harnessing the power of lean to advance behavioral health...

6/20/2018

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Harnessing the Power of Lean to Advance Behavioral Health Crisis Care

Margie Balfour, MD, PhD

Connections Health SolutionsChief of Quality & Clinical Innovation

Assistant Professor of Psychiatry, University of Arizona

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AZ Statewide Strategy Session: Averting Preventable Psychiatric ReadmissionsMay 24, 2018

Previously presented at the National Council for Behavioral Health Annual ConferenceApril 2018

The Crisis Response Center

• Built with Pima County bonds in 2011 to provide an alternative to jail, ED, hospitals– 12,000 adults + 2,400 youth each year

– 24/7 urgent care/triage + 23 hour observation + subacute

• Law enforcement receiving center

• Space for community clinic staff

• Adjacent to– Crisis call center/mobile team dispatch

– Mental health court

– Inpatient psych hospital for civil commitment evals

– Emergency Department (ED)

• Managed by Connections since 2014

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Crisis Response Center in Tucson, AZ ConnectionsAZ/Banner University Medical Center

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The Connections 23‐Hour Observation Model• Safe and welcoming environment that can quickly meet any behavioral health need

• No wrong door

– <10 min drop off for cops

– No behavioral health exclusionary criteria (can be highly agitated etc.)

• Community stabilization as an alternative to inpatient:

– 60‐70% discharged to the community

– Early intervention

– Interdisciplinary team, including MD/NP/PA 24/7

– Aggressive discharge planning and community collaboration

– Assumption that the crisis can be resolved3

Peers with lived experience are an important part of the

interdisciplinary team.

Problems at the Crisis Response Center

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The climate of an organization influences an individual's contribution far more than the individual himself.

A bad system will beat a good person every time.

W. Edwards Deming

1900-1993

“

”

The Technology of CQI: The Toyota Way (Lean)

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Respect

• Respect others• Make every effort

to understand each other

• Take responsibility• Do our best to

build mutual trust

Teamwork

• Stimulate personal and professional growth

• Share opportunities for development

• Maximize team and individual performance

Challenge

Long term vision to meet challenges with courage and creativity to realize our dreams

Kaizen

Improve business operations all the time by always trying for innovation and evolution

GenchiGenbutsu

Go to the source to find the facts to make correct decisions and build consensus and trust

RESPECT FOR PEOPLE CONTINUOUS IMPROVEMENT

THE TOYOTA WAY

“Lean” = The Toyota Way adopted for US manufacturing

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Where to begin at the CRC?

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Genchi Genbutsu• Town‐hall meetings with executive leadership and front‐line staff• Rounding on units, asking questions of patients and staff• Leaders working clinical shifts to experience problems firsthand

Findings• Culture in which staff were were afraid of being punished for

mistakes• No clear consensus on vision and values (even among the

management staff)• Lots of problems but agreement that the adult triage process

was top priority

Developed new mission and valuesOnce there was consensus, leadership could set goals and engage front‐line staff with a consistent message

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New CRC Mission:

To meet the immediate needs of people in behavioral health crisis in a safe and supportive environment in collaboration with community partners.

New CRC Values: Care that is• Timely• Safe• Accessible• Least‐restrictive• Effective• Consumer & Family Centered• Partnership with community stakeholders

When in doubt: 1) Safety is the Prime Directive, and 2) Follow the Golden Rule

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Excellence in Crisis

Services

Timely

Safe

Least Restrictive

• Door to Diagnostic Evaluation• Left Without Being Seen• Median Time from ED Arrival to ED Departure for ED

Patients: Discharged, Admitted, Transferred• Admit Decision Time to ED Departure Time for ED

Patients: Admitted, Transferred

• Rate of Self‐directed Violence with Moderate or Severe Injury

• Rate of Other‐directed Violence with Moderate or Severe Injury

• Incidence of Workplace Violence with Injury

• Community Dispositions • Conversion to Voluntary Status• Hours of Physical Restraint Use• Hours of Seclusion Use• Rate of Restraint Use

Partnership

Effective • Unscheduled Return Visits – Admitted, Not Admitted

• Law Enforcement Drop‐off Interval• Hours on Divert• Provisional: Median Time From ED Referral to

Acceptance for Transfer• Post Discharge Continuing Care Plan Transmitted to

Next Level of Care Provider Upon Discharge• Provisional: Post Discharge Continuing Care Plan

Transmitted to Primary Care Provider Upon Discharge

• Denied Referrals Rate• Provisional: Call Quality

Accessible

Consumer and Family Centered

• Consumer Satisfaction• Family Involvement

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Values-Based Outcome MetricsCRISES: Crisis Reliability Indicators Supporting Emergency Services

Balfour ME, Tanner K, Jurica PS, Rhoads R, Carson C. (2015) Community Mental Health Journal. 52(1): 1‐9 .http://link.springer.com/article/10.1007/s10597‐015‐9954‐5

Identified Problems & Project Aim

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Went back to front line staff to better understand the problem…

Project Aim: Decrease the time to assessment and initiation of treatment while ensuring that care is delivered the safest and least‐restrictive

treatment setting required to meet each individual’s needs.

Patient Experience Patient Safety

• Long waits in the clinic/triage area• Delays and inconsistencies in physician

decisions to either discharge or admit to the observation unit

• Patient frustration with long waits and being asked the same questions over and over

• High‐risk patients left unattended for long periods of time.

• Staff spread out over a large area.• Frequent calls to security• Staff injuries and assaults

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Process Mapping

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Process mapping

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Genchi GenbutsuAsk the people who actually do the work to map the process

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Value AnalysisWhich tasks provide value to the customer?

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130

130

265

183

246

60

0 100 200 300 400 500 600 700

Old Process

New Process

Time Spent (Minutes)

Value‐Added Non Value‐Added But Necessary Waste

Examples:• Value‐added: Doctor meeting with the patient to do a psych eval• NVAN: Unit clerk entering demographics information in the chart for billing• Waste: Patient sitting in the waiting room twiddling her/her thumbs

Process Changes

Phase I Interventions: July 1, 2014• Early sorting of high‐risk vs. low risk patients via new triage tool

• Standing order set eliminating the need to wait for physician orders to move high risk patients to the obs unit

• Redistributed staff (but did not add) – Stationed a tech in the waiting room so that the lower risk patients could all be observed there instead

of waiting in assessment rooms

– Consolidated the rest of the staff onto the obs unit to care for the high‐risk patients

• Reduced redundancy in documentation

Phase II Interventions: October 1, 2014• Aligned provider staffing pattern to better match demand

• Added a 12 hour shift assigned specifically to triage

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More efficient use of space

• Nearly half of the clinic space was repurposed

• Overflow observation unit increased the observation unit capacity from 25 to 35 patients

• Resulting in less time on diversion (unable to accept transfers from other hospitals/ERs)

Balfour ME, Tanner K, Jurica JS, Llewellyn D, Williamson R, Carson CA. (2017) Using Lean to Rapidly Transform a Behavioral Health Crisis Program: Impact on Throughput and Safety. Joint Commission Journal on Quality and Patient Safety 2017 Jun;43(6):275‐283. https://dx.doi.org/10.1016/j.jcjq.2017.03.008

Outcomes: Throughput measures

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DecNovOctSepAugJulJunMayAprMarFebJan

600

400

200

0

S l

Minu

tes

__X=436.5

__X=174.5

__X=138.8

UCL=614.6

UCL=306.6 UCL=380.2LCL=258.5

LCL=42.3 LCL=-102.62

1

1

111111

111

11

22222

111111

A. Clinic door-to-door dwell timePhase I Phase II


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Outcomes: Throughput measures

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DecNovOctSepAugJulJunMayApr

30

20

1 0

0

Hour

s - M

ean

__X=7.53

__X=10.67

__X=2.93

UCL=9.71

UCL=25.58

UCL=4.23

LCL=5.34LCL=-4.24 LCL=1.63

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111

1

1

111

1

Phase II

B. Observation unit door to doctor timePhase I


Outcomes: Safety measures

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0

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90

Jan‐Jun Jul‐Dec

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Baseline(Apr‐Jun)

Phase I Phase II

Obs Unit

Clinic

Staff Injuries

There are fewer assaults to staff.

Calls to Security

There are fewer calls to security for behavioral emergencies.

Balfour ME, Tanner K, Jurica JS, Llewellyn D, Williamson R, Carson CA. (2017) Using Lean to Rapidly Transform a Behavioral Health Crisis Program: Impact on Throughput and Safety. Joint Commission Journal on Quality and Patient Safety 2017 Jun;43(6):275‐283.

Injuries in the clinic triage area were

completely eliminated

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Lean principles support the clinical goals of behavioral health crisis services

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Maximize value‐added

time

Assign peer to sit w/pt during admission process

Better patient engagement

Focus on customer

Consolidate staff on obs

unit

Higher staff to patient ratio

Better monitoring of high risk patients

Efficient use of resources

Decreased wait time

Treatment starts earlier

Least restrictive care (DC or avoid escalation to restraint)

Reduce waste


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Quality is not something you install like a new carpet or a set of bookshelves.

You implant it.

Quality is something you work at. It is a learning process.

W. Edwards Deming

1900-1993

“

”

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HardwireCQI concepts into management structure and culture in order

to sustainchanges and

advance further.

Line‐level leadership is critical

• Empower the people who do the work every day to lead the team and make improvements

• Push the decision‐making as far down as possible

• Created “leads” for each discipline on each shift (charge nurse, lead tech, etc.)

• Training the leads in Lean methods and so they can do their own process improvement projects

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Key philosophical shift:

• Management is here to support the line staff not the other way around.

• The culture must shift from asking “Why DIDN’T they do their job” to “Why COULDN’T they do their job?”

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Impact of sharing data with staff

• Problem: Nurses were assessing patients on arrival, but delayed entering their assessment into the EHR where others could read it.

• Intervention: Gave this graph to the Charge Nurses.

• Result: Dramatic reduction in the time from Arrival to RN Assessment

• Cost: Printing 4 copies of this graph.

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0

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40

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120

140

SUN MON TUE WED THU FRI SAT

Minutes

Arrival to RN Assessment

Feb April

Lessons Learned / Key Ingredients

• Buy‐in and support from leadership

• Engagement of the front‐line staff

• Clear vision and values

• Measuring and sharing performance data

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Research challenge:Baseline data destroyed when we arrived, but due to safety concerns, we had to start improvements ASAP.

• Couldn’t do rigorous analyses of baseline data before starting interventions.

• Didn’t have good pre‐post comparison for some measures.

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Without data you’re just another person with an opinion.

W. Edwards Deming

1900-1993

“”

Metrics are the incarnation of values.

Why care about performance data?

Metrics help us determine whether we are

– Living up to our core values

– Providing value to our customers and stakeholders• People/families receiving care

• Community partners

• Payers

• Regulators

– And tell us what to improve

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The obvious answers:– Regulatory Compliance (Stay out of trouble)

– Pay for Performance (Get paid)

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Excellence in Crisis

Services

Timely

Safe

Least Restrictive

• Door to Diagnostic Evaluation• Left Without Being Seen• Median Time from ED Arrival to ED Departure for ED

Patients: Discharged, Admitted, Transferred• Admit Decision Time to ED Departure Time for ED

Patients: Admitted, Transferred

• Rate of Self‐directed Violence with Moderate or Severe Injury

• Rate of Other‐directed Violence with Moderate or Severe Injury

• Incidence of Workplace Violence with Injury

• Community Dispositions • Conversion to Voluntary Status• Hours of Physical Restraint Use• Hours of Seclusion Use• Rate of Restraint Use

Partnership

Effective • Unscheduled Return Visits – Admitted, Not Admitted

• Law Enforcement Drop‐off Interval• Hours on Divert• Provisional: Median Time From ED Referral to

Acceptance for Transfer• Post Discharge Continuing Care Plan Transmitted to

Next Level of Care Provider Upon Discharge• Provisional: Post Discharge Continuing Care Plan

Transmitted to Primary Care Provider Upon Discharge

• Denied Referrals Rate• Provisional: Call Quality

Accessible

Consumer and Family Centered

• Consumer Satisfaction• Family Involvement

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Values‐Based Outcome MetricsCRISES: Crisis Reliability Indicators Supporting Emergency Services

Balfour ME, Tanner K, Jurica PS, Rhoads R, Carson C. (2015) Community Mental Health Journal. 52(1): 1‐9 http://dx.doi.org/10.1007/s10597‐015‐9954‐5

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Connections Crisis Facility KPIsMetric Outcome Relevance

Urgent Care Clinic: Door‐to‐Door

Length of Stay < 2 hoursPatients get their needs met quickly instead of going to an ED or allowing symptoms to worsen.

23‐Hour Obs Unit:

Door‐to‐Doctor Time < 90 minTreatment is started early, which results in higher likelihood of stabilization and less likelihood of assaults, injuries and restraints.

23‐Hour Obs Unit:

Community Disposition Rate (diversion from inpatient)

60‐70%Most patients are able to be discharged to less restrictive and less costly community‐based care instead of inpatient admission.

Law Enforcement Drop‐Off

Police Turnaround Time < 10 minIf jail diversion is a goal, then police are our customer too and we must be quicker and easier to access than jail.

Hours of

Restraint Use per 1000 patient hours

< 0.15Despite receiving highly acute patients directly from the field, our restraint rates are 75% below the Joint Commission national average for inpatient psych units.

Patient Satisfaction Likelihood to Recommend > 85%

Even though most patients are brought via law enforcement, most would recommend our services to friends or family.

Return Visits within 72hfollowing discharge from 23h obs 3%

People get their needs met and are connected to aftercare. A multiagency collaboration addresses the subset of people with multiple return visits.

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Thinking bigger…

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Crisis Center “There was a problem at the pharmacy and I couldn’t get my meds filled.”

“I couldn’t get in to see my

doctor at my clinic.”

“I got kicked out of my group

home… AGAIN.”

“I missed my appointment because I don’t

have transportation.” “I can’t handle my

child at home by myself.”

“I couldn’t get my case manager on

the phone.” “I don’t have a safe place to stay.”

“These meds aren’t working.”

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Harnessing crisis data to drive system improvement

• Every CRC visit is a story about how someone couldn't get their needs met in the community.

• If we turn the stories into data, it can reveal trends about things that need improving in the overall behavioral health system.

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“Maybe stories are just data with a soul.”

‐ Brene Brown

Arizona Behavioral Health System Structure

Hospitals, Crisis Facilities, Clinics, etc.

Counties

Other state funds

AZ Medicaid

Regional Behavioral Health Authorities (RBHAs)

The southern region is comprised of 38,542

square miles in 8 counties or

3 Marylands

+ + =

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Connections‐CenpaticoData Analysis Partnership

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System‐wideQuality Improvement

AnalysisCrisis

Response Center(CRC)

Monthly Joint Data Meeting

Regional Behavioral Health

Authority (Cenpatico)

Daily Data Feed

and other reports

Cenpatico – an insurance company – mostly gets its data from billing, which can be up to 90 days old. The CRC developed a daily data report of the Cenpatico patients who went through the CRC that day. This allows more up‐to‐date and useful analyses.

Balfour ME, Zinn T, Cason K, Fox J, Morales M, Berdeja C, Gray J; Provider‐Payer Partnerships as an Engine for Continuous Quality Improvement; Psychiatric Services; Epub ahead of print; March 1, 2018. http://dx.doi.org/10.1176/appi.ps.201700533

Return Visits/Readmissions

• CRC UM staff already reads all inpatient charts in order to do concurrent reviews

• This provides an excellent opportunity to glean meaningful data for quality improvement purposes.

• Charts are abstracted each month

– Return to CRC within 72 hours resulting in an admission to the inpatient unit

– 30 day readmissions to inpatient unit

– Time permitting, all other 72‐hour return visits

• Summaries are given to involved CRC staff, Cenpatico, and outpatient clinic.

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Example Application: Crisis utilization by Clinic

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0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

July '16 Aug. '16 Sept. '16 Oct. '16

Percent of each clinic’s adult population that had a CRC visit

Maybe this clinic needs some

help?

Connections has the NUMERATORCenpatico has the DENOMINATOR

Youth Services Trends,

Interventions, and Outcomes

Special thanks to Karena Cason at Cenpatio Integrated Care

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Identifying Stress Points

0

5

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15

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25

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10/30 ‐11/05

11/06 ‐ 11/11

11/12 ‐ 11/18

11/19 ‐ 11/25

11/26 ‐ 12/02

12/03 ‐ 12/09

12/10 ‐ 12/16

12/17 ‐ 12/23

12/24 ‐ 12/30

12/31 ‐ 01/06

01/07 ‐ 01/13

01/14 ‐ 01/20

01/21 ‐ 01/27

01/28 ‐ 02/03

02/04 ‐ 02/10

02/11 ‐ 02/17

02/18 ‐ 02/24

02/25 ‐ 03/02

03/03 ‐ 03/09

03/10 ‐ 03/16

03/17 ‐ 03/23

03/24 ‐ 03/30

03/31 ‐ 04/06

04/07 ‐ 04/13

04/14 ‐ 04/20

04/21 ‐ 04/27

04/28‐05/04

05/05‐05/11

05/12‐05/18

05/19‐05/25

05/26‐06/01

06/02‐06/08

06/09‐06/15

06/16‐06/22

06/23‐06/29

06/30‐07/06

07/07‐07/13

07/14‐07/20

07/21‐07/27

07/28‐08/03

08/04‐08/10

08/11‐08/17

08/18‐08/24

08/24‐08/31

Cen

patico M

embers

Week

Youth Visits Per WeekWeek before

Winter Break Return from

Spring Break + Testing

Return from Summer Break

How can we address this proactively?

Courtesy Karena Cason, Cenpatico

Youth Services: Interventions driven by data

BEFORE THE CRISIS: Improved outpatient support

DURING THE CRISIS: Improved CRC‐clinic

collaboration

AFTER THE CRISIS: Improved placement processes

• Cenpatico developed a process for Crisis Mobile Teams to respond to school calls instead of the police

• Cenpatico created a new program to provide more in‐home supports for at‐risk youth

• Worked with clinics re appropriate use of the CRC

• CRC set times for each clinic to call into morning rounds on the youth observation unit to participate in discharge planning for their patient

• CRC created slotted times for Child and Family Team meetings to make them easier to schedule while the patient is at the CRC

• Agencies developed process to determine BIP/Level 2 availability after morning rounds to facilitate quicker placement

• CRC, Cenpatico, and agency medical directors developed closer collaborations and communication, especially around challenging patients

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Results: Reduced Readmissions

1.60%

1.10%

0%

1%

2%

2016 2017

Youth 23 hr obsReturn visits within 72 hours

*Comparison of Q1‐Q3 (Oct‐June) each year. YCSU p < 0.03

*

Balfour ME, Zinn T, Cason K, Fox J, Morales M, Berdeja C, Gray J; Provider‐Payer Partnerships as an Engine for Continuous Quality Improvement; Psychiatric Services; Ebup ahead of print; March 1, 2018; https://doi.org/10.1176/appi.ps.201700533

Results: Improved flow = less kids getting stuck

UCL 33:55

CL 25:53

LCL 17:52

14:24

19:12

24:00

28:48

33:36

38:24

43:12

48:00

X Values

CRC Youth 23 Hour Obs Unit Median Length of Stay

BEFORE: Kids often got stuck at the CRC due to placement issues, resulting in lengths of stay well over 24 hours

AFTER: Length of stay is consistently below 24 hours

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Adult Services Trends,

Interventions, and Outcomes

Special thanks to Tylar Zinn at Cenpatio Integrated Care

Identifying the Problem

The adult project focused on the highest utilizers of CRC services.

QUESTIONS:– As a system, are we treating high utilization of the CRC as a symptom of something lacking for members?

– Are we being proactive in trying to solve that problem?

– What do these individuals need that they’re not getting?

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Defining High Utilizers

72.4%

82.8%89.2%

95.5% 98.3% 100.0%

0%

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100%

120%

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1600

1 Visit 2 Visits 3 Visits 4 Visits 5‐6 Visits 7‐8 Visits 9+ Visits

Adult 23 hr Obs Visits Oct 2015 ‐ Jan 2016

# of Individuals Count of visits Cum %

CUTOFF POINT: 82.8% of all visits were by individuals who had fewer than 4 visits in a 4 month period. Therefore a high utilizer was defined any individual with 4 more more visits in the preceding 4 months.

Collecting the Data: Beyond claims = Outreach to clinics

Courtesy Tylar Zinn, Cenpatico

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Analyzing the Data: Example

• The Service Plan and Crisis Plan should be “living documents” that change in response to each member’s needs.

• Is this happening?

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0.1

0.2

0.3

0.4

0.5

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Clinic 1 Clinic 2 Clinic 3

CRC visits per week vs Plan changes per week (3 largest clinics)

Avg CRC visits Avg Plan changes

The clinic with the MOST number of plan changes had the FEWEST number of CRC visits.

Courtesy Tylar Zinn, Cenpatico

High Utilizer QI Plan

DATA REPORTING: The CRC sends a monthly rolling frequent utilizer report to Cenpatico.

Lastname

Firstname dob ICC T19 status rbha payer

Clinic Only Obs Total

Visit this month?

LA FRONTERA SMI T19 Cenpatico AHCCCS only 9 10 19 Y

LA FRONTERA SMI T19 Cenpatico AHCCCS only 0 4 4 YCOPE SMI T19 Cenpatico AHCCCS & Medicare 0 4 4 Y

LA FRONTERA SMI T19 Cenpatico AHCCCS only 0 6 6 Y

COPE SMI T19 Cenpatico AHCCCS only 1 4 5 Y

MULTI‐AGENCY TEAM MEETINGS with CRC, Cenpatico, clinic staff to discuss the patient’s needs and develop improved crisis and service plans. The goal is at least 3 staffings per patient regardless of whether they are at the CRC that day.

CHARTS FLAGGED at the CRC with information about the new crisis plan and who to contact so that the new plan can be implemented.

1

2

3

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Results: Reduced Readmissions

5.50%

2.80%

0%

1%

2%

3%

4%

5%

6%

2016 2017

Short‐Term Inpatient30 Day Readmissions

3.30%

2.20%

0%

1%

2%

3%

4%

2016 2017

Adult CSU Return visits within 72 hours

*Comparison of Q1‐Q3 (Oct‐June) each year. ACSU p < 0.02, STIU p < 0.01

**


Results: Fewer “Familiar Faces”There were 64 individuals on the original list of high utilizers. One year later, only 7 of the original 64 remain high utilizers, and only 37 meet the high utilizer definition.

Case Example: Ms. X becomes lonely during the weekend, which is a trigger for feeling overwhelmed and suicidal and coming to the CRC. She has a partner who is also enrolled in services.

PLAN: • The outpatient provider will do welfare checks on nights and weekends to help

plan for boredom and other triggers that historically result in CRC visits. • The team will explore working with her partner’s team (if they consent) in

order to assist both in recovery together.• The CRC will call her case manager and Peer Support Specialist immediately

upon arrival to reinforce the relationship with her outpatient team and help connect her more quickly with outpatient support.

Result: Ms. X is no longer a high utilizer. CRC visits decreased from 14 in 2016 Q1 to only 1 during the same time frame in 2017.

7

64

37

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50

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70

May 2016 May 2017

CRC Adult High Utilizers

Curent High Utilizer Group

Original High Utilizer Group


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Lessons Learned/Key Ingredients

• Real‐time data sharing and analysis

• Rapid cycle QI approach

• Team composition:

– Leaders who can make decisions

– Front‐line staff who can provide context based on real‐world experience

• Collaborative culture of “figure out how to say yes instead of look for reasons to say no”

Thinking even biggerSystem Dashboards to catalyze collaborative

solutions to system problems

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The best dashboard EVER.

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Ideal crisis system

Resolve crisis in the least restrictive setting

Community safety

Minimize ED Boarding

• % mobile team resulting in community disposition (%L1, CRC, com, BIP, ED, DTX)• % 23‐hr obs visits resulting in community disposition• Crisis facilities % conversion to voluntary• % Revocations of outpatient civil commitment • % SWAT calls that are mental health related

• Suicide attempts post ED visit for SI/self harm• Overdoses post ED visit for opiate use disorder or naloxone administration• % law enforcement mental health transports resulting in use of force• % law enforcements fatalities with “mental health nexus”• % law enforcement calls for welfare check or suicidal.• # suicidal barricade calls ($10K each)

• Median time from admit decision to ED departure for behavioral health admits• Total hours of psych boarding in medical EDs• Crisis facilities % hours on diversion

Meet needs of complex pts

Get people connected• % crisis encounters with a followup phone call in 72 hours: % attempt, % reached• % receiving X followup in Y days (need to define parameters, HEDIS?)• % Medicaid applications initiated in crisis episode that were completed

• % high utilizers (need separate meeting to work through this complex issue)

• % jail bookings with mental illness (how do we measure?) and SMI (AZ specific)• # jail days for mental health/SMI population (or % total jail days?)• # MHST cases worked without a criminal nexus

Diversion from justice system

Consumer & family centered • Satisfaction (Likelihood to recommend)

Timely• Call center: speed of answer, abandonment rate)• Median time from mobile team dispatch to arrival (police and non‐police)• Crisis facilities Median Door to Qualified Behavioral Health Professional

Accessible• Something assessing language accessibility• Rural accessibility: To start look at rural counties outcome measures separately

DRAFTCrisis System

Dashboard for Pima Co

& SouthernAZ

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Pima Title 36 Workgroup: Data MapAll of the points a patient encounters along the civil commitment path.

What metrics should we be looking at and who has the data?

Courtesy Sarah Davis, Pima County

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Repeat emergency revocations to the CRC(for patients on outpatient civil commitment)

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0

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40

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60

70

‐2.0 ‐1.0 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0

Number

Values

VisitsLSL ‐1.5 USL 4.5

Mean 1.5Median 1.0Mode 1.0n 89 Cp 1.6

Cpk 1.6CpU 1.6CpL 1.6Cpm 1.0Cr 0.6ZTarget/Z0.0Pp 1.0Ppk 1.0PpU 1.0PpL 1.0Skewness2.8Stdev 1.0Min 1.0Max 6.0Range 5.0Z Bench 4.7% Defects3.4%PPM 33707.9Exp PPM ST1.6Exp PPM LT2737.5Sigma 3.3

Who arethese people?

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Where are these

patients coming from?

Can we target interventions to prevent the need for

involuntary law enforcement transports?

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Group Home

Crisis Line

Mobile Crisis Team

Outpatient Clinic

Crisis Response Center

911 Dispatch

Law Enforcement

The“Group Home Guy”

Multiagency QI Process to reduce T36 revocations

Early Results

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UCL 74.63

CL 58.67

LCL 42.71

37.4

42.4

47.4

52.4

57.4

62.4

67.4

72.4

77.4

Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17 Oct‐17 Nov‐17 Dec‐17

Apr‐17 ‐ Dec‐17

CRC T36 Revocations per month

6/20/2018

29

Questions?

57

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