Psychological Therapies HEAT Target
Early Implementer Feedback – NHS Lothian Site- Jan 2012
Purpose of Paper
This paper provides a brief summary of key learning to date from the NHS Lothian DCAQ Early Implementer site.There is also work progressing in NHS Ayrshire and Arran and a separate update will be provided to the group on the learning from this at a future meeting.
Aims of project, approach used and background
The main aims of this project were to:
- improve access times for psychological therapies for two teams providing Psychological Therapies in NHS Lothian, within their existing resourcing frameworks and without impacting negatively on clinical outcomes, and;
- identify early learning from the application of DCAQ to Psychological Therapies Services, which could be shared across NHS Scotland to assist with delivery of the A12 target.
The approach used was a collaboration between NHS Lothian and the Scottish Government’s QuEST team. Funding was provided to NHS Lothian for a clinical lead for each of the two services involved, for a psychology assistant for six months, and for time limited analytical support. QuEST provided project management, improvement support advice and capture of lessons for the wider arena.
A report on phase 1 of the project was made available in April 2011. The section of that report on wider learning is attached as an appendix for reference. The position at the time of writing the phase 1 report was that a full analysis of DCAQ data for each service was not possible due to a number of constraints around the amount and quality of data available for each service. Although the project is still ongoing, there are a number of additional learning points below that have resulted from the work that has taken place since April 2011. These are listed below.
1. Data Quality
The Psychological Therapies services in NHS Lothian use PIMS as their electronic patient record system. A combination of how the system works and how it was being used led to the following barriers to progressing with DCAQ analysis;
- It was not possible to identify how many referrals were going specifically to the psychological therapies service(s) for assessment(PT services are delivered as part of wider mental health services).
- It was not possible within PIMS to identify how many people were waiting for a Psychological Therapy, how long for and for what
- It was difficult for clinicians to get information back on activity, which led to low motivation to record or use data to inform service delivery and to localised development of unsupported, standalone data recording tools
- There were several different ways of capturing activity, which led to inconsistencies in how data was recorded
- There was a lack of clarity around clinical ownership of the data at service level
- Although there was a function for capturing clinical outcomes within PIMS, it was not routinely used or reported
To address the above issues, a number of steps were taken;
1. PIMS data was checked against case notes, and variation in current information capture processes documented
2. a new information flow map was produced, with the involvement of clinicians, admin, PIMS manager and project team inclusive of the Transformation Station. The aim was to develop and agree a process which would enable easy reporting of A12, DCAQ analysis and capture of clinical outcomes.
3. the new process was implemented with training support
As a result of the work done, NHS Lothian now has a robust information flow process, easily articulated and demonstrated, supported by training materials and expertise which will enable the approach to be rolled out across the Health Board.
If Mental Health services are to properly embrace the use of data in routine practice,it is vital that the work is done to improve the quality of (ideally) the IT systems that are in use, or the completeness and timeliness of data that gets captured in existing systems.
Information Flow Mapping is a very powerful tool in ensuring the reliability, consistency and validity of data in the provision of Psychological Therapies. It is possible to address the data requirements of DCAQ, of A12 reporting and of use of clinical outcomes in doing so.
2. Admin Support
The new information flow process is seen as essential by NHS Lothian for the management, reporting and delivery of A12. However, the new process takes longer to adhere to. Much of this increase could be absorbed by a strengthened admin resource.However, the admin resource for the two services was already extremely limited prior to implementation of the new process and, as a result, clinical capacity has been impacted as clinicians have had to take on additional data entry tasks. Furthermore, progressing service improvement opportunities often requires either a change in administrative processes or administrative support to prepare the necessary materials.
The extent of administrative support that Psychological Therapies services have available will be a key factor in both their ability to deliver the target and to make the significant improvements required.
3. Operational Management of Psychological Therapies Services
The NHS Lothian project sponsor for the improvement work holds a strategic planning role across all of Adult Mental Health in NHS Lothian. The health board does not at present have an organizational structure that provides a point of single operational management of its Psychological Therapies Services. Instead, the nurse-led parts of the service are accountable through their professional structures, and recruitment of a psychology lead is currently underway. This type of structural accountability is true of many Psychological Therapies services that comprise of multi-professional teams, perhaps the two largest groups of which are psychology and therapists of a nursing background. Clearly the significance of the divide between these groups differs from area to area and from team to team and in some areas it will be practically non-existent. However, where it does exist, this divide presents some questionsthat need to be addressed in the undertaking of service improvement work for those services;
- Who should undertake the planning, management and coordination of the project and how can this be done to best effect across the organisation?
- How can the ownership and responsibilityfor delivery of the target, and for the redesign and improvement work needed, be properly embedded within each team?
- What is the mechanism for handling cross-professional differences in belief, working cultural practice and ideology, and within-profession pressures that may target one part of the team and not the other? For example to manage the interface of PT-wide work with a similar piece of Nursing redesign work.
- Who will provide a clear and constant driving force behind the improvement work locally?In other words, to properly embed the culture of continuous quality improvement within each team
- Who should lead on broader aspects of change management that may be necessary as a result of the redesign? In particular, DCAQ work may identify the need to change the balance of professional resources within any given team so as to most efficiently match capacity with demand. Systems must be in place to enable resources to be moved between professional groups when there is a clear need to do so.
Where there is not a single point of operationalmanagement that covers the service overall, consideration needs to be given to how the above issues willbe handled, should they arise.Further, where a single point of operational management does exist, there needs to be clarity on how decisions to move resources between professions are made.
4. Analytical input
The analyst providing support for the project during phase 1 left post at the end of March 2011 when the Mental Health Collaborative ended. Since then, NHS Lothian has been unable provide an analyst to support the work going forward. Further, when staff take time out to do work on the data side of service delivery and are sold the benefits that good data collection and analysis can provide, if analytical support is not available, timely, or of the right kind then it can have a negative impact on staff engagement with data and associated work in future. Some of the tasks that would have benefitted from analytical input are;
- Support in setting up, collating, analyzing and presenting the results of the activity audits that were undertaken
- Helping to design the new information flow process
- Quality control of new information flow process by timely generation of reports on data quality and completeness
- Development of standard/ routine reports of operational data for clinicians to inform redesign and operational delivery
- Analytical support in taking forward PDSA tests of change
- DCAQ analysis
NHS Lothian and QuEST have addressed these issues by finding short-term solutions and NHS Lothian are currently looking to put in place analytical support for all mental health improvement work going forward.
Where there is not an analytical post specifically designated to support Mental Health work in other areas, the input required will need to be discussed with NHS Boards’ information services teams at the outset to ensure that appropriate support is available when needed.If staff are being asked to undertake additional work to collect data then there must be a clearly agreed mechanism and resource to ensure this data is then analysed and presented back in a user friendly format. Failure to do this will generate additional resistance to engaging in such work in the future.
5. Other Issues for consideration
Following the activity audits undertaken, it emerged that some members of staff worked well over their contracted hours during the activity audit and that this was routine practice. In discussing how to increase clinical capacity by reducing the amount of time staff spent undertaking non-clinical activities, reduction in hours worked over and above contracted time was one seen as one potential outcome of working more efficiently. This issue is likely to emerge as teams begin to more greatly understand and analyse their clinical capacity, and therefore consideration should be given as to how time released by improvement work can best be utilised.This needs to include an acknowledgement that, where staff are working over and above their contracted hours, the first priority may be to address this.
Lastly, concern has been raised around the potential skewing effect of a target designed specifically to measure waiting times for Psychological Therapies in services which provide interventions that cannot be described as psychological therapies but are clearly meeting identified needs. NHS Lothian has framed the project and the A12 target as a lever to drive wider improvements in its mental health services by using the priority afforded to the work by its HEAT status. Nonetheless, this message needs to be consistently and repeatedly delivered to ensure that staff and services are engaged appropriately.
The project is still ongoing and has encountered some significant challenges along the way, some of which were anticipated, some of which were not. However, these challenges have been addressed to the benefit of both services involved, and to the benefit of the other services across NHS Lothian. This was part of the rationale for the early implementer approach. Both services feel that they have much more clarity around how they operate and have a real motivation to continue with the DCAQ work and to use data to drive down waiting times, and to inform how they plan, improve and deliver their services.
Paul Arbuckle, National Improvement Advisor, Quality and Efficiency Support Team (QuEST)
Linda Irvine, Strategic Programme Manager, Mental Health and Wellbeing (NHS Lothian Early Implementer Project Sponsor)
Appendix 1 – Access to Psychological Therapies/ DCAQ in NHS Lothian Phase 1 Report/ Section 7
7. Wider Learning
One of the aims of this project was to provide learning for other areas and services interested in undertaking DCAQ analysis to support delivery of the HEAT target on Access to Psychological Therapies. The project in NHS Lothian has identified several points for consideration by other areas.
Project Management and Context
1.Ideally, services would be at a place where monitoring demand and capacity was a routine part of their systems. However, most mental health services are at the start of this journey and setting up the processes and systems to do DCAQ work takes a significant investment in time and will need dedicated resource. This project required a mix of input including DCAQ expertise, project management, analytical and improvement resource. These functions may overlap and the number of hours required to carry them out will depend on the local context and expertise. Time should be taken prior to commencement of work to consider who needs to be involved to carry out the work.
2.The work also required considerable interrogation of the PIMS system. In NHS Lothian the data downloads had to be undertaken by the PIMS team and their input was not identified in the Project Initiation Document. Therefore, in the absence of an organizational agreement that this work was a priority for the PIMS team and appropriate capacity allocated, this created understandable but significant time delays in accessing data. Before embarking on a DCAQ analysis, sufficient resource needs to be allocated up front for both interrogation of the system and data analysis.
3.At the outset of the work, it is important to obtain a clear understanding of what the service delivers and how it’s currently set up, prior to obtaining data. If there are different parts of the service which have different processes for handling referrals then there may need to be an analysis for each part of the service. In addition to mapping the service processes, we also recommend undertaking a process map of the data flows.
4.Gather an understanding of the issues that the team would like to address – what are they dissatisfied with? Where do they feel there are opportunities to improve their service? Set expectations around the DCAQ work with this in mind; DCAQ may address some problems and not others.
5.The approach of running this as a joint project between the national and local Mental Health Collaborative teams appears to have worked well. It enabled the project to be firmly owned by NHS Lothian (which has been important in terms of overcoming barriers) and enabled skills and knowledge transfer both ways. The links to the national team mean there is a clear mechanism in place for sharing learning across NHS Scotland and also feeding any key issues into the national governance arrangements for the new psychological therapies HEAT target.
Service Improvement Opportunities
6.Opportunities for immediate improvement in the management of demand and capacity will emerge almost as soon as the work commences. Indeed, the DCAQ Psychological Therapies Guides highlight that considerable progress can be made without looking at any data. There needs to be a system in place which clearly identifies how these opportunities will be captured, who will take them forward, how action will be taken and in what timeframes.
7.The team may already be involved in, or have recently concluded, a change programme. This needs to be considered, inclusive of changes that are being or are about to be implemented. DCAQ work needs to be integrated into that work wherever possible.
8.Data work requires discussion around what’s available, what definitions have been used, for how long, how consistently they’ve been applied, what points it’s collected at in the care pathway and which system(s) are used to capture this information. This requires the full team as you cannot assume everyone has the same understanding. It also requires discussion with the Information Services department of the NHS Board.
9.Where more than one data source exists, a decision needs to be made around which is more robust to feed into the DCAQ analysis. Ideally, data should only be input once and should be input into the main organizational system (eg in NHS Lothian, this is PIMS). However, if this system doesn’t collect it and in the short term can’t be modified to collect it, then use an ad hoc or locally developed system in the interim. Going forward, the organisational system will need to be modified to provide this functionality, and ideally the project should be set up with this in mind and link across to the system development team. Locally developed systems fragment patient records and should only be used as an interim measure when the wider system cannot be modified to provide the functionality.
10.Not all information will be available. It may be quicker to set up a 12 week data collection exercise and to conduct an activity audit over 3 or 4 weeks than to try to “fit” currently collected or historic data into the analysis.