Improving Access to Acute Psychiatry Beds in NWMH - AusMHLP Project

1. Improving access to acute psychiatry beds in NWMH - a platform project to improve leadership skills via Australian Mental Health Leadership Program (AusMHLP) DrVinay Lakra Gary Ennis

2. Dr Vinay LakraMBBS, MD (Psychiatry), MRACMA, FRANZCPDeputy Director of Clinical Services & Consultant PsychiatristMid West Area Mental Health ServiceMrGary EnnisBSc (Practice Development), Cert Ed Program ManagerNorthern Psychiatry UnitNorthern Area Mental Health Service

3. Presentation of the project for leadership skills through AusMHLP Background to the access project, project outcome & future directions Vinay’s journey through the AusMHLP Gary’s journey through the AusMHLP Joint reflections Today’s presentation

4. NWMH Inner West AMHS North West AMHS Mid West AMHS Northern AMHS Youth Services Aged Services Organisation structure

5. Improving access to acute psychiatry beds in NWMH Part of Access Improvement Project of NWMH Active involvement in the project from the beginning Background

6. It was recognised that there was an uncoordinated approach to bed access within and across adult area mental health services within NWMH Lack of timely bed availability Increasing length of stay in ED’s Some urgency to address this issue Background

7. • To reduce the waiting times for consumers requiring psychiatric care in the ED. • To improve timely and appropriate access to inpatient beds. • To develop a discharge planning process that reflects the needs of the consumer, carer, staff and stakeholders. • To match the clinical needs of consumers to available resources —for example ensuring that the most acutely unwell consumers are matched to available IPU beds • To improve and facilitate communication processes between various mental health teams within the service. Aims of access improvement project

8. Project Planning occurred in October/ November of 2006. Commencement of Steering Committee meetings – late November. Four consultative meetings took place in November/December, involving each Area Executive—MW, IW, NW and Northern. Work Groups commenced in February, including all stakeholders Recommendations and subsequent implementation plans tabled in March/ April 2007. Project implemented in May 2007 Process

9. A range of initiatives established to facilitate practice change and improve clinical pathways: Daily telephone conference call between 4 IPU’s Proactive discharge planning process established, - daily weekday i.e. 2 per weekday & 1 per weekend day Daily weekday Emergency Department demand updates Bed access escalation process Key groups identified to monitor access process, within IPU’s and across NWMH Key feedback mechanism developed to NWMH Executive and NWMH PACS Improved communication within and across AMHS Process

10. Vinay’s journey through AusMHLP

11. Feb 2008 Mail from Director, Operations NWMH “that this will help you to develop further in your current role and better prepare you for other leadership roles in the future” Feb/Mar 2008- Application process Mar/Apr 2008 - Multifactor Leadership Questionnaire (MLQ) 360 Leadership Assessment Leadership skills prior to MLQ assessment Identified current leadership skills and deficits Template to work on during the program

12. April – Leadership, management and organizational culture in mental health services June – Mental health policy in relation to mental health system, challenges and case studies in implementation July - Substantive areas of challenge for leadership in mental health services. Unmet & complex needs, clinical governance & evidence based practice, mental health & immigration September - Change management and team building and role analysis in organizations AusMHLP Seminars

13. Initially innate and non formal learned skills After MLQ specific focus on leadership styles – coaching (junior medical staff, nursing staff) Feedback Communication Some definitions which I relate to– “Process of influencing others to understand and agree about what needs to be done and how it can be done effectively, and the process of facilitating individual and collective efforts to accomplish the shared objectives” How did it work?

14. Political theory Middle management (my role) Some models which were helpful Top down rationalists Bottom up pragmatists

15. Organisational role analysis Stace and Dunphy’s model for change Participative evolution – use when organization is considered fit but needs minor adjustment, or is out of fit but time is available and key interest groups favour change Coaches

16. Meeting senior leaders in the field Knowledge and skill from the AusMHLP group – good mix Discussion during and in between sessions Formal learning about management, leadership, change management, policy and current challenges in mental health in Australia Better understanding of Mental health systems What else?

17. Lead consultant – Decision making, availability, better communication with colleagues Population health view vs current patient focus Coaching junior medical staff Empower other staff – information and knowledge sharing Streamlining some basic processes e.g. early discharge management Review of staffing – appropriate use of stats What worked

18. Prevent conflict or quick resolution Support from senior leadership for complex situations Regular and honest feedback about goals Regular discussions about meeting goals My leadership style – more conscious now Improved communication Within the IPU With other community programs With the other professionals e.g. consultant diary for the weekend

19. Convincing others – right way to go, here to stay Ownership of the project – change not embraced by everyone Managing emotions during difficult situations Increased workload and stress – additional work Resolving conflict quickly before escalation Trust issues – for other teams and AMHS Medical staff leave coverage Challenges

20. Gary’s journey through ausMHLP

21. Programme identified as important for my professional development NWMH Exec. MLQ – very beneficial for me. Clarified some some areas and reinforced that I was on the right track. The feedback from the raters prompted some thoughtful reflection. Each group of sessions introduced me to some key concepts that will develop over time. Had a “light bulb” moment in first session in Melbourne.

22. Although all of the sessions prompted thought and discussion the sessions in Sydney started to put some structure around the project I was undertaking and provided a framework that the process could sit in. Session on Clinical Governance was very useful and the process of Clinical Practice Improvement that was discussed, although not completely new as a concept certainly seemed to fit with the project I had been working on.

23. Leadership has many different definitions. At its most basic, concepts like democratic; autocratic and totalitarian are familiar to us all. Then we the have the transformational and transactional leadership styles and there associated attributes. The informative discussions on the ausMHLP surrounding leadership and participating in the 360% MLQ have led me to form the opinion that there is no one favored style of leadership. Indeed to be restricted to one style could be counter productive in the complex working environment that is the public healthcare system. Leadership

24. The ausMHLP has reinforced to me that to be an effective leader you certainly need to understand and embrace the different types of leadership styles but the bigger challenge is to select the style that is right for that moment in time or for that particular cohort of staff. In carrying out my project these thoughts informed my interactions with the staff group and influenced the way in which I negotiated the process.

25. Background to Project • Initial focus on change management only. • Not sustainable as only a small number with clear ideas and “vision”. • Became person reliant with the result of too much ownership and responsibility on a small group. • Change not embraced by team. • Leadership at wrong end of spectrum. • Was experienced as additional work for team. • No local systemic approach.

26. Leadership Challenges • Increase focus on sustained change. • Encourage wider ownership of the access project and sharing of the vision • among the staff group on NPU. • Identify key staff and get them on board. • Provide additional opportunities for staff to voice there opinions and • influence the process locally. • Raise the profile of the access improvement project with staff and • reinforce key objectives. • Take advantage of opportunities for systemic change when/if they arose. • Support key staff in the clinical area. • Influencing change in other professional disciplines.

27. The framework for undertaking this process was informed by the Clinical Practice Improvement Method. There are five stages to this process: • Defining the project • Diagnosing the problem • The Intervention(s) • The Impact • Sustaining the Improvement

28. Defining the Project Inpatient inconsistent in achieving targets in terms of number of discharges or times of discharges. This was having a significant impact on the network as a whole. Feedback from Crisis Team indicated that discharge planning was failing when key staff were absent. Local data showed that there was lots of peaks and troughs in terms of reaching the benchmark. The project looked at addressing these inconsistencies.

29. Diagnosing the Problem A series of meeting was held with the NAMHS Exec, Discharge Cooridnator, Medical Staff and Senior Nursing Staff on the unit to elicit the reasons for our inconsistent approach. A number of common themes emerged: No sense of ownership with staff group Seen as exclusively discharge coordinators role Discharge coordinators PD Clinical leaders contributing to this by with drawing from active involvement Although processes in place feedback was that they were person dependent

30. The Interventions NAMHS Exec support of the project. Timing, using an opportunity to assist the process. Review of discharge coordinators PD. Discussion with leadership group on IPU. Getting key change agents to become more involved. Focus of a team day. Improved communication strategy. Involving all staff and rasing the profile of access improvement. Discipline Senior support.

31. The Impact A greater sense of shared ownership More systemic in approach, just another process Data indicates that we hit targets much more consistently Process continued regardless of who was present Allowed for discharge coordinator to concentrate on other aspect of access improvement

32. Sustaining the improvement As discussed earlier, this was the objective of the project. To ensure that the process in relation to access improvement became systemic and integrated into every day practice. By ensuring that key members of staff were on board and reviewing the PD of the discharge coordinator we managed to achieve the aim. The process no longer relies on a small group of individuals. Any minor changes are undertaken with the view that they must be made in a way that supports a systemic and sustainable approach.

33. Outcomes Desired Improved bed availability Reduced length of stay in ED’s Undesired (but expected) Stressssssssssss Increased workload Increase in critical incidents Changing profile of admissions (admissions to clear ED)

34. Admission/discharge comparison

35. Comparison of length of stay Jul 06 – Jun07 Jul 07 – Jun08 Graphs not to scale

36. Patients with ED LOS > 24 hours Jul 2006 – Jun 2007 -- 48 Jul 2007 – Jun 2008 -- 2

37. Future Challenges Sustainability – increasing workload needing more resources – under review Workforce issue – medical staff allocation Review and minimize critical incidents – under review Communication & collaboration issues within and across four AMHS Leadership – rub skills onto others/encourage to take leadership role – big challenge Ongoing journey

38. Opens up participants to ways of thinking and working that they may have previously not encountered Group setting - Multidisciplinary Changes the way to look at the mental health systems Exposure to leaders in the field Better prepared for the leadership challenges in mental health field Platform for ongoing professional development AusMHLP reflections

39. Acknowledgement of support: NWMH Exec- Work Colleagues- AusMHLP Team- Fellow Course Participants- Family-

40. Economics of Healthcare Population Health View Leadership and management Organizational Theories Complex Adaptive Systems ausMHLP 2008, Key concepts Opportunity Costs Dynamic Stability Sustainability of Change