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.
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Improving access to acute psychiatry beds in NWMH - a platform project to improve leadership skills via Australian Mental Health Leadership Program (AusMHLP)
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
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
Improving access to acute psychiatry beds in NWMH
Part of Access Improvement Project of NWMH
Active involvement in the project from the beginning
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
•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.
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
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
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
Initially innate and non formal learned skills
After MLQ specific focus on leadership styles – coaching (junior medical staff, nursing staff)
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”
Middle management (my role)
Top down rationalists
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
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
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
Within the IPU
With other community programs
With the other professionals e.g. consultant diary for the weekend
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 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
The framework for undertaking this process was informed by the Clinical Practice Improvement Method.
There are five stages to this process:
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
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.
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.
Improved bed availability
Reduced length of stay in ED’s
Undesired (but expected)
Increase in critical incidents
Changing profile of admissions (admissions to clear ED)
Jul 06 – Jun07
Jul 07 – Jun08
Graphs not to scale
Jul 2006 – Jun 2007 -- 48
Jul 2007 – Jun 2008 -- 2
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
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:
Fellow Course Participants-
Economics of Healthcare
Population Health View
Leadership and management
Complex Adaptive Systems
ausMHLP 2008, Key concepts
Sustainability of Change