a more comprehensive list of tools please visit the QI HUB website at The Model for Improvement (including PDSA) Process Mapping Value Stream Mapping Process Reliability Statistical Process Control Charts (SPC) Pareto Analysis The 5 Whys Cause and Effect Skill Mix Analysis Skills Matrix Mental Health Specific Tools CAPA Scottish Recovery Indicator 2 Aston Team Performance Indicator and CMHT Effectiveness Questionnaire Mental Health Activity Tracker Mental Health Capacity Calculator The DCAQ Tool Wiseman Workload Measure Guidance on Calculating New to Follow-up Ratios Mental Health Waste Spotters Guide Summary of Data needed for DCAQ Analysis in Mental Health Telehealth Telecare Examples / Resources Version 1 May

110 Model for Improvement & Plan Do Study Act (PDSA) What is the Model for Improvement? The Model for Improvement is a framework for accelerating improvement. The model is based on three fundamental questions: What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Any effort to improve something should provide the answers to these three questions. The answers could be answered in any order. These three questions combined with the Plan- Do-Study-Act (PDSA) cycle form the basis of the model. How to use it? Firstly begin with using the three framework questions: 1) What are we trying to accomplish? Set the aim which should be time specific and measurable - see Aims Tool. Define the specific population that will be affected. 2) How will we know that a change is an improvement? Establish the measures that will determine whether a specific change leads to an improvement. (See Measurement topic area for more information) 3) What changes can we make that will result in improvement? This is an opportunity for the team to develop ideas for testing. If there is a clear evidence base then you need to use this. However, in cases where this does not exist then you can use creative thinking techniques to generate ideas for testing. Next use the PDSA cycle, which allows you to test the change in the workplace setting. Plan Planning what needs done, list the tasks needed to set up the test of change, predict what will happen when the test is carried out, determine who will run the test. Do Run the test, document what happened when you ran the test, describe problems and observations. Study Observing the results, describe the measured results, compare to the predictions. Act Version 1 May

111 Acting on what has been learned; determine what your next PDSA cycle will be based on. PDSA allows you to learn from each small test and refine. If the initial test of change shows the predicted improvement, you should implement the change to a specific population before broadening to a whole work area or unit. Once a change has been shown to be an improvement, every opportunity should be taken to spread the success of implementing a change to other parts of the organisation. However the improvement may require testing in the new setting to allow staff to work out how they can fit the change into their practice. Version 1 May

112 Process Mapping What is it? Health and Social care systems and processes are often complex and fragmented. It is unlikely that a single member of staff would fully understand a complete service user pathway or process. Process Mapping is a powerful tool to understand how service users and information flows through the health and social care system, and to demonstrate how various parts of the system link together. It is a great way of highlighting visually what happens and enables you to identify unnecessary steps and duplication. The aim of process mapping is to map each step of the current process to help identify opportunities for improvement. Furthermore, process mapping helps all members of the team to identify issues with the current process and generate ideas for testing improvements. It is vital that the service users and carers perspectives are included in the process mapping exercise, otherwise you will just end up mapping what people think happens rather than what actually happens. Ideally you want to actually map a couple of individual s actual experiences of using the service and ask them for their opinions about what did and didn t add value. The outcome is a map of the service user or information s journey as a visual representation - a picture or model - of the relevant procedures and administrative processes. The map shows how things are and what happens, rather than what should happen. This helps anyone involved see other people s views and roles. It can also help you to diagnose problems and identify areas for improvement. There are different approaches to mapping service user journeys, procedures and administrative processes in healthcare services. Which one you select will depend on: What you need to know Resources and timescales Engagement and interest of staff Each one gives you a slightly different perspective and there is no definitive right or wrong. The key is to reflect how things are and not how they should be. Version 1 May

113 Process Mapping Event This section provides guidance for holding a process mapping event. Prior to the Process Mapping Event: Define start and end point of process to be mapped; Invite all members of the multi-disciplinary team involved in that process to a mapping event, including service user and carer representatives; Do not be too concerned if you can t get all members of the multi-disciplinary team to attend. After the event you can take the map to them; Send out some preparatory information on process mapping for participants to read prior to the event. The following resources may be required at the Process Mapping Event: Brown paper or flipcharts or wallpaper/ lining paper; Post-it notes (possible coloured for different types of issues); Marker pens; Sellotape. At the event Start by outlining the process to be mapped and then encourage participants to start writing their part of the process on Post-it notes. Please note the following: Process mapping events often require strong facilitation to keep people on track with the task and prevent distractions caused by discussing the issues in detail; Encourage people to write issues and ideas for improvements on separate Post-it notes and park them on a flipchart; Reinforce the importance of mapping the process as it usually happens, not the ideal or how it should happen, but what happens for the majority of service users; Arrange the Post-it notes to ensure they capture the service user journey in the correct sequence; Where relevant capture times, delays, waits, hand-offs etc.; Thank all participants for their involvement, and reinforce the need for a follow-up meeting to agree the map and actions to be progressed; Following on from the process mapping exercise, ensure you walk the service user journey and continue to involve service users to gain an understanding of their experience and to capture their ideas for improvement. Show the process map to the relevant individuals from the multi-disciplinary team who were unable to attend the event and encourage comments on current state as well as ideas for improvement. Also, display the process map in the relevant clinical area and encourage all staff to amend/update and put forward ideas for improvement. And finally, type up the process map, issues and ideas and send out to all participants with a date for a follow-up meeting quite soon afterwards, to maintain momentum. Version 1 May

114 Follow-up meeting recommended activities It is often too time consuming to analyse the process map in the first meeting. It is recommended that this is undertaken at a follow-up meeting which will allow relevant information to be captured from other members of staff, service users and carers as well as vital information from walking a service user journey. At the follow-up meeting it is advisable to start by analysing the process map. Consider the following: How many times is the service user passed from one person another (hand off)? Where are delays, queues built into the process? Where are the bottlenecks? What are the longest delays? What is the approximate time taken for each step (task time)? What is the approximate time between each step (wait time)? What is the approximate time between the first and last step? How many steps are there for the service user? How many steps add no value for the service user? (see section on value and waste for more information on this) Are there things that are done more than once? Look for rework loops Is work being batched? Where are the problems for the service user? At each step is the action being undertaken by the most appropriate staff member? Where are the problems for staff? Where is the greatest amount of time currently lost or wasted? Can any processes be carried out simultaneously? Consider what service users complain about. Whether any other teams might be affected should your team change its processes. You don t need to map everything: concentrate on the area where there is a gap in your understanding, or which needs improvement. Ideally, you will know where the bottleneck is before you go into more detailed mapping, as the information you need should be slightly different. Wherever possible, use photographs and pictures of places, staff and equipment in mapping exercises. This brings your representation of how things are to life. Also, try and look beyond the pathway when mapping, as it s often the same staff or resources that look after service user before and after the first step of treatment. Adapted from: Mental Health Collaborative Programme Toolkit 2009 Version 1 May

115 What is it? Value stream mapping is a lean technique used to analyse processes and understand what steps add value and which steps are non-value adding (wasteful activities). A current state map is developed identifying all the current steps in the service user pathway and categorising them as value adding or non-value adding (wasteful). Value-adding activities are those which service users can easily identify as being an important part of their journey. Wasteful activities are those which are non-value-adding and do not make any contribution to supporting the service user journey. A future (or Ideal) state map is then produced which often represents a significant change in the way the system currently operates. This means that the team then need to develop an implementation strategy to make the future state a reality. For more information on how to undertake a Value Stream Mapping exercise, see the Institute for Innovation and Improvements guidance at: improvement_tools/process_mapping_-_value_stream_mapping.html Or on the Quality Improvement Hub: Version 1 May

116 Process Reliability What is it? Process reliability helps teams understand the reliability of a current process. One way to measure the reliability is to find out how well staff understand the process and how consistently they are using it. What are the benefits of using this tool? Using this exercise with team members will help you highlight: the different approaches that staff may be using in a single activity any gaps in that process, for instance where staff skip steps (e.g. completing a form) in an agreed procedure the importance of having a standardised approach. This is a very simple exercise and will take around 10 minutes depending on how many team members are involved in the session. When to use it? This exercise can be used when prioritising areas to work through first i.e. in process mapping but can be used at any stage The tool and associated guidance can be accessed using the hyperlink to the Productive GP Series; you will need to register with the Institute for Innovation and Improvement to get a log on to use the resources. Version 1 May

117 Statistical Process Control Chart (SPC) What is it? Statistical Process Control (SPC) is a statistical tool based on robust methodology that uses data to analyse and understand the inherent variation within processes and systems. S Statistical, because we use some statistical concepts to help us understand processes P Process, because we deliver our work through processes, i.e. how we do things C Control, by this we mean predictable SPC can help in virtually all aspects of managing healthcare. From monitoring of waiting times for a Board to monitoring prescribing on a ward, SPC provides a way of separating the information from the noise so that managers and clinicians can understand what is going on. It does this by providing a mathematical basis for establishing the upper and lower limits of variation in processes that occur normally. Too often decisions are made without knowing whether changes in data are due to actions taken, or merely due to chance. Two of the simplest SPC techniques to implement are the run chart and control chart. The purpose of these two techniques is to identify when a process is displaying strange or unusual behaviour. Formally, the purpose of the run chart and the control chart is to distinguish between two sorts of variation that a process can exhibit, namely common cause variation and special cause variation. Common cause variation is normal and expected. Special cause variation produces unusual or unexpected variations for the system. As special cause variations occur only occasionally, they need to be addressed differently from common cause variations. This is to prevent anyone from making unnecessary changes or tampering with a system that works well. Run charts are a significant improvement over traditional reporting techniques, because they introduce the concept of changes over time. In order to manage a trend it is necessary to go one step further and ask, Is the change in the run chart due to a change in the process, or is it simply due to random fluctuation? To do this, the trend must be separated from the noise resulting from random variation. Much damage can be done by assuming a monthly change is the break in a trend, or represents a change resulting from action taken last month, when in fact it represents the effect of routine variation caused by random factors. This is where control charts come in. The control chart is a type of run chart. The aim of a run chart is to look for changes in performance over time. The aim of a process control chart is to show whether the changes seen in the run chart are as a result of routine variation in the process or the result of exceptional variation, i.e. an indication that something in the process has changed. From the separation of routine exceptional variation it is possible to determine whether the changes in data represent changes in performance or simply the normal variability of the system. Version 1 May

118 How to use it? SPC charts enable you to identify whether variation is common or special cause. When you are interpreting SPC charts there are 5 rules that help you identify what the system is doing. If one of the rules has been broken, this means that special cause variation is present in the system. It is also perfectly normal for a process to show no signs of special cause and this means that only common cause variation is present. Rule 1 Any point outside one of the control limits. Rule 2 A run of eight or more points in a row all above or all below the centre line Rule 3 Six consecutive points increasing (trend up) or decreasing (trend down) Rule 4 Two out of three consecutive points near (outer one third) a control limit Rule 5 Fifteen consecutive points close (inner one-third of the chart) to the centre line. If you want a more efficient system, you need to reduce the variation. Common causes and special causes of variation indicate the need for two different types of improvement which can help you achieve this. If controlled variation (common cause) is displayed in the SPC chart, the process is stable and predictable, which means that the variation is inherent in the process. If you want to improve the process, you will have to change the whole system. If uncontrolled variation (special cause) is displayed in the SPC chart, the process unstable and unpredictable. Variation may be caused by factors outside the process. In this case, you need to identify these sources and resolve them, rather than change the system itself. There are three issues that you should be aware of when using SPC charts to improve a process: You should not react to special cause variation by changing the process, as it may not be the system at fault; You should not ignore special cause variation by assuming that its part of the process. It is usually caused by outside factors which you need to understand in order to reduce them; You should ensure that the chart is not comparing more than one process and displaying false signals. An example of this would be data covering two hospital sites, or two procedures that are very different. Some issues you may encounter when creating your own SPC charts: Available data you may need to collect the data for analysis as it may not be available. To be statistically rigorous, the number of observations (the points you are measuring) are important. The more frequently you record the observation the better: daily or weekly is better than monthly; Aggregate data is discouraged (e.g. the use of percentages, as this often hides the pattern of the data); The problem you are observing may be due to data accuracy issues, not what is really happening to the service user. Sometimes it is better not to act if you aren t sure. Investigate further instead; Version 1 May

119 01/01/ /01/ /01/ /01/ /01/ /02/ /02/ /02/ /02/ /03/ /03/ /03/ /03/ /04/ /04/ /04/ /04/ /04/ /05/ /05/ /05/ /05/ /06/ /06/ /06/ /06/2008 Numbers Remember that when you change something in the process, the data points after then change will be from a new system. When you have a run of points which break a rule you will need to recalculate the SPC control limits to show an improvement (showing the control limits of the new system). Example of SPC Charts Daily Discharge data from a Scottish Acute Psychiatric Ward Daily Discharges Special cause variation Date D. Disch UCL LCL mean Version 1 May

120 Adapted from Sample SPC Charts and further information available at: The Clinical Indicators Support Team has produced an SPC chart package and tutorial that can be accessed at: Topics/Quality-Indicators/Statistical-Process-Control/ They have also developed workshops presentations that can be accessed at: Control/ The Institute for Innovation and Improvement have developed SPC packages which are available at: 8B9FC73BAFC1/0/SPCgenerator.xls Version 1 May

121 Pareto Analysis What is Pareto Analysis? Pareto analysis is a simple technique that helps you focus your efforts on the problems that offer the greatest potential for improvement. It does this by displaying your data in a descending bar graph that shows clearly the relative size or frequency of the problems and issues you have identified. Example of a Pareto chart indicating where falls occur in a fictional hospital Source: NHS Quality Improvement Hub, Quality Improvement Tools, Pareto What are the benefits of using this tool? Pareto's 80/20 principle asserts that for many events, roughly 80 per cent of the effects come from 20 per cent of the causes. The principle is a reminder to focus time and energy on the 20 per cent of issues that really make a difference. When to use it? Use Pareto when: you need to quickly identify the major causes of a problem and allocate resources accordingly you want others to quickly understand your data and the story it is telling. Version 1 May

122 The 5 Whys What is it? The 5 Whys is a simple tool to identify the root cause of a problem by systematically asking why? What are the benefits of using this tool? By repeatedly asking why? you can peel away the layers of a problem to get to the root cause. The earlier you can identify the cause, the earlier you can focus your resources in the right areas. This tool is quick and easy to learn and apply. It will help ensure you are tackling the true cause of the problem, not just the symptoms. When to use it? Use this tool at any time in your improvement work to understand the reasons behind a poorly performing process. The tool and associated guidance can be accessed using the hyperlink to RTC resources. In order to access the various resources you need to register with the Knowledge Network and request to join the Community of Practice. Version 1 May

123 Cause and Effect What is it? Cause and effect analysis is another way, in addition to the 5 whys tool, to think through the causes of a problem thoroughly. Both tools will lead to a similar result, so use the one your team prefers or try both if you have the time. This tool can help you identify the major causes of a problem and indicate the most fruitful areas for further investigation. The cause and effect diagram is sometimes called a fishbone diagram because it looks like the skeleton of a fish. What are the benefits of using this tool? This tool creates a snapshot of the team s collective knowledge about the problem develops consensus within the team focuses everyone on the root cause of the problem - not its symptoms. When to use it? Use this tool when you need to quickly and fully understand an issue and identify the possible causes. The tool and associated guidance can be accessed using the hyperlink to the Productive GP Series; you will need to register with the Institute for Innovation and Improvement to get a log on to use the resources. Adapted from: About RTC - Releasing Time to Care (RTC) Version 1 May

124 Skill Mix - Approaches to Support Analysis Main Approaches to Determining Skill Mix Task analysis Activity analysis/ activity sampling Daily diary / selfrecording Case mix/patient dependency Zero based profiling Professional judgement Frequency and cost of task elements of jobs identified. Skills and knowledge required for agreed tasks ; used to profile staff and identify gaps Activity performed by each staff member recorded by observers at predetermined intervals, for agreed time period. Frequency of different activities/time required identified. Data analysed, used as basis for reallocation of activities/tasks to staff As above, but staff record activities Patients/clients classified in groupings according to diagnosis or dependency. Formula is used to relate scores to staff hours required Detailed analysis of current mix, activity, skills and costs. Working group considers alternatives within available resources; aim is to achieve ideal mix Staff/management in work area assess current activity and staffing, review data available, apply collective judgement to reallocation of work Reliance on trained observers (costly; problematic if no agreement of skills/knowledge required). Task-based approach criticized because it focuses on the measurable Quantitative approach can be used as basis for discussion and debate. Observers can be expensive; difficult approach if workplace is not a fixed ward or unit; danger that if staff are not involved they will not accept results Can overcome cost implications of using observers (but has an opportunity cost). Staff may not provide accurate details. Strength is direct involvement of staff Uses mix of qualitative and quantitative methods. Benefits can include determining variations in staffing over time to match changing workload. Gives only overall numbers of staff; further work required to determine mix Often radical and fundamental. Rarely applied in full, because of organisational/political constraints. Danger of becoming a wish list, with less focus on how to get there Low tech approach; involves staff, can be quick. Constraints are possible lack of transparency/objectivity; possibility of little change Job analysis interviews/role Detailed individual or group interviews; can include critical Structured approach, if interviewers are skilled, can Version 1 May

125 reviews Group discussion/ brainstorming incident technique; repertory grid Facilitates workshop/discussion group of staff to identify issues requiring change. Use of available data as basis for discussion reveal much relevant information. Involves staff. Main problems are potential for bias and lack of objectivity Can be quick, often used as diagnostic phase of other approaches. Involves staff. Requires skilled facilitation; raises expectations and can generate mass of contradictory information Buchanan J. Determining Skill Mix: Lessons from an International Review. Department of Management and Social Sciences, Queen Margaret College, Edinburgh 1999; Version 1 May

126 Skill Matrix The Skill Matrix The skill matrix is a tool to help you clearly identify the activities and skills required for particular staff groups. It uses symbols to reflect the level of skill needed, e.g. whether someone needs training to undertake a task, or whether someone is competent to train others. What are the benefits of using this tool? Using this tool will: help your practice manage the skill mix for different staff groups help you identify where skills are missing and who can train staff in these skills assist in planning and scheduling your current services help you shape your future practice. When to use it? The skill matrix can be populated during analysis of capacity and activity to help ensure you are utilising skills and resources efficiently. It can also be used as part of the Shaping Our Future Practice module where it will help you understand the resource implications of any new ways of working. The tool and associated guidance can be accessed using the hyperlink to the Productive GP Series; you will need to register with the Institute for Innovation and Improvement to get a log on to use the resources. Adapted from: About RTC - Releasing Time to Care (RTC) Version 1 May

127 Choice and Partnership Approach What is it? The Choice and Partnership Approach (CAPA) is a clinical system that has been implemented in many CAMHS teams across the UK, Australia and New Zealand. It is informed by demand and capacity theory and has links with lean thinking. Hence the approach is underpinned by the same theory that is used in this toolkit. Many CAMHS services in Scotland have adopted the CAPA approach and it can equally be applied within adult services. For more information please see their website at There is also a useful guide to CAPA. Unfortunately they have sold out of the latest version and are currently in the process of updating the guide. You can pre-order the new version from their website or from Amazon. However, most CAMHS services already have a copy, so if you are interested in seeing one and not able to wait for the updated version, we recommend you contact your local CAMHS team. Version 1 May

128 Scottish Recovery Indicator 2 (SRI2) What is it? SRI2 enables mental health practitioners to provide ever more recovery focused services. The SRI2 is a revised and enhanced tool based on the experiences and feedback received from version 1 of the tool. SRI2 provides the opportunity for people who provide the service, and people who use the service along with their carers, to rate aspects of the service against ten recovery indicators. This results in stimulating and reflective conversations, leading to an action plan which is then fed into the web based tool. The resulting service improvements can be recorded and celebrated, and the next SRI 2 scheduled, thus ensuring continuous improvement and service development. When to use it You should consider using the tool when you are trying to gain a better understanding of your current state in relation to the recovery focus of your teams/services. The tool will encourage you to involve service users and carers in the redesign of your service and will help you facilitate this process. Version 1 May

129 Aston Team Performance Indicator and CMHT Effectiveness Questionnaire The following is provided for information only. Please note that this tool is copyrighted and Aston Organisational Development Ltd have not yet made a decision about making the CMHT version of the ATPI available to a wider audience. Their research team is still assessing wider applicability and doing some final validity testing. They do currently offer it to researchers to use as an on-line tool. A decision on whether to offer it wider should be made by the end of 2012 and if you are interested in using it then you may want to contact them directly to register your interest. If approved the tool would be offered under the same conditions as the ATPI, potential users need to attend a one-day accreditation programme and are then registered users, able to register teams on-line and access support from their team when necessary. They run open programmes (Assessing and Developing Teams) regularly, dates are on their web-site, cost is 250 per participant plus VAT and this includes 1 free administration of the ATPI and of the Aston Real Team Profile Plus with coaching support through first uses. The ATPI currently costs 120 plus VAT per administration. Full details of costs are on their website. Version 1 May

130 Version 1 May

131 Version 1 May

132 Version 1 May

133 Version 1 May

134 Version 1 May

135 Version 1 May