Improving access to acute psychiatry beds in
NWMH - a platform project to improve
leadership skills via Australian Mental Health
Leadership Program (AusMHLP)
Dr Vinay Lakra
Gary Ennis
Dr Vinay Lakra
MBBS, MD (Psychiatry), MRACMA, FRANZCP
Deputy Director of Clinical Services & Consultant
Psychiatrist
Mid West Area Mental Health Service
Mr Gary Ennis
BSc (Practice Development), Cert Ed
Program Manager
Northern Psychiatry Unit
Northern Area Mental Health Service
Today’s presentation
• 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
Organisation structure
NWMH
Inner West North West
AMHS
AMHS
Mid West
AMHS
Northern
AMHS
Youth
Services
Aged
Services
Background
• Improving access to acute psychiatry beds
in NWMH
• Part of Access Improvement Project of
NWMH
• Active involvement in the project from the
beginning
Background
• 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
Aims of access improvement
project
• 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.
Process
• 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
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
Vinay’s journey through
AusMHLP
• 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
AusMHLP Seminars
• 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
How did it work?
• 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”
Some models which were helpful
Top down rationalists
• Political theory
Middle management (my role)
Bottom up pragmatists
• 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
What else?
• 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 worked
• 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
•
•
•
•
•
•
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
Challenges
• 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
Gary’s journey through ausMHLP
•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.
•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.
Leadership
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.
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.
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.
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.
The framework for undertaking this process was informed by the
Clinical Practice Improvement Method.
There are five stages to this process:
1.
Defining the project
2.
Diagnosing the problem
3.
The Intervention(s)
4.
The Impact
5.
Sustaining the Improvement
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.
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
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.
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
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.
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)
Admission/discharge comparison
Admissions
IVA
Discharges
Total
Average
Inpatients LOS
Readmis
sion
Rate
Jul06- 484
Jun07
271 483
509
17.47 9.52
Jul07- 696
Jun08
368 699
722
11.61 12.02
Comparison of length of stay
• Jul 06 – Jun07
• Jul 07 – Jun08
Graphs not
to scale
Patients with ED LOS > 24 hours
• Jul 2006 – Jun 2007 -- 48
• Jul 2007 – Jun 2008 -- 2
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
AusMHLP reflections
• 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
Acknowledgement of support:
NWMH ExecWork ColleaguesAusMHLP TeamFellow Course ParticipantsFamily-
Economics of Healthcare
Population Health View
Leadership and management
Organizational Theories
Complex Adaptive Systems
ausMHLP 2008, Key concepts
Dynamic Stability
Opportunity Costs
Sustainability of Change