Basic ideas on internal waits to Specific interventions

Soundbite statement

The only solutions to changing a bottleneck are REDUCING demand or INCREASING capacity. For waits to Specific interventions/assessments you will need to either reduce the demand (i.e. what is coming into the bottleneck) or increase the capacity (i.e. widen the bottleneck).

The 7 HELPFUL Habits of Effective CAMHS are useful here and five of them act directly on bottlenecks. We’ll present them below and then think through a few examples. See the 7 HELPFUL Habits section for more detail. Each Habit consists of several items.

Reducing demand: HANDLE DEMAND, PROCESS MAPPING AND REDESIGN and FLOW MANAGEMENT Increasing Capacity: EXTEND CAPACITY, PROCESS MAP AND REDESIGN and LET GO of FAMILIES

Handle Demand

The items under Handle Demand that are particularly relevant in managing bottlenecks, by reducing demand, are:

1. Eligibility Criteria: what is needed to get into this process? Can this be amended? Who makes the decision?
2. Diversion Criteria: who else could do this?
6. Full Booking: no waiting lists…
7. Screen referrals directly: how do you know that all are appropriate? And who decides?
8. Flex capacity: could this help?

(The numbering of the items is as that in the 7-HAT for ease of reference).

Extend Capacity

The Extend Capacity items that can help you widen the bottleneck are:

9. Know capacity: how much of this process (Specific intervention/assessment) can be done? Can we plan for the activity or set an activity level (this is the CAPACITY reason of why we plan for Specific work)
10. Follow-up focus: could anything make this process more effective/briefer?
12. Extend clinical roles: KEY TASK… Can the capacity at that step be wider? Can some of the skill be devolved to an earlier step? Are there enough core skills ahead of this Specific skill? E.g. do you need to train more people up to do threshold level CBT?
14. Monitor Activity: how well is this step used? E.g. DNA’s?

Let go of Families

If there is not a set new activity level then take up rates depend on discharge from the Specific component. Thus sometimes the flow is blocked by an outflow issue and so the Let go of Families questions are:

16. Closing case variation: reducing variability in the process.

This means having ways to be more consistent in the discharge of the patient from this intervention. Having a consistent reviewing process. Just carrying on is too easy to do. All the evidence is that it is our variation in practice that has the main impact on poor flow (see Variation in the Demand and Capacity Theory chapter 25). How many surgical patients are discharged on Christmas Eve? How many cases can you close when you are leaving your job? Amazing!

17. Care plans: is the process clear? Are goals clear? How do you know when the work is finished?

Process Mapping

Process Mapping will enable you to identify the steps in the patient pathway:

19. Process Map and Redesign: aim to get rid of those that do not add value to the user.

Flow Management

The Flow Management item that relates directly to bottlenecks is:

29. Something to Do: does this step add value for the client?