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MENTAL HEALTH Collaborative Programme

TOOLKIT

ii

© Crown copyright 2009

The Scottish Government

St Andrew’s House

Edinburgh

EH1 3DG

Produced for the Scottish Government by RR Donnelley B57636 02/09

Published by the Scottish Government, February, 2009

The text pages of this document are printed on recycled paper and are 100% recyclable

iii

CONTENTS

1 INTRODUCTION 01

Mental Health Collaborative Overview 02

What is Collaborative Methodology? 11

2 SYSTEM DIAGNOSIS TOOLS

Delivering the Dementia HEAT Target 14

Delivering the Readmissions HEAT Target 33

Delivering the Depression HEAT Target 53

3 IMPROVEMENT TOOLS 73

Process Mapping 75

Identifying Value and Waste 81

Demand, Capacity, Activity, Queue (DCAQ) 85

Statistical Process Control 91

Model for Improvement (PDSA) 97

Service User Stories 101

4 CONTACTS 105

5 GLOSSARY OF TERMS 107

6 CASE STUDIES 113

iv

SECTION ONE:Introduction

Welcome to the Mental Health Collaborative Toolkit which has been

developed to support you in using improvement methods to deliver the

Mental Health HEAT targets.

This toolkit will develop over the life of the Collaborative. Our initial focus has been on

providing:

a) An overview of the Mental Health Collaborative;

b) Guidance on how to use improvement tools to analyse your current systems, identify

key areas for change and then to make change;

c) Information about the improvement tools we promote;

d) Key contact details for the National Collaborative Team.

We have also included a divider for a Case Study Section that will be populated over the

life of the Collaborative. These case studies will focus on the application of improvement

tools to deliver better services and will promote the sharing of good practice between

Boards about what has actually worked.

This guide is designed primarily for Mental Health Collaborative Programme Managers

and Clinical Leads – though the information in it may be useful to a range of others

involved with the work of the Collaborative. For this reason, the guide does use

improvement terminology. However, we have provided a glossary at the end to define

the terms we use and the section on Improvement Tools also provides more detailed

information about the various methods.

1

SECTION ONE

Introduction

MENTAL HEALTH COLLABORATIVE OVERVIEW

What are the Collaborative Aims and Objectives?

The overall aim of the Mental Health Collaborative is to support NHS Boards to make

the improvements needed to deliver against key national targets set out by the Scottish

Government. These targets are:

f To improve the quality of healthcare experienced;

f To reduce the annual rate of increase of defined daily dose per capita of

antidepressants to zero by 2009/10, and put in place the required support framework

to achieve a 10% reduction in future years;

f To reduce the number of hospital readmissions (within 1 year for those that have had

a psychiatric hospital admission of over 7 days) by 10% by the end of December 2009;

f To have achieved improvements in the early diagnosis and management of patients

with dementia by 2011.

Specifically, the objectives of the Mental Health Collaborative are:

f To deliver systematic and sustainable improvement to support the delivery of the four

HEAT targets;

f To identify where the use of improvement methods and techniques will lead to

improved performance, and to then work with NHS Boards and other key partners to

ensure effective application;

f Provide training for front line staff working in Mental Health services on the use of

improvement methods;

f To enable NHS Boards to use information effectively to support improvement;

f To develop a culture of NHS Boards sharing information and knowledge about what

works and what doesn’t for improving mental health services;

f To support the development of a culture of continuous improvement across mental

health services in Scotland.

How will it deliver its Aims and Objectives?

The MH Collaborative will deliver its aims and objectives through working at a national level

and in partnership with local NHS Boards as follows:

Nationally

f Provide training for front line staff working in Mental Health services on the use of

improvement methods;

f Provide funding to NHS Boards to develop improvement infrastructures which include

clinical leadership, programme management and information management;

f Set up a reference group of clinicians, managers, people who have a lived experience

of mental illness, carers and third sector representatives to identify: a) Additional

measures for improvement that relate to the HEAT targets and b) High Impact

Changes that, if implemented, will deliver significant improvements in key HEAT

target areas. This group has also informed the development of the diagnostic toolkit

for each workstream;

2

SECTION ONE

Collaborative Overview

f Put in place structures to enable effective sharing of information and knowledge

between different areas;

f Develop resources and toolkits to enable the application of improvement methods in

mental health services.

In partnership with local NHS Boards

f Provide support to NHS Boards to ensure effective programme management is in

place at a local level;

f Enable front line staff to access training both nationally and locally;

f Provide practical support to enable front line staff to put improvement methodology

into practice;

f Put in place mechanisms for monitoring the spend of collaborative resources and the

return on investment in terms of improvements actually delivered;

f Enable and support NHS Boards to make more effective use of information to inform

service improvement;

f Enable and support NHS Boards to effectively share information and ‘collaborate’ on

both what has worked and what hasn’t worked in terms of delivering improvements;

f Develop resources and toolkits to enable the application of improvement methods in

mental health services.

How will services find the time to do this work?

The Mental Health Collaborative has allocated additional funding for 3 years to all NHS

Boards in Scotland to enable them to put in place:

a) Programme Management and dedicated Service Improvement time;

b) additional Information Analysis time;

c) dedicated Clinical Leadership;

Amounts allocated per year are:

3

SECTION ONE


Ayrshire and Arran £150,738

Borders £79,404

Dumfries and Galloway £91,908

Fife £139,966

Forth Valley £119,716

Grampian £169,822

Greater Glasgow £369,591

Highland £134,263

Lanarkshire £191,278

Lothian £228,645

Orkney £55,532

Shetland £56,027

Tayside £153,626

Western Isles £59,484

HOW LONG WILL IT LAST AND WHAT WILL IT DO WHEN?

The Mental Health Collaborative is a three year programme running from April 2008 to

31st March 2011. However, our aim is to leave a lasting legacy of a culture of continuous

improvement across Mental Health services in Scotland.

The following table highlights key milestones for the Programme.

4

SECTION ONE


Time

Programme

Phase Key Actions Key Dates

Feb 08 –

Oct 08

National

and Local

Preparation

National

f Recruitment of national/regional teams

f Setting up Programme Infrastructure

including Reference Group

f Engagement with key Stakeholders

f Allocation of funding to NHS Boards

f Supporting NHS Boards to develop

local programme plans

f Clarity on interface with other national

programmes

f Develop Toolkit resources and training

resources

f Reference Group produces initial

guidance on focus of improvement work

Local

f Develop Programme Proposals

f Recruit to local teams

f Sort Governance arrangements

f Make links with existing work

24th April –

Launch

30th April –

Boards Submit

Programme

Proposals

30th Sept –

local

programme

posts appointed

to.

Nov 08 –

Feb 09

Diagnostic

Phase

National

f Finalise diagnostic toolkit

f Develop other improvement tools

f Training and Support to Boards

f First national learning event

Local

f Local teams and staff trained in

improvement methods

f Process mapping and gathering

information

f Analysing information within project

teams

f Develop comprehensive programme

plans

f Start using PDSA cycles

December –

Diagnostic

Toolkit produced

3rd December –

First National

Learning Event

March 09 –

Boards start

monthly

reporting

The following diagram provides a visual representation of the key project stages.

5

SECTION ONE


Time

Programme

Phase Key Actions Key Dates

Mar 2009

– Oct

2009

Action Period

1f Testing with PDSA Cycles and

embedding successful change

f Ongoing information analysis and

monthly reporting

f Ongoing training

f Focus regional support on Boards making

slower progress on HEAT targets

Nov 09 National

Learning

Event

Dec 09 –

May 10

Action Period




monthly reporting

f Ongoing training

f Focus regional support on Boards

making slower progress on HEAT

targets.

f Dec 09 –

target date

for achieving

reduction in

readmissions

f April 2010 –

target date

for achieving

levelling off

of anti-

depressant

prescribing

June 10 National

Learning

Event

July 10 –

April 11

Action Period




monthly reporting

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f Focus regional support on Boards

making slower progress on HEAT

targets.

f April 2011 –

target date

for achieving

increase in

number of

individuals

diagnosed

with

dementia

Jan 11 –

Mar 11

Evaluation f Evaluation of Programme

6

SECTION ONE


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7

SECTION ONE


HOW DOES THIS WORK LINK TO OTHER NATIONAL MENTALHEALTH PROGRAMMES?

The Mental Health Collaborative is one of a range of national initiatives attached to the

Mental Health Delivery Plan including:

f Benchmarking Programme

f Mental Health Integrated Care Pathways Programme

f Rights Relationships and Recovery Programme

f NES Psychological Therapies Programme

f SPARRA

f Towards a Mentally Flourishing Scotland

f Mental Health Leadership Programme

f Choose Life

Ultimately, all programmes are focused on supporting Boards to deliver improvements

to services. However, we take different but complementary approaches. The following

Improvement Jigsaw Diagram provides a high level summary of the different types of

improvement work.

The Improvement Jigsaw

Improving service user1 outcomes and experiences –

what we need to work on and how it fits together.

System and Processes Staffing

System and Processes Staffing

Ensuring we deliver effectivecare interventionseg (ICPS, SIGN,Matrix

Improving thedesign of caredelivery processes

Ensuring staff have theskills to delivereffective careinterventions

Ensuring staff have theright attitudesand values

Wh

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1 We recognise that some people who have experienced mental health problems and used mental health

services prefer to use words such as consumer, client or survivor. For ease of reading this document we have

chosen to use one consistent term for those who are receiving treatment and support – ‘service user’. We hope

this does not cause offence to those who prefer to use different words.

Improving service userexperience

Improving outcome of care

interventions

8

SECTION ONE


The focus of all our work is improving the outcomes for service users and improving their

experience of the service. To do this we need to focus on a number of different issues:

a) Ensuring services deliver effective care interventions – this relates to ensuring

that ICP standards and any other best practice standards (ie SIGN, Crisis Standards,

Care Management Standards) are followed. The Mental Health Collaborative and

NQIS ICP work are both focused on this area of improvement.

b) Improving the design of the care delivery processes – this is about ensuring a

well designed process that eliminates duplication and unnecessary steps, minimises

potential for error, and delivers the right amount of treatment capacity to see the

work without unnecessary waits. This is central to the work of the Mental Health

Collaborative, which promotes a range of tools and techniques to help services deliver

this aspect of improvement.

c) Ensuring staff are appropriately equipped to deliver services – both in terms of

what they do, but also the attitudes and values that underpin their practice. Rights,

Relationships and Recovery, the 10 Essential Shared Capabilities, the NES

Psychological Therapies Programme, Working with Older People – A Framework for

Mental Health Nurses, Choose Life Training, and the Mental Health Leadership

Programme are all examples of national programmes which support services to

improve both the skills and attitudes of staff.

The Mental Health Collaborative is focused primarily on the left hand side of this

diagram – improving the systems and processes – both in terms of what we do but also

how we do it. It also has a skills development focus around improving the understanding

and use of improvement methods across Mental Health Services. However, this is only

part of the picture and clearly ensuring staff have the right skills, attitudes and values is

also vital. Further, previous Collaboratives have found that looking at systems and

processes will highlight a range of staff development issues. This means it is important

that the work of the Collaborative is linked locally to workforce planning and training

structures.

Another way of thinking about improvement work is that it is about answering the

questions:

i) Are we doing the right things?

ii) in the right way?

iii) with appropriately trained staff? and

iv) using information to review if we are doing all of the previous three?

9

SECTION ONE


The following Diagram highlights how these questions link back to the Improvement

Jigsaw.

The focus of the Mental Health Collaborative work means it has particularly strong interfaces

with the Mental Health ICP programme, the Psychological Therapies Programme and the

Benchmarking Programme. The following diagram shows how these four programme

relate to each other.

Ensuring we deliver effectivecare interventions(ICPS, SIGN,Matrix)

Improving thedesign of caredelivery processes

Ensuring staff have theskills to delivereffective careinterventions

Ensuring staff have theright attitudesand values

Are we doingthe rightthings?

Withappropriatelytrained staff?

In the rightway?

Using information to review all of the above

Improving service userexperience

Improving outcome of care

interventions

10

SECTION ONE


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11

SECTION ONE

Collaborative Methodology

WHAT IS COLLABORATIVE METHODOLOGY?

Collaborative methodology originates from the work of the Institute for Health

Improvement in 1996 in the USA and has been used to deliver successful improvements

to health services in Scotland, Wales and England.

A Collaborative is an evidence based, service improvement methodology, which delivers

systems-wide engagement and demonstrable improvements in the care offered to service

users and their carers.

The focus of the Collaborative is to support NHS Boards through the development of

capability and capacity in technical and behavioural change management. This means

that the programme design incorporates:

f an approach to engage all staff, acknowledging the roles of executive sponsorship,

improvement leaders and champions, at national and local level;

f dedicated time for clinical leadership, project management and information analysis;

f front line staff actively engaged in redesign through rapid cycles of change;

f use of Lean techniques to reduce waste and duplication, improve patient flow and

reliability of clinical processes;

f a robust training and development strategy to develop skills and competency in the

use of improvement tools and techniques and behavioural change management;

f practical support to help staff develop confidence in using these tools and techniques

through the establishment of technical experts at a national level;

f provision of formal and social networking opportunities to enable staff to share, adopt

and spread good practice: this includes the development of ‘shared space’ facilities,

national and regional events;

f a national, regional and local programme management infrastructure including

dedicated programme teams, who work to embed the changes through operational

and clinical management.

Key to the development of the programmes has been an approach of identifying,

co-ordinating and where appropriate integrating work already in progress at both a

national and local level.

Collaborative Methodology also focuses on the concept of High Impact Changes. These

are those key changes that will deliver significant improvements to outcomes. These can

be either changes to the clinical delivery of services or changes to the design of services.

The initial Collaboratives in the USA tended to focus on clinical issues, where there was

clear evidence that a clinical intervention would make a difference and clear evidence

that that services weren’t routinely implementing the intervention. The approach was

then developed to focus on system design issues – particularly those that impact on

access to services.

For Mental Health Services, clinical standards already exist in the form of the ICP Standards

and SIGN guidelines. At a local level, collaborative resources can be used to focus on

implementing those clinical standards that are relevant to the delivery of the HEAT targets.

For the design of care delivery processes, the first step is for each Board to understand

what their key system and process design issues are. This toolkit provides support on

how to do this. Please see the Diagnostic Section, which has been developed with the

support of the Collaborative Reference Groups. Each workstream (Depression, Dementia

and Readmissions) has a reference group that is populated with clinicians, service user

representatives, carer representatives, voluntary sector representatives, key partner

representatives and managers from across the Boards.

Over the life of the Collaborative, we will collate and share information across the Boards

to identify where there are common system and process design issues and what works in

terms of redesigning those systems and processes. We will draw on the existing evidence

base about how to design efficient services and also draw on the actual experiences of

Boards. The Reference Groups will help us to do this. This will enable us to identify the

High Impact Changes. The following diagram shows this process visually.

12

SECTION ONE


Applydiagnosticsto identifykey issues

Provideadvice onapplicationof tools fordiagnosingsystemissues

BOARDS

REF

GROUP

Identify anycommon

systems/processissues across

Boards

Analyse PDSAoutcomes

plusExisting evidenceabout what works

High ImpactChanges

Improvedservices andHEAT targets

met

+ =

df

d

f

Act Plan

Study Do

df

d

f

Act Plan

Study Do

df

d

f

Act Plan

Study Do

13

SECTION ONE


IS THIS JUST AN NHS INITIATIVE?

The Mental Health Collaborative is part of the Improvement and Support Team, which

sits within the Health Delivery Directorate at the Scottish Government. Funding for local

infrastructures has been allocated to NHS Boards. However, we recognise that NHS

Mental Health Services don’t sit in isolation and delivering the HEAT targets will mean

working across health, social care and the voluntary sector. Therefore, we expect all NHS

Boards to involve their key partners in the work of the Collaborative. At a national level,

we are also working to establish links with key partners.

We’ve taken the ‘Improvement Tools’ section of this toolkit directly from current online

resources:

f Improvement and Support Team Toolkit

http://member.goodpractice.net/ContinuousImprovementToolkit/resources/core-

improvement-tools

f 18 Weeks Toolkit

http://www.nodelaysscotland.scot.nhs.uk/ServiceImprovement/pages/default.aspx

That means some of the language used is health focused. However the tools equally

apply to social care and voluntary sector organisations.

14

SECTION ONE


SECTION TWO:System Diagnosis Tools

DELIVERING THE DEMENTIA HEAT TARGET

HEAT target

Each NHS Board will achieve agreed improvements in the early diagnosis

and management of patients with dementia by March 2011.

Delivering the Dementia HEAT target is about improving access to diagnosis and the

provision of early management and support. Improvements can be categorised under

three main headings:

1. Improving the design of the care delivery processes – this is about ensuring

well-designed processes that eliminate duplication and unnecessary steps, minimise

potential for error, and deliver the right amount of treatment capacity to see the work

without unnecessary waits. This needs to take a whole systems perspective working

across the traditional health and social care boundaries. Changes here should result in

an improved experience of using care services.

2. Ensuring the delivery of effective care interventions – this relates to ensuring ICP

standards and any other national approved guidance (ie SIGN) is routinely followed.

However, this is not just about improving the clinical standards of care – it is about

the range of care interventions including those delivered by the local authority and

voluntary sector services. Changes here should lead to improved outcomes for people

with dementia.

3. Ensuring staff are properly equipped to deliver services – this recognises the

importance of applying knowledge and skills within a values-based framework. All

improvement work is underpinned by continuous professional development and

workforce planning. There may be a need to develop the skills of existing staff, extend

roles, develop new roles and to review the skill mix within services. Training a wide

range of health and social care staff on how to respond effectively to individuals with

Dementia will be key to delivering this HEAT target. Changes here should contribute

to both improved outcomes and improved experiences for those using services.

15

SECTION TWO

Delivering the Dementia HEAT Target

The following diagram highlights the key elements of the Dementia Journey that you

will need to work on to meet the dementia HEAT target:

f For design of care delivery processes – the first step is for each Board and their key

partners, to understand what their key system and process design issues are and this

document provides advice on how to do this. Over the life of the collaborative we will

collate and share information across Boards and key partners, to identify where there

are common system and process design issues and what works in terms of

redesigning those systems and processes.

f Standards already exist for ensuring we deliver effective care interventions (eg

ICP Guidance and SIGN guidelines). At a local level, collaborative resources can be

used to focus on implementing those clinical and care standards that are relevant to

the delivery of the HEAT target. The following diagram shows how ICP Standards and

SIGN guidelines relate to this workstream. Further work will be completed to map

other relevant national guidance against the key elements of pathway. In addition,

action on ICP standards 6 and 7 will be of direct relevance to achieving the dementia

HEAT target.

f The diagram also highlights some of the key workforce programmes that underpin

the delivery of improved services.

16

SECTION TWO


17

SECTION TWO


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18

SECTION TWO


19

SECTION TWO


DEMENTIA PATHWAY – SYSTEMS DIAGNOSIS CHECKLIST

This document is aimed at those involved in leading and planning the Mental Health

Collaborative (MHC) work. It is provided as a supportive tool to help those involved in

leading and planning the work of the MHC locally to think about how to apply improvement

methods to enable the delivery of the Dementia HEAT target.

It is designed to be used as part of the Mental Health Collaborative Toolkit which

includes sections on the different improvement methods mentioned and an overview

of the Collaborative Approach.

It works on the basis that the first 3-6 months should be on visioning and diagnosis.

Visioning involves defining and describing the ideal systems, processes and pathways

of care to fulfil and exceed the HEAT targets. These ‘ideals’ will be firmly rooted in the

best evidence available and complemented by experiential input and insights from

service users, carers and staff. Diagnosis involves comparing current service behaviour

with the ideal to establish where changes need to be made and what these changes

might look like in order to achieve the ideal. It also involves understanding your current

processes, what works well and what doesn’t work so well.

As with clinical care – getting the diagnosis right is important as it guides what interventions

are taken. If clinicians treat the wrong problem – chances are the treatment won’t be

effective. Likewise – if change programmes are based on an incorrect analysis of the

problem – chances are that the change programme will be ineffective. So it’s worth

investing the time up front to get the diagnosis of the problem right. Visioning is a key

part of this – as we need to be clear that we are doing the right things, not just doing

the wrong things more efficiently.

We realise that many Boards (and key partners), have already made significant progress

against this target and we are not suggesting you put on hold any work already in progress.

However, the following suggestions may give you some ideas about how to progress this

work further.

20

SECTION TWO


21

SECTION TWO


SYSTEMS OVERVIEW

When looking at changes to one part of the pathway, it’s important to consider the

impact on other parts of the system. Otherwise, services can end up making one part

work better but just move the problem elsewhere. For instance, a team might change

their referral criteria and end up effectively reducing the demand on this service, only to

find out that requests for services in another part of the system go up.

The Collaborative promotes looking at whole systems and to do this, services need to

have mechanisms in place for discussing potential changes across different parts of the

health and social care system. For the dementia pathway there are key interfaces

between all of the following:

f Primary Care

f Old Age Psychiatry

f Social Work Services and wider local authority services

f People with Dementia and their Carers

f Acute General Medicine

f Care Homes

f Voluntary and Independent sector provider

22

SECTION TWO


SY

ST

EM

S O

VE

RV

IEW

CH

EC

KL

IST

Issu

es

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Is t

he

re a

str

uct

ure

in

pla

ce f

or

eff

ect

ive

dis

cuss

ion

of

inte

rfa

ce i

ssu

es

be

twe

en

th

e v

ari

ou

s te

am

s

resp

on

sib

le f

or

de

live

rin

g t

he

pa

thw

ay

?

Do

yo

u h

ave

a s

yst

em

fo

r p

rovid

ing

de

me

nti

a

tra

inin

g a

cro

ss a

ll s

ect

ors

wh

o c

om

e i

nto

co

nta

ct

wit

h i

nd

ivid

ua

ls w

ith

de

me

nti

a?

Is A

dva

nce

d C

are

Pla

nn

ing

be

ing

pro

mo

ted

lo

call

y

an

d d

oe

s th

is i

ncl

ud

e p

eo

ple

wit

h a

de

me

nti

a/

cog

nit

ive

im

pa

irm

en

t?

23

SECTION TWO


DATA ANALYSIS – ASSESSING CURRENT PERFORMANCE

The Mental Health Collaborative promotes using data to: understand how well your

current system is working; identify where to focus improvement actions; and to assess

whether any changes are really delivering improvements. Please also see the Model for

Improvement within the improvement tools section for further information on using data

to assess whether change is working.

The HEAT Target baseline year is the number of patients on the register at the 31st March

2007. A practical start point is therefore downloading data (from the ISD website –

http://www.isdscotland.org/isd/3305.html) on the number of patients on local GP QOF

registers as at 31st March 2007. You can also download data on the registers as at

31st March 2008 and identify those practices who are managing to increase numbers.

As a first step we recommend all areas compare QOF numbers against those

diagnosed with dementia in secondary care and cross-check names on lists to

establish if any registers are incomplete. Where there is a difference in names –

we recommend you then look at your processes to ensure those who are

diagnosed by secondary care are routinely entered onto the register.

A helpful step is to compare current (actual) QOF levels with expected UK Dementia

prevalence levels for each practice. This will give you an indication of how many patients

have been diagnosed compared to how many (given demographics and national

prevalence) ought to have been diagnosed for each practice.

If there is a Practice, or a number of Practices, with a high percentage of patients on the

register then you could consider comparing this practice with one at the lower end of

detection. Retrospective patient tracking may be helpful in addition to interviews with

GPs/Practice visits in order to compare and contrast knowledge, training, systems and

processes.

For those practices already displaying a high level of diagnosis (compared to expected

prevalence) it may be worthwhile comparing their performance with practices in other

Boards to see if they can further improve their performance. Please consult your

Regional Manager if you need help in identifying practices outside of your region.

We also recommend you look at the QOF information with regards to numbers of those

on the register who have had a formal review after 15 months.

The following table helps you to think about applying data analysis to the Dementia

workstream. This is not an exhaustive list, it is simply provided as a starting point to help

MHC teams think about how improvement tools apply to this work.

24

SECTION TWO


DA

TA

AN

ALY

SIS

CH

EC

KL

IST

Issu

es

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Ass

ess

ing

Cu

rre

nt

Pe

rfo

rma

nce

–B

ase

lin

e

Do

yo

u k

no

w t

he

nu

mb

er

of

pa

tie

nts

on

lo

cal

QO

F

reg

iste

rs a

s a

t 3

1st

Ma

rch

20

08

?

Da

ta A

na

lysi

s

Ha

ve y

ou

va

lid

ate

d y

ou

r Q

OF

re

gis

ters

ag

ain

st t

ho

se

kn

ow

n t

o s

pe

cia

list

me

nta

l h

ea

lth

se

rvic

es?

Da

ta A

na

lysi

s

Ha

ve y

ou

co

mp

are

d c

urr

en

t /

act

ua

l re

gis

ter

nu

mb

ers

ag

ain

st e

xp

ect

ed

de

me

nti

a p

reva

len

ce

rate

s p

er

pra

ctic

e?

Da

ta A

na

lysi

s

Do

pra

ctic

es

kn

ow

wh

ere

th

ey

sit

in

co

mp

ari

son

to

oth

ers

pe

rfo

rma

nce

in

th

eir

He

alt

h B

oa

rd –

bo

th i

n

term

s o

f p

erc

en

tag

e o

n r

eg

iste

r o

f e

xp

ect

ed

pre

vale

nce

an

d o

ng

oin

g p

erc

en

tag

e i

ncr

ea

se?

Da

ta A

na

lysi

s

Va

ria

nce

If y

ou

ha

ve s

ign

ific

an

t va

ria

nce

s b

etw

ee

n p

ract

ice

s –

ha

ve y

ou

fo

llo

we

d a

co

up

le o

f p

ati

en

ts t

hro

ug

h t

he

ind

ivid

ua

l p

ath

wa

ys

to i

de

nti

fy d

iffe

ren

ces

in

pra

ctic

e t

ha

t m

igh

t co

ntr

ibu

te t

o t

he

dif

fere

nt

ou

tco

me

s?

Pro

cess

Ma

pp

ing

If t

he

re a

re i

nd

ivid

ua

ls k

no

wn

to

se

con

da

ry c

are

bu

t

no

t o

n t

he

QO

F r

eg

iste

r –

ha

ve y

ou

ma

pp

ed

yo

ur

pro

cess

es

fro

m t

ea

m d

iag

no

sin

g t

o i

nd

ivid

ua

l b

ein

g

en

tere

d o

nto

th

e r

eg

iste

r to

id

en

tify

wh

ere

th

e

pro

cess

bre

aks

do

wn

?

Va

ria

nce

an

aly

sis

Pro

cess

Ma

pp

ing

25

SECTION TWO


DA

TA

AN

ALY

SIS

CH

EC

KL

IST

Issu

es

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Ass

ess

ing

Cu

rre

nt

Pe

rfo

rma

nce

–B

ase

lin

e

Do

yo

u h

ave

a s

yst

em

fo

r re

gu

larl

y r

ep

ort

ing

pro

gre

ss t

ow

ard

s th

e H

EA

T t

arg

et

at

Bo

ard

le

vel?

Da

ta A

na

lysi

s

Ha

ve y

ou

lo

oke

d a

t w

ha

t p

erc

en

tag

e o

f th

ose

on

th

e

De

me

nti

a R

eg

iste

r re

ceiv

e t

he

15

mo

nth

re

vie

w b

y

pra

ctic

e?

Da

ta A

na

lysi

s

Do

pra

ctic

es

kn

ow

wh

ere

th

ey

sit

in

co

mp

ari

son

to

oth

ers

in

th

eir

He

alt

h B

oa

rd w

ith

re

ga

rds

to t

he

pe

rce

nta

ge

of

tho

se o

n t

he

De

me

nti

a r

eg

iste

r

rece

ivin

g a

15

-mo

nth

re

vie

w?

Va

ria

nce

Ha

s th

e Q

OF

re

gis

ter

be

en

an

aly

sed

in

te

rms

of

eth

nic

ity

an

d d

ep

riva

tio

n?

Da

ta A

na

lysi

s

26

SECTION TWO


PROCESS ANALYSIS

Process Mapping is key for understanding what currently happens and where things

break down. It helps to identify what needs to change. Involving service users and carers

in the analysis helps you to understand how it feels to be on the receiving end of our

processes. Understanding care processes from the service user’s perspective is essential

for making service user focused improvements.

All the organisations/teams involved in the pathway should be identified and involved in

the process mapping activity. This process mapping work should already be taking

place in all Boards as part of the work to develop a Dementia ICP. The mapping work

should include service user and carers perspectives, in line with the ICP standards (See

ICP Process Standard 2). It should also include relevant social care providers. In addition

to the process mapping exercise – it might also help to undertake discovery interviews,

feedback questionnaires, and data sampling in order to fully understand the service

user and carers experience.

The Mental Health Collaborative team can help facilitate this process mapping exercise

and suggest approaches to other diagnostic work if you’re not sure. Please contact your

Regional Manager to discuss further.

But the work doesn’t stop at process mapping – you now need to look at streamlining

the pathway and look at the flow through the pathway. Using value-stream mapping,

you can identify:

f those steps in the process that don’t add any value

f bottlenecks in the process where capacity is not sufficient to meet the demand

f unnecessary delays (long waits)

f steps where there are quality issues – ie work has to be redone or sent back to a previous

step or where there is confusion over who is responsible for which aspects of care.

A further question to ask is whether there’s a group/individual that is responsible for

ensuring that the different teams/people involved in delivering care to someone with

dementia all work together effectively.

A range of tools within Lean are available to help with analysing the pathway, and

facilitation support is available from the Collaborative Team. The output of this

‘overview’ investigative work should be clarity on the key issues you need to address

locally to simplify and improve the care process. The Collaborative promotes then using

the PDSA approach to make incremental improvements to the process.

The following table helps you to think about applying process mapping to the Dementia



27

SECTION TWO


28

SECTION TWO


PR

OC

ES

S A

NA

LYS

IS C

HE

CK

LIS

T

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Imp

rove

pu

bli

c a

nd

sta

ff a

wa

ren

ess

Is a

wa

ren

ess

an

d t

rea

tme

nt

info

rma

tio

n a

vail

ab

le t

o

the

ge

ne

ral

pu

bli

c, p

ati

en

ts, c

are

rs a

nd

pro

fess

ion

als

.

Is t

his

in

form

ati

on

re

gu

larl

y u

pd

ate

d a

nd

ta

rge

ted

?

Is t

his

in

form

ati

on

acc

ess

ible

by

pe

op

le f

rom

dif

fere

nt

eth

nic

ba

ckg

rou

nd

s a

nd

th

ose

wit

h

lea

rnin

g d

isa

bil

itie

s?

Ro

ute

s in

to D

iag

no

sis/

Ach

ievin

g a

Dia

gn

osi

s

Ha

s th

e D

em

en

tia

Pa

thw

ay

be

en

ma

pp

ed

ou

t b

y

tho

se i

nvo

lve

d i

n t

he

se

rvic

e –

in

clu

din

g t

ho

se t

ha

t

use

th

e s

erv

ice

an

d t

he

ir c

are

rs?

Pro

cess

Ma

pp

ing

Ha

ve y

ou

ma

pp

ed

yo

ur

pro

cess

es

for

soci

al

wo

rk t

o

refe

r fo

r d

iag

no

sis

an

d a

na

lyse

d t

he

se t

o s

ee

if

the

y

cou

ld b

e m

ad

e s

imp

ler?

Pro

cess

Ma

pp

ing

Ha

ve y

ou

ag

ree

d a

n i

nte

gra

ted

ca

re p

ath

wa

y (

ICP

)

thro

ug

h t

o d

iag

no

sis?

Is e

ach

te

am

re

spo

nsi

ble

fo

r d

eli

veri

ng

th

e p

ath

wa

y

cle

ar

on

wh

at

de

me

nti

a c

are

th

ey

pro

vid

e a

nd

cle

ar

ab

ou

t w

ha

t in

form

ati

on

th

ey

ne

ed

fro

m o

the

rs?

Pro

cess

Ma

pp

ing

29

SECTION TWO


PR

OC

ES

S A

NA

LYS

IS C

HE

CK

LIS

T

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Ro

ute

s in

to D

iag

no

sis/

Ach

ievin

g a

Dia

gn

osi

s –

con

tin

ue

d

Ha

ve y

ou

an

aly

sed

th

e p

roce

ss m

ap

s a

nd

id

en

tifi

ed

du

pli

cati

on

, un

ne

cess

ary

ste

ps,

mis

sin

g s

tep

s a

nd

wo

rk t

ha

t n

ee

ds

to b

e r

ed

on

e b

eca

use

no

t d

on

e r

igh

t

the

fir

st t

ime

?

Va

lue

Str

ea

min

g

Ha

ve s

erv

ice

use

rs a

nd

ca

rers

be

en

in

volv

ed

in

th

is

pro

cess

ma

pp

ing

an

d i

de

nti

fie

d w

ha

t a

dd

s va

lue

fro

m t

he

ir p

ers

pe

ctiv

e?

Va

lue

Str

ea

min

g

In p

art

icu

lar,

ha

ve y

ou

ma

pp

ed

th

e p

roce

ss f

or

care

ho

me

s to

re

fer

for

dia

gn

osi

s w

he

re t

he

y s

usp

ect

an

ind

ivid

ua

l h

as

de

me

nti

a?

Do

es

this

pro

cess

fe

ed

thro

ug

h t

o r

eg

istr

ati

on

on

th

e r

ele

van

t p

ract

ice

s

De

me

nti

a r

eg

iste

r?

Pro

cess

Ma

pp

ing

Va

lue

Str

ea

min

g

Do

yo

u k

no

w w

he

re t

he

bo

ttle

ne

cks

are

in

th

e

syst

em

?

Flo

w A

na

lysi

s

30

SECTION TWO


PR

OC

ES

S A

NA

LYS

IS C

HE

CK

LIS

T

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Ea

rly

Ma

na

ge

me

nt

an

d S

up

po

rt

Ha

ve y

ou

an

aly

sed

yo

ur

pro

cess

es

for

rece

ivin

g

sup

po

rt p

ost

dia

gn

osi

s a

nd

id

en

tifi

ed

du

pli

cati

on

,

un

ne

cess

ary

ste

ps,

mis

sin

g s

tep

s a

nd

wo

rk t

ha

t n

ee

ds

to b

e r

ed

on

e b

eca

use

no

t d

on

e r

igh

t th

e f

irst

tim

e?

Pro

cess

Ma

pp

ing

Va

lue

Str

ea

min

g

Ha

ve s

erv

ice

use

rs a

nd

ca

rers

be

en

in

volv

ed

in

th

is

pro

cess

ma

pp

ing

an

d i

de

nti

fie

d w

ha

t a

dd

s va

lue

fro

m t

he

ir p

ers

pe

ctiv

e?

Va

lue

Str

ea

min

g

Ha

ve y

ou

ag

ree

d t

he

po

st d

iag

no

stic

su

pp

ort

ele

me

nt

of

ICP

?

ICP

s

Is A

dva

nce

d C

are

Pla

nn

ing

pro

mo

ted

in

Ca

re

Ho

me

s?

Are

Cri

sis

Se

rvic

es

ava

ila

ble

fo

r p

eo

ple

wit

h

De

me

nti

a d

uri

ng

th

e O

ut-

of-

Ho

urs

pe

rio

d?

31

SECTION TWO


UNDERSTANDING DEMAND AND CAPACITY

Understanding the demand for services is essential, as without this services cannot

effectively plan to meet this demand. However, they also need to understand the capacity

that they have to respond to that demand and whether they are making best use of this.

For instance, if a team has a highly skilled member of staff spending a day booking care

plan reviews, this is not making effective use of their current capacity. An audit across

one community mental health area showed that differences in waiting lists between

teams were five times more to do with what they did with each case (ie differences in

number of sessions and duration) than the number of referrals the teams received.

Matching demand and capacity is important because delays in receiving a timely response

can leave people in distress with no support. Further, delays can lead to an escalation of

someone’s illness.

The presence of a waiting list is a sign that demand is not being matched with capacity,

it is not necessarily an indication that the demand exceeds the capacity (please see

improvement tools section of toolkit for more information on this). It is therefore

important to gather information on demand, activity, and capacity and to analyse this

in greater detail to understand profiles, trends and variances and whether additional

resources are really needed, or it is a case of redesigning to make better use of what

already exists.

The following table helps you to think about areas you could apply demand and capacity

analysis in relation to the Dementia workstream. Again, it is not an exhaustive list, it is

just provided as a starting point to help MHC teams to think about how demand and

capacity work applies to the Dementia workstream.

32

SECTION TWO


DE

MA

ND

, CA

PA

CIT

Y A

ND

QU

EU

E

Issu

es

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Ro

ute

s in

to D

iag

no

sis/

Ach

ievin

g a

Dia

gn

osi

s

Do

yo

u k

no

w w

ha

t th

e p

roje

cte

d d

em

an

d f

or

dia

gn

ost

ic

ass

ess

me

nts

is?

DC

AQ

Do

yo

u k

no

w w

ha

t y

ou

r ca

pa

city

to

pro

vid

e d

iag

no

stic

ass

ess

me

nts

is?

DC

AQ

Ea

rly

Ma

na

ge

me

nt

an

d S

up

po

rt

Do

yo

u k

no

w w

ha

t y

ou

r d

em

an

d f

or

po

st d

iag

no

stic

su

pp

ort

is?

DC

AQ

Do

yo

u k

no

w w

ha

t y

ou

r ca

pa

city

to

pro

vid

e p

ost

dia

gn

ost

ic

sup

po

rt i

s?

DC

AQ

Ha

ve y

ou

ma

xim

ise

d u

se o

f g

rou

p s

up

po

rt, p

ee

r su

pp

ort

an

d

self

-he

lp, s

elf

-ma

na

ge

me

nt?

33

SECTION TWO

Delivering the Readmissions HEAT Target

DELIVERING THE READMISSIONS HEAT TARGET

HEAT target

To reduce number hospital readmissions (within one year for those that have

had a psychiatric hospital admission of over seven days) by 10% by the end

of 2009

Delivering the Readmissions HEAT target is about improving both community mental

health services (including crisis services/functions) and inpatient services. Improvements

can be categorised under three main headings:

1. Improving the design of the care delivery processes – this is about ensuring a well

designed processes that eliminate duplication and unnecessary steps, minimise the

potential for mistakes, and deliver the right amount of treatment capacity to see the

work without unnecessary waits. This needs to take a whole systems perspective

working across the traditional health and social care boundaries. Changes here should

result in an improved experience of using care services.

2. Ensuring we deliver effective care interventions – this relates to ensuring that the

relevant standards for Integrated Care Pathways and any other nationally approved

guidance (ie SIGN) is routinely followed. However, this is not just about improving the

clinical standards of care – it is about the range of care interventions including those

delivered by the local authority and voluntary sector services. Changes here should

lead to improved outcomes.


importance of applying knowledge and skills within a values-based and recovery

oriented framework. All improvement work is underpinned by continuous professional

development and workforce planning. There may be a need to extend roles, to develop

new roles and to review the skill mix within teams. Changes here should contribute to

both improved outcomes and improved experiences for those using services.

The following diagram highlights the key elements of the services users journey of care

that you will need to work on to reduce readmissions:

f For the design of care delivery processes – the first step is for each Board, and their

key partners, to understand what their key system and process design issues are and

this document provides advice on how to do this. Over the life of the collaborative we

will collate and share information across Boards and key partners, to identify where

there are common system and process design issues and what works in terms of

redesigning those systems and processes.

f Standards already exist for ensuring we deliver effective care interventions (eg ICP

Guidance and SIGN guidelines). At a local level, collaborative resources can be used

to focus on implementing those clinical and care standards that are relevant to the

delivery of the HEAT target. The following diagram shows how ICP Standards and

SIGN guidelines relate to this work stream.

f The diagram also highlights the key workforce programmes that underpin the

delivery of improved services.

34

SECTION TWO


SUM

MA

RY O

F RE

AD

MIS

SIO

NS

IMPR

OV

EMEN

T W

ORK

Imp

rove

de

sig

n o

f ca

re

de

live

ry p

roce

sse

s

Cu

rre

nt

focu

s is

on

dia

gn

osi

ng

th

e k

ey is

sue

s w

ith

cu

rre

nt

syst

em

s a

nd

pro

cess

es

usi

ng

:

fP

ath

wa

y M

ap

pin

g, V

alu

e S

tre

am

ing

an

d F

low

An

aly

sis

to id

en

tify

: wh

at

ad

ds

valu

e, u

nn

ece

ssa

ry s

tep

s, d

up

lica

tio

n, r

ew

ork

be

cau

se n

ot

do

ne

rig

ht

firs

t ti

me

, bo

ttle

ne

cks

an

d h

an

d-o

ffs;

fD

ata

An

aly

sis

to id

en

tify

va

ria

tio

n a

nd

un

de

rsta

nd

wh

en

th

is is

just

ifia

ble

an

d w

he

n it

ca

n b

e r

ed

uce

d;

fD

em

an

d, C

ap

aci

ty a

nd

Qu

eu

e T

he

ory

so u

nd

ers

tan

d w

ha

t th

e d

em

an

d is

, wh

at

the

ca

pa

city

is t

o r

esp

on

d t

o it

, op

po

rtu

nit

ies

to

ma

ke m

ore

eff

ect

ive

use

of

curr

en

t ca

pa

city

, wh

en

qu

eu

es

are

ca

use

d b

eca

use

of

the

pro

cess

de

sig

n r

ath

er

tha

n a

mis

ma

tch

be

twe

en

de

ma

nd

an

d c

ap

aci

ty, a

nd

wh

ere

in t

he

pro

cess

th

ere

is a

mis

ma

tch

be

twe

en

de

ma

nd

an

d c

ap

aci

ty;

fP

DS

Ato

pilo

t im

pro

vem

en

ts.

Ke

y e

lem

en

ts o

f se

rvic

e u

ser

jou

rne

y t

ha

t n

ee

d t

o i

mp

rove

to d

eli

ver

HE

AT

Ta

rge

t.

Imp

rove

de

live

ry a

nd

ou

tco

me

s o

f a

sse

ssm

en

ts f

or

ad

mis

sio

n

Imp

rove

th

e I

np

ati

en

t

Ex

pe

rie

nce

Imp

rove

Dis

cha

rge

Pla

nn

ing

En

sure

all

se

rvic

es

are

fo

cuse

d

on

su

sta

inin

g w

ell

be

ing

an

d

reco

very

En

sure

we

de

live

r e

ffe

ctiv

e

care

in

terv

en

tio

ns

ICP

Sta

nd

ard

s

5,7

,8,9

10

,11

,12

,14

,16

,19

,20

ICP

Sta

nd

ard

s

5,7

,8,9

11

,12

,13

,14

,15

,16

,18

,19

,20

ICP

Sta

nd

ard

s

5,7

,8

16

,17

,20

,21

ICP

Sta

nd

ard

s

5,6

,7,8

,9

10

,11

,12

,13

,14

,15

,16

,

17

,18

,19

,21

,

SIG

N 3

0,6

0,7

4,8

2

Psy

cho

log

ica

l T

he

rap

ies

Ma

trix

Na

tio

na

l w

ork

forc

e

pro

gra

mm

es

rele

van

t to

wo

rk

Mo

de

rnis

ing

Me

dic

al

Ca

ree

rs

Rig

hts

, Re

lati

on

ship

s a

nd

Re

cove

ry

Ch

an

gin

g L

ive

s (S

oci

al

Wo

rk)

Mo

de

rnis

ing

Me

dic

al

Ca

ree

rs

Rig

hts

, Re

lati

on

ship

s a

nd

Re

cove

ry

Re

cove

rin

g O

rdin

ary

Liv

es

(OT

s)

Mo

de

rnis

ing

Me

dic

al

Ca

ree

rs

Rig

hts

, Re

lati

on

ship

s a

nd

Re

cove

ry

Re

cove

rin

g O

rdin

ary

Liv

es

(OT

s)

Ch

an

gin

g L

ive

s (S

oci

al

Wo

rk)

Mo

de

rnis

ing

Me

dic

al

Ca

ree

rs

Rig

hts

, Re

lati

on

ship

s a

nd

Re

cove

ry

Re

cove

rin

g O

rdin

ary

Liv

es

(OT

s)

Ch

an

gin

g L

ive

s (S

oci

al

Wo

rk)

35

SECTION TWO


READMISSIONS – SYSTEMS DIAGNOSIS CHECKLIST


Collaborative work. It is provided as a supportive tool to help you think about how to

apply improvement methods to enable the delivery of the Readmissions HEAT target

and associated improvements. It is designed to be used as part of the Mental Health

Collaborative Toolkit which includes sections on the different improvement methods

mentioned and an overview of the Collaborative approach. It works on the basis that

the first 3-6 months should be on diagnosis – establishing the key problems that are

hindering effective delivery against the HEAT targets.

As with clinical care – getting the diagnosis right is important as it guides what interventions

you then go on to undertake. If you’re treating the wrong problem – chances are the

treatment won’t be effective. Likewise – if change programmes are based on an incorrect

analysis of the problem – chances are that the change programme will be ineffective. So

it’s worth investing the time up front to get the diagnosis of the problem right.

Visioning is a key part of diagnosis– as we need to be clear that we are doing the right

things, not just doing the wrong things more efficiently.

We realise that many Boards have already made significant progress against this target

and we are not suggesting you put on hold any work already in progress. However, the

following suggestions may give you some ideas about how to progress this work further.

36

SECTION TWO


37

SECTION TWO


SYSTEMS OVERVIEW

When looking at changes to one part of the pathway, it’s important to consider the

impact on other parts of the system. Otherwise, we can end up making one part work

better but just move the problem elsewhere. For instance, you might change referral

criteria into a community team and end up effectively reducing the demand on this

service, only to find out that your requests for community crisis assessments go up.

The Collaborative promotes looking at your whole system and to do this you need to

have mechanisms in place for discussing potential changes across teams and

organisations. For the readmissions workstream there are key interfaces between:

f Inpatient Wards – Crisis Services/Crisis Functions

f Crisis Services/Functions – Community Teams

f Community Teams – Inpatient Wards

f Health – Voluntary Sector – Social Work Services

f Primary Care – Specialist Services

f Mental Health Services – Substance Misuse Services

f Mental Health Services – Child and Adolescent Mental Health Services (CAMHS)

f Mental Health Services – Learning Disabilities Services

38

SECTION TWO


SY

ST

EM

S O

VE

RV

IEW

CH

EC

KL

IST

Issu

es

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Is t

he

re a

str

uct

ure

in

pla

ce f

or

eff

ect

ive

dis

cuss

ion

of

inte

rfa

ce i

ssu

es

be

twe

en

th

e v

ari

ou

s te

am

s

resp

on

sib

le f

or

de

live

rin

g d

iffe

ren

t a

spe

cts

of

the

serv

ice

use

rs c

are

?

Sy

ste

ms

Th

inkin

g

Is t

he

re a

str

uct

ure

in

pla

ce t

o s

up

po

rt v

isio

nin

g/

solu

tio

n f

ocu

sed

th

inkin

g t

o e

sta

bli

sh t

he

go

ld

sta

nd

ard

sy

ste

m/p

roce

ss t

o f

aci

lita

te c

om

pa

riso

n

be

twe

en

wh

at

ha

pp

en

s n

ow

an

d w

ha

t sh

ou

ld b

e

ha

pp

en

ing

?

Vis

ion

ing

/

So

luti

on

Focu

sed

39

SECTION TWO



The Mental Health Collaborative promotes using data to: understand how well your

current system is working, identify where to focus improvement actions, and to assess

whether any changes are really delivering improvements. Please see also the Model for

Improvement, within the improvement tools section, for further information on using

data to assess whether change is working.

The HEAT target is a proxy measure for improving both the quality of inpatient services

but also the range and quality of community services available. This means it’s important

that you have a system for collecting the reason for a readmission, as this will help to

identify if there are elements of the community system that are routinely breaking down

and hence leading to a readmission. Your data collection needs to consider not just the

presenting reason, but whether additional support/services might have removed the

need for readmission. We highly recommend you put mechanisms in place locally to

collect this data if you are not already doing so. If you have no historic information, then

you might consider doing a retrospective audit. For large services, this could focus on the

wards or teams that have high readmission rates.

We recommend you analyse the data to identify those areas/teams with high levels of

readmissions, and focus your work here. Where there are significant variances between

teams and wards covering the same speciality, we recommend you look at the reasons

for these differences. Retrospective patient tracking may be helpful in addition to

interviews with teams in order to compare and contrast knowledge, training, systems and

processes. You will also need to take deprivation into account in this analysis. If you want

further advice on how to do this, please contact your Collaborative Regional Manager.

We also recommend you use the SPARRA data to identify those individuals who are at

a high risk of readmission locally. This will give you named patients. You can then do an

audit of these care plans and check that relapse plans are in place. You may also want to

look at how you feed the SPARRA analysis into any social work assessment of eligibility

for services – as you may want to ensure that those identified as high risk of readmission

under SPARRA show as high risk under social work eligibility criteria and hence are a

priority for social work input.

You may also want to look at use of alternatives to admission – and compare any variances

between areas. For instance, if one area/team makes much better use of alternatives to

admission than another, do you know why?

The following table helps you think about applying data analysis to the readmissions



40

SECTION TWO


DA

TA

AN

ALY

SIS

CH

EC

KL

IST

Issu

es

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Acu

te A

sse

ssm

en

t

Ha

ve y

ou

co

mp

are

d y

ou

r a

dm

issi

on

an

d r

ea

dm

issi

on

rate

s in

to y

ou

r in

pa

tie

nt

un

its

by

sp

eci

alt

y, w

ard

an

d

tea

m?

Do

yo

u k

no

w i

f th

e r

ea

dm

issi

on

s a

re c

lust

ere

d

aro

un

d a

pa

rtic

ula

r se

rvic

e o

r te

am

?

Va

ria

tio

n

Wh

ere

th

ere

are

sig

nif

ica

nt

vari

an

ces

in r

ea

dm

issi

on

rate

s b

etw

ee

n t

ea

ms

wo

rkin

g i

n t

he

sa

me

sp

eci

ali

ty

– d

o y

ou

un

de

rsta

nd

th

e r

ea

son

s w

hy

?

Va

ria

tio

n

Do

yo

u c

oll

ect

da

ta o

n t

he

re

aso

n f

or

ad

mis

sio

n/r

ea

dm

issi

on

an

d i

f so

, do

yo

u h

ave

a

syst

em

fo

r ro

uti

ne

ly a

na

lysi

ng

th

is?

Me

asu

rem

en

t

Da

ta A

na

lysi

s

If y

ou

do

n’t

co

lle

ct d

ata

on

re

aso

ns

for

ad

mis

sio

n/r

ea

dm

issi

on

– h

ave

yo

u c

on

sid

ere

d a

retr

osp

ect

ive

au

dit

– p

art

icu

larl

y f

or

an

y a

rea

s w

he

re

hig

h r

ate

s o

f a

dm

issi

on

s/re

ad

mis

sio

n?

Au

dit

Do

yo

u c

oll

ect

da

ta o

n w

he

the

r th

e i

nd

ivid

ua

l w

as

un

de

r th

e i

nfl

ue

nce

of

sub

sta

nce

s a

t a

dm

issi

on

an

d

if s

o –

ha

ve y

ou

an

aly

sed

wh

at

pe

rce

nta

ge

of

ind

ivid

ua

ls a

re a

dm

itte

d a

nd

re

ad

mit

ted

wh

ere

th

is

is t

he

ca

se?

If t

he

re a

re v

ari

an

ces

be

twe

en

wa

rds

an

d

ad

mit

tin

g t

ea

ms

do

yo

u u

nd

ers

tan

d t

he

re

aso

ns

wh

y?

Me

asu

rem

en

t

Va

ria

tio

n

41

SECTION TWO


DA

TA

AN

ALY

SIS

CH

EC

KL

IST

Issu

es

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Acu

te A

sse

ssm

en

t –

con

tin

ue

d

Ha

ve y

ou

lo

oke

d a

t d

iag

no

sis

of

ind

ivid

ua

ls

rea

dm

itte

d t

o s

ee

if

an

y t

ren

ds

ap

ply

?

Me

asu

rem

en

t

Ha

ve y

ou

lo

oke

d a

t re

ferr

al

rou

tes

into

yo

ur

cris

is

fun

ctio

ns/

serv

ice

s a

nd

id

en

tifi

ed

wh

eth

er

an

y

dif

fere

nce

s b

y a

rea

, te

am

, an

d s

pe

cia

lity

. If

the

re a

re

vari

an

ces,

do

yo

u u

nd

ers

tan

d t

he

re

aso

n w

hy

?

Me

asu

rem

en

t

Va

ria

tio

n

Do

yo

u k

no

w w

ha

t p

erc

en

tag

e o

f re

ferr

als

to

yo

ur

fun

ctio

ns/

serv

ice

s e

nd

up

in

an

ad

mis

sio

n b

y

tea

m/a

rea

? If

th

ere

are

sig

nif

ica

nt

vari

an

ces,

do

yo

u

un

de

rsta

nd

th

e r

ea

son

wh

y?

Me

asu

rem

en

t

Va

ria

tio

n

Ha

ve y

ou

lo

oke

d a

t d

ail

y a

dm

issi

on

ra

tes

usi

ng

SP

C

cha

rts

to u

nd

ers

tan

d t

he

in

he

ren

t va

ria

tio

n i

n t

he

syst

em

an

d i

de

nti

fy a

ny

sp

eci

al

cau

se v

ari

ati

on

s?

SP

C

42

SECTION TWO


DA

TA

AN

ALY

SIS

CH

EC

KL

IST

Issu

es

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Inp

ati

en

t E

xp

eri

en

ce

Do

yo

u r

ou

tin

ely

co

lle

ct d

ata

on

th

e p

urp

ose

of

ad

mis

sio

n?

Ha

ve y

ou

lo

oke

d a

t va

ria

nce

s b

etw

ee

n

ad

mit

tin

g t

ea

ms

an

d d

o y

ou

un

de

rsta

nd

th

e r

ea

son

s

wh

y?

Me

asu

rem

en

t

Va

ria

tio

n

Ha

ve y

ou

co

mp

are

d t

he

pre

dic

ted

le

ng

th o

f st

ay

(lo

s) w

ith

act

ua

l lo

s a

nd

ma

pp

ed

th

at

to t

he

pre

dic

ted

an

d a

ctu

al

pu

rpo

se o

f a

dm

issi

on

?

Me

asu

rem

en

t

Do

yo

u h

ave

a s

yste

m in

pla

ce f

or

mo

nit

ori

ng

ou

tco

me

s

– f

or

inst

an

ce h

as

the

ad

mis

sio

n m

et

its

pu

rpo

se?

Ha

s th

e p

ati

en

t’s

me

nta

l w

ell

be

ing

im

pro

ved

?

Me

asu

rem

en

t

Do

yo

u h

ave

a s

yst

em

fo

r co

lle

ctin

g i

nfo

rma

tio

n o

n

pa

tie

nts

ex

pe

rie

nce

wh

ilst

on

th

e u

nit

an

d r

ou

tin

ely

mo

nit

or

the

in

form

ati

on

to

id

en

tify

are

as

for

imp

rove

me

nt?

Me

asu

rem

en

t

Ha

ve y

ou

lo

oke

d a

t w

ha

t p

erc

en

tag

e o

f w

ard

sta

ff

tim

e i

s sp

en

t in

dir

ect

ca

re?

Me

asu

rem

en

t

Do

yo

u c

oll

ect

da

ta o

n w

ha

t in

terv

en

tio

ns

take

pla

ce

du

rin

g a

dm

issi

on

an

d if

so

, do

yo

u a

na

lysi

s th

is b

y a

ge

,

eth

nic

ity

etc

to

ide

nti

fy if

th

ere

are

an

y e

qu

alit

y is

sue

s?

Me

asu

rem

en

t

43

SECTION TWO


DA

TA

AN

ALY

SIS

CH

EC

KL

IST

Issu

es

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Dis

cha

rge

Ha

ve y

ou

lo

oke

d a

t d

ail

y d

isch

arg

e r

ate

s u

sin

g S

PC

cha

rts

to u

nd

ers

tan

d t

he

in

he

ren

t va

ria

tio

n i

n t

he

syst

em

an

d i

de

nti

fy a

ny

sp

eci

al

cau

se v

ari

ati

on

?

Me

asu

rem

en

t

SP

C

Ha

ve y

ou

lo

oke

d a

t d

ela

ye

d d

isch

arg

es

an

d r

ea

son

s

wh

y?

Me

asu

rem

en

t

Ha

ve y

ou

au

dit

ed

th

e q

ua

lity

of

care

pla

ns

on

dis

cha

rge

?

Au

dit

44

SECTION TWO


DA

TA

AN

ALY

SIS

CH

EC

KL

IST

Issu

es

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Su

sta

inin

g W

ell

be

ing

an

d R

eco

very

Ha

ve y

ou

lo

oke

d a

t y

ou

r S

PA

RR

A d

ata

to

id

en

tify

tho

se a

t g

rea

test

ris

k o

f re

ad

mis

sio

n. H

ave

yo

u

loo

ked

at

wh

ich

te

am

s th

ese

in

div

idu

als

sit

wit

h a

nd

the

le

vel

of

care

be

ing

pro

vid

ed

?

SPA

RR

A (

MD

)

Me

asu

rem

en

t

Ha

ve y

ou

sh

are

d y

ou

r S

PA

RR

A d

ata

wit

h s

oci

al

wo

rk

(ple

ase

en

sure

yo

u f

oll

ow

yo

ur

rele

van

t in

form

ati

on

sha

rin

g p

roto

col)

an

d d

oe

s th

eir

eli

gib

ilit

y c

rite

ria

ass

ess

me

nt

an

d c

are

pa

cka

ge

ta

ke a

cco

un

t th

at

hig

h

risk

of

rea

dm

issi

on

?

SPA

RR

A (

MD

)

Do

th

ose

in

div

idu

als

th

at

SPA

RR

A i

de

nti

fie

s a

s b

ein

g

at

risk

of

rea

dm

issi

on

ha

ve a

cri

sis

pla

n a

nd

/or

a

rela

pse

pla

n i

n p

lace

?

SPA

RR

A (

MD

)

Au

dit

Ha

ve y

ou

an

aly

sed

yo

ur

rea

dm

issi

on

s a

ga

inst

ab

sen

ce o

f co

mm

un

ity

ke

y w

ork

er?

Me

asu

rem

en

t

Ha

ve y

ou

lo

oke

d a

t h

ow

qu

ickly

an

d o

fte

n

ind

ivid

ua

ls a

re f

oll

ow

ed

up

in

co

mm

un

ity

fo

llo

win

g

dis

cha

rge

an

d c

om

pa

red

an

y v

ari

an

ces

be

twe

en

tea

ms

wit

h r

ea

dm

issi

on

ra

tes?

Me

asu

rem

en

t

Va

ria

tio

n

45

SECTION TWO


PROCESS ANALYSIS






All the organisations/teams involved in the care process should be identified and

involved in the process mapping activity. This process mapping work should already be

taking place in all Boards as part of the work to develop a Generic ICP (See ICP Process

Standard 3). The mapping work should include service user and carers perspectives, in

line with the ICP standards (See ICP Process Standard 2). In addition to the process

mapping exercise – it might also help to undertake discovery interviews, feedback

questionnaires, and data sampling in order to fully understand the service user and

carers experience.





the care process and look at the flow through it. Using value-stream mapping, you can

identify:







ensuring that the different teams/people involved in delivering care all work together

effectively.

A range of tools within Lean are available to help analyse the care process, and facilitation

support is available from the Collaborative Team. Please also see the Improvement Tools

section of this Toolkit for further information on tools. The output of this ‘overview’

investigative work should be clarity on the key issues you need to address locally to simplify

and improve the care process. The Collaborative promotes then using the PDSA approach

to make incremental improvements to the process. It encourages all services to start

using the PDSA approach as quickly as possible – so you can start to see practical small

scale improvements.

The following table helps you to think about applying process mapping to the Readmissions



46

SECTION TWO


PR

OC

ES

S A

NA

LYS

IS C

HE

CK

LIS

T

Issu

es

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Ad

mis

sio

n

Ha

ve y

ou

pro

cess

ma

pp

ed

an

d v

alu

e s

tre

am

ed

yo

ur

un

pla

nn

ed

ca

re p

ath

wa

ys?

Pro

cess

Ma

pp

ing

Do

yo

u h

ave

a s

tan

da

rdis

ed

, va

lid

an

d r

eli

ab

le r

isk

ass

ess

me

nt

too

l?

Do

ass

ess

ors

co

nsi

de

r a

lte

rna

tive

s to

ad

mis

sio

n?

Pro

cess

Ma

pp

ing

Ha

ve y

ou

lo

oke

d a

t w

ho

ma

kes

the

de

cisi

on

to

ad

mit

?

Pro

cess

Ma

pp

ing

Inp

ati

en

t E

xp

eri

en

ce

Ha

ve y

ou

ma

pp

ed

th

e i

nve

stig

ati

on

s, t

rea

tme

nt

de

cisi

on

s a

nd

re

vie

w p

roce

ss?

Pro

cess

Ma

pp

ing

Do

yo

u k

no

w w

hic

h t

he

rap

eu

tic

act

ivit

y t

ake

s p

lace

on

an

d o

ff t

he

wa

rd, h

ow

oft

en

an

d w

he

n?

Se

rvic

e U

ser

Tra

ckin

gG

len

da

y S

ieve

Ha

ve y

ou

use

d t

he

Sco

ttis

h R

eco

very

In

dic

ato

r to

ge

tin

form

ati

on

ab

ou

t th

e c

ult

ure

wit

hin

wh

ich

ca

re i

sd

eli

vere

d?

Sco

ttis

hR

eco

very

Ind

ica

tor

47

SECTION TWO


PR

OC

ES

S A

NA

LYS

IS C

HE

CK

LIS

T

Issu

es

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Dis

cha

rge

Ha

ve y

ou

pro

cess

ma

pp

ed

an

d v

alu

e s

tre

am

ed

yo

ur

dis

cha

rge

pla

nn

ing

?

Pro

cess

Ma

pp

ing

Ha

ve y

ou

lo

oke

d a

t w

ho

is

invo

lve

d i

n t

he

dis

cha

rge

pla

nn

ing

pro

cess

an

d h

ow

th

ey

are

in

volv

ed

?

Pro

cess

Ma

pp

ing

Ha

ve y

ou

lo

oke

d a

t w

ho

ma

kes

the

de

cisi

on

to

dis

cha

rge

an

d h

ow

th

at

is c

om

mu

nic

ate

d?

Pro

cess

Ma

pp

ing

Do

es

eve

ry s

erv

ice

use

r h

ave

a d

isch

arg

e p

lan

an

d i

s

the

re a

me

cha

nis

m f

or

sha

rin

g t

he

pla

n w

ith

all

sta

keh

old

ers

?

Pro

cess

Ma

pp

ing

48

SECTION TWO


PR

OC

ES

S A

NA

LYS

IS C

HE

CK

LIS

T

Issu

es

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Su

sta

inin

g W

ell

be

ing

an

d R

eco

very

Ha

ve y

ou

ma

pp

ed

th

e t

ran

siti

on

fro

m i

n-p

ati

en

t to

com

mu

nit

y c

are

in

clu

din

g t

he

tim

e f

rom

dis

cha

rge

to c

om

mu

nit

y f

oll

ow

up

?

Pro

cess

Ma

pp

ing

Ha

ve y

ou

ma

pp

ed

yo

ur

pla

nn

ed

ca

re s

erv

ice

s a

nd

fun

ctio

ns?

Pro

cess

Ma

pp

ing

Ha

ve y

ou

ma

pp

ed

th

e t

ran

siti

on

pro

cess

es

be

twe

en

serv

ice

s a

nd

fu

nct

ion

s?

Pro

cess

Ma

pp

ing

Ha

ve y

ou

id

en

tifi

ed

th

ose

pa

tie

nts

ag

ed

15

ye

ars

an

d o

ver

at

gre

ate

st r

isk o

f p

sych

iatr

ic a

dm

issi

on

to h

osp

ita

l a

nd

lin

ked

th

is w

ith

use

of

the

ca

re

pro

gra

mm

e a

pp

roa

ch?

SPA

RR

A(M

D)

Pro

cess

Ma

pp

ing

Do

yo

u h

ave

a s

tan

da

rdis

ed

, va

lid

an

d r

eli

ab

le r

isk

ass

ess

me

nt?

Is r

isk m

an

ag

em

en

t in

clu

de

d i

n r

ela

pse

ca

re p

lan

s?

49

SECTION TWO



Understanding the demand for your service is essential, as without this you cannot

effectively plan to meet that demand. However, you also need to understand the capacity

that you have to respond to that demand and whether you are making best use of this.

For instance, if you have a highly skilled member of staff spending a day booking care

plan reviews, this is not making effective use of your current capacity. An audit across






someone’s illness which may result in an admission. For inpatients, a difference between

capacity and demand can lead to individuals being ‘boarded’ out in other wards. This

can impact on the quality of care received and results in unnecessary moves for the

individual patient. In some circumstances, it can also make it a lot harder for relatives to

remain in contact (if individuals are boarded out at a distance).

The presence of a waiting list or ‘boarding out’, is a sign that demand is not being matched

with capacity, it is not necessarily an indication that the demand exceeds the capacity

(please see improvement tools section of toolkit for more information on this). It is

therefore important to gather information on demand, activity, and capacity and to

analyse this in greater detail to understand profiles, trends and variances. There are a range

of tools that can be used to analyse data in a format that identifies trends over time.

The Mental Health Collaborative is working on a demand and capacity analysis tool for

community mental health teams. Please liaise with your regional manager for more

information on this tool which is currently in its testing phase.


analysis in relation to the Readmissions Workstream. Again, it is not an exhaustive list, it

is just provided as a starting point to help MHC teams to think about how demand and

capacity work applies to the Readmissions work.

50

SECTION TWO


DE

MA

ND

, CA

PAC

ITY

AN

D Q

UE

UE

CH

EC

KLI

ST

Issu

es

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Acu

te A

sse

ssm

en

t

Do

yo

u u

nd

ers

tan

d t

he

de

ma

nd

fo

r in

pa

tie

nt

be

ds

–

an

d h

ave

yo

u l

oo

ked

to

se

e i

f y

ou

ha

ve t

he

ca

pa

city

to r

esp

on

d. H

ave

yo

u l

oo

ked

at

ho

w v

ari

ati

on

s in

dis

cha

rge

ra

tes

mig

ht

imp

act

yo

ur

inp

ati

en

t ca

pa

city

?

DC

AQ

SP

C

Do

yo

u m

on

ito

r d

em

an

d f

or

inp

ati

en

t b

ed

s u

sin

g

SP

C –

so

yo

u u

nd

ers

tan

d t

he

va

ria

tio

n t

ha

t is

inh

ere

ntl

y b

uil

t in

to t

he

cu

rre

nt

syst

em

de

sig

n a

nd

can

id

en

tify

an

y s

pe

cia

l ca

use

va

ria

tio

n?

SP

C

Do

yo

u u

nd

ers

tan

d y

ou

r d

em

an

d f

or

acu

te

ass

ess

me

nts

– a

nd

ha

ve y

ou

lo

oke

d a

t w

he

the

r y

ou

ha

ve t

he

ca

pa

city

an

d c

ap

ab

ilit

y t

o r

esp

on

d

ava

ila

ble

at

the

rig

ht

tim

e?

DC

AQ

Do

yo

u m

on

ito

r d

em

an

d f

or

acu

te a

sse

ssm

en

ts u

sin

g

SP

C –

so

yo

u u

nd

ers

tan

d t

he

va

ria

tio

n t

ha

t is

inh

ere

ntl

y b

uil

t in

to t

he

cu

rre

nt

syst

em

de

sig

n a

nd

can

id

en

tify

an

y s

pe

cia

l ca

use

va

ria

tio

n?

SP

C

Ha

ve y

ou

id

en

tifi

ed

th

e n

um

be

r o

f p

ati

en

ts a

ge

d

15

ye

ars

an

d o

ver

at

gre

ate

st r

isk o

f p

sych

iatr

ic

ad

mis

sio

n t

o h

osp

ita

l w

ho

th

ere

fore

ne

ed

a c

are

pro

gra

mm

e a

pp

roa

ch?

SPA

RR

A(M

D)

51

SECTION TWO


DE

MA

ND

, CA

PAC

ITY

AN

D Q

UE

UE

CH

EC

KLI

ST

Issu

es

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Inp

ati

en

t E

xp

eri

en

ce

Do

yo

u k

no

w y

ou

r d

em

an

d f

or

inp

ati

en

t

inte

rve

nti

on

s a

nd

ha

ve y

ou

ma

pp

ed

th

is a

ga

inst

yo

ur

cap

aci

ty t

o r

esp

on

d?

DC

AQ

Dis

cha

rge

Do

yo

u k

no

w y

ou

r d

ail

y d

isch

arg

e r

ate

s fr

om

inp

ati

en

ts b

y t

ea

m a

nd

wh

at

the

le

vel

of

no

rma

l

vari

ati

on

is?

DC

AQ

SP

C

Do

yo

u r

ou

tin

ely

ho

ld s

lots

fo

r te

am

me

mb

ers

to

foll

ow

in

div

idu

als

up

po

st d

isch

arg

e?

DC

AQ

52

SECTION TWO


DE

MA

ND

, CA

PAC

ITY

AN

D Q

UE

UE

CH

EC

KLI

ST

Issu

es

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Su

sta

inin

g W

ell

be

ing

an

d R

eco

very

Do

yo

u k

no

w w

ha

t th

e d

em

an

d f

or

yo

ur

com

mu

nit

y

serv

ice

s is

?

DC

AQ

Do

yo

u k

no

w w

ha

t y

ou

r a

ctu

al

cap

aci

ty i

s? D

o y

ou

kn

ow

wh

at

yo

ur

rea

lise

d c

ap

aci

ty i

s? D

o y

ou

un

de

rsta

nd

wh

y t

he

re i

s a

dif

fere

nce

?

DC

AQ

Wis

em

an

Wo

rklo

ad

Me

asu

re

Ha

ve y

ou

co

mp

are

d n

ew

to

fo

llo

w-u

p r

ati

os

acr

oss

sta

ff m

em

be

rs a

nd

te

am

s w

ork

ing

wit

h s

imil

ar

clie

nt

gro

up

s. I

f th

ere

is

sig

nif

ica

nt

vari

ati

on

, do

yo

u

un

de

rsta

nd

th

e r

ea

son

wh

y?

Va

ria

tio

n

Do

yo

u r

ou

tin

ely

mo

nit

or

act

ivit

y?

Ha

ve y

ou

ag

ree

d

wh

at

is a

re

aso

na

ble

act

ivit

y le

vel f

or

sta

ff a

nd

te

am

s?

Me

asu

rem

en

t

Ha

ve y

ou

lo

oke

d a

t w

ha

t in

terv

en

tio

ns

dif

fere

nt

gra

de

s o

f st

aff

are

do

ing

to

ass

ess

wh

eth

er

yo

u a

re

ap

pro

pri

ate

ly s

kil

l m

ixin

g?

53

SECTION TWO


DELIVERING THE DEPRESSION HEAT TARGET

HEAT target

To reduce the annual rate of increase of defined daily dose per capita of

antidepressants to zero by 2009/10, and put in place the required support

framework to achieve a 10 per cent reduction in future years;

The HEAT target for depression aims to improve the treatment of depression, particularly

within Primary Care. It is therefore vital that Primary Care is actively engaged in

this work. Improvements can be categorised under three main headings:

1. Improving the quality and effectiveness of care interventions – this relates to

ensuring that the relevant standards for Integrated Care Pathways and any other

nationally approved guidance (ie SIGN, Crisis Standards, NICE) is routinely followed.

However, this is not just about improving the clinical standards of care – it is about

the range of care interventions including those delivered by the local authority and

voluntary sector services. Changes here should lead to improved outcomes.

2. Improving the design of the care delivery processes – this is about ensuring a

well designed process that eliminates duplication and unnecessary steps, minimises

the potential for mistakes, and delivers the right amount of treatment capacity to

see the work without unnecessary waits. Again, this needs to take a whole systems

perspective working across the traditional health and social care boundaries.

Changes here should result in an improved experience of using care services.


importance of applying knowledge and skills within a values based and recovery

oriented framework. All improvement work is underpinned by continuous professional

development and workforce planning. There may be a need to extend roles, to

develop new roles and to review the skill mix within teams. Further, staff must be

treated with the same respect and care that we expect them to provide for patients.

Changes here should contribute to both improved outcomes and improved

experiences for those using services.

The following diagram highlights the key issues that Boards (and their partners) will

need to focus on to improve the treatment of depression and hence support delivery of

the HEAT target. As part of the plan to deliver the Depression HEAT target, Boards will

also need to take action on the preventative agenda in line with the forthcoming

‘Towards a Mentally Flourishing Scotland’.

f Standards already exist with regards to improving the quality of clinical services

provided (ICP Guidance, draft SIGN non pharmacological treatment of mild to

moderate depression, and NICE guidelines). At a local level, collaborative resources

can be used to focus on implementing those clinical standards that are relevant to

the delivery of the HEAT target. The following diagram shows how ICP Standards and

SIGN guidelines relate to this work stream. Further work will be completed to map

other relevant national guidance against the key issues.

f To improve the design of care delivery processes – the first step is for each Board

to understand what their key system and process design issues are, and this document

provides advice on how to do this. Over the life of the collaborative we will collate and

share information across Boards to identify where there are common system and

process design issues across Boards and what works in terms of redesigning those

systems and processes

f The diagram also highlights the links between the Collaborative work and the NES

Psychological Therapies Programme. Further, over the next 2 years, the Collaborative

will highlight any relevant workforce issues that need a national response in relation

to the commissioning of training or support to develop new roles.

54

SECTION TWO

Delivering the Depression HEAT Target

55

SECTION TWO


Imp

rove

de

sig

n o

f ca

re

de

live

ry p

roce

sse

s

Cu

rre

nt

focu

s is

on

dia

gn

osi

ng

th

e k

ey is

sue

s w

ith

cu

rre

nt

syst

em

s a

nd

pro

cess

es

usi

ng

:

fD

ata

An

aly

sis

to id

en

tify

va

ria

tio

n a

nd

un

de

rsta

nd

wh

en

th

is is

just

ifia

ble

an

d w

he

n it

ca

n b

e r

ed

uce

d

fP

ath

wa

y M

ap

pin

g, V

alu

e S

tre

am

ing

an

d F

low

An

aly

sis

to id

en

tify

: wh

at

ad

ds

valu

e, u

nn

ece

ssa

ry s

tep

s, d

up

lica

tio

n, r

ew

ork

be

cau

se n

ot

do

ne

rig

ht

firs

t ti

me

, bo

ttle

ne

cks,

ha

nd

-off

s a

nd

mis

sin

g s

tep

s.

fD

em

an

d, C

ap

aci

ty a

nd

Qu

eu

e T

he

ory

to u

nd

ers

tan

d w

ha

t th

e d

em

an

d is

, wh

at

the

ca

pa

city

is t

o r

esp

on

d t

o it

, op

po

rtu

nit

ies

to

ma

ke m

ore

eff

ect

ive

use

of

curr

en

t ca

pa

city

, wh

en

qu

eu

es

are

ca

use

d b

eca

use

of

the

pro

cess

de

sig

n r

ath

er

tha

n a

mis

ma

tch

be

twe

en

de

ma

nd

an

d c

ap

aci

ty, a

nd

wh

ere

in t

he

pro

cess

th

ere

is a

mis

ma

tch

be

twe

en

de

ma

nd

an

d c

ap

aci

ty.

fP

DS

Ato

pilo

t im

pro

vem

en

ts

Ke

y e

lem

en

ts o

f D

ep

ress

ion

Ca

re t

ha

t n

ee

d t

o i

mp

rove

to

de

live

r H

EA

T T

arg

et.

Imp

rove

acc

ess

to e

vid

en

ce-

ba

sed

sup

po

rte

d s

elf

ma

na

ge

me

nt

an

d s

elf

he

lp

Imp

rove

sup

po

rt t

o

pri

ma

ry c

are

to

en

ab

led

eli

very

of

ho

list

ic

ass

ess

me

nts

fo

r

tho

se p

rese

nti

ng

wit

h s

ym

pto

ms

of

de

pre

ssio

n

Imp

rove

un

de

rsta

nd

ing

of

pri

ma

ry c

are

sta

ff, s

erv

ice

use

rs a

nd

ca

rers

of

the

dif

fere

nt

op

tio

ns

for

inte

rve

nti

on

Pro

mo

te

evid

en

ce b

ase

d

pre

scri

bin

g a

nd

com

pli

an

ce

wit

h f

orm

ula

ry

Imp

rove

acc

ess

to n

on

-

ph

arm

aco

log

ica

l

inte

rve

nti

on

s

incl

ud

ing

evid

en

ce b

ase

d

psy

cho

log

ica

l

the

rap

ies

Imp

rove

acc

ess

to s

oci

al

sup

po

rts

(em

plo

ym

en

t,

ed

uca

tio

n,

ho

usi

ng

an

d

leis

ure

)

Ro

uti

ne

ly

mo

nit

or

ou

tco

me

s a

nd

mo

dif

y s

erv

ice

s

acc

ord

ing

ly

Imp

rove

sta

nd

ard

of

clin

ica

l

serv

ice

de

live

red

(IC

P

Sta

nd

ard

s a

nd

SIG

N

Gu

ida

nce

Sta

nd

ard

34

S

tan

da

rds

33

-34

Sta

nd

ard

s

3-3

7

Sta

nd

ard

35

Ra

ng

e o

f

op

tio

ns

sho

uld

be

ava

ila

ble

in

lin

e w

ith

SIG

N

gu

ida

nce

.

Sta

nd

ard

36

S

tan

da

rd 3

3

Ke

y N

ati

on

al

Wo

rkfo

rce

Pro

gra

mm

es

rele

van

t to

Wo

rk2

NE

S

Psy

cho

log

ica

l

Th

era

pie

s

Pro

gra

mm

e

2Fu

rth

er

wo

rk is

in p

lace

to

ide

nti

fy o

the

r n

ati

on

al w

ork

forc

e p

rog

ram

me

s re

leva

nt

to t

his

wo

rk.

56

SECTION TWO


DEPRESSION PATHWAY – SYSTEMS DIAGNOSIS CHECKLIST


Collaborative (MHC) work. It is provided as a supportive tool to help those involved

in leading and planning the work of the MHC locally to think about how to apply

improvement methods to enable the delivery of the Depression HEAT target and

associated improvements. It is designed to be used as part of the Mental Health

Collaborative Toolkit which includes sections on the different improvement methods

mentioned and an overview of the Collaborative approach.

It works on the basis that the first 3-6 months should be on visioning and diagnosing

the issues with the current system. Visioning involves defining and describing the ideal

systems, processes and pathways of care to fulfil and exceed the HEAT targets. These

‘ideals’ will be firmly rooted in the best evidence available and complemented by

experiential input and insights from service users, carers and staff. Diagnosing the

system involves comparing current service behaviour with the ideal to establish where

changes need to be made and what these changes might look like in order to achieve

the ideal. It also involves understanding your current processes, what works well and

what doesn’t work so well.

We realise that many Boards (and key partners), have already made significant progress

against this target and we are not suggesting that any work is put on hold that is already

in progress. However, the suggestions below may give you some ideas about how to

progress this work further.

57

SECTION TWO


58

SECTION TWO


59

SECTION TWO


SYSTEMS OVERVIEW

When looking at changes to one part of the system, it’s important to consider the

impact on other parts of the system. Otherwise, services can end up making one part

work better but just move the problem elsewhere. For instance, you might change

referral criteria into a community team and end up effectively reducing the demand on

this service, only to find out that individuals start booking many more appointments

with their GP.

The Collaborative promotes looking at the whole system and to do this you need to

have mechanisms in place for discussing potential changes across teams. For the

depression pathway there are key interfaces between all of the following:

f General Practice

f Specialist Mental Health Services

f Voluntary Sector

f Local Authority including social services

60

SECTION TWO


SY

ST

EM

S O

VE

RV

IEW

CH

EC

KL

IST

Issu

es

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Do

es

yo

ur

CH

CP

ta

ke r

esp

on

sib

ilit

y f

or

de

live

rin

g t

his

targ

et

an

d r

ece

ive

re

gu

lar

rep

ort

s o

n p

rog

ress

?

Do

yo

u h

ave

in

pla

ce a

str

uct

ure

fo

r e

ffe

ctiv

e

dis

cuss

ion

of

inte

rfa

ce i

ssu

es

be

twe

en

Sp

eci

ali

st

Me

nta

l H

ea

lth

Se

rvic

es

an

d P

rim

ary

Ca

re?

eg

if p

rim

ary

ca

re w

ere

co

nce

rne

d a

bo

ut

lon

g w

ait

ing

tim

es

for

acc

ess

to

a C

MH

T f

or

de

pre

ssio

n c

are

wh

ere

wo

uld

th

ey r

ais

e t

his

? O

r if

th

ere

we

re c

on

cern

s th

at

GP

s

we

re n

ot

pre

scri

bin

g t

o f

orm

ula

ry r

eco

mm

en

da

tio

ns

for

AD

s, w

ho

wo

uld

de

al w

ith

th

is p

rob

lem

? W

ha

t fo

ra c

ou

ld

they

ra

ise

it in

? W

ho

se r

esp

on

sib

ility

wo

uld

it b

e t

o

en

ha

nce

co

mp

lian

ce?

Do

yo

u h

ave

pre

scri

bin

g a

dvi

sors

wo

rkin

g w

ith

pri

ma

ry

care

to

lo

ok a

t e

ffe

ctiv

e u

se o

f a

nti

-de

pre

ssa

nts

Do

yo

u h

ave

sy

ste

ms

in p

lace

wit

hin

pri

ma

ry c

are

to

acc

ess

th

e n

on

-ph

arm

aco

log

ica

l in

terv

en

tio

ns

reco

mm

en

de

d b

y t

he

dra

ft S

IGN

gu

ide

lin

es

(ie

psy

cho

log

ica

l th

era

pie

s a

nd

ex

erc

ise

)?


The HEAT target is a proxy measure for improving the treatment of depression –

particularly within primary care. Boards need to assess:

a) Whether prescribing is in line with the evidence base? This is not just about the

decision whether to prescribe or not – it is also about ensuring guidelines are followed

in relation to the way in which anti-depressants are used. For example, what proportion

of anti-depressant prescribing follows local formulary guidance? Are appropriate

doses being used for appropriate lengths of time? Are systems in place to monitor

non-response to treatment and respond appropriately? It is not the intention of this

target to prevent anyone who needs anti-depressants from receiving them. The aim

is to use the target to help Boards to enhance rational prescribing for depression.

b) Whether there is appropriate access to effective non-drug treatments? This

might not be about alternatives – as often a person will need a combination of

different approaches such as an anti-depressant and a psychological therapy.

The Collaborative promotes the use of data to highlight how well a system is currently

working. In particular, it promotes identifying and understanding variations in

practice. These might be variances against a given standard (as promoted by ICP

variance analysis) or comparing the practice of different clinicians and services. We do

not promote the concept that variance is necessarily bad – indeed variance that arises

because of the different needs of the service users is positive and demonstrates an

appropriate flexibility in the system. Further, our systems will always have some degree

of natural variation – such as the number of referrals per week. The key is to identify the

variance, understand why it is there and then make a judgement call as to whether the

reason is acceptable (ie variances due to different levels of deprivation) or not (ie

variances in waiting times just because someone lives in a different part of town). As the

Depression ICP is developed, careful choice of data collection/variance points will help

services to understand better whether care is being delivered to an acceptable level.

There is a note of caution needed though – a lot of time can be spent investigating

differences which return to an average the next time they are measured. Statistical

Process Control charts take account of random variation, and show what differences

are significant, and which differences are likely to be chance variation. Training on SPC is

available through the Collaborative – please contact your Regional Manager or Service

Improvement Manager to discuss further.

The following checklist highlights some areas where looking at the data might identify

key issues that need further work. This is not an exhaustive list, it is simply provided as a

starting point to help MHC teams think about how improvement tools apply to this work.

61

SECTION TWO


62

SECTION TWO

Delivering the Depression Heat Target

DA

TA

AN

ALY

SIS

CH

EC

KL

IST

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Pro

mo

te e

vid

en

ce b

ase

d p

resc

rib

ing

an

d c

om

pli

an

ce

wit

h f

orm

ula

ry w

ith

in p

rim

ary

ca

re

Ha

ve y

ou

co

lle

cte

d d

ata

on

co

mp

lia

nce

wit

h

form

ula

ry a

cro

ss p

ract

ice

s a

nd

do

in

div

idu

al

pra

ctic

es

kn

ow

ho

w t

he

y c

om

pa

re w

ith

oth

ers

?

Da

ta A

na

lysi

s

Va

ria

nce

An

aly

sis

Wh

ere

th

ere

are

sig

nif

ica

nt

leve

ls o

f n

on

-co

mp

lia

nce

,

ha

ve y

ou

id

en

tifi

ed

th

e p

ote

nti

al

savin

gs

fro

m

com

pli

an

ce a

nd

ag

ree

d a

pla

n l

oca

lly

aro

un

d h

ow

to

rele

ase

th

ose

sa

vin

gs

into

th

e f

un

din

g o

f a

lte

rna

tive

serv

ice

s?

Da

ta A

na

lysi

s

Is y

ou

r a

nti

-de

pre

ssa

nt

pre

scri

bin

g d

ata

ro

uti

ne

ly

an

aly

sed

by

pra

ctic

e, C

MH

T a

rea

, an

d C

HC

P a

rea

.

Is t

his

an

aly

sis

bro

ken

do

wn

by

an

ti-d

ep

ress

an

t

an

d a

nti

-de

pre

ssa

nt

typ

e?

Da

ta A

na

lysi

s

Va

ria

nce

An

aly

sis

Do

es

yo

ur

Bo

ard

re

ceiv

e s

um

ma

ry r

ep

ort

s o

n t

his

da

ta a

nd

re

leva

nt

vari

an

ces?

Da

ta A

na

lysi

s

Va

ria

nce

An

aly

sis

Do

yo

u r

ou

tin

ely

mo

nit

or

pre

scri

bin

g a

ga

inst

th

e

sta

nd

ard

ise

d s

eve

rity

sca

le b

ein

g u

sed

in

pri

ma

ry

care

(ie

PH

Q9

, HA

D e

tc)?

Da

ta A

na

lysi

s

Va

ria

nce

An

aly

sis

63

SECTION TWO


DA

TA

AN

ALY

SIS

CH

EC

KL

IST

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Pro

mo

te e

vid

en

ce b

ase

d p

resc

rib

ing

an

d c

om

pli

an

ce

wit

h f

orm

ula

ry w

ith

in p

rim

ary

ca

re –

con

tin

ue

d

Do

yo

u m

on

ito

r th

e l

en

gth

of

tim

e i

nd

ivid

ua

ls a

re o

n

the

pre

scri

pti

on

fo

r a

nd

re

po

rt t

his

by

pra

ctic

e a

nd

do

pra

ctic

es

kn

ow

ho

w t

he

y c

om

pa

re w

ith

ea

ch o

the

r?

Da

ta A

na

lysi

s

Va

ria

nce

An

aly

sis

Do

yo

u a

na

lyse

pre

scri

bin

g d

ata

by

ge

nd

er,

eth

nic

ity

an

d s

oci

o-e

con

om

ic g

rou

ps?

Da

ta A

na

lysi

s

Imp

rove

acc

ess

to

evid

en

ce b

ase

d s

up

po

rte

d

self

he

lp a

nd

se

lf m

an

ag

em

en

t

Ha

ve y

ou

co

mp

are

d r

efe

rra

l ra

tes

to s

up

po

rte

d

self

-he

lp b

y p

ract

ice

?

DC

AQ

Wh

ere

th

ere

are

va

ria

nce

s –

do

yo

u u

nd

ers

tan

d w

hy

?V

ari

an

ce

An

aly

sis

64

SECTION TWO


DA

TA

AN

ALY

SIS

CH

EC

KL

IST

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Imp

rove

su

pp

ort

to

pri

ma

ry c

are

to

en

ab

le d

eli

very

of

ho

list

ic a

sse

ssm

en

ts f

or

tho

se p

rese

nti

ng

wit

h

sym

pto

ms

of

de

pre

ssio

n

Do

yo

u k

no

w w

ha

t tr

ain

ing

th

ose

wo

rkin

g i

n p

rim

ary

care

ha

ve h

ad

wit

h r

eg

ard

s to

th

e a

sse

ssm

en

t a

nd

tre

atm

en

t o

f d

ep

ress

ion

?

Ha

ve y

ou

lo

oke

d a

t p

ract

ice

co

mp

lia

nce

ra

te w

ith

QO

F p

oin

ts f

or

de

pre

ssio

n, a

re t

he

re a

ny

sig

nif

ica

nt

vari

an

ces

an

d i

f so

, do

yo

u u

nd

ers

tan

d w

hy

?

Da

ta A

na

lysi

s

Va

ria

nce

An

aly

sis

Imp

rove

acc

ess

to

no

n-p

ha

rma

colo

gic

al

inte

rve

nti

on

s in

clu

din

g e

vid

en

ce b

ase

d

psy

cho

log

ica

l th

era

pie

s

Do

yo

u r

ou

tin

ely

mo

nit

or

an

d r

ep

ort

on

wa

itin

g

tim

es

to a

cce

ss n

on

-ph

arm

aco

log

ica

l in

terv

en

tio

ns?

Da

ta A

na

lysi

s

Do

yo

u h

ave

sy

ste

ms

in p

lace

to

re

po

rt w

ha

t

pro

po

rtio

n o

f se

rvic

e u

sers

are

un

ab

le t

o b

en

efi

t

fro

m t

rea

tme

nts

off

ere

d t

o t

he

m (

eg

no

n-r

esp

on

se

to A

Ds,

un

ab

le t

o e

ng

ag

e i

n t

he

rap

y)

an

d d

o y

ou

an

aly

sis

the

da

ta f

or

eq

ua

lity

iss

ue

s (i

e e

thn

icit

y,

de

pri

vati

on

, ge

nd

er)

?

Da

ta A

na

lysi

s

65

SECTION TWO


DA

TA

AN

ALY

SIS

CH

EC

KL

IST

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Ro

uti

ne

ly M

on

ito

r o

utc

om

es

an

d m

od

ify

serv

ice

s a

cco

rdin

gly

Do

sp

eci

ali

st s

erv

ice

s h

ave

ou

tco

me

me

asu

rem

en

ts

in p

lace

an

d d

o y

ou

ro

uti

ne

ly r

ep

ort

on

th

ese

?

Da

ta A

na

lysi

s

Do

sp

eci

ali

st s

erv

ice

s kn

ow

wh

at

pro

po

rtio

n o

f

pa

tie

nts

re

ferr

ed

wit

h s

ym

pto

ms

of

de

pre

ssio

n:

fD

NA

fir

st a

pp

oin

tme

nt?

fD

rop

ou

t o

f tr

ea

tme

nt

aft

er

att

en

din

g a

t le

ast

on

ce?

fS

ho

w n

o i

mp

rove

me

nt

du

rin

g t

he

co

urs

e o

f

tre

atm

en

t?

fR

eco

ver

full

y o

r e

nte

r p

art

ial

rem

issi

on

?

fA

re t

ran

sfe

rre

d t

o o

the

r se

rvic

es

an

d i

f so

wh

ich

on

es?

Da

ta A

na

lysi

s

Is a

sy

ste

m i

n p

lace

to

mo

nit

or

use

r sa

tisf

act

ion

wit

h

serv

ice

s?

Da

ta A

na

lysi

s

Ha

ve y

ou

lo

oke

d a

t u

sin

g a

lo

cal

en

ha

nce

d s

erv

ice

in

pri

ma

ry c

are

to

de

live

r ro

uti

ne

mo

nit

ori

ng

of

ou

tco

me

s?

66

SECTION TWO


DA

TA

AN

ALY

SIS

CH

EC

KL

IST

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Imp

rove

acc

ess

to

so

cia

l su

pp

ort

s

(em

plo

ym

en

t, e

du

cati

on

, ho

usi

ng

an

d l

eis

ure

)

Do

yo

u c

oll

ect

da

ta o

n r

efe

rra

ls t

o n

on

-sta

tuto

ry

ag

en

cie

s fo

r so

cia

l su

pp

ort

an

d a

na

lyse

th

ese

fo

r

vari

ati

on

s b

etw

ee

n r

efe

rre

rs a

nd

va

ria

tio

n i

n r

ate

s

ove

r ti

me

?

Da

ta A

na

lysi

s

SP

C

Va

ria

nce

An

aly

sis

67

SECTION TWO


PROCESS ANALYSIS






All the organisations/teams involved in delivering services should be identified and

involved in the process mapping activity. This process mapping work should already be

taking place in all Boards as part of the work to develop a Depression ICP. The mapping

work should include service user and carers perspectives, in line with the ICP standards

(See ICP Process Standard 2) In addition to the process mapping exercise – it might also

help to undertake discovery interviews, feedback questionnaires, and data

sampling in order to fully understand the service user and carers experience.





the pathway and look at the flow through the pathway. Using value-stream mapping,

you can identify:







ensuring that the different teams/people involved in delivering care to someone with

depression all work together effectively?

A range of tools within Lean are available to help with analysing the pathway, and

facilitation support is available from the Collaborative Team. The output of this process

mapping should be clarity on the key issues you need to address locally to simplify and

improve the systems. The Collaborative promotes then using the PDSA approach to

make incremental improvements to the system of care.

The following table helps you to think about applying process mapping to the Depression



68

SECTION TWO


PR

OC

ES

S A

NA

LYS

IS C

HE

CK

LIS

T

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Imp

rove

acc

ess

to

evid

en

ce b

ase

d s

up

po

rte

d

self

he

lp a

nd

se

lf m

an

ag

em

en

t

Ha

ve y

ou

ma

pp

ed

th

e p

roce

sse

s fo

r in

div

idu

als

to

acc

ess

su

pp

ort

ed

se

lf h

elp

an

d s

elf

ma

na

ge

me

nt

–

incl

ud

ing

se

rvic

e u

sers

an

d c

are

rs i

n t

his

ma

pp

ing

pro

cess

Pro

cess

Ma

pp

ing

Ha

ve y

ou

an

aly

sed

th

e p

roce

ss m

ap

an

d i

de

nti

fie

d

du

pli

cati

on

, un

ne

cess

ary

ste

ps,

mis

sin

g s

tep

s,

bo

ttle

ne

cks

an

d q

ua

lity

iss

ue

s?

Va

lue

Str

ea

min

g

Ha

ve s

erv

ice

use

rs a

nd

ca

rers

be

en

in

volv

ed

in

th

is

pro

cess

ma

pp

ing

, id

en

tify

ing

wh

at

ad

ds

valu

e f

rom

the

ir p

ers

pe

ctiv

e?

Va

lue

Str

ea

min

g

Imp

rove

su

pp

ort

to

pri

ma

ry c

are

to

en

ab

le d

eli

very

of

ho

list

ic a

sse

ssm

en

ts f

or

tho

se p

rese

nti

ng

wit

h

sym

pto

ms

of

de

pre

ssio

n

Ha

ve y

ou

lo

oke

d a

t h

ow

oft

en

so

me

on

e w

ith

de

pre

ssio

n p

rese

nts

to

pri

ma

ry c

are

, ave

rag

e l

en

gth

of

ap

po

intm

en

t a

nd

wh

o t

he

y s

ee

?

Da

ta

Sa

mp

lin

g

Do

yo

u h

ave

cle

ar

gu

ide

lin

es

on

wh

en

an

in

div

idu

al

sho

uld

be

re

ferr

ed

on

to

sp

eci

ali

st s

erv

ice

s?

69

SECTION TWO


PR

OC

ES

S A

NA

LYS

IS C

HE

CK

LIS

T

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Imp

rove

un

de

rsta

nd

ing

of

pri

ma

ry c

are

sta

ff,

serv

ice

use

rs a

nd

ca

rers

of

the

dif

fere

nt

op

tio

ns

for

inte

rve

nti

on

Ha

ve y

ou

re

vie

we

d w

ha

t w

ritt

en

/au

dio

/vis

ua

l

info

rma

tio

n is

giv

en

to

th

ose

pre

sen

tin

g w

ith

sy

mp

tom

s

of

de

pre

ssio

n i

n p

rim

ary

ca

re a

nd

to

th

eir

ca

rers

?

Da

ta

Sa

mp

lin

g

Ha

ve y

ou

wo

rke

d w

ith

yo

ur

serv

ice

use

rs a

nd

ca

rers

to i

de

nti

fy w

ha

t in

form

ati

on

th

ey

wa

nt

to r

ece

ive

?

Do

yo

u h

ave

a p

roce

ss t

o e

nsu

re i

nfo

rma

tio

n i

s

rou

tin

ely

ava

ila

ble

?

Pro

cess

Ma

pp

ing

Is t

he

in

form

ati

on

yo

u p

rovid

e a

t a

n a

pp

rop

ria

te

rea

din

g a

ge

3

Is i

nfo

rma

tio

n a

vail

ab

le i

n t

he

fo

rma

t to

me

et

the

ne

ed

s o

f y

ou

r lo

cal

com

mu

nit

y (

ie r

ele

van

t

lan

gu

ag

es,

Bra

ille

, on

ta

pe

)?

3R

eco

mm

en

de

d t

ha

t p

ati

en

t in

form

ati

on

de

sig

ne

d f

or

rea

din

g a

ge

of

be

twe

en

8-1

1 y

ea

rs.

70

SECTION TWO


PR

OC

ES

S A

NA

LYS

IS C

HE

CK

LIS

T

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Imp

rove

me

nt

Too

ls R

ele

van

t

Pro

mo

te e

vid

en

ce b

ase

d p

resc

rib

ing

an

d

com

pli

an

ce w

ith

fo

rmu

lary

wit

hin

pri

ma

ry c

are

Do

yo

u h

ave

gu

ida

nce

on

pre

scri

bin

g o

f a

nti

-

de

pre

ssa

nts

wit

hin

pri

ma

ry c

are

?

Do

yo

u k

no

w w

he

the

r th

e g

uid

an

ce i

s fo

llo

we

d?

Da

ta

Sa

mp

lin

g

Imp

rove

acc

ess

to

so

cia

l su

pp

ort

s (e

mp

loy

me

nt,

ed

uca

tio

n, h

ou

sin

g a

nd

le

isu

re)

Do

yo

u h

ave

a s

yst

em

in

pla

ce w

ith

in p

rim

ary

ca

re

(ie

se

lf h

elp

co

ach

es,

da

tab

ase

) th

at

en

ab

les

the

m t

o

pro

vid

e a

dvic

e o

n a

cce

ssin

g s

oci

al

sup

po

rts

?

Ha

ve y

ou

wo

rke

d w

ith

se

rvic

es

use

rs t

o i

de

nti

fy h

ow

acc

ess

ible

th

ese

so

cia

l su

pp

ort

s a

re t

o i

nd

ivid

ua

ls

stru

gg

lin

g w

ith

sy

mp

tom

s o

f d

ep

ress

ion

? (r

efe

ren

ce

ove

r to

LA

du

tie

s u

nd

er

Act

)

Da

ta

Sa

mp

lin

g

Ro

uti

ne

ly M

on

ito

r o

utc

om

es

an

d m

od

ify

serv

ice

s a

cco

rdin

gly

Do

yo

ur

pra

ctic

es

ha

ve a

pp

rop

ria

te p

roce

sse

s in

pla

ce f

or

revie

win

g t

ho

se w

ith

re

curr

en

t e

pis

od

es

of

de

pre

ssio

n o

r d

ep

ress

ion

last

ing

mo

re t

ha

n o

ne

ye

ar?

Pro

cess

Ma

pp

ing

71

SECTION TWO



Understanding the demand for services is essential, without this services cannot effectively

plan to meet that demand. However, you also need to understand the capacity to respond

to that demand and whether best use is being made of this. For instance, seeing everyone

individually is not necessarily the best use of the capacity, particularly when some

interventions can be just as effectively provided in groups or even over the telephone.



someone’s illness which will take up more resources in the longer term. In primary care,

a failure to match demand and capacity can lead to an individual repeatedly presenting

to primary care, which can result in far more time being allocated to them than if the

appropriate time was given in the first place.

Mental Health Services often refer to demand as the number of referrals received, however,

this is not the demand. Each referral is a request for clinical input so the demand is the

total number of clinical hours provided in response to that request. Hence demand is

partly impacted by the type of service teams provide. An audit across one community

mental health area showed that differences in waiting lists between teams were five

times more to do with what they did with each case (ie differences in number of

sessions and duration) than the number of referrals the teams received.

In addition to understanding their demand, teams/services also need to understand

their capacity. Capacity is the number of clinical hours that are available. Not all of this

will be available for direct patient contact as time will be spent travelling, on leave, at

meetings etc. The Collaborative promotes careful analysis of capacity and how it is used.

For instance, where clinically appropriate, seeing individuals in groups enables limited

capacity to meet a much higher level of demand than just using one to one contact.

The Mental Health Collaborative is working on a demand and capacity analysis tool for

community teams and this is currently in testing stage. Please liaise with your Regional

Manager for more information on this tool. We plan to modify this tool so it can also be

applied specifically to psychological therapy services.


analysis in relation to the Depression Workstream. This is not an exhaustive list, it is

simply provided as a starting point to help MHC teams think about how improvement

tools apply to this work.

72

SECTION TWO


DE

MA

ND

AN

D C

APA

CIT

Y C

HE

CK

LIS

T

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Re

leva

nt

Imp

rove

me

nt

Too

ls

Imp

rove

acc

ess

to

evid

en

ce b

ase

d s

up

po

rte

d

self

he

lp a

nd

se

lf m

an

ag

em

en

t

Do

yo

u r

ou

tin

ely

co

lle

ct a

nd

an

aly

se i

nfo

rma

tio

n o

n

the

de

ma

nd

fo

r su

pp

ort

ed

se

lf h

elp

by

GP

pra

ctic

e?

(Ple

ase

se

e D

CA

Q s

ect

ion

of

too

lkit

fo

r fu

rth

er

de

tails

on

de

fin

itio

ns

of

de

ma

nd

)

DC

AQ

Ha

ve y

ou

lo

oke

d a

t h

ow

th

is c

om

pa

res

wit

h y

ou

r

cap

aci

ty t

o p

rovid

e s

up

po

rte

d s

elf

he

lp b

y G

P

pra

ctic

e?

(Ple

ase

se

e D

CA

Q s

ect

ion

of

too

lkit

fo

r fu

rth

er

de

tails

on

de

fin

itio

ns

of

cap

aci

ty)

DC

AQ

Ha

ve y

ou

lo

oke

d a

t a

lte

rna

tive

s to

in

div

idu

al

con

tact

– i

e t

ele

ph

on

e s

up

po

rt, g

rou

p w

ork

etc

DC

AQ

En

ab

le d

eli

very

of

ho

list

ic a

sse

ssm

en

ts f

or

tho

se

pre

sen

tin

g w

ith

sy

mp

tom

s o

f d

ep

ress

ion

Ha

ve y

ou

est

ima

ted

th

e d

em

an

d f

or

ho

list

ic

ass

ess

me

nts

wit

hin

pri

ma

ry c

are

an

d t

he

ca

pa

city

ne

ed

ed

to

re

spo

nd

?

DC

AQ

73

SECTION TWO


DE

MA

ND

AN

D C

APA

CIT

Y C

HE

CK

LIS

T

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Re

leva

nt

Imp

rove

me

nt

Too

ls

Imp

rove

acc

ess

to

no

n-p

ha

rma

colo

gic

al i

nte

rve

nti

on

s

incl

ud

ing

evid

en

ce b

ase

d p

sych

olo

gic

al

the

rap

ies

Do

yo

u r

ou

tin

ely

co

lle

ct a

nd

an

aly

se i

nfo

rma

tio

n o

n

the

de

ma

nd

fo

r p

sych

olo

gic

al t

he

rap

ies

by

GP

pra

ctic

e?

DC

AQ

Do

yo

u k

no

w w

ha

t y

ou

r ca

pa

city

to

pro

vid

e

psy

cho

log

ica

l th

era

pie

s is

?

DC

AQ

Wis

em

an

Wo

rklo

ad

Me

asu

re

Ha

ve y

ou

co

mp

are

d y

ou

r ca

pa

city

wit

h y

ou

r d

em

an

d?

DC

AQ

Ha

ve y

ou

co

nsi

de

red

wa

ys

to e

xp

an

d t

he

ca

pa

city

of

curr

en

t re

sou

rce

s –

ie t

ele

ph

on

e s

up

po

rt, g

rou

p w

ork

etc

DC

AQ

Ha

ve y

ou

co

mp

are

d a

vera

ge

ne

w t

o f

oll

ow

-up

ra

tio

s

acr

oss

sta

ff m

em

be

rs a

nd

te

am

s w

ork

ing

wit

h

sim

ila

r cl

ien

t g

rou

ps.

If

the

re i

s si

gn

ific

an

t va

ria

tio

n,

do

yo

u u

nd

ers

tan

d t

he

re

aso

n w

hy

?4

Un

de

rsta

nd

ing

Va

ria

tio

n

Do

yo

u h

ave

a s

tan

da

rd o

n t

he

am

ou

nt

of

tim

e s

taff

sho

uld

sp

en

d i

n d

ire

ct p

ati

en

t co

nta

ct?5

Me

asu

rem

en

t

4P

lea

se n

ote

, we

are

no

t sa

yin

g n

ew

to

fo

llow

up

ra

tio

s sh

ou

ld b

e t

he

sa

me

fo

r e

very

pa

tie

nt

or

clie

nt

gro

up

. Clin

ica

l ne

ed

will

re

sult

in d

iffe

ren

ces.

Ho

we

ver

larg

e d

iffe

ren

ces

in a

vera

ge

ne

w t

o

follo

w-u

p r

ati

os

be

twe

en

sta

ff m

em

be

rs a

nd

te

am

s w

ork

ing

in a

sim

ilar

fie

ld a

re w

ort

hw

hile

exp

lori

ng

to

en

sure

th

ey a

re b

ase

d o

n p

ati

en

t n

ee

d.

5In

se

ttin

g a

ny

sta

nd

ard

, ca

re n

ee

ds

to b

e t

ake

n t

o b

ala

nce

th

e n

ee

d t

o m

axi

mis

e d

ire

ct p

ati

en

t co

nta

ct t

ime

wit

h t

he

imp

act

of

inte

nsi

ve w

ork

ing

on

an

ind

ivid

ua

l’s

me

nta

l we

llbe

ing

. Bu

rnin

g

sta

ff o

ut

is n

ot

an

eff

ect

ive

lon

g t

erm

str

ate

gy.

74

SECTION TWO


DE

MA

ND

AN

D C

APA

CIT

Y C

HE

CK

LIS

T

Ye

sY

es

– b

ut

ne

ed

s

refi

nin

g

No

Pri

ori

ty f

or

Lo

cal

Act

ion

?

If p

rio

rity

fo

r

act

ion

– w

ho

wil

l

take

fo

rwa

rd a

nd

by

wh

en

Re

leva

nt

Imp

rove

me

nt

Too

ls

Imp

rove

acc

ess

to

no

n-p

ha

rma

colo

gic

al i

nte

rve

nti

on

s

incl

ud

ing

evid

en

ce b

ase

d p

sych

olo

gic

al

the

rap

ies

–

con

tin

ue

d

Do

yo

u k

no

w w

ha

t p

erc

en

tag

e o

f ti

me

yo

ur

sta

ff

spe

nd

in

dir

ect

pa

tie

nt

con

tact

?

Me

asu

rem

en

t

Ha

ve y

ou

lo

oke

d a

t w

ha

t in

terv

en

tio

ns

dif

fere

nt

gra

de

s o

f st

aff

are

do

ing

to

ass

ess

wh

eth

er

yo

u a

re

ap

pro

pri

ate

ly s

kil

l m

ixin

g?

Me

asu

rem

en

t

Imp

rove

acc

ess

to

so

cia

l su

pp

ort

s (e

mp

loy

me

nt,

ed

uca

tio

n, h

ou

sin

g a

nd

le

isu

re)

Do

yo

u k

no

w w

ha

t so

cia

l su

pp

ort

s a

re a

vail

ab

le i

n

yo

ur

are

a?

SECTION THREE:Improvement Tools

75

SECTION THREE

Process Mapping

PROCESS MAPPING

What is the Tool?

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.

The aim of process mapping is to involve a multi-disciplinary team to identify each step

of the current process, which may help to identify opportunities for improvement.

Furthermore, a process mapping event presents the opportunity for all members of the

team to identify issues with the current process and generate ideas for testing improvements.

The Mental Health Collaborative strongly recommends that service users and

carers are involved in the process mapping exercise.

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:

f What you need to know

f Resources and timescales

f 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.

How to use it?

1. Prior to the Process Mapping Event:

f Define start and end point of process to be mapped;

f Invite all members of the multi-disciplinary team involved in that process to a

mapping event, including service user and carer representatives;

f 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;

f 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:

f Brown paper or flipcharts or wallpaper/lining paper;

f Post-it® notes (possible coloured for different types of issues);

f Marker pens;

f Sellotape.

2. 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:

f 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;

f Encourage people to write issues and ideas for improvements on separate Post-it notes

and park them on a flipchart;

f 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;

f Arrange the Post-it® notes to ensure they capture the service user journey in the

correct sequence;

f Where relevant capture times, delays, waits, hand-offs etc;

f 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.

3. 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.

76

SECTION THREE

Process Mapping

At the follow-up meeting it is advisable to start by analysing the process map. Consider

the following:

f How many times is the service user passed from one person another (hand off)?

f Where are delays, queues built into the process?

f Where are the bottlenecks?

f What are the longest delays?

f What is the approximate time taken for each step (task time)?

f What is the approximate time between each step (wait time)?

f What is the approximate time between the first and last step?

f How many steps are there for the service user?

f How many steps add no value for the service user? (see section on value and waste

for more information on this)

f Are there things that are done more than once?

f Look for rework loops

f Is work being batched?

f Where are the problems for the service user?

f At each step is the action being undertaken by the most appropriate staff member?

f Where are the problems for staff?

f Where is the greatest amount of time currently lost or wasted?

f Can any processes be carried out simultaneously?

f Consider what service users complain about.

f Whether any other teams might be affected should your team change its processes –

processes seldom work.

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

who look after service user before and after the first step of treatment.

Adapted from:

f http://member.goodpractice.net/ContinuousImprovementToolkit/resources/core-

improvement-tools/systems-and-processes.gp

f http://www.nodelaysachiever.nhs.uk/ServiceImprovement/Tools/IT220_A+

Comprehensive+Overview+of+Mapping+Processes+and+Patient+Journeys.htm

77

SECTION THREE

Process Mapping

Sample Process Maps and further information available at:

f NHS Scotland’s Centre for Change and Innovation covers measurement, analysis,

techniques and solutions for service improvement in health, including a section on

mapping at http://www.scotland.gov.uk/Resource/Doc/76169/0019037.pdf

f Tools, software and ideas for mapping are also available from

http://www.mindtools.com/pages/article/newPPM_03.htm

f Visit the CHAIN’s Lean Subgroup, which includes contacts and information about

improvement in healthcare at the website at http://chain.ulcc.ac.uk/chain/index.html

78

SECTION THREE

Process Mapping

79

SECTION THREE

Process Mapping

Example of High LevelProcess Map

Register in

system

Care planpreparation

Care andTreatment

Refer toCrisis Team

Suitable for primary care

Assess Refer to CMHTReferral in

CMHT. Register

Routine/non urgentCMHTAssess

CMHT take on

caseNon emergency/crisis

No capacity

CMHTassessment

Suitable, crisis or Routine?

CMHT assessment

Care planpreparation

Looks suitableAdmit or

community?

Crisis team assess

suitability

Requiresadmission Suitable for

community

Capacity?Check bed

availability

admitCrisis takes

on client

Yes

No

No capacity

Crisis teamdo

assessment

Yes

Not suitable for crisis

Crisis?

CMHT accept

Treat in primary care

Presentation to GP

80

SECTION THREE

Process Mapping

IDENTIFYING VALUE AND WASTE

What is the Tool?

In healthcare systems, as in most other systems, there are value adding, non-value

adding and wasteful activities. Value-adding activities are those which service

users can easily identify as being an important part of their journey. Non-value

adding activities are those which are difficult for service users to 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.

It is important to identify the steps in the service user journey that add value, and also

the areas of waste, in order to create a flow that is effective and valuable through the

eyes of service users.

Waste-free activities are ones that:

f Are done right first time. It is important that the right care is delivered at the right

time, the first time and every time. So doing a test for a second time because the first

one was lost is a wasteful activity.

f Transform the service user in some way. There should be a direct result or outcome

for the service user (e.g. assessment of service user that leads to a plan of intervention).

The activity should help move the service user along the pathway, or the activity

should help add to the overall service user experience (e.g. effective communications

with the service user).

f The service user cares about. Waste-free activities are valuable in the eye of the

service user, e.g. an x-ray to enable diagnosis. One way to identify this is by asking

the service user.

How to use it?

Waste

Waste is anything that does not add real value for the service user and slows systems

down unnecessarily. Asking staff to stand back and analyse the systems in which they

work, the way they work, and the way their colleagues work can be a very useful exercise

to identify waste within the system.

There are seven commonly recognised types of waste that exist in service user journeys:

1. Waiting

Waits may manifest in different ways, for example waits for treatment, waits for

decisions, waits for transport, etc. It is important to continually seek to eliminate waits

by identifying where service users wait in your system. Think as well about who else

might be able to undertake activities, e.g. therapist-led discharge instead of consultants.

Look for where processes are not linked (so the service user arrives at the next process

before it is ready) and consider how they can be improved.

81

SECTION THREE

Identifying Value and Waste

2. Mistakes

Mistakes can not only directly impact on service user care, they can also cause harm to

service users and can lengthen the time it takes service users to be treated due to

unnecessary rework. It is vital that mistakes are identified and acted on as soon as

possible. This can be achieved in two ways:

f Building redundancy/check points into the system.

f Designing a system that enables people to do the right thing every time, e.g.

windowed envelopes for sending out service user letters – so that letters are always

sent to the right person.

3. Unco-ordinated activity

It is important that processes are linked across the service user journey and that each

stage of the process has effective communication/information links with the previous

stage of the journey. Unco-ordinated activity is where two parts of the service user journey

are not seamlessly joined together, for example, requesting a therapy assessment for a

service user who was previously discharged.

4. Stock

Stock refers to consumables, equipment or medical supplies. Too much equates to waste,

but too little can cause delays in service user treatment, which again is wasteful. Too much

or too little stock, and stock that is in the wrong place can inhibit staff from finding things

quickly, which is wasteful. It is important to store appropriate levels of stock where it is

easily identified and accessible.

5. Transportation

Transportation, for example of notes, information and materials add no value to the

service user, but may be necessary. Unnecessary transportation can be reduced. Consider

co-locating staff to encourage interaction. Also examine how communication and

information flows can be improved so that people pass on the relevant information to

the next person in the process, or input it into the appropriate recording system.

6. Unnecessary movement

Waste may occur, for example with staff who have to walk excessive distances between

wards to see service users; or it may be small wasteful movements repeated many times

a day, e.g. having to walk round a pillar to answer a phone. Staff searching for equipment,

notes, information etc. is unnecessary movement and is wasteful. Unnecessary movement

can be monitored through the use of pedometers and video recordings.

7. Inappropriate processing

Inappropriate processing is any activity that is unnecessary. Duplicating activity is waste,

e.g. recording data manually as well as electronically. Batching is an example of inefficient

processing. It is important to look for ways to reduce duplication and delays in the

service user’s journey.

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Conclusion

The identification of opportunities to reduce waste can produce numerous benefits to

both service users and staff in reducing frustration, rework, hunting and gathering. This

will ultimately lead to a more efficient and effective service user-focused service.

Adapted from


improvement-tools/lean/documents/identifying-value-and-waste.gp

Further Reading

f Bicheno J (2004) ‘The New Lean Tool Box’ PICSIE Books, Buckingham.

f Hopp W and Spearman M (2000) ‘Factory Physics’ McGraw Hill, Boston.

f Rich N, Bateman N, Esain A, Massey L and Samuel D (2006) ‘Lean Evolutions’

Cambridge University Press, Cambridge.

f Rother and Shook (1999) ‘Learning to See’.

f Womack J and Jones D (1996) ‘Lean Thinking’ Simon and Schuster, New York.

f Womack J and Jones D (2005) ‘Lean Solutions’ Simon and Schuster, New York.

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Demand, Capacity, Activity, Queue

DEMAND, CAPACITY, ACTIVITY, QUEUE (DCAQ)

What is the Tool?

Traditional models of healthcare process design tend to focus on improving a

particular department or part of the process in isolation, rather than achieving

a whole system improvement.

The philosophy underpinning today’s improvement thinking starts from a different

mindset to these historical performance improvement strategies. It is firmly grounded in

the view that the SYSTEM should be designed to function effectively and efficiently

with the ability to continuously improve. Therefore, utilising tools such as DCAQ allows

us to analyse systems and processes that support clinical activities.

The variation between demand and capacity is one of the main reasons why queues

occur in the NHS, because every time demand exceeds capacity, a queue is formed,

showing itself as a waiting list or backlog. Knowing what your demand is, and having the

right capacity at the right time to respond to it, is key to reducing overall service user

journey times.

Improvement of the service user’s journey (Flow) will not be made by having more staff,

more equipment and more facilities alone. Improvement will be achieved by:

f Taking a process view of service user FLOW, and following the service user journey

through the healthcare delivery SYSTEM;

f Working smarter by focusing on bottlenecks that prevent smooth service user flow, and

removing activities that do not add any value to service users;

f Understanding capacity and demand. Several studies have demonstrated that

continually adding capacity is not the answer to our problems;

f Managing and reducing sources of demand and capacity variation in service user flow.

Poor understanding of this variation is compounded by low yields at key resources

and by increases in resources at parts of the process that are not bottlenecks (that

results in excess activity without any increase in service user throughput);

f Segmenting service users according to specific needs;

f Implementing measurement systems that identify the true performance of the system

and the opportunities for improvement.

A first step in making improvements to service user flow is to look at bottlenecks in the

process. A bottleneck is often the stage in the process under most pressure; it creates

queues and slows down the whole process. It may be the most time consuming step in a

process, or it may be a functional bottleneck where two or more service user flows

converge at say a diagnostic unit.

A bottleneck determines the pace at which the whole process can work. If changes are

made to improve parts of the care process without addressing the bottleneck, improvement

projects are unlikely to succeed. The objective at all times must be to systematically identify

and then eliminate bottlenecks in the service user flow process.

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To manage smooth flow requires identification of the bottleneck process and its rate of

performance. This then needs to be reviewed in light of the demand for the process. The

bottleneck is the key system constraint and all efforts need to be directed towards

optimising its performance (by removing it or changing it) to meet the demand on the

process. Speeding up the journey at the wrong point can cause a build-up of service

users further along the process at the site of the system constraint (bottleneck). To

deliver improvement we need to:

f Increase capacity at the stage of the process where it will create the greatest outcome;

f Increase capacity of the bottleneck by moving resources from previous (upstream)

steps or future (downstream) steps of the process;

f Reduce inappropriate demand to the constraint;

So, by clearly understanding Demand, Capacity, Activity and Queue, and identifying the

bottlenecks in the process you can:

f manage and plan work in all teams;

f increase throughput by reducing variation and/or matching variations in capacity and

demand at the bottleneck;

f focus improvement effort on the place (bottleneck) where throughput can be increased;

f shift capacity to the bottleneck or manage demand to the bottleneck;

f protect the bottleneck and constraint as the implications of reduced capacity or

mismatches in capacity and demand effect throughput along the whole pathway;

f plan work around the bottleneck

Note: Queues aren’t necessarily always bad as they can help to manage and plan

capacity to demand. For example based on this weeks demand for referrals, it is possible

to plan capacity at the right level so the right amount of activity can take place in say

three weeks time. However, generally unnecessary backlogs and Queues with long

delays aren’t good.

How to use it?

In order to make the most of service user flow through a healthcare system, we need to

look at the whole service user process and analyse the capacity, demand, backlog and

activity issues wherever there are queues and waiting lists (bottlenecks)

Measuring Demand, Capacity, Activity and Queue

Demand, capacity, activity and backlog need to be measured in the same units for the

same period of time. Once you have started to measure capacity, demand, backlog and

activity you can use the data and the patterns that emerge to start predicting demand

and managing capacity, activity and backlog at the bottleneck. The overall goal is to

manage capacity and demand appropriately, effectively and permanently.

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Demand – Mental Health Services often refer to demand as the number of referrals

received. However this is not the demand. Each referral is a request for clinical input so

demand is the total number of clinical hours provided in response to that request.

Hence demand is partly impacted by the type of service teams provide. An audit across




f Actual demand. What we are asked for.

f Failure demand. What we have to do again as didn’t do right the first time

f Created demand. Demand we create because of way respond to needs

f Hidden demand. Demand that is out there but not currently presenting – ie those

who need psychological therapies but due to length of waiting lists are not referred

through.

f Total demand = actual + failure + created + hidden demand

Capacity – Resources available to do work which includes staff and any equipment needed

(such as rooms). Not all of the clinical staff time will be available for direct service user

contact as time will be spent travelling, on leave, at meetings etc. It is important to take

this into account when looking at your capacity.

Activity – All the work done. This does not necessarily reflect capacity or demand on a

day to day basis. The activity or the work done on say a Monday may be a result of some

of Mondays demand (i.e. emergency) and the previous weeks’ demand. The capacity is

the capacity available on the Monday but activity is often less than the available capacity.

Queue – Previous demand that has not yet been dealt with, showing itself as a backlog

of work or a waiting list. It’s logical, if you don’t deal with today’s demand today, there

will be a backlog for tomorrow.

Identifying backlog and queues

Queues occur where demand has not been dealt with and results in a backlog. The main

reason why a queue develops is the mismatch between variation in demand and capacity

at specific times, because the right people or equipment (e.g. suitable rooms to see

people in) are not always available to deal with the demand in a timely manner.

Every time the demand exceeds the capacity, a queue is formed. However, every time

the capacity exceeds the demand, the extra capacity is lost or it is filled from the queue.

So plans based on matching the average daily demand to the average daily capacity are

fundamentally flawed.

The diagram below illustrates how waiting lists may build up if demand for work exceeds

our capacity to do that work. Evidence suggests that our capacity to deal with work

varies more than the demand.

Eliminate backlogs (queues)

When huge backlogs occur, they take a lot of effort to manage and often create more

work, including dealing with complaints and needing to reschedule appointments etc.

The elimination of backlogs needs to be dealt with early on in the project. Once the

backlog is eliminated, you will need to keep it in that position so that you can match

true capacity and demand.

The key aim is to AVOID having every stage of the journey so busy that there is no

room for flexibility. When teams are still dealing with backlogs they are not agile enough

to be able to deal with today’s requests.

In order to reduce backlogs requires a plan that includes at a minimum:

f Quantification of the true nature of the backlog

f A plan to add capacity on a temporary basis (NB beware of creating a large wave of

activity further down the pathway)

Once the backlog is cleared you need to work hard at maintaining that position, ideally

by matching capacity and demand on a daily basis to avoid new backlogs occurring.

Carve Out

Typically, when we are faced with long Queues we ‘prioritise’, ‘ring fence’ or ‘carve out’

the time of an expert, the time of specialised equipment or by keeping resources or

facilities only for one particular group of service users, e.g. reserving specific slots for

‘urgent’ service users. By carving out in this way, the process of care for one group of

service users is prioritised over another irrespective of their needs. Accurate measuring of

the backlog or waiting time for other groups of service users has shown that carving

out capacity significantly increases waiting times overall, and creates a very

difficult system to manage effectively; the system will exhibit a constant mismatch

between case mix, process type and reserved capacity.

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Waiting = queue = backlog =

number of patients waiting

x the time it takes

to process a patientDemand =

All the requests

for a service

from all sources

x the time it takes

to process a patient

Measure everything in the same unit of time

Bottleneck

Capacity = what we

could do = resource

x time of skill supplied

Activity = what we did

x the time it takes to

process a patient

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This means that Carve out worsens both queues and waiting times because:

f Slots reserved for urgent service users may not be filled, creating greater capacity loss;

f Carved out spaces are misused, being filled by non-urgent service users;

f If service users are not seen in chronological order variation and maximum waiting

times will increase;

f Frustrated service users and clinicians will ‘game the system’ typically labelling every

request urgent in order to jump a continually climbing ‘routine’ queue.

An alternative may be Segmentation, which is about the separation of the whole process

of care for one group, to improve the overall flow of service users, but not at the expense

of other service users. Segmentation identifies service users with similar needs and or

preferences and groups them together.

Matching Demand and Capacity

Once the backlog has been eliminated, the next aim is to ensure that demand and capacity

are in equilibrium. This requires that capacity and demand are matched. Matching of

(service) capacity to (service user) demand is critical to ensure access to every stage of

the service user journey. The capacity of the system needs to be flexible enough to cope

with small changes in daily demand. There are two key strategies, which are outlined below,

and at this time we also need to start thinking about possibilities to reduce demand, or

increase capacity:

Thinking about – reducing demand:

f Should we see all these service users? – implement protocols

f Who is appropriate to see them? – provide alternatives

f Do we need to see them for as long as we are? – caseload management

f Can the service user pathway or the process at the bottleneck be streamlined? (Do

we need to do all these steps?)

f Reduce waiting lists – reduce the demands they create

f Prevention and service user education

Thinking about – extending capacity:

f look for ways of gaining capacity within the system – for instance can you reduce your

sickness rates, can you reduce time spent travelling, can you reduce time in meetings,

is your skill mix right or do you have very expensive staff doing basic admin duties?

f look for ways of increasing the flexibility of the capacity so you have it available at

the right time – for instance, can you organise your service so discharges from

inpatient user units are done daily?

f Reduce the number of appointment types to reduce complexity/carve out!

f Bid for resources only when constraint is equipment or staff and working differently

will not help

Adapted from

f http://member.goodpractice.net/content.htm?id=29b53fe7-5362-0024-9d1e-

0019b9df0ed9&format=rtf

f http://www.nodelaysachiever.nhs.uk/ServiceImprovement/Tools/IT247_Demand

andCapacityBasicConcepts.htm

f http://www.nodelaysachiever.nhs.uk/ServiceImprovement/Tools/IT052_Demand

andCapacityAComprehensiveGuide.htm

Spread sheets for modelling DCAQ are available at

f http://www.nodelaysachiever.nhs.uk/Resources/ResourceGuideItems/Demand+and

+Capacity+Spreadsheet.htm

f www.steyn.org.uk

f Mental Health specific spreadsheets are available from your Regional Service

Improvement Manager or Regional Information Manager. These are currently in

testing phase.

Further reading

f Bicheno J (2004) ‘The New Lean Tool Box’, PICSIE Books, Buckingham Goldratt E

(1990) ‘The Theory of Constraints’, North River Press, New York Hopp W and

Spearman M (2000) ‘Factory Physics’, McGraw Hill, Bosto

f www.goldratt.com

f NHS Modernisation Agency Capacity and Demand Improvement Leaders Guide 2003.

f Sylvester et al; Reducing Waiting Times in the NHS: is Lack of capacity the Problem?

(Sylvester et al September 2003)

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Statistical Process Control

STATISTICAL PROCESS CONTROL

What is the Tool?

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, ie 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, ie 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.

How to use it?

If you want a free excel based SPC chart generator please contact your Regional

Service Improvement Manager or Information Manager for the Mental Health

Collaborative.

SPC charts enable you to identify whether variation is common or special cause. When

you are interpreting SPC charts there are 4 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. This means that only ‘common cause’ variation is present.

Rule 1 Any point outside one of the control limits.

Rule 2 A run of seven points all above or all below the centre line, or all increasing or

decreasing.

Rule 3 Any unusual pattern or trends within the control limits.

Rule 4 The number of points within the middle third of the region between the control

limits differs markedly from two-thirds of the total number of points.

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.

f 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.

f If uncontrolled variation (special cause) is displayed in the SPC chart, the process is

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.

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There are three issues that you should be aware of when using SPC charts to improve a

process:

f You should not react to special cause variation by changing the process, as it may not

be the system at fault;

f 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;

f 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:

f 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;

f Aggregate data is discouraged (ie the use of percentages, as this often hides the

pattern of the data);

f The problem you are observing may be the means by which you are measuring, not

what is really happening to the service user. Sometimes it is better not to act if you

aren’t sure. Investigate further instead;

f Remember that when you change something in the process, the data points after the

change will be from a new system. When you have a run of points which break a rule

(see below), you will need to recalculate the SPC control limits to show an

improvement (showing the control limits of the new system).

Sources of variation in a clinical system

Staff Process Patients

skillsillness

shifts

machines not the same

supplies

rooms not the same

GP

Resource

motivationholiday

training

unclearguidelines

differcomplications

age

racesex

motivationdisease

education

transcription

transport

applications

Information

Example of SPC Charts

Daily Discharge data from a Scottish Acute Psychiatric Ward

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Weekly outcomesSpecial cause

Mean

40

% o

f p

ati

en

ts w

ith

ou

tco

me

35

30

25

20

15

10

5

0

Split 30 Mar 2003 20 Jul 2003UCL =28.5 11.8Mean =15.9 4.7LCL =3.3 N/A

30

Ma

r 2

00

3

6 A

pr

20

03

13

Ap

r 2

00

3

20

Ap

r 2

00

3

27

Ap

r 2

00

3

4 M

ay

20

03

11

Ma

y 2

00

3

18

Ma

y 2

00

3

25

Ma

y 2

00

3

1 J

un

20

03

8 J

un

20

03

15

Ju

n 2

00

3

22

Ju

n 2

00

3

29

Ju

n 2

00

3

6 J

ul 2

00

3

13

Ju

l 20

03

20

Ju

l 20

03

27

Ju

l 20

03

3 A

ug

20

03

10

Au

g 2

00

3

17

Au

g 2

00

3

24

Au

g 2

00

3

31

Au

g 2

00

3

7 S

ep

20

03

14

Se

p 2

00

3

21

Se

p 2

00

3

target

No lower limit as zero is closer

Mean

Stable period, so UCL represents capacity of process

UCL

LCL

UCL

7 consecutive points below mean, data split and new mean and limits calculated

Daily Discharges

Date

0

1

2

3

4

5

01

/01

/20

08

08

/01

/20

08

15

/01

/20

08

22

/01

/20

08

29

/01

/20

08

05

/02

/20

08

12

/02

/20

08

19

/02

/20

08

26

/02

/20

08

04

/03

/20

08

11

/03

/20

08

18

/03

/20

08

25

/03

/20

08

01

/04

/20

08

08

/04

/20

08

15

/04

/20

08

22

/04

/20

08

29

/04

/20

08

06

/05

/20

08

13

/05

/20

08

20

/05

/20

08

27

/05

/20

08

03

/06

/20

08

10

/06

/20

08

17

/06

/20

08

24

/06

/20

08

Nu

mb

ers

D. Disch UCL LCL mean

Special cause

variation

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Adapted from

f http://member.goodpractice.net/content.htm?id=ab7f41cd-5362-0024-9d1e-

0019b9df0ed9&format=rtf

f http://www.nodelaysachiever.nhs.uk/ServiceImprovement/Tools/IT16_spc.htm

Sample SPC Charts and further information available at:

f The Clinical Indicators Support Team has produced an SPC chart package and

tutorial that can be accessed at: http://www.indicators.scot.nhs.uk/SPC/SPC.html

f They have also developed workshops presentations that can be accessed at:

http://www.indicators.scot.nhs.uk/Workshops/SPC.html

f The Institute for Innovation and Improvement have developed SPC packages which

are available at: http://www.nodelaysachiever.nhs.uk/NR/rdonlyres/84CC2E80-A839-

4952-A64A-8B9FC73BAFC1/0/SPCgenerator.xls

Further Reading

f Bicheno and Catherwood ‘Six Sigma and the Total Quality Toolbox’ Picsie Books,

2005

f Donald Wheeler ‘Understanding Variation’ Knoxville: SPC Press Inc, 1995

f Donald Wheeler ‘Making Sense of Data. SPC for the Service Sector’ Knoxville, SPC

Press Inc, 2003

f Walter A Shewhart ‘Economic Control of Quality of Manufactured Product’ New York,

D Van Nostrand 1931

f W E Deming ‘Out of the Crisis’ Massachusetts: MIT 1986

f Donald M Berwick ‘Controlling Variation in Health Care: a Consultation from Walter

Shewhart’ Med Care 1991; 29: 1212-25.

f Esain, A ‘Problem Solving, TQM and Six Sigma’ in Rich, Batemen, Esain, Massey and

Samuel (2006)

f ‘Lean Evolution: Lessons from the Workplace’ Cambridge University Press

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MODEL FOR IMPROVEMENT (PDSA)

What is the Tool?

The Model for Improvement (PDSA Cycle) is a tried and tested framework for

developing, testing and implementing changes that lead to improvement. The

Model was developed for use in healthcare systems by the Institute for Healthcare

Improvement based in the USA. It has been widely used to deliver improvements

in healthcare systems throughout Europe and the USA. It is popular with clinicians

and managers because it is simple to use.

The model offers the following benefits:

f It is a simple approach that anyone can apply

f It reduces risk by starting small

f Changes can be focused at the operational level around your teams needs

f It supports rapid cycles of improvement

f It is highly effective, changes are quick and immediately evident

f It is a powerful tool for learning. As much is learned from ideas that don't work as

from those that do

f Where people have been involved in testing and developing ideas there is often less

resistance on implementation

f It can also be used to support the implementation of large scale strategic plans

How to use it?

PDSA Cycles are small scale, reflective tests used to try out ideas for improvement. They

should be repeated and built on using learning from each test cycle to refine the

improvement idea.

1. Plan. What are you trying to accomplish? How will you know that a change is an

improvement? What will be done, who will do it, in what timescales. You may need to

collect data to inform your study of the change.

2. Do. This is the stage where the plan is put into action. Remember to keep it small and

manageable, i.e. one service user, one doctor, one nurse, one day.

3. Study. At this stage, the cycle is reviewed and reflected on with all relevant stakeholders.

Any data collected will be analysed. Any ideas for improvements to the cycle should

be raised prior to re-testing.

4. Act. It may be that the cycle should be tested again unchanged under different

conditions, i.e. different service user, doctor, nurse or day of the week. Alternatively,

you may decide to amend your plan to reflect learning from first cycle and re-test.

If all has gone well, you may decide to roll your change out.

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Model for Improvement

Often multiple PDSA cycles will need to be used. This approach is in contrast to using

one cycle to attempt to accomplish everything. The use of multiple cycles for sequential

testing and implementation reduces risk, as the change process progresses from hunches,

theories and ideas to actual changes that result in improvement. It is worth noting that

not all changes will result in an improvement. Measurement is therefore a fundamental

part of answering the question ‘how do we know that a change is an improvement?’ Also,

it is essential that learning from what did work as well as what didn’t work is captured

before undertaking your next PDSA.

It is also worth considering the scope and risks associated with projects. Sometimes

PDSA’s, or the diagnostic work may identify changes which are out with our control, or

to ‘risky’, and then it may be a case of highlighting issues to line management, or

escalation of responsibility. The following diagram highlights the appropriate scope

for a PDSA cycle under different conditions:

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Model for ImprovementWhat are we trying to

accomplish?How will we know that a

change is an improvement?What change can we make

that will result in improvement?

Act Plan

Study Do

Appropriate Scope for PDSA Cycle

Adapted From


improvement-tools/model-for-improvement.gp

f http://www.nodelaysachiever.nhs.uk/ServiceImprovement/Tools/IT142_PlanDo

StudyAct%28PDSA%29.htm

Further Information

f The Improvement Support Team has a wide range of experience of applying the

Model for Improvement, visit our web site at:

http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/Delivery-Improvement

f Langley G, Nolan K, Nolan T et al. (1996) ‘The Improvement Guide: A Practical

Approach to Enhancing Organisational Performance’ San Fransisco, Jossey-Bass.

f http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/

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SECTION THREE


Current Situation Staff Readiness to make change

Resistant Indifferent Ready

Low confidence

that change

idea will lead to

improvement

Cost of

Failure

Large

Very Small

Scale test

Very Small

Scale test

Very Small

Scale test

Cost of

Failure

Small

Very Small

Scale test

Very Small

Scale test

Small Scale

Test

High confidence

that change idea

will lead to

improvement

Cost of

Failure

Large

Very Small

Scale test

Small Scale

Test

Large Scale

Test

Cost of

Failure

Small

Small Scale

Test

Large Scale

Test

Implement

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SECTION THREE


101

SECTION THREE

Service User Stories

SERVICE USER STORIES

What is the Tool?

Stories are more than just a listing of random incidents and anecdotes. They have

a beginning, middle, and end and they include characters who convey feelings and

communicate ideas. This facilitates an insight into what it feels like to be on the

receiving end of services, and that makes them powerful tools to create recognition

for the need to change, and discomfort with the status quo. It also helps to place the

service user and their needs at the centre of any discussion, and hence can be used to

improve services.

How to use it?

There is no one right way of collecting service users’ views: different methods suit different

purposes. However, it is important that to use a method appropriate to the group of

service users involved, and the planned service improvement. Four of the main methods

of obtaining service user perspectives: questionnaires, focus groups, semi-structured

interviews and service user shadowing, are described below.

1. Questionnaires

A questionnaire is a straightforward way of getting information from lots of people.

Easy to administer, they can capture the perceptions and experiences of service users,

users, and carers. They can also be used to measure levels of satisfaction with a process

or service. Questionnaires are useful for measuring baseline information, and to evaluate

change over time.

2. Focus groups

A focus group is an informal collection of people sharing common characteristics. They

meet to discuss and debate their experiences about a specific topic or problem e.g.

service users who have recently visited the department. They are a useful way to listen

to a wide range of experiences about a single area.

3. Semi-structured service user interviews

Semi-structured one to one interviews are used to collect qualitative data. They aim to

understand the respondent’s point of view rather than make generalisations. The

interviewer can delve more deeply and ask why. This often yields more information and

emotional response than a questionnaire. The service user also has the opportunity to

ask for clarification, and highlight ‘their’ most significant issues or needs. They are

however, more time consuming to conduct.

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4. Service user shadowing

This is when a member of staff or volunteer accompanies the service user on their

journey through the health and social care system. Preferably, the shadower will

be unfamiliar with the process and should also be comfortable asking 'why?’.

It provides objective, observational feedback that needs to be balanced by other

approaches, for example by obtaining the views of the staff providing the service.

Using this technique, a service user movement record in time and space can

be developed, as well as capturing perceptions of the service. This enables a

comprehensive picture of movement, combined with a flow diagram of actions

and a qualitative perception of the process, to be developed. While the service user

is being shadowed, their shadower can use interview techniques and observation

to supplement the information provided by the service user, to develop a richer,

more detailed picture.

Adapted from

f http://www.nodelaysachiever.nhs.uk/ServiceImprovement/Tools/IT080_Listening_

to_patient_perspectives.htm

f http://www.healthliteracy.com/article.asp?PageID=3809

Further Reading

f Wheeler, Rosie ‘Making a Difference: Stories from the Point of Care’, AORN Journal,

Feb, 2007 http://www.pickereurope.org/page.php?id=6

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SECTION THREE


FURTHER INFORMATION ON IMPROVEMENT TOOLS ANDTECHNIQUES

By accessing the following websites you will find further information on the tools and

techniques described in this ‘toolkit’ and used in service improvement including

examples of case studies:

www.goodpractice.net

www.goldratt.org.uk

www.institute.nhs.uk

www.ihi.org/ihi

www.improvementfoundation.org

www.nodelaysscotland.scot.nhs.uk

www.scotland.gov.uk/Publications

www.steyn.org.uk

www.tin.nhs.uk

www.wise.nhs.uk

To access The Continuous Improvement Toolkit please visit:

www.scotland.gov.uk/Topics/Health/NHS-Scotland/Delivery-Improvement

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SECTION FOUR:Contacts

105

SECTION FOUR

Mental Health Collaborative National Team Contact Details

MENTAL HEALTH COLLABORATIVE NATIONAL TEAM CONTACT DETAILS

Ruth

Glassborow

Programme Manager 07500 066722

0131 244 5142

[email protected]

David Hall Consultant & Clinical

Lead Re-admissions

01387 244114 [email protected]

Gary Morrison Consultant & Clinical

Lead Dementia


Michael Smith Consultant & Clinical

Lead Depression

0141 314 4079 [email protected]

Frances

Wiseman

Regional Manager (N) 07500 126190 [email protected]

Caroline

Paterson

Service Improvement

Manager (N)


TBC Information Manager

(N)

TBC [email protected]

David McClay Regional Manager

(S&E)


Rahul Shanker Service Improvement

Manager (S&E)


Paul Arbuckle Information Manager

(S&E)


Alana Atkinson Regional Manager (W) 07500 126193 [email protected]

David Law Service Improvement

Manager (W)


Vijay Gill Information Manager

(W)


Rachna Dheer Programme Officer 07500 606725

0131 244 2377

[email protected]

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SECTION FOUR

Mental Health Collaborative National Team Contact Details

SECTION FIVE:Glossary

107

SECTION FIVE

Glossary of Terms

GLOSSARY OF TERMS

Term Definition

Data Analysis Process of gathering, modelling, and transforming data

with the goal of highlighting useful information,

suggesting conclusions, and supporting decision making.

Data Sampling Part of statistical practice concerned with the selection

of individual observations intended to yield some

knowledge about a population of concern.

Demand, Capacity,

Activity and Queue

Theory

View that systems should be designed so that the right

capacity is there to match the demand as it presents.

The theory also looks at ways of managing demand and

extending capacity. Queuing Theory is the mathematical

study of waiting lines and principles from it can be used

to understand the different reasons why waiting lists

form in the NHS and how to effectively manage these.

(See Improvement Tools Section on DCAQ for more

information)

Discovery interviews Form of Interviews which provide opportunities for service

users and their carers to directly tell the story of their

illness or condition using a framework (referred to as a

‘spine’) that guides them through the key stages of their

experience.

Feedback Questionnaires A method by which healthcare organisations can capture

patients' views rapidly and effectively.

Flow In the NHS flow is the movement of patients, information

or equipment between departments, staff groups or

organisations as part of their pathway of care.

Flow Analysis Analysis of above to identity blockages or delays in a

system.

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SECTION FIVE

Glossary of Terms

Term Definition

Glenday Sieve The Glenday Sieve is an approach to identifying common

groups of procedures, conditions or activities in healthcare.

These processes are grouped by volume of activity in the

first instance, helping you to identify specific

improvement and management strategies. In addition,

focusing improvement on a few, high volume activities

will help you to prioritise efforts to improve patient flow.

The approach has its origins in the Pareto Principle but has

a stronger operational focus. It was originally developed

by Ian Glenday. The Pareto principle is the observation

that 20% of something are usually responsible for 80%

of the results. For instance, 20% of patients may use

80% of your bed days.

Improvement Methods A range of change concepts, measures, resources,

improvement stories, and tools – to help make

improvement successful.

Integrated Care Pathways

(ICPs)

An explicit agreement by a local group of staff, both

multidisciplinary and multi-agency, to provide a

comprehensive service to a clinical or care group on the

basis of current views of good practice and any available

evidence or guideline. For more information on ICPs see:

http://www.nhshealthquality.org/mentalhealth/projects/

4/Integrated_Care_Pathways_(ICPs).html

Lean The practice of a theory that considers the expenditure of

resources for any means other than the creation of value

for the presumed customer to be wasteful, and thus a

target for elimination.

Measurement Measurement is fundamental to any model for service

improvement. In redesigning services we use it for two

key purposes:

f To diagnose the problems with the service. For

example to identify if there is a recurring problem of

capacity in a service it is necessary to properly

measure demand, activity, capacity and queue;

f To define whether a service change has been an

improvement.

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SECTION FIVE

Glossary of Terms

Term Definition

Model for Improvement The Model for Improvement is a simple tool foraccelerating improvement. This model has been usedvery successfully by hundreds of health care organisationsin many countries to improve many different health careprocesses and outcomes.

The model has two parts:

f Three fundamental questions, which can be addressedin any order.

f The Plan-Do-Study-Act (PDSA) cycle to test andimplement changes in real work settings. The PDSAcycle guides the test of a change to determine if thechange is an improvement.

(See Improvement Tools Section on Model forImprovement for more information)

Pathway This is the route that a service user will take from contact

with first member of NHS staff (usually GP) through

referral to completion of treatment. It can also be used to

cover the pathway though health and social care services.

Patient Tracking Patient Tracking involves the selection of a randomisedgroup of patients and the detailed noting of their andtheir relatives’ experiences throughout their contact withthe healthcare care system.

PDSA Forms the operational part of the Model for Improvement– Plan, Do, Study Act is a method of rapid systematicchange, which focuses on small cycles of change.

(See Improvement Tools Section on Model for

Improvement for more information)

Process Mapping Pictorial representation or mapping and understanding of the patient journey used to identifying bottlenecks,multiple hand offs etc.

(See Improvement Tools Section on Process Mapping for

more information)

Scottish Recovery

Indicator (SRI)

This tool helps services to assess the extent to whichrecovery principles are being realised in practice. The toolis intended to be used in a way which will help serviceproviders assess and consider their practice in a supportiveand developmental way. It is not intended to be used asan audit tool designed only to identify shortcomings.

For more information on this please visit

http://www.scottishrecovery.net/content/default.asp?

page=s16_4

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SECTION FIVE

Glossary of Terms

Term Definition

Statistical Process Control Practical statistical approach to resolving problems,

through the highlighting of normal and special variation

in systems.

(See Improvement Tools Section on SPC for more

information)

SPARRA MD Scottish Patients at Risk of Re-Admission; new mental

health version. This tool helps to identify patients at risk

of re-admission to psychiatric inpatient units.

Value Streaming Identifying the key people, material, and information

flows required to deliver a product or service, and

distinguish between value-adding and non-value adding

steps.

(See Improvement Tools Section on Process Mapping and

Identifying Value and Waste more information)

Variance/Variation There are two types of variance analysis used in

improvement work:

f Variance analysis against a given standard such as anICP standard;

f Comparing variation in practice between differentteams/services. When comparing variation in practicebetween different teams/services (such as benchmarkingdata) it is important not to automatically assume thatdifference is bad. The key is to understand the reasonsfor the variation as in some cases it may be justified.

Visioning Visioning or solution focused thinking is a method of

creating a very clear picture of what a gold standard

system or process should look like and how it should

operate. Visioning involves all stakeholders and enables

change by helping people to identify what elements of

the perfect/gold standard system/process are already

happening and what needs to change to bring the

current state in line with the desired future state. These

three elements of visioning are sometimes called Desired

Future, Early Existing Signs and Experimental Phase.

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SECTION FIVE

Glossary of Terms

Term Definition

Wiseman Workload

Measure

The Wiseman Workload Measure (WWM) is a tool that

measures actual and total workload. Within the tool,

total workload is defined as ‘Direct Care, Indirect Care,

Role/Agency Tasks and Travel’.

The tool is completed by individual practitioners and can

be aggregated to represent team and service total

activity and total capacity.

The Wiseman Workload Measure was originally devised

in 1992 and has been used successfully by multi-disciplinary

and multi-agency staff working in Community Mental

Health Teams (CMHT) for adults and older people. The

tool has been audited and updated several times and

has proved to be valid and reliable in all settings

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SECTION SIX:Case Studies

Documents

Mental Health Collaborative Programme Toolkit - NHSGGClibrary.nhsggc.org.uk/mediaAssets/Mental Health Partnership/Mental... · Mental Health Collaborative ... Queue (DCAQ) 85 Statistical