Patient Transport Services for the Northern SCAS area of operations were consolidated at Northern House Bicester in order to achieve better economies of scale and synergies. The control room struggled to get off the ground and in August 2009 call waiting times for wards and practices booking journeys were excessive. By Spring data suggested that some improvements had occurred but call volumes were as high as 800 per day and abandonment rate was at 30%. Staff were demoralised and stressed.

Archipelago were commissioned by the Manager of PTS with support from the Director of Transformation, principally to address the pressure being placed upon the control room (call volumes and abandonment rate), although as the three day operational diagnostic illustrated these statistics were symptomatic of operational problems on the ground particularly at transport operations bases. For this reason Archipelago widened the scope of the task and instigated measures to affect the wider operation.

Archipelago orchestrated a staff meeting and prepared leaders to appeal to staff to permit a rapid change to shift patterns. The staff gave unanimous consent when they heard the presentation of the Archipelago diagnostic. Actions taken were numerous and selected on the basis of the ease with which they could be completed and their impact on the operation (although it in the event, some actions which should have been straight forward i.e. the activation of agent and application displays that would allow supervisors to balance demand and capacity in the control room took weeks due to scarce IT / telecoms engineering support).

Archipelago worked alongside staff to deliver changes in many key areas of the operation, a selection of these include:

• Adjustments to Contact Centre 6 system – transition to single logon, dynamic switching, live application (lines) and agent displays (staff) that allowed supervisors to manage the control room.
• Adjustments to Cleric – use of SMS messaging, use of cancellation pop-ups, development of failure logging, use of vehicle capacity layout features to name a few.
• The development of a optimised planning process for Oxon and Bucks calculated to reduce mistakes.
• Support to supervisor recruitment using specially designed competencies and competency based interviewing. Supervisor training in objective setting and appraisal, control room management.
• Instigation of transport operations managers meetings to address short comings in bases (i.e. management of: mobile phones, vehicle service schedules, rota management).
• Instigation of a pilot to extend the use of the On-line Booking System to capture increasing percentages of bookings on-line.
• Set up arrangements for regular data delivery and analysis to give staff an awareness of and excitement at their progress.

The results were pleaseing for us and most importantly for the client:

• Crew Lines – Although average calls offered to these lines were increased by 50% over the period to 285 per day (Calls relating to ‘same day journey cancellations’ and crew calls previously handled using mobile phones (approx 100 per day) were redirected to the Day Control Team), however through other interventions capacity was created within Day Control to handle this. In spite of the increased volumes, abandonment rate was reduced by 63% to just from 30% to just 11%.
• Hospital Line – Average calls offered decreased by 49% over the period from 560 to 284 call per day. Abandonment rate reduced from 35% to 10.25%.
• Abort rate fell well below industry norms and was as low as 6% in April for journeys related to the Oxford PCT (focus for the intervention).
• In July 2010, on the busiest application (line) (Future Bookings and General Enquires) the average answer delay was 2 mins and 56 seconds (1 minute of that time is taken up with the message)
• 94% (2850) of calls to line 4 were answered within just 5 mins
• 6% (168) of calls were answered after 5 mins

There is still a long way to go, but the service has made significant strides forward in partnership with Archipelago.

A common reaction to systems improvement methodologies (like Lean applied in healthcare) is to perceive them as somehow careless about patient care and concerned only with systems and processes. It is an understandable reaction until one realises that Lean managers are actually trying to shape organisational behaviour to make the organisation more responsive to patients needs, not less so. Some will hold that the emphasis on systems and processes aims to diminish the role of the individual clinician when in fact the reverse is true, the whole philosophy drives managers to understand patient need and up- skill their teams accordingly, developing a ‘learning organisation culture’.

The importance of systems and processes cannot be dismissed, individuals are important, of course they are, but surely patients in any setting seldom experience good quality care, safe care or even life saving care by the actions of one person working alone. Effective care is delivered by teams working together (often across boundaries) and to a common purpose. It is delivered by teams with shared operating principles and procedures, willing and able to communicate. Effective care is delivered by teams that have adopted clear systems and processes.

Another common temptation is to believe that grouping patients in some way is to ignore their distinct and unique needs, when in fact by grouping patients and thus understanding the demand that each group exerts and meeting it, better patient care for each individual is more certain.

It is a kind of ‘tough love’ that good Lean operations managers practice in this field, but it is love none the less.

]]> http://www.archipelago-health.com/mental-health/diagnostic-for-south-staffordshire-mental-health-nhs-foundation-trust/feed/ 0 http://www.archipelago-health.com/uncategorized/archipelago-work-show-cased-on-mental-health-nhs-foundation-trust-quality-and-productivity-website/ http://www.archipelago-health.com/uncategorized/archipelago-work-show-cased-on-mental-health-nhs-foundation-trust-quality-and-productivity-website/#comments Mon, 08 Feb 2010 13:54:22 +0000 admin http://sailingtalk.com/archipelago-health.com/?p=220 The OBMH Quality & Productivity site has been launched, designed to promote the sharing of ideas and information throughout OBMH and to enable the sharing of best practices.

Some Archipelago Healthcare Ltd’s extensive work with the Trust is ’show cased’ in articles written by the staff with whom we have worked:

Community Acute Service Improvements Community Acute Services (Crisis Resolution and Home Treatment / Acute Day Hospitals): Changing the focus of Acute care to provide Step up and step down care

See also:
1) Transformation using Lean thinking
2) The Out of Hours Coordination Centre
3) Buckinghamshire Adult Acute wards quality Improvement Initiative

Some of Archipelago Healthcare Ltd’s extensive work with the Trust is ’showcased’ in articles written by the staff with whom we have worked:

Community Acute Service Improvements Community Acute Services (Crisis Resolution and Home Treatment / Acute Day Hospitals): Changing the focus of Acute care to provide Step up and step down care

See also:
1) Transformation using Lean thinking
2) The Out of Hours Coordination Centre
3) Buckinghamshire Adult Acute wards quality Improvement Initiative

This is almost certainly true unless we as believers in the power of Lean promote the difference between transactional change and transformational change.

Transformational change is what the NHS desperately needs (and the rhetoric is replete with the word ‘transformation’) yet many organisations (public sector, commercial and academic alike) misguidedly pursue what they believe to be transformational change, but is in fact transactional change.

Transactional change in my view, even if it is combined with tools lifted from the Lean toolbox, will ultimately fail to deliver.

How does this happen? I think it is because transactional change is comforting to executive and non executive boards. Proposals from advisors often contain Lean / Sigma models, jargon and concepts that are technically correct and sound appealing. 

The ‘Transformation’ promised takes the form of a project or a programme, it will follow a single and comprehensive approach and it emphasises clear structure, control and governance measures. Strategic choice will be on offer.  The plan may include time for mapping the whole organisation, gathering all manner of data, visioning and planning in the board room through workshops.

By contrast real transformation: Starts at the frontline with those who work closest to the patient, it seeks to give ownership to staff and align system forces by consent,  persuading staff with believable and locally collected data and with fact based argument.

 The design is owned locally and there is room for innovation, learning and discovery.

 Resources such as outside experts help and techniques such as lean models are used to enable change, not to control it.

 Small and frequent steps are taken, rarely wholesale redesign or complete change in the operating model. Transformation is never a project; it is part of the ‘day job’.

 Transformation is messy, different operating environments will demand different solutions, some interventions will take straight away, others will take longer.

 Impact on the cost / quality profile of the organisation certainly comes but is not always easy to explain by deductive reasoning. For executives the process will be uncomfortable.

 So what am I proposing to those who may be thinking, what part do the executive play? Will I be unleashing chaos in my organisation and abdicating control?

 My response would be, make enabling change part of the executive’s ‘day job’, there is plenty to do:

 Make sure you have a planning process that sets out unified strategic direction, not a strategy for transformation, just one for commercial and service operations, one which gives your department’s bold clear missions which they in turn can in turn interpret and pass down. Objectives must be bold and leave room for local interpretation and adaptation.

 Is your model of clinical governance integrated and enabling of frontline led care, while giving the necessary demonstrable safeguards required by regulators?

 Are you managing the organisation’s human resources well, spotting and developing talent (the talent to transform and manage services)?

 Are your Informatics team enabling change, facilitating rapid system improvements as the staff transforming services require them?

 Are you promoting a customer service culture that positions frontline staff as the customer of the corporate centre?

 Are you visible at the frontline, building your understanding and reinforcing and nurturing success wherever it breaks out.

 Make sure it is transformation that you have got, it may use Lean tools, but all that glitters is not gold!

In 2007 OBMH reorganised its specialist psychological therapies services based around the commissioning of these services by the local Primary Care Trusts (PCT).

The Psychology Departments and Psychotherapy Departments in Oxfordshire and Buckinghamshire and the Isis Centre in Oxfordshire were amalgamated into one Psychological Services (PS) within the CAMHS and Specialist Services Directorate. The service included therapists for adults of working age, older people and those who worked with both. Staff from all the different therapeutic approaches and professional backgrounds came together. The Oxfordshire staff were to cover three areas across the county designated by; North (Banbury and Bicester), City and South (Witney, Abingdon, Didcot, Henley and Thame). Buckinghamshire staff were split into North (Aylesbury) and South (High Wycombe and Amersham). These five teams were led by Clinical Managers with the support of Consultant Psychiatrists in Psychotherapy. Work is carried out on the main OBMH inpatient sites and team bases. There is an overall Service Manager and a Clinical Head who cover both counties.

Bringing together the clinicians also brought together differing systems of recording activity and waiting lists. All staff other than those at the Isis Centre were using the Patient Centred Recording System (PCIS), the central database and recording system for OBMH patient records. All patients entering a service are given a unique hospital number and their demographic details are stored in this system.

The psychologists had kept waiting lists on their own locality MS Access database. Psychotherapy in Oxfordshire had moved to the Outpatient Module in PCIS that allowed them to set up clinics for each of the Therapies such as Cognitive Behavioural Therapy (CBT), Cognitive Analytic Therapy (CAT), individual Psychodynamic Psychotherapy and various groups, but still had waiting lists on a separate MS Access database. The Isis Centre had their own database waiting list and did not use PCIS as most of their patients self referred. The Buckinghamshire teams used PCIS and their own databases. This variation in data collection resulted in limited accuracy of information held, slow access to information and wasted managers’ and clinicians’ time having to collate information from a number of sources.

What Happened Next?

Work was led by Archipelago Healthcare Ltd who specialise in transformation of mental health services and use Lean methods,

Lean thinking involved a number of stages including

Clarifying the key elements of the patient pathway
Identifying the main decisions and transition points
Streamlining all the systems into one
Working with IT to ensure that the Trust’s data requirements were met
Cleansing the data
Producing a manual for staff
Staff training
Rolling out the new system and embedding

What improvements has this made?

Applying LEAN thinking to PS patient data produced one system for all which has led to the following improvements:

Oxfordshire localities record all data into PCIS; Buckinghamshire will have the same system before end 2010. There are virtual clinics which help to track the progress of each patient from point of referral, to treatment and to discharge. Once a patient is entered on the system correctly they do not get lost in the system.

In the South Oxfordshire locality, 805 patients were identified in the system and a number of duplicate referrals were identified. All eligible patients were distributed into the appropriate clinics and 399 were discharged from the service.

Triage Clinics hold the referrals, they are discussed by the locality PS staff in triage meetings and either accepted for assessment if meeting the now clearly defined criteria or returned to the referrer with suggestions for care.

Clinicians are able to see all waiting lists accountable to them including the length of wait and proposed date for first contact. The patient should be seen within 8 weeks assessment period or 18 week treatment period measured from entry into the Triage clinic.

Timely recording of contacts in line with PCIS guidance has allowed more accurate reporting for each individual staff member, each locality and the service as a whole in terms of productivity and quality
Data reports are collated into the Operations and Commissioning excel spreadsheet, colour coded to enable lead clinicians in each locality to follow up those patients who have been waiting the longest where there is no appointment yet offered. This is pulled from the PCIS data and refreshed by IT Analysts weekly.

Use of the staff calendar having assessment slots booked 8 weeks in advance has speeded up booking and choice where resources permit this.

Appointments in the staff calendar allow the clinician to record their contact more efficiently.

A handbook available for admin and clinicians to aid them in correctly applying the new system. A separate clinician guide is also available. The clinician guide is more specific in detailing the clinicians’ responsibilities for data entry and monitoring of their caseload.

What Next?

We are rolling the system out into Buckinghamshire for the Aylesbury and Amersham Psychological Service localities.

The weekly data reports are being revised and modified to make them more accessible, precise and informative for the clinicians and managers alike. This will be an ongoing project with the imminent introduction of RIO (new patient information centre).

Flow

Measures that describe flow through the system such as length of stay (provided they are clearly defined and interpreted) are most likely to encourage frontline staff to eliminate costly sources of failure and waste which themselves detract from high quality care.
Flow measures such as these must be applied at every stage in the patient’s journey (they are typically thought of in respect of inpatient stays, but flow in relation to CMHT caseload is just as crucial).

Clinical / Holistic Outcome

These measures of flow must be tempered however, otherwise the net result is that patients are progressed too fast and maybe put at risk or at best simply re-access the system.
The patient’s progress should only be held up if the patient is too ill, or too ill equipped in terms of the skills needed to resume an independent life in the community (not, as is commonly the case, due to other system failures or failures of synchronisation of inputs).
The rightful brake on flow, in my view, is the application of appropriate clinical measures and other holistic assessment measures that can help us to guage objectively if the patient is sufficiently recovered to progress (in other words reached a quality standard sufficient for referring to the next service).

Patient Value Patient Experience

Finally and ultimately patient experience measures captured by surveys that are bespoke, locally derived and relate to the service in question are essential. It is these that when analysed have the potential to encourage staff to entwine good clinical care with good service. One just has to look at the average clutch of complaints to see how it is poor service rather than poor clinical care that undermines the journey to wellness.

Discovery by inductive reasoning …some things defy measurement!

I believe that the presence of significant proportions of the true quality we seek can only be accounted for by a process of ‘inductive’ rather than ‘deductive’ thinking. In other words.. presence of quality is ‘induced’ rather than ‘deduced. Only inductive thinking will reveal quality because quality is in fact to a large extent the absence of ‘things that harm the system’ (the absence of unnecessary constraints on freedoms to serve the patient, the absence of failure, the absence of waste …all these things are difficult to measure).

When we attempt to ‘deduce’ quality only through the measurement of things that we can see and touch (the presence of a care plan say), we run the risk of creating another target that results in the wrong behaviours (the perfect and comprehensive auditing of countless potentially low quality care plans, rather than the delivery of well planned care).

Too many targets arrived at by deduction also soak up much needed staff capacity, capacity that could be used to produce more frontline oriented measures to which staff can really relate to and which give them encouragement in their work. Look after the patient and the targets will look after themeselves.

Stefan Mieczkowski