The Clinicians Dashboard, introduced in 2016 by NAViGO’s Performance Team, is an innovative, low cost tool. We received development funding via The Health Foundation - it is a simple innovation to assist Community Mental Health (MH) Clinicians manage high caseloads and improve patient safety, increase parity of esteem and reduce incidences of suicides for those in treatment. Once developed, it costs around £2k initially to set up and is free going forward. This means sharing our innovation will offer a low cost solution to peers within MH Trusts nationwide who wish to create Dashboards of their own. It improves patient safety by preventing the most vulnerable Service Users ‘falling through the gaps’; improves efficiency and can save lives.
Highly Commended - Innovation in Digital Health category - #MHAwards18
Co-Production
From start: Yes
During process: Yes
In evaluation: Yes
Evaluation
Peer: No
Academic: No
PP Collaborative: Yes
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Lisa Denton - Head of Performance & Business Support
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
The Clinicians Dashboard, introduced in 2016 by NAViGO’s Performance Team, is an innovative, low cost tool. We received development funding via The Health Foundation – it is a simple innovation to assist Community Mental Health (MH) Clinicians manage high caseloads and improve patient safety, increase parity of esteem and reduce incidences of suicides for those in treatment. Once developed, it costs around £2k initially to set up and is free going forward. This means sharing our innovation will offer a low cost solution to peers within MH Trusts nationwide who wish to create Dashboards of their own. It improves patient safety by preventing the most vulnerable Service Users ‘falling through the gaps’; improves efficiency and can save lives. It was designed to help Clinicians safely manage large caseloads, combatting upward trends amongst MH service users in:- 1. self-harm 2. suicide 3. poor physical health Disparate data is collected using our existing Data Warehouse and fed into the Dashboard which interrogates the information by known Service User risk factors/triggers against the three drivers above. Processes were informed by all stakeholders (clinicians, Service Users, Carers, commissioners, primary and secondary care) and by utilising existing national and local data analysis/research.
Cost effective and quick to develop, the Dashboard has immediate impact, sending weekly warning emails to Clinicians against the risk triggers together with automatic emails should someone DNA. Clinicians/Managers can also access Dashboards as and when required to monitor caseloads in a ‘live’ format. The initiative supports key national drivers (Parity of Esteem for MH, the FYFV and Crisis Concordat). The Problem: 1. Local health statistics measured poorly against national figures; 2. We were experiencing a high volume of serious incidents attributable (or at least having some connection) to missed appointments/DNA’s/length of time between reviews. E.g.:- 1) N E Lincs health statistics are stark:- • 217.6 people per 100,000 cause themselves intentional self-harm • 11 people per 100,000 commit suicide annually (110th worst out of 147 local authorities) • Long term condition prevalence is 19.5% of the population (against England average of 17.6%) • Premature Mortality Rate ranks 124th out of 150 Counties/Unitary Authorities (Public Health Profiles) 2) Data analysis from NAViGO serious incidents showed:- • Low physical health checks • Root causes were also linked to staffing levels/processes connected with follow-up care after transition from Inpatients to Community What were our Rationale/Goals? • Patient representatives asked for subtle suicide risks/protective factors to be included in safety indicators; • Staff requested a simple electronic solution to enable proactive management of caseloads with automatic prompts around known risk factors; • Serious Incident investigations clearly evidenced a need to implement tools around improved efficiency; timely patient contacts/reviews; early diagnosis of LTC’s ; improved liaison between teams/wider health sector and reduction in costs associated with Crisis/A&E presentations. Implementation:- • We reviewed patient surveys/clinical audits/serious incidents/complaints and compliments alongside speaking with patients and carers • Staff engaged with Data Analysts, reviewing designs of dashboards, frequency of emails; owning the development idea. • We used the Lewin Change Management Model to embed the Dashboard into local practice
What makes your service stand out from others? Please provide an example of this.
The Clinicians Dashboard is unique nationally (confirmed via FOI requests to 55 other mental health trusts and to the National Confidential Inquiry Suicide and Homicide). It represents excellent value for money with no on-going costs and an initial set up of around £2k (emails automatically generated thereafter via normal EPR records when Clinicians update individual care plans):- • 37.5 hours top Band 5 Performance Analyst (£28,746 annual salary) + 28% on-costs to create the Dashboard (£708) using our development information • Costs associated with internal/external consultation and planning meetings estimated at around £1300 It offers so many advantages and turns a reactive service into a proactive one. For example, benefits include:- Qualitative Benefits: EFFICIENCY/PRODUCTIVITY • Increased efficiency/productivity; less time between visits, reduced time between DNA’s and/or 7-day follow ups • Effective/consistent/safer patient care e.g. DNA/7-day reviews now unlikely to be missed • Increased Time to Care by 130 hours per month INSTANT ACCESSIBLITITY • Status of caseload instantly available to both Clinicians/Clinical Managers • Real-time access to review dates, risk factors, flagging of most vulnerable; status of Service Users on the case load can be viewed together on one screen – saving Clinical time/increasing productivity. COMMUNICATION/INTEGRATION • Improved communication both within the organisation/externally – e.g. with primary/secondary health care around physical health checks Quantitative Benefits:- REDUCTION IN INPATIENT STAYS FOR KNOWN SERVICE USERS = saving £1,091,600 (2729 bed days @ £400 per bed day) PHYSICAL HEALTH CHECKS = saving £72,560 (GP per visit £38 = £81,016/MH Clinician mid Band 7 x 355 hours = £8455) saving 82% of SMI Service Users (2132) have received a physical health check relieving pressure on GP’s
How do you ensure an effective, safe, compassionate and sustainable workforce?
Our innovation helps to prevent burn-out within our community staff team. Some clinicians have caseloads of over 50 people to monitor or have lower caseloads with some very complex cases who may need constant intervention. The Dashboards help clinicians to keep track on the status of their caseloads and give them the confidence to know a Service User hasn’t ‘slipped through the gaps.’ The Dashboard sits in the background and monitors each Service User. It automatically emails the clinician responsible for care coordination if a Service User does not attend their appointment. Clinicians are then able to telephone the Service User to check they are okay; this proactive intervention helps to prevent a breakdown to crisis and lets the Service User know they are not alone. Furthermore the Dashboard sends a weekly overview email directly to each Clinician with a break-down of when service users were last seen. The dashboard is able to use the triggers set when it was developed to work out which Service Users may be most at risk against the set indicators, automatically warning clinicians. Line Managers are also benefiting from having sight of Dashboards. They are able to see the caseloads of each Clinician they line manage. Initially, there was scepticism about this facility from Clinicians as they saw it as ‘checking up on them’ but as the Dashboards have become more embedded they appreciate the benefits this brings. Line Managers are able to see at the ‘push of a button’ if any of their team appears to be struggling or needs extra support to manage their workload.
Who is in your team?
Performance 1 x Senior Performance analysts (1 x FTE) 1 x Data Warehouse Developer (1 X FTE) 2 x Performance Analysts (2 x FTE) 1 x Assistant Performance Analyst (0.6 x FTE) 1 x Clinical Systems Trainer (0.8 x FTE) Business Support 1 x Business Development Manager (1 x FTE) 1 x Project Manager (1 x FTE) 7.4 FTE across the whole team.
How do you work with the wider system?
The Performance Team provides information reports and analysis from NAViGO’s EPR (Electronic Patient Record) system and Datix (Accident/Investigation Reporting Tool) for the whole of NAViGO. We are called upon by each and every service area within NAViGO to produce accurate/current statistics around a huge variety of services and to find evidence or solutions to problems. We are for the most part a ‘back-office service’ although we do on occasion shadow our clinical staff colleagues to ensure we fully understand their needs and are able to design digital solutions for problem areas. By way of a Positive Practice Award we hope to bring the role we play to the fore and demonstrate how we fit into the dynamic service that is NAViGO. We provide information to Commissioners and statutory bodies such as the Department of Health and the CQC (Care Quality Commission) and offer evidence that outcomes/goals have been met (or otherwise). The team also supports Clinical Audit and the production of the Quality Account. The objective of the Performance team within the service is to support NAViGO in continuous quality improvement and enhancement of Service User experience. All Information generated complies with NAViGO policies and procedures, GDPR (General Data Protection Regulation 2018) and the Data Protection Act 1998.
Do you use co-production approaches?
We consulted with our Membership (i.e., c700 staff/Service Users/Carers/community representatives) to determine what risk factors they saw as being synonymous with suicide. Responses were incorporated into our Dashboard Indicators. Clinicians worked with our Data Analysts to refine how they wanted Dashboards to look, how they wanted email alerts to be conducted etc. Everything we do as an organisation is linked to the principles of patient partnership/co-production. NAViGO is a not-for-profit, membership organisation and as such ‘owned’ by its staff – all uniquely have equal voting rights. The thought behind the initiative featured in our 2015 Corporate & Membership Objectives, relating specifically to Objective 2 below, when SU’s requested pro-active/safer care:- “We will embed the 5 CQC principles throughout NAViGO to improve our service delivery still further o Safe o Effective o Well-led o Responsive to People’s Needs o Caring” This meant, before embarking on designing the Dashboard, we were fully aware of:- • what was important to our SU’s • what we would monitor to prove action taken SU’s were also involved in project design, ensuring the correct indicators were used to map baselines/improve safety. The technology has been created in-house so does not link to a particular vendor externally.
Do you share your work with others?
This project has potential for low-cost national spread, affecting the up to 1 in 4 people in the UK who are diagnosed with a mental health condition. Having proved efficacy, we were successful in achieving a grant of £75k from the Health Foundation – Innovating for Improvement fund to develop into a useable entity for national spread. Data Analysts are presently working on developing a package to offer this solution across the health sector in the belief it will also assist our peers to improve patient experience/safety, staff morale and organisational reputation. In developing the project we engaged with the National Confidential Inquiry Suicide and Homicide and contacted 55 Mental Health trusts through FOI requests – 32 responded; none were using similar dashboards but most had existing Data Warehouses, meaning the technology can be easily/cheaply installed and adapted to reflect particular specialties. The National Confidential Inquiry into Homicide/Suicide also confirmed no knowledge of other similar projects making NAViGO’s innovation unique nationally. We continue to apply for national awards in the development phase to ensure our peers are aware this solution will shortly be available nationwide; to this end, we have been shortlisted for the BMJ Awards in the Mental Health Category (announced on 10th May 2018).
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
Amanda Simpson, our Clinical Project Lead, is also responsible for Quality/Clinical Governance. As such, she is party to all Serious Incidents/Near Misses/Deaths that may from time to time occur as part of the day-to-day operation of services. A recorded increase in Serious Incidents prompted an investigation into the scale of the problem within our own organisation; this in turn led to research being carried out regionally/national to determine if high suicide rates/high physical health mortality amongst MH service users was in fact a systemic problem. The poor findings/details in 17 above resulted in our project being developed. The following baseline indicators were chosen to demonstrate an improvement in patient safety, offering excellent results:- Baseline/outcome measures were a reduction in:- • Crisis Presentations per referral • Number of days between appointments • Average days to follow-up a DNA • Average number of days to follow-up on discharge These were achieved and more for example:- • Number of days between appointments – was 24 days in May 2016 – now 4 days on average • Physical health checks increased from 44% to 82% with decreased pressure on GP’s/savings through early diagnosis of physical illness • Average days to follow up on a DNA – was 40 days in May 2016 – now 4 days – a 90% reduction • 7-day follow-ups on discharge reduced 4 days to 1 day • Serious incidents locally since April 2016 action plan profile has changed to exclude people being seen regularly (within 28 days) • Service user satisfaction increased – Friends/Family Test increased from 96% to 100% – England Average is 89% • Managers can now actively see ‘live’ staff caseloads, offering development opportunities accordingly
Has your service been evaluated (by peer or academic review)?
A peer or academic review is not applicable for this innovation. However, we were awarded £75k from the Health Foundation Innovating for Improvement funding pot in recognition of our innovation being unique. We used this to develop the Dashboard concept and will use to spread our idea nationally. We have also been shortlisted out of 271 applicants to the last 6 in the Mental Health category of the British Medical Journal Award (announced 10th May 2018).
How will you ensure that your service continues to deliver good mental health care?
We continue to monitor outcomes across the Dashboards on an on-going basis to ensure they are continually improved where possible. Consultations with staff, service users and carers take place on a regular basis across all service delivery. We intend to consult on dashboard use/efficacy at regular intervals to inform the monitoring necessary for our HF Grant and will add to/amend accordingly to ensure the best quality and safest patient care. This innovation has little or no cost going forward so does not need to generate income to be sustainable – in fact it generates savings for the organisation in reducing bed days and costly time spent on investigating serious incidents.
What aspects of your service would you share with people who want to learn from you?
Once designed, the main challenge was ‘culture change’ – other than this the Dashboard was created exactly in line with what they requested, this was just a perverse outcome which hadn’t been anticipated. Clinicians initially saw it as a performance indicator tool for managers rather than a patient safety initiative. This was gradually overcome as Clinicians realised the huge benefit to them in ensuring the safety of those on their caseloads. Usage is now embedded and sustainable across the organisation with a 74% increase in use since inception.
Population details
Brief description of population (e.g. urban, age, socioeconomic status):
North East Lincolnshire is a small unitary authority covering an area of 192km2 with a population of around 159,000. The majority of the resident population (around 94.2%) live in the urban towns of Grimsby and Cleethorpes with the remainder living in the smaller town of Immingham, or in surrounding rural villages. On the Northern border, the Humber estuary has been designated as a Site of Special Scientific Interest and to the south, the Lincolnshire Wolds are recognised as an Area of Outstanding Natural Beauty. Cleethorpes gained 4 national Seaside Awards in 2015. North East Lincolnshire has a distinctive economy, built on expertise in manufacturing, engineering, ports and logistics, and food processing. The local area has some significant advantages stemming from its location, labour force, and transport infrastructure that position it for growth in renewables, chemicals, advanced manufacturing and the food and drink sector. Taken together, Grimsby and Immingham constitute the UK’s largest port by tonnage shipped.
Whilst the general direction of travel for the locality is around improving the environment and perception of the area, N E Lincolnshire does have pockets of high deprivation, ranking high on the IMDO (Index of Multiple Deprivation) which measures the following 7 deprivation indicators:- • Income • Barriers to housing and services • Employment • Living Environment • Health/Disability • Crime • Education/Training An example, East and West Marsh, two Wards within the North East Lincolnshire Council area, now rank in the top 1% deprived sub-areas nationally. As a result of the deprivation there are long standing health inequalities with those in the more deprived areas dying on average 8 – 10 years before those in the most affluent. According to the National Office of Statistics, around 18.46% of the population have some sort of emotional disorder. Other key points to note:- • The boundary of North East Lincolnshire is comprised of 106 Lower Super Output Areas (LSOAs); these LSOAs which contain a minimum population of 1,000 and a mean average of 1,500 are distributed amongst the fifteen electoral wards. • Overall, North East Lincolnshire is ranked as the 31st most deprived local authority in England, out of 326. (increased from 46th in the ID 2010.). • 32,567 residents, which is approximately 20% of the population are classed as income deprived with 25% of LSOAs being in the 10% most deprived for income nationally. • 15,140 residents are classed as employment deprived. • 20.1% of the working age (16 to 64) population of North East Lincolnshire have a known disability • 95.4% of the resident population of NEL are White British. • The January 2015 School Census shows 23,541 children on roll, 2981 (12.5%) of school pupils were identified as having Special education needs • Presently 28.5% (8,500) local children are thought to live below the poverty line
Size of population and localities covered:
Population c159,000 – NAViGO covers the area of N E Lincolnshire
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England): *
North East Lincolnshire Clinical Commissioning Group (NELCCG) and NHS England (Rharian Fields and Liaison & Diversion Teams)
Provided by (e.g. name of NHS trust) or your organisation: *
NAViGO CIC – NAViGO is a not for profit social enterprise formed in 2011 under the Right to Request Agenda with a staff team of around 550 people. The whole of mental health services in N E Lincolnshire transferred out of the NHS yet is still the preferred provider to the NHS delivering both statutory and a range of innovative additional services in N E Lincolnshire. Becoming a social enterprise has allowed the organisation the autonomy to develop innovative projects. Any surplus made by working smarter is re-invested to improve services for local people.
