bentley family clinic safety, quality, performance

Bentley Family Clinic

Safety, Quality, Performance, Patient Experience and Patient Outcomes Report

1 July 2015 – 30 June 2016

CAMHS Senior Project Officers

Child and Adolescent Mental Health Service (CAMHS)

© Child and Adolescent Mental Health Services, Child and Adolescent Health Services, Department of Health 2016

Version: 1.0

Last Updated: March 2017

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Contents

1. Executive Summary 2

2. Community CAMHS 3

2.1 Bentley Family Clinic 4

2.2 Bentley catchment overview 4

2.3 Staff 5

2.4 Capacity and demand modelling 6

2.5 Integration and shared care arrangements 6

2.6 Appointment scheduling 8

3. Budget 9

4. Referral Sources 10

5. Activity 11

5.1 Referrals 12

5.2 Access 13

5.3 Activations and Deactivations 17

5.4 Service Contacts (Occasions of Service) 19

5.5 Access by Aboriginal children and young people 20

5.6 Number of treatment sessions per episode of care 23

6. Safety and Quality 25

6.1 Documentation Audit Results 25

6.2 Internal Audit Results 26

6.3 Clinical Incidents 27

6.4 Risks 27

6.5 Quality Improvements 27

7. Education and Training of staff 29

7.1 Mandatory Training 29

7.2 Other training completed by BFC 30

8. Consumer and carer experience 31

8.1 Experience of Service Questionnaire (ESQ) 31

8.2 Complaints and Compliments 32

9. Patient Outcomes 33

9.1 NOCCS 33

10. Policy 34

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1. Executive Summary Bentley Family Clinic (BFC) provide services to the Bentley catchment area for infants, children and young people, up to their 18th birthday with severe and/or complex emotional and mental health wellbeing concerns. The service serves an estimated population of approximately 61,435 zero to 17 year olds with 16.1 FTE (Full Time Equivalent) staff. The multidisciplinary team is comprised of a number of clinical disciplines lead by a Consultant Child and Adolescent Psychiatrist and Service Manager. The team operates to an approximate budget of $2.1 million per annum.

BFC has a number of key partnerships with other services in the local area, both internally and externally. Targeted funding has allowed the team to appoint an Aboriginal Mental Health worker, which has resulted in a significant increase in the number of referrals of Aboriginal children and families to the service. BFC also has a Bentley CAMHS Community Acute Response (BCCAR) stream which has assisted the service to develop strong links with CAMHS Acute services, Youth services and Tier 2 providers in the management of high risk and vulnerable young people accessing the service.

In the last financial year, BFC received an average of 38 referrals each month. The referrals were most commonly from external medical practitioners. Their median wait time from referral to a Routine Choice appointment was 25 days and that from referral to Partnership (treatment) was 45 days. They activated 11 new clients per month on average and deactivated approximately the same number. The median number of treatment sessions per episode of care was 7, and the Interquartile range (IQR) 10.5 sessions. The average number of occasions of service completed for Aboriginal young people activated each month over the reported period was 56.

BFC were assessed against National Safety and Quality Health Service Standards and all areas assessed were successfully met. An internal documentation audit conducted in the last financial year generated recommendations that have all been completed. No clinical incidents were reported at BFC during this period. The BFC team maintains its level of compliance with mandatory training above the level expected of Community CAMHS teams. Some team members have further extended their clinical skills by completing training in areas such as infant mental health and family therapy. The team also took part in clinical outcome measures training in October 2016.

BFC actively seeks consumer feedback via an Experience of Service Questionnaire (ESQ). In the last financial year 47 children and adolescents and 60 parents/carers provided feedback via the ESQ. In response to the ESQ’s, feedback posters that describe the actions taken are regularly displayed in the BFC waiting area. In this period, BFC received one formal compliment and three formal complaints. All complaints were investigated and responded to promptly.

BFC regularly review and implement service wide policies and guidelines to ensure overall compliance to policy. Service improvement is addressed through team Business and Governance meetings, where regular discussion, review and initiation of service improvement activities takes place.

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2. Community CAMHS Community CAMHS provide services for infants, children and young people under 18 years of age who have severe and/or complex emotional and mental health wellbeing concerns which are causing them to experience substantial impairment in functioning on a continuous or intermittent basis. Community CAMHS services are located throughout the Perth metropolitan area, staffed by multidisciplinary teams who offer evidence-based individual, family and group interventions.

In working together with children, young people, families and support networks, Community CAMHS supports them to become decision-makers in their own care, implementing the principles of recovery-oriented child and adolescent mental health practice. Recovery oriented practice supports and recognises the following:

The uniqueness of the individual;

Real choices;

Attitudes and rights;

Dignity and respect; and

Partnership and communication.

Key principles for service delivery:

Provides a holistic framework that informs all contact with children, young people and families;

Builds and enhances strength, resilience and social well-being;

Supports children to return to a normal developmental trajectory;

Is underpinned by the premise that children and young people do recover from mental health problems;

Engages with all areas of the child, young person and family’s life, including relationships, education, vocation and leisure; and

Informs the recovery plan that is regularly reviewed by the child or young person, family and multidisciplinary team.

Children and adolescents often present with complex, multifactorial problems. The reason for entry to CAMHS must relate to mental health problems, although other concurrent and/or associated difficulties may exist (e.g. autism, intellectual disability, child protection issues). The range of presenting problems usually considered on referral includes:

Persisting suicidal ideation and/or behaviour;

Severe risk-taking behaviour (including self-harm);

Psychotic symptoms;

Depressed, sad and/or agitated mood;

Severe and persisting behavioural and conduct disturbance;

Severe and persisting peer and/or family problems leading to significant emotional distress and/or behavioural problems;

Persisting and severe school avoidance and/or phobia;

Severe anxiety (e.g. phobias, post-traumatic stress disorder);

Severe obsessions and compulsive rituals;

Eating and body image disturbances; and

Complex ADHD with co-morbid emotional / mental health wellbeing concerns.

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2.1 Bentley Family Clinic

BFC is located at P block on the Bentley Health Service site, Mills Street, Bentley.

2.2 Bentley catchment overview

The total estimated population in the Bentley Catchment in 2015 was 297518 based on projections from the Australian Bureau of Statistics (ABS) data. Of the total population, 61435 were aged between 0 – 17 years old. The estimated 0-19 year old Aboriginal population in the Bentley catchment in 2013 was 2513 (data based on ABS data and planning data by the CAHS Epidemiology team).

Total population, population by age


Total Population Population of 0 - 17 year olds

Population of Aboriginal 0 - 19 year olds

297518 61435 2513

Map of Bentley catchment

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2.3 Staff

Bentley Family Clinic is comprised of a multidisciplinary team with members from Child Psychiatry, Clinical Psychology, Nursing, Occupational Therapy, Speech Therapy, Social Work, and an Aboriginal Mental Health worker. The team is led by the Service Manager and Head of Service and supported by Administration staff. The Service Manager manages the financial, physical and human resources and works in partnership with the Head of Service (the Child Psychiatrist) in providing clinical governance, together ensuring the delivery of an integrated child and adolescent mental health service based on a community-driven and consumer-focused model of care. The FTE breakdown at BFC is shown in the below table.

Staff and FTE, BFC, June 2016

BFC staff FTE Note

Administration (non-clinical) 1.6

BFC administrative staffing has not grown at the same rate as clinical staffing which has led to significant under-resourcing in this area. BFC utilises casual contracts and unfilled clinical FTE in order to ensure that the lack of administrative support does not impact on clinical service provision.

Social work 2.3

Includes 0.4 FTE Child Protection Consultation Liaison position. 0.2 FTE used for AMBIT training.

Social work - Integrated Service Centre at Thornlie

1.0

Nursing 3.0

Clinical Psychology 2.0

Service Manager (non-clinical) 1.0

Head of Service – Psychiatry 1.0

Aboriginal Mental Health Worker G4 (non-recurrent funding)

1.0

Occupational and Speech Therapy (clinical)

1.2

Psychiatry - Consultant 0.5

Psychiatry - Registrar 1.0

Suicide Intervention clinician (non-recurrent funding)

0.5

TOTAL 16.1

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2.4 Capacity and demand modelling

The ratio of available clinical FTE per total population is used as a way of describing capacity of mental health services to adequately service a population. A ratio of 14 clinical FTE per 100,000 total populations has been used in Queensland as a goal which would create sufficient capacity for a child and adolescent mental health services to meet known demand for service for children with severe and complex mental health disorders.

Suggested capacity of specialist mental health services to meet demand

It has been estimated that 3.2% of children and adolescents experience a severe mental health disorder in a one year period, which for Bentley would mean a group of 1966 children and adolescents experiencing a severe mental health disorder in a one year period.

Specialist mental health services have previously met demands of 1% of the 0-17 year old population, converting to an estimate of 614 children in the Bentley area.

Population and FTE actual staff ratios

2.5 Integration and shared care arrangements Children, young people and families are recognised as being part of a wider community and Community CAMHS are viewed as one element in a wider service network. Each Community CAMHS collaborates and develops partnerships within all areas of CAMHS (Community, Acute and Specialised) and externally with other service providers to facilitate coordinated and integrated services for children, young people and their families. Community CAMHS also provides consultation liaison with primary care partner agencies and all other key stakeholders.

Key partnerships:

The Child Development Service (CDS) is part of the Child and Adolescent Health Service, providing a range of support services for children, with or at risk of developmental difficulties, and their families. Bentley CAMHS meets monthly with their local CDS clinic to discuss recent trends and individual cases.

The Department for Child Protection and Family Support (CPFS) provides a range

of child safety and family support services to West Australian individuals, children and their families, from the Kimberley to the Great Southern regions of the State. Bentley CAMHS covers both the Armadale and Cannington CPFS catchments. Bentley CAMHS attends monthly liaison meetings with CPFS to discuss recent trends and individual cases. In 2016 BFC also participated in and assisted with the delivery of joint workshops between CAMHS and CPFS which were aimed at facilitating information sharing between the two agencies.

Total population Clinical FTE Clinical FTE per 100,000

Recommended FTE for Bentley population


297518 13.5 4.5 41.65

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The Armadale Family Support Network is funded by CPFS and is a new way of working to integrate family support services and provide support to children, young people and families who are experiencing problems that are causing them stress. Bentley CAMHS is intending to join this group and has made steps towards developing a formal agreement with the network (there are some complications with this as the network crosses the BFC postcode boundary).

Department of Education – In the reporting period Bentley CAMHS commenced

consulting with the School of Special Educational Needs and Midland Academy in relation to developing a school anxiety pathway within the service. Bentley CAMHS also delivers psychoeducation and risk management consultations to a range of high schools in the local area, including Clontarf College, Willetton Senior High School, Belmont High School and Canning Vale College. Bentley CAMHS also liaises regularly with the local CAMHS Education Liaison Teacher.

Statewide Specialised Aboriginal Mental Health Service (SSAMHS) – Through the SSAMHS funding program, BFC has been able to employ an Aboriginal Mental Health Worker. As a result of implementing a flexible and assertive outreach approach with a culturally-competent SSAMHS clinician, BFC has seen a significant increase in referrals to the service for Aboriginal young people and been able to successfully address access issues for Aboriginal families in their catchment area. Clinical outcomes have centred around a reduction of suicidal and self-harm, improvement in family functioning, and early identification and intervention for Aboriginal children and youth with complex trauma and mental health problems. In particular, BFC have had increased success with Aboriginal young people showing signs of early psychosis and significant risk factors who have previously had a tendency to dis-engage from the service.

CAMHS Acute, Specialised and Community Directorates – As BFC is located on

the same site as Touchstone, the two services work closely together and are currently working on strengthening their relationship and smoothing transitions between their services. Touchstone is a structured day service for young people aged 12-17 years who are struggling to cope with relationships, mood difficulties and impulsive self-harming behaviours such as cutting. As BFC have both a Speech Pathologist and an Occupational Therapist on their team, they also have strong relationships with both the Complex Attention and Hyperactivity Disorders Service and the Pathways service. BFC also has a Bentley CAMHS Community Acute Response (BCCAR) role which has enabled the service to develop strong links with CAMHS Acute services, Youth services and Tier 2 providers in the management of high risk and vulnerable young people accessing the service. The BFC acute stream was recently nominated as a finalist in the WA Health Excellence Awards for their parent intervention group for adolescence with suicidal ideation and self-injury. BFC also incorporates specialist acute Choice Appointments within its CAPA framework of service provision.

Fiona Stanley Hospital (FSH) – The BCCAR clinicians and other members of the BFC

team regularly participate in discharge planning and clinical review meetings with the FSH Youth Inpatient Team for any shared care cases. BFC also works closely with the FSH Youth Community Assessment and Treatment Team (YCATT) to coordinate access to the most appropriate service. When YCATT was initially established, BFC

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met with the team to discuss how the clinic, and especially the BCARR role, might interface with the YCATT team for any common referrals. An informal Memorandum of Understanding was established whereby YCATT re-direct any referrals to BFC that presented within the FSH Emergency Department, to support access to Community CAMHS.

Strong Families – Strong Families is a planning and coordinating process for

consenting families who are receiving services from two or more agencies. The BFC Service Manager was a member of the local Strong Families management group and regularly attended meetings of this group. BFC frequently referred to and worked with Strong Families on numerous cases. Strong Families and the regional management group were recently disbanded.

General Practitioners (GPs) – BFC works closely with GPs to promote and guide

them on referrals, entry criteria, service developments, and cases involving shared care. BFC also works closely with GP’s to ensure that the physical health needs of their consumers are met.

Other Tier 2 Providers – BFC has also developed key partnerships with a range of

other Tier 2 service providers in the local area, including Mercy Care, headspace, YCounselling, Centrecare, Infocus, and Youth Focus.

2.6 Appointment scheduling

The workload of clinical staff is managed by allocating resources to choice and partnership appointments. The allocation of choice and partnership appointments varies for different staff members depending on their role, i.e. some staff provide more choice appointments and others more partnership appointments. Overall more choice appointments are provided than partnership appointments, since not all children and families choose to receive or are offered partnership appointments. The partnership appointment is the commencement of therapy for the child and family.

BFC schedule approximately 80 urgent Choice Appointments and 60 Routine Choice appointments per 13 week cycle.

BFC schedule approximately 50 Routine Partnership Appointments each cycle when at full clinical capacity. Acute and specialist partnerships are also provided in addition to these routine partnership appointments to support additional intervention for relevant clients. These appointments may be used for interventions such as brief crisis stabilisation and risk management, as well as for specialist groups (e.g. infants, Aboriginal and CALD families).

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3. Budget BFC budget for the financial year of 2015/2016

Type of expenses

Actual Full Year June 2016

Budget Full Year June 2016

Sub-Total

Other Funds Targeted Programs 15-16 (Note 1)

Variation

Total Expenses 2,391,906 2,140,568 251,338 250,000 -1,338

Total Employments Cost[1]

2,280,249 2,046,104 234,145 234,000 -145

Total Other Goods & Services[2]

111,657 94,464 17,193 16,000 -1,193

Negative variance / % is unfavourable Note 1:

Employment costs unfavourable variance due to an accounting method used in 2015-16 financial year to report costs for targeted programs such as Suicide Response Initiative; SSAMHS and Mandatory Reporting.

Effectively, costs were not matched with funding at the Cost Centre level (reported above) in 2015-16.

Employment costs were aggregated by location (BFC CAMHS). The funding was reported in a separate Cost Centre rather than fragmented across over 10 different Community CAMHS Cost Centres. CAMHS then used a common methodological approach that aggregated by Activity stream classification. This allocation method attributed 15% of employment costs (i.e. $250k BFC CAMHS) applicable to the targeted funding programs. Therefore, the variation of $251,000 shown above has been funded by the above-mentioned targeted programs which results in a minor variation.

This allocation method was discontinued as at 1 July 2016, whereby in the current 2016-17 financial year direct employment costs for targeted programs are matched against the targeted funding.

Other Goods and Services unfavourable variance is due to unbudgeted expenses mainly office supplies and outsourced services such as language translation and interpretation services.

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4. Referral Sources

Breakdown of referral sources for BFC from July 2015 – June 2016.

Unique referrals only (i.e. if a young person was referred to the service 3 times it is only counted once)

Referral Source Number of Referrals Received

Percentage of Referrals Received

EXTERNAL PROGRAM 1 Less than 1%

HOSPITAL 39 9%

INTERNAL PROGRAM 57 14%

MEDICAL PRACTITIONER 180 44%

OTHER ORGANISATION 63 15%

OTHER PROFESSIONAL 13 3%

SCHOOL 59 14%

Grand Total 412

Referrals excluded on a month-by-month basis (i.e. if a young person was referred to the service 3 times in a single month we only count 1 referral. If they were referred to the service 3 times, all in different months, then we include all 3).

Referral Source Number of Referrals Received

Percentage of Referrals Received

EXTERNAL PROGRAM 1 Less than 1%

HOSPITAL 43 10%

INTERNAL PROGRAM 62 14%

MEDICAL PRACTITIONER 193 43%

OTHER ORGANISATION 72 16%

OTHER PROFESSIONAL 14 3%

SCHOOL 66 15%

Grand Total 451

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5. Activity Notes about activity graphs:

All graphs reflecting referral numbers, activations, deactivations and occasions of service show a trend that is apparent across all Community CAMHS service, whereby activity is heavily influenced by school holiday periods (April, July, October, December/January).

Control Charts: Control charts have two general uses in the management and continuous improvement of a service The most common application is as a tool to monitor specific processes and functions to check for stability and control. A less common but potentially more powerful use is as an analysis tool. Data is plotted in time order. A control chart always has a central line for the average, an upper line for the upper control limit and a lower line for the lower control limit. These lines are determined from historical data. By comparing current data to these lines, you can draw conclusions about whether the process variation is consistent (in control) or is unpredictable (out of control, affected by special causes of variation). If your data points are within the upper and lower control limits they are in control, if they are above or below then they are out of control. Service Managers can use control charts to monitor the variation over a period of time for the number of days that each child and family waits for an appointment. Remarkable levels of variation and trend might indicate a change in the process or increase in referrals received.

Box and whisker plots: A box and whisker plot is used to display information about the range, the median and the quartiles. In descriptive statistics, the IQR, also called the midspread or middle 50%, is a measure of statistical dispersion, being equal to the difference between 75th and 25th percentiles, or between upper and lower quartiles. In the box and whisker plots, our middle 50% is represented by the two grey boxes.

Scatter Plots: Scatter plots are similar to line graphs in that they use horizontal and vertical axes to plot data points. However, they have a very specific purpose. Scatter plots show how much one variable is affected by another. The relationship between two variables is called their correlation. Scatter plots usually consist of a large body of data. The closer the data points come when plotted to making a straight line, the higher the correlation between the two variables, or the stronger the relationship. If the data points make a straight line going from the origin out to high x- and y-values, then the variables are said to have a positive correlation. If the line goes from a high-value on the y-axis down to a high-value on the x-axis, the variables have a negative correlation.

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5.1 Referrals

This control chart shows:

Referrals – the total number of referrals received each month.

Average – the average number of referrals received each month over the reported period (38).

Control Limits – control limits are set three standard deviations above and below the mean.

BFC has seen a steady increase in average referrals since the implementation of CAPA; approximately 28 referrals per month pre-CAPA up to 38 referrals per month post-CAPA (July 2015 - June 2016). Peaks and troughs correlate with school terms/number of school referrals received.

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5.2 Access

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The top graph is a box and whisker plot. The consumer specification line is set to 28 days in order to provide a visual representation of how soon most young people and their families expect to access our community services. This graph shows that the Median wait time for Choice was 25 days. Interquartile range (IQR) is 24.5 days.

The bottom graph is a control chart. This shows:

Access time (orange line) – represents wait times from referral to choice over time, each dip and spike represents an individual young person’s wait times.

Median – the median wait time from receipt of referral to choice over the reported period (25 days).


The 25 day median time to wait is reflective of routine choice appointments only. As BFC has an Acute stream within its CAPA model of care, referrals deemed urgent are offered an urgent choice within three business days of referral. If it takes more than three days to see the child, it is usually due to diffiuclties in contacting the family to arrange an appointment or the family choosing a later time.

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The top graph is a box and whisker plot. The consumer specification line is set to 56 days in order to provide a visual representation of how soon most young people and their families expect to access our community services. Median wait time for Partnership is 45 days. Interquartile range (IQR) is 35 days.

The bottom graph is a control chart. This shows:

Access time (orange line) – represents wait times from referral to choice over time, each dip and spike represents an individual young person’s wait times.

Median – the median wait time from receipt of referral to partnership over the reported period (45 days).


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5.3 Activations and Deactivations


Activations – the total number of activations each month.

Mean – the mean number of activations each month over the reported period (11).

UCL – the upper control limit is set three standard deviations above the mean.

LCL – the lower control limit is set three standard deviations below the mean.

Top 10 principal activation codes 2015/16 FY:

Activation Count

Principal Admission Diagnosis Code

Principal Admission Diagnosis

41 Z00.4 General psychiatric examination, not elsewhere classified

14 F43.2 Adjustment disorders

11 F41.2 Mixed anxiety and depressive disorder

10 F41.1 Generalised anxiety disorder

5 F32.0 Mild depressive episode

5 F32.1 Moderate depressive episode

4 F43.1 Post-traumatic stress disorder

4 F93.0 Separation anxiety disorder of childhood

4 F92.9 Mixed disorder of conduct and emotions, unspecified

3 F41.9 Anxiety disorder, unspecified

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Deactivations – the total number of deactivations each month.

Mean – the mean number of deactivations each month over the reported period (12).



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5.4 Service Contacts (Occasions of Service)


OOS – the total number of occasions of service completed each month.

Mean – the mean number of occasions of service completed each month over the reported period (1086).


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5.5 Access by Aboriginal children and young people


Referrals – the total number of referrals received for Aboriginal young people each month.

Mean – the mean number of referrals received for Aboriginal young people each month over the reported period (5).


Please note that if a young person is not identified in the Patient Administration System (PAS) as Aboriginal then we have no way of identifying them in our reports.

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Activations – the total number of Aboriginal young people activated each month.

Mean – the mean number of Aboriginal young people activated each month over the reported period (2).



Please note that if a young person is not identified in the Patient Administration System (PAS) as Aboriginal then we have no way of identifying them in our reports. Referrals for Aboriginal families have reduced since April 2016. The BFC Leadership team has held discussions with their new Aboriginal Mental Health Worker regarding focussing on previous referral sources for Aboriginal families referred to BFC.

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OOS – the total number of occasions of service completed for Aboriginal young people each month.

Mean – the mean number of occasions of service completed for Aboriginal young people activated each month over the reported period (56).


Please note that if a young person is not identified in the Patient Administration System (PAS) as Aboriginal then we have no way of identifying them in our reports.

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5.6 Number of treatment sessions per episode of care

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The above graph only includes a count of the following service event items:

Assessment

Medication Review

Therapy The box and whisker plot shows that the median number of treatment sessions per episode of care is 7. The Interquartile range (IQR) is 10.5 sessions. The scatter plot shows length of stay in months on the y axis and number of treatment sessions per episode of care on the x axis.

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6. Safety and Quality

6.1 Documentation Audit Results

Quality mental health care is dependent on good clinical documentation. Assessment and diagnosis requires detailed and subjective information, often obtained from many sources. Care may be provided by a team of multidisciplinary clinicians, often from different services, and frequently after hours or in emergency settings. Clinical information needs to be accurately communicated quickly and without confusion. Standardised forms are one way of ensuring common reporting standards and ease of use across services.

In 2012, representatives from across WA Health agreed to a set of standardised forms to be implemented across the State. The forms that resulted span the overarching processes that are completed as part of the mental health assessment process, from triage to discharge.

These forms are known as the Statewide Standardised Clinical Documentation (SSCD) suite. It is acknowledged that the forms were developed by New South Wales Health, and that the WA Government was granted permission to use the forms across public mental health services.

The purpose of audit in April 2015 was to assess the degree of implementation and roll-out of SSCD documentation at various different mental health organisations throughout the state. The results helped to identify areas where implementation was yet to be completely rolled out. It was expected that some areas would be more advanced in their implementation than others. The data was used to provide the Office of Mental Health with a complete picture of baseline implementation of the SSCD.

There was 1 documentation audit at BFC between 1 July 2015 – 30 June 2016. This was undertaken in June 2016 and audit results are summarised in the table below. BFC will be re-audited in February 2017 to assess improvement.

Audit area Number of actions against areas of low compliance

Comments Actions completed (yes/no)

Medical record ‘basics’ (16 criteria)

2 1. Reminder to staff that Patient ID Stickers on back of progress notes in addition to front side

2. Reminder to staff that no blank lines are left between entries in progress notes

Yes

Yes

Intake and assessment (7 criteria)

0 Compliant

Individual Management Plan /Recovery Plan (26 criteria)

1 Management plan has been developed with and signed by and provided to consumers

Yes

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Shared Care (3 criteria) 0 Compliant

Risk Assessment (10 criteria) 0 Compliant

Risk Management (5 criteria) 0 Compliant

Discharge Planning (19 criteria)

0 Compliant

6.2 Internal Audit Results

The CAHS Internal Audit (IA) Program assesses nominated areas throughout CAHS against the National Safety and Quality Health Service Standards (NSQHSS) and where relevant the National Standards for Mental Health Services (NSMHS). The audit aims to provide feedback on current progress, identify gaps, provide recommendations, and highlight achievements.

Audit interviews take place during the 4th week of the month. Princess Margaret Hospital have elected to undergo two interviews per month, CAMHS one per month, and CACH one every alternate month.

There was 1 internal audit at BFC during this period covering both the National Standards for Mental Health Services (NSMHSS) and National Safety and Quality Healthcare (NSQHS) Standards.

BFC were assessed against the following action items:

NSQHSS 2.5.1 - Consumers and/or carers participate in the design and redesign of health services;

NSQHSS 2.6.1 - Clinical leaders, senior managers and the workforce access training on patient-centred care and the engagement of individuals in their care;

NSQHSS 4.1.2 - Policies, procedures and/or protocols are in place that are consistent with legislative requirements, national, jurisdictional and professional guidelines;

NSQHSS 4.2.1 - The medication management system is regularly assessed;

NSQHSS 5.5.1- A documented process to match patients and their intended treatment is in use;

NSQHSS 5.2.2 - The process to match patients to any intended procedure, treatment or investigation is regularly monitored;

NSMHS 1.7 - The MHS upholds the right of the consumer to have their needs understood in a way that is meaningful to them and appropriate services are engaged when required to support this;

NSMHS 1.4 - The MHS provides consumers and their carers with a written statement, together with a verbal explanation of their rights and responsibilities, in a way that is understandable to them as soon as possible after entering the MHS and at regular intervals throughout their care;

NSMHS 10.2.2 - The MHS informs its community about the availability, range of services and methods for establishing contact with its service; and

NSMHS 10.4.7 - The MHS has a procedure for appropriate follow-up of those who decline to participate in an assessment.

BFC was assessed as being compliant with all of the standards assessed. However there were two suggestions recorded:

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Standard 2.6.1: Suggestion for staff to access training around patient centred care. This has been addressed and compliance amongst BFC staff with Patient Centred Care training is now at 57%.

Standard 4.2.1: Suggestion that medication audit results are regularly disseminated to the Medication Safety Review Group. This has been successfully implemented and all medication audits are now reviewed by the Medication Safety Review Group.

Further information regarding the standards can be found at the following links: https://www.safetyandquality.gov.au/publications/national-safety-and-quality-health-service-standards/ http://www.health.gov.au/internet/main/publishing.nsf/content/mental-pubs-n-servst10

6.3 Clinical Incidents

There were no clinical incidents at BFC during the reporting period.

6.4 Risks

There were zero specific risks for BFC activated, archived or remaining on the risk register for the reporting period. Two generic Community CAMHS risk were listed on the risk register during this period:

Failure of CAMHS community facilities meeting mental health standards which was activated in 2012. This risk was ranked as high during this period.

Inadequate and invariable access to Community CAMHS services. This risk was ranked as high during this period.

Treatment Action Plans (TAPS) were in place to mitigate the risks throughout the reporting period.

6.5 Quality Improvements

During the period 1 July 2015 to 30 June 2016 BFC undertook a range of activities aimed at improving the quality of service they provide to their consumers. These included:

Reviewed BCARR provision at BFC, including the model of care and integration of Acute Mental Health care in the local area;

Established a parent intervention group for adolescents with suicidal ideation and self-injury (NB: this project was nominated for a WA Health Excellence award);

Delivered ‘Circle of Security’ parenting groups;

Introduced regular Family Therapy clinics and associated monthly systemic supervision and training for staff working with families;

Created a monthly ‘service improvement’ team meeting slot to allow for regular discussion, review and initiation of service improvement activities;

Introduced monthly complex case discussions using the AMBIT framework;

Implemented twice weekly ‘high risk’ meetings to support the team in managing high risk clients and improve internal coordination and communication of clinical governance;

https://www.safetyandquality.gov.au/publications/national-safety-and-quality-health-service-standards/

https://www.safetyandquality.gov.au/publications/national-safety-and-quality-health-service-standards/

http://www.health.gov.au/internet/main/publishing.nsf/content/mental-pubs-n-servst10

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Established specialised Choice appointment slots for infants, Culturally and Linguistically Diverse (CaLD) families and Aboriginal young people and their families; and

Established a BFC specialised infant mental health clinical reference group.

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7. Education and Training of staff

7.1 Mandatory Training BFC have one day set aside in each CAPA cycle specifically for mandatory training. This has allowed the team to significantly improve their mandatory training statistics.

Mandatory Training completion statistics from iLearn as of 8th

December 2016 (this is for Active users only i.e. thoses who are not on LSL, Paternity leave etc.)

Mandatory training name Employee count

Percentage not

complete

Percentage is complete

Narrative (where required)

CAHS induction 19 5% 95%

Aboriginal cultural awareness 19 10% 90%

Accountable and ethical decision making

19 10% 90%

Mandatory reporting of child sexual abuse

7 0.0% 100.0%

Record keeping awareness 19 21% 79%

Manual Tasks 19 32% 68% *

Hand hygiene 19 42% 58% *

Workplace aggression and violence 19 68% 32% *

Basic life support 19 58% 42% Compliance is low due to problems with accessing practical training on site.

Aseptic technique

7 71% 28%

Compliance is not as low as is indicated here. Some staff who have completed this training have had difficulties accessing and uploading evidence onto iLearn, This is being addressed as staff receive training in iLearn.

Clinical handover 16 37% 63% *

Human error and patient safety 16 81% 19% *

Infection control principles 16 87% 13% *

Medication Safety 7 71% 29% *

Patient and family centred care 16 319% 69% *

Emergency Management - Community

19 89% 10% *

*BFC encountered significant difficulties with moving data from the CLOVERS system to the new iLearn system. An audit was recently conducted to address this. BFC have also introduced a Mandatory Training day into the team CAPA’s cycle. The agenda for each training day is set according to current levels of compliance.

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Compliance rates have steadily increased over the last two CAPA cycles since implementing the above two initiatives

7.2 Other training completed by BFC Table 11: Other Training completed by BFC staff, as of 30 June 2016

Training Number of staff who completed training

CAMHS Orientation 2 (all staff compliant)

Clinical Skills Training 1

Alcohol and Other Drug training through the Drug and Alcohol Office

16

Introduction to Infant mental Health (Circle of Security)

4 ( up to 30 September 2016)

Mentalization Based Treatment Skills (MBT Skills)

15

NOCC training 10 (with remainder of team due to undertake training in February 2017)

Narrative therapy 2

Autism Diagnostic Observation Schedule training

2

Clinical Psychology Supervisor Training 2

Art therapy 3

AMBIT training 16

Reflective family play therapy 3

Family therapy (Anne Holloway) 16

Dialectic behavioural therapy 4

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8. Consumer and carer experience

8.1 Experience of Service Questionnaire (ESQ)

The use of the Experience of Service Questionnaire (ESQ), has enabled front line staff and the management team to better understand the way in which the service respond to the needs of children and families in Bentley. Originally developed by the Commission for Health Improvement (CHI) in the UK and adapted for use in CAHS CAMHS, the Experience of Service Questionnaire (ESQ) is a 15-item self-completion questionnaire that assesses users’ views of services with respect to accessibility, humanity of care, organisation of care and environment. The ESQ can be completed by parents/carers, children and young people and is anonymous.

During the period 1 July 2015– 30 June 2016, 47 children and 60 parents provided feedback via the ESQ.

BFC inform children, young people and their families of the changes made as a result of ESQ feedback via ‘You spoke, we listened’ posters, which are displayed throughout the clinic. An example of a recent ‘You spoke, we listened’ posters is included on the following page.

9 - 11 years 10

12- 18 years 37

Parent/Carer 60

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8.2 Complaints and Compliments In the reporting period, BFC received the following formal compliment:

Parent gave two flower arrangements and box of chocolates to clinicians. In the reporting period, BFC received the following formal complaints:

1. After Police attended an incident involving her child, the parent of the child attempted to report the events to the team responsible for her child’s care at BFC. The parent could not get in touch with the Case Manager and left a message with the clerical staff for him to urgently phone her back. The parent stated that the only contact she received from the Case Manager was a text message the next day inviting her to attend the clinic for an appointment the same day. The parent felt that the response was inadequate and left her family without appropriate support.

2. A past patient of BFC lodged a complaint about a report that was written by a BFC nurse in 2009 and sent to the Department of Child Protection. The past patient claimed that some of the information contained within the report was false. At the time of lodging the complaint, the past patient was undergoing a court process and felt that the information in the report may prejudice her court case.

3. A parent stated that her daughter was ‘contracted’ to six appointments at BFC but that the 6th appointment was cancelled without consultation with the parent. The parent felt that BFC were ‘anticipating’ the child’s discharge. The parent also complained that the staff at BFC would not give her the email address of the BFC Service Manager.

All of these complaints were analysed to determine whether any service process improvements could be implemented at BFC to reduce the likelihood of similar complaints being received. It was determined that complaints 1 and 2 did not present any opportunities for service improvement. Letters were sent to both complainants in response to the concerns raised which summarised the decisions made and actions taken by BFC and options for the future. In relation to the third complaint, the following actions were undertaken:

The BFC Service Manager and the child’s case manager initiated a review of the child’s management plan and arranged for a slot to remain open for the continuation of the child’s therapy.

The BFC Service Manager conducted a review of the BFC appointment scheduling system, which had recently been changed due to the implementation of the Choice and Partnership Approach.

The parent’s feedback regarding the provision of email addresses was noted for future planning around establishing a more direct and consumer-focussed means of communication with CAMHS services. BFC have since established a generic email address for the clinic and provide this address to all consumers.

A letter was sent to the complainant apologising for any upset and inconvenience the family experienced. The letter summarised the decisions made and actions taken by BFC and made note of the service improvement activities the clinic was planning to undertake in response to the complainant’s letter.

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9. Patient Outcomes

9.1 NOCCS

NOCC, and in particular the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA), may be used to fund episodes of care on a national level from the beginning of the 2017 financial year. NOCC training was identified as a gap in the training currently delivered face to face in Community CAMHS, as the online training package gave clinicians little opportunity to practice rating and no opportunity to discuss the clinical vignette with colleagues and managers. With the objective of training Community CAMHS clinicians in the clinical rating tools and embedding the scores into clinical management plans to improve services delivered to children, young people and their families/carers, a project was initiated to provide NOCC training and clinical utility training workshops to all CAMHS clinical staff that are responsible for completing NOCC measures. It was decided that special attention would be given to the HoNOSCA and ensuring that ratings given in this measure are reflected in clinical management and crisis management plans. BFC staff completed this new training on 26 October 2016. A follow-up training session was held on 14 February 2017.

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10. Policy

New/reviewed policy documents are implemented at BFC CAMHS via: o Discussion at team Business meetings; and o Subsequent circulation to all team members in the Business meeting minutes.

Recently released policy documents that have been discussed and implemented at team level include: o Operational CAMHS policy document

CAMHS Leave Backfill o Clinical CAMHS policy documents:

CAMHS Managing Clinical Risk After Disclosure of Child Sexual Abuse CAMHS Sexual Safety Guideline CAMHS Shared Care Guideline

Including new FAQ for children and families CAMHS Temporary Electronic Storage Of SSCDs and MHA forms

o Community CAMHS policy: Community CAMHS Multidisciplinary Team Review Guidelines – updated to

include reference to shared care

Recently reviewed policy documents that have been discussed and implemented at team level include: o CAMHS Risk Assessment and Management policy

BFC also have a standing agenda item on their Business meeting agenda for ‘Service Improvement’. Any issues relating to policy compliance or lack of knowledge around policy are discussed in this slot.

https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/CAHS/CAMHS.PM.LeaveBackfill.pdf

https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/CAHS/CAMHS.PM.ManagingClinicalRiskAfterDisclosureofChildSexualAbuse.pdf

https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/CAHS/CAMHS.PM.SexualSafety.pdf

https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/CAHS/CAMHS.PM.SharedCare.pdf

https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/CAHS/CAMHS.PM.TemporaryElectronicStorageOfSSCDsAndMHA%20forms.pdf

https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/CAHS/CAMHS.COMM.CommunityCAMHSMultidisciplinaryTeamReview.pdf

https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/CAHS/CAMHS.PM.RiskAssessmentAndManagement.pdf

This document can be made available in alternative formats on request for a person with a disability.

© Department of Health 2016

Copyright to this material is vested in the State of Western Australia unless otherwise indicated. Apart from any fair dealing for the purposes of private study, research, criticism or review, as permitted under the provisions of the Copyright Act 1968, no part may be reproduced or re-used for any purposes whatsoever without written permission of the State of Western Australia.

http://www.health.wa.gov.au/

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