1. Improving access to CAMHS Applying LEAN within CAMHS Beverley Mack Bexley CAMHS

2. What is LEAN ? Approach to service improvement Developed by Toyota, increasingly applied in Health sector LEAN Principles  Maximise activities that add value to those using services  Improve flow – using resources efficiently  Eliminate waste i.e. activities that do not ‘add value’ to patient outcomes & / or experience

3. LEAN processes aim to: Minimise time spent & effort Reduce waste Improve quality Improve efficiency (flow) Maximise resource & potential Create flexibility

4. LEAN in Bexley CAMHS Applied to Tier 3 team to address: Variability in patient flow Delays at all stages – completed core assessments, treatments commencing, reviews and discharge Variable queues for different treatments Lack of systems to manage capacity, demand & throughput Variability in clinical systems e.g. care coordination, care planning, reviews, use of outcome measures

5. Aims of the LEAN project To develop clinically effective & efficient processes for improving the patient journey at Tier 3 from referral, through assessment, treatment, review and discharge

6. Specific objectives Through analysis of demand & capacity, develop systematic flow, improving throughput Improve capacity through increased efficiency Provide consistent access to different treatments with reduced waiting times Identify standards & improve clinical quality – assessments, care planning, reviews, systematic use of outcome measures, discharge planning Improve patient experience – sharing care plans, PROMs, user feedback Develop integrated team functioning – better use of all professions Improve management information systems

7. How we did it 22 days LEAN consultancy Whole team approach Required tenacious leadership & project management Required shared vision & drive between clinical & management leads Challenge to free up clinical & management time

8. 3 stages 1. Map the existing state  identify steps families go through & how information flows through service to support the pathway  Identify activities that add value to patient care & those that do not (value stream mapping)  Analyse historical flow rates 2. Map the future state  Identify desired changes, eliminate unnecessary process steps, match available capacity to likely demand, link processes to run sequentially  Set up work streams & metrics 3. Implementation  Trial new systems, review & make changes  Review metrics

9. LEAN workstreams 27 workstreams relating to all stages of patient journey: E.g. Processing referrals T3 assessment clinic Standardisation re processes & information Operational policy – timelines, flows, process maps

10. Output Standard letters / templates / forms Risk matrix–admin screening new referrals Emergency referral form re-designed Outcome of Intake meeting form re-designed 10 standard letters – referrals not accepted 4 standard letters – initial appointments New patient information pack Templates for Core Assessment, Care Plan & Review Standard Care Plan letter to client Standard discharge letter to client PROMs

11. Procedures & policies Role & scope of Care Coordinator Detailed operational policy – timelines, flow diagrams for patient journey, standards for clinical practice

12. New processes Pre assessment telephone consultations Collection of personal data – New patient information packs Tracking / use of RIO to manage throughput Routine use of outcome measures Standardised recording of core assessments, reviews, care plan letters to clients Focussed use of T3 meetings to assist with clinical standards & throughput

13. Outcomes - Patient journey: referral – 1 st appt Changes to timing & membership of referrals team – right people at meeting = decisions made, faster response to all referrals, diminished need to ‘pend’, C&YP access alternative help more quickly Changes to ‘outcome of intake meeting’ form – captures more info = improved risk management, identifies who should attend 1 st appt and which CAMHS professions to assess

14. 10 standard letters - saving of up to 5 hrs pw processing inappropriate referrals Standard initial appt letters – saves clinical time, eliminates delay caused by clinician’s lack of capacity, improved consistency re info to service users Removing a step (meeting) which repeated work - saves 2 hours pw of admin & team leader’s time

15. Introduced Pre Assessment Consultation– replaces forms sent out, engages service user, gathers info, fine tuning of 1 st appt ( who should be there); additional demand on clinical time but reduces DNAs New patient registration forms – improves DQ, gathers baseline outcome measures (SDQ)

16. Outcomes: Patient journey: 1 st Appt – care plan Developed model for core assessments – using resources according to analysis of demand Increased capacity as clinician availability improved – 7 T3 assessments p/month increased to 15 Structure for allocation of assessments & care coordination created efficient use of staff

17. Integrated psychiatry into MDT – attendance at T3 MDT meeting improved from 10% to 60% & 73% Psychiatrists now doing joint initial assessments on cases requiring psychiatry input Augmented admin support provides framework to support clinical processes – saves clinical time, improves functioning of MDT & DQ, cost effective for organisation

18. T3 meetings – improved focus, clinicians prepare presentations of assessments & care plans – need for continued culture change Small improvement in use of outcome measures, need for continuous improvement Improved satisfaction rating for T3 team members

19. Improved timeline from referral to completed care plan – shortened patient journey by 4 weeks Core assessment template – compatible with RIO, saves 1.5hrs clinical time, improved consistency & DQ CAMHS policy – Role & Scope of Care Coordinator – clarified expectations, overcame concerns, embedded the care co-ordination

20. Process mapped re allocation / changes of care coordinator & finalising care plan ‘Care Plan & Review’ template – RIO compatible, standardised reviews Care Plan & discharge letter to client – user friendly format, resulted in improved sharing of care plans & more timely discharges Developed PROM – integrates care plan, popular with patients & clinicians

21. Reflections & challenges Stimulating but arduous process Required time, active leadership & project management Needed to keep team members motivated to safeguard LEAN project time, take responsibility for workstreams Requires attitudinal changes – need to counter the ‘gravitational pull’ back to the way things were Improved team functioning & dynamic – shared goals, ownership of changes Embedding the changes – develop a cycle of continuous improvement using LEAN principles The devil is in the detail! No shortcut to rigorous attention to detail