The journey of a complex case
psychotherapy team in trying to
achieve efficient service delivery
Dr Carol Valinejad
Consultant Clinical Psychologist
Aims of the presentation

Suggest that we can be lean without being mean. By
not being lean we are in fact being mean
 I will do this by drawing on my experiences of working
within secondary care, using Lean thinking to structure
my talk.
 Identify what Lean/efficient service delivery can look
like.
 Describe what our service is currently doing to achieve
this.
 Describe some challenges and opportunities we
encountered along the way.
The Setting
Area Lead Psychologist
Psychotherapy
(6.5 wte)
CMHT Psychology
(0.5wte in 4 teams)
Acute and
Specialist Teams
(3.5wte)
Deputy Area Lead
(0.5)
Performance
Strategy
Research
Skill mix of psychotherapy team
Acting co-ordinator(Family Therapist)
 Art therapist
 Counselling Psychologist(CBT)
 Psychotherapists(1.7wte)
 Clinical Psychologist(0.8)
 2 full-time vacancies.
 Trainees and honoraries.

Lean Thinking

Lean is an improvement approach to
improve flow and eliminate waste that
was developed by Toyota. Lean is
basically about getting the right things to
the right place, at the right time, in the
right quantities, while minimising waste
and being flexible and open to change.
What does efficient service delivery
look like? (Porter, 1985)
Finance
Human Resources
Information Technology
Partners
General Management
Referral
.
Assessment
.
Psychological
Therapy
Customers
Service
Development
Journey of achieving Lean
Leadership
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Over a 3 year period:
Service Redesign – From 4 autonomous psychotherapy teams to
a co-ordinated team, led by a clinical lead(0.5).
Single access gate.
Clinical governance.
IAPT – From seeing all levels of presentations to step 4 only.
Appointment of new Area Lead Psychologist led to :
Further changes in leadership of the service in order to address
wider service issues:
A focus on proactive rather than reactive provision.
A need for CMHT psychology and psychotherapy to work more
closely together.
Types of waste
Excess Transportation
Excessive movement of people, information or products
Excess inventory
Excessive storage and delay of information or products
Excess Motion
Any motion that does not add value to the product or process
Waiting
Long periods of inactivity for people, information, or materials
Overproduction
Producing more/sooner than the external or internal customer needs
Over processing
Work around, wrong tools, cumbersome systems
Defects
Paper work errors, quality problems
Types of waste within the core
processes
Excess Transportation
Excess referrals (55/month)
Excess Storage
Delay in access to therapy. Clients seen for up to 5 years. Capacity?
Excess Motion
‘Revolving door’ psychotherapy clients
Waiting
The service had a waiting list of at least 2 years.
Overproduction
Providing more therapy than is required? Scattergun referrals
Over processing
No robust information system to manage referral data to track PJ
Defects
No established way of evaluating the service, absence of audit activity.
Eliminating waste within core
processes.
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Reducing Transportation.
Defined the capacity of the service(i.e. around 13 to 17
hours face to face).
An allocation of 50 referrals per year per sector.
CMHT psychology act as rep within sector to negotiate
with referrers who best to offer this resource to.
Reducing Storage (Increasing Access)
Move from unlimited to time limited Psychotherapy.
Tailor assessment to client’s needs rather than
referrer’s needs. That is, therapy assessment, generic
assessment or specialist assessment.
Offer a ‘preparing to change group’.
Eliminating waste within core
processes.
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Reducing Motion
Improved clinical governance, increased skill mix.
Reduce Waiting
Improved transportation will impact upon reducing the waiting list.
Reduce Overproduction.
Fixed contracts with clients between 1 an 48. Reviewable 6 to 12
sessions up to a maximum of 48.
Over processing
This is yet to be addressed.
Reducing defects(Improving quality)
Use of satisfaction survey and CORE
Challenges

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Managing resistance to change by clincian’s.
Leadership.
Opportunities
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Commissioning Quality and Innovation(CQINN).
PbR
SMI-IAPT
Evaluation of Lean initiative