Improving Mental Health ED Flow – A partnership approach

Dr Kathryn Zeitz, former Director Strategic Operations, Mental Health Directorate, Central Adelaide Local Health Network - SA Health

Dr Tim Fountaine, McKinsey & Company

1

• Provide intervention and care for consumers aged between 16 and 64 years with mental health issues.

• Population 450,000 people across 10 Local Government Areas (LGAs) plus some statewide services

• 2600 of the adults and young people are registered to a community mental health team

• 4 integrated community teams geographically based

• 3 inpatient sites. 2 of these sites have emergency departments.

• Intermediate care (sub-acute, bed based, step up/step down care).

• Crisis respite (bed based or home based).

• Inpatient rehabilitation.

• Community rehabilitation centre.

• Supported accommodation.

Central Adelaide MHD

2

MH ED wait times have been increasing by ~20% / year since 2012 while MH presentations have only grown 1% / year

The problem

SOURCE: OBI 2012-2014 ED presentations

14

18

16

5

6

7

12

11

13

10

8

9

20

6

12

10

8

CALHN MH presentations and average visit time1

ThousandsHours

20132012 Year

+20% hours / year

2014

+1% thousand / year

1 For general adult (18-64), no specialist services (e.g., eating disorders)

MH presentations

Average MH ED wait time

3

We have worked with lots of consultants…..

• EY – Review of the SA stepped system of MH care and capacity to respond to emergency demand 29th July 2013

• Nous – Optimising Specialist Outpatient Support Services Central Adelaide Local Hospital Network 14 October 2013

• KMPG – KPMG Review of consumer flow across the mental health Stepped System of Care” Final Report March 2015

• KPMG – NALHN MH Service Benchmarking December 2015

…..and we were already doing lots things

4

The approach

5

Generated ideas

Analysedata

Encountered barriers

Imple-mented pilots

and refined

• Chronic and complex initiative

• Journey boards

• Day-1 discharge planning

• Inpatient-community interactions

• Transport

• Community ECT

• Discharge scheduling and projections

• Communication gaps

• Technical challenges

• Staff leave

• Resistance to new processes

• Workshops

• Discussions with staff

• Leadership meetings

• Multi-D brainstorming

• Case for change, big wins

• Program KPIs

• Project performance

• Day to day operational data

• DC Forecasts

External flags• Forensic beds

• IRS allocation process

• Housing

CALHN monthly performance % of consumers staying <24 hours in ED

CALHN

Hospitals

CALHN

TQEHRAH

8 Glenside beds opened

8 Glenside beds opened

Facts – to debunk myths (2014-15)

8890

86868485

8381

84

8992

848585

80

90

95

MayApr Jun JanDecJul AugJan MarFeb FebSep NovOct

9094

908886878585

8887

9389

97

85

100

95

90

80FebJan Mar FebApr May AugJulJun Nov JanDecOctSep

83

797981

7881

77

73

76

808385

75

80

70Apr AugJunMay Jul

72

Feb

71

Jan Mar FebDecOct NovSep Jan

6

Things that really made a difference

• Discharge Practices

• Journey Boards & huddles

• Benchmark LOS

• Forecasts

• Inreach & care coordination allocation

• Strengthen practices – conference call

• Chronic and Complex

• Protocols

• Referral process

• Case management

• Reporting

• Tracking and managing progress

• Easily understood live target: discharges per day

• Weekly review and dashboards

• Proactive planning

• Coaching and supporting the leadership

• Perfect week

• The art of the possible

7

8

From this….

To this….

A critical component to our ongoing success has been setting a discharge schedule and tracking daily discharges`

The Chronic & Complex Initiative significantly decreased the average number of patients with LOS>35 days

1 Baseline calculated as average of last year, first quarter 2015 and winter 2014.

▪ Average number of patients with LOS>35 days was 9.6.Baseline

▪ For June, the average number of patients with LOS>35 days was 5.

– Equivalent to saving roughly 130 bed days1.

▪ Over the period of 8 weeks:

– 13 patients with LOS>35 days were identified.

– Additional 21 patients were tracked, who were flagged as potentially having either LOS>35 days (acute ward) or LOS>14 days (ICC).

– Only 7 of the 21 flagged patients reached LOS>35 days(if in an acute ward) or LOS>14 days (if in an ICC).

– End of August only 2 consumers >35 days

Results

▪ Sustained over time

– Clinical Directors took over coordination of C&C with teleconference

– Continued the liaison role short term, then weekly teleconference (for a short time)

– End October 4

Next Steps

9

Perfect Week - The art of possible

▪ Preceding weeks (Sept/Oct) Average number of patients staying >24 hours in ED was still 21

▪ Daily Average 3

▪ ED LOS 16.5 (2014)

Baseline

▪ Suite of actions – Cancelled all meeting– Lots of communications– Daily teleconference – there was more to learn– Senior staff allocated an area each to visit and be available.

▪ For the week of Perfect Week: 5 breaches over 24 hours. Daily Avg of 0.7 ED LOS 6.2

• Perfect Week Avg Daily presentations 24 compared to 26 (Sept/Oct)

Results

▪ Sustained over time

– We got distracted

– Implementing Short Stay units and closing beds

Next Steps

C

10

How we approach clinical transformation

• Deliver results, not reports

• Use data to drive decisions – too many opinions in healthcare!

• Staff people who can engage – 3 medical doctors on the team

• Bring the best thinking from other industries e.g. lean process improvement skills

• Think of ourselves as coaches or personal trainers to our clients

• Approach change management holistically

11

Role-modelling“I see superiors, peers and subordinates behaving in the new way”

Fostering understanding and conviction

“I know what is expected of me – I agree with it, and it is

meaningful”

“I have the skills and competencies to behave in the new way”

Reinforcing with structure and

processes“The structures, pro-

cesses and systems reinforce the change in

behaviour I am being asked to make”

“I will change my mindset and behaviour, if…”

Developing skills required for change

Changing people’s behavior is not just about process and skills

12

Overall LOS (days) Patients with LOS >35 days ED patients waiting >24hrs

1 Average LOS for all separations in the past 28 days from PICU, acute units and SSU (Source: Daily Dashboard from Department of Health;)2 Current number of patients with a LOS >35 days in PICU, acute unit and SSU (Source: Daily Dashboard from Department of Health;)3 Percentage of people in QEH and RAH EDs waiting >24 hours in the past 28 days (Source: Daily Dashboard from Department of Health; )

10.4

8.4

10.4

12.4 -16%

End Project July

Base-line

August

(# patients) (%)

SOURCE: OBI and ISAAC datasets

Improvement

12.0

10.0 10.0

5.0

-17%

JulyBase-line

7.0

2.02.0

9.6 -79%

JulyBase-line

13

Nov/Dec AugustAugust Nov/Dec Nov/Dec