The Royal Children's Hospital Melbourne

Projects - IMHP

The IMHP Quality Projects

• Assessment Quality Project 
• Banksia IPU Seclusion Project (PDF 30KB)
• Banksia Speech Pathology Project   
• Clinical File Audit (PDF 30KB)   
• Clinical Guidelines 
• Consumer and Carer Participation
• Core Competencies
• Dual Diagnosis (PDF 653KB)
• Koori Mental Health Project
• Outcome Measures (PDF 30KB)
• Review of Clinical Governance Framework
• Risk Assessment Management (RAM) CQI Project (PDF 14KB)
• Staff Wellbeing (PDF 88KB)

 

The IMHP Strategic Plan 2007-2010

Background

The Royal Children’s Hospital Strategic Plan 2007-10 described a philosophy of Care with 4 principles, which have informed the Strategic Plan of the RCH Integrated Mental Health Program:

• Child & Family Centred Care
• Respect for children’s needs & issues
• Care coordination
• Partnerships and Linkages.

The listed top priorities in the RCH Strategic Plan were as follows:

1. Achieve budget and activity targets, and develop key organisational processes and systems that promote a ‘business-like’ environment and provide discipline and management control.
2. Commence the RCH ‘Building our Future Program’, which is focused on change projects related to models of care; clinical and business process/system redesign; and organisational development.
3. Work with DHS to implement the ‘Review of Victorian Paediatric Services’ recommendations, particularly in relation to State-wide Paediatric Services and clarification of the role of RCH.
4. Develop an RCH-wide philosophy and culture of patient and family-centred care, based on the key principles of customer service and satisfaction.
5. Develop an integrated approach to quality and risk management, with a particular focus on patient safety and the development of effective clinical and corporate reporting tools and structures.
6. Build and improve relationships with key partners – Murdoch Children’s Research Institute,  University of Melbourne and Dept of Health, to clarify relationships, positions and  management.
7. Align the development and implementation of the new models of care with key enabling strategies, such as:
   • ICT Strategic Plan and implementation of HealthSMART initiatives; and
   • Human Resources Strategic Plan, particularly workforce planning and alignment initiatives.
8. Develop a strategic approach to internal communications to align with the cultural change components of Building our Future and fosters ‘a strong, united and focused organisation’.

These priorities also helped to shape the Review of the RCH Mental Health Service in 2007 conducted by its new Director, who used an interview methodology to gain multiple perspectives on its structure, culture, design, use of information, communication and function. This was collated with quantitative data about MHS performance to identify strengths and weaknesses of the service. The Review Report outlined a new strategic direction for the service, which was agreed by the Hospital. This strategic direction had two major activity streams:

1. To strengthen the mental health service, and
2. Develop a more coordinated system of mental health care within the hospital.

Stream One: Strengthening the Integrated Mental Health Program

This stream will be the initial focus of activity, with the directions and goals outlined below:

1. That the proposed new Vision and service principles are adopted, after extensive discussion within the MHS.
2. That MHS staff discuss and debate the proposed new values and behaviours to establish whether they are worthy of the service, and agree on behaviours that will define MHS membership and be embraced and upheld by all staff.
3. That the service is restructured into four interdependent programs, two of which will address the clinical needs of the Western Region community and the Hospital. Other programs will aim to build a broader system of mental healthcare, and support research and training.
4. That all the community MHS teams are managed as a distinct Community Program, to support greater consistency of practice, processes and procedures, and to strengthen clinical governance and coordination in service planning and delivery.
5. That a Hospital Program is established to support more consistency of practice, processes and procedures within RCH, and facilitate coordination of planning and service delivery, and improved clinical governance and service coordination within the Hospital setting.
6. That a new Linkages Program is created to support an agenda of improved collaborative practice and coordination of community activity, more strategic community development or capacity building, the development of a community MH Plan and work to strengthen consumer partnerships and cultural competency in the service. 
7. That MHS specialist skills are enhanced to improve access to specialist services for low to moderate prevalence special patient populations, such as distressed infants and preschool children, Eating Disorders and Autism. This will require a strategy to develop specialist clinical programs and enhance professional development in the MHS. 
8. That within the Hospital Program, the Department of Psychology is no longer a separate department and will become a service in the MH program, but state-wide psychology services will continue, and the position of head of psychology will be maintained.
9. That in the absence of separate revenue streams for child psychoanalytic psychotherapy or psychotherapy research, the separate department of psychotherapy will not continue as a separate department. A child psychotherapy discipline stream and discipline head will be maintained to support ongoing quality child psychotherapy services in RCH MHS. 
10. That the HC&L service will continue as a key component of the Hospital Program and will implement the recommendations in the HC&L Review Report, including integrating its Intake into the central MHS Intake. 
11. That the Banksia Unit model of care and staffing allocations will be reviewed against Australian best practice, with a view to increasing the range of therapeutic programs available there. This review will include comprehensive consideration of the training needs of Banksia nursing staff. 
12. That the Management of Clinical Aggression (MoCA) training will be continued in the Banksia Unit, and be rolled out across the community and hospital teams as soon as practicable to support safe clinical practice. The Banksia quality plan will include a project to reduce the use of seclusion and restraint within the unit. 
13. That specialist Clinical Programs are built into each of the Community or Hospital Programs to support clinical research, with specific programs related to the prevalence of a problem and potential to build partnerships with other hospital departments or programs. 
14. That the Infant specialist Program will be maintained within the Hospital Program, with interdepartmental links, and its focus will be expanded to train and support community MHS clinicians to work more effectively with infants and pre-school children. 
15. That the Autism Program remains linked with the Community Outpatient Program to continue its work of education and capacity building for Autism assessment and support services in the WMR. New programs will be developed for Infants and Preschool Children and for clients with Complex Problems that do progress despite intra-team review. 
16. That the Intensive Mobile Youth Outreach Service will become a specialist team to be managed under the Community Program, and will specialize in the care of adolescents who are hard to engage and present clinical problems that present high risk of harm to these clients or the community. 
17. That the Linkages Program will manage the Mental Health Promotion Officer, Festival for Healthy Living Program, Koori Social and Emotional Wellbeing Program, Consumer Consultant, Community Group Program, CASEA (Conduct Disorder Early Intervention), and RCH MHS Intake. 
18. That the RCH MHS Intake will remain a part of the RCH MHS and will not be integrated into a centralized Triage with the NW Mental Health Service. Intake will utilise the Victorian CAMHS triage tool when this developmental work is completed, and will develop a quality improvement project to assess the validity of Intake decisions. 
19. That regular consultant psychiatrist supervision is required for Intake, IMYOS, Community Group Program and CASEA teams.  These clinical leadership roles will be provided by consultant psychiatrist staff, and clinical governance systems will be strengthened. 
20. That a paper is developed to provide guidance on clinical governance and clinician manager partnerships, and management education and coaching is developed for the new management team in dialogue and effective team functioning to support sound operation. 
21. That the MHS management structure will be changed to more strongly reflect clinician manager partnerships, to increase management skills within the service, and drive a new vision that entwines clinical care, business-like resources management, research and training for effective and collaborative clinical practice. 
22. That managers work as partners with clinician leaders to support strong clinical governance within programs, and ensure that the management structure is aligned with the functional organizational structure and that decision-taking is supported by relevant information. 
23. That decision-taking in business management is supported by the position of decision support analyst in the MHS to provide relevant data to managers, clinicians and researchers. Key Performance Indicators will be strengthened to support benchmarking activity at a national and hospital level. 
24. That the Integrated MHS Executive members are offered management development training and management coaching to develop an effective business management culture and a capacity for dialogue, debate and skilful discussion in management decision taking.
25. That all service units will require team leaders or coordinators to support individual clinicians, maintain a focus on effective and efficient practice, and coordinate clinical roles that may involve complex challenges for clinicians and clients. 
26. That discussion is commenced with the MCRI,  University of Melbourne and Mental Health Branch to strengthen funding for the academic child psychiatry program at RCH, to reach parity with funding of academic adult psychiatry in peer teaching hospitals. 
27. That this document is circulated widely for discussion and feedback to develop an Implementation Plan informed by key stakeholders and prepare an effective and supportive change management strategy, with review of the impact of change. 
28. That the existing psychiatrist review be completed as soon as possible and the availability of full-time or maximum part-time consultant staff be tested by a suitable recruitment strategy, to reduce the number of sessional staff and increase full-time or maximum part-time staff. 
29. That the MHS staffing is reviewed as soon as a realistic budget for 2007/8 is finalised, in order to appoint staff to formal (not acting) positions, and to maximize the clinical workforce in each functional team or unit, as soon as possible. 
30. That a senior position of Deputy Director of the IMHS is established to be filled by an appropriate MHS discipline senior, and appointed through an appropriate process, to carry delegated responsibilities and support and deputize for the Director as required. 
31. That all position descriptions are updated to link with new structures, team responsibilities and MHS Business Plans. Staff training will focus on building core competencies and skills needed for quality clinical practice, consumer-focused and collaborative care. 
32. That administrative arrangements in the MHS are reviewed and modified where necessary, to ensure they are consistent with the new structure, that practices and standards are applied reliably and the new programs can be supported.
33. That new meeting arrangements are developed to support the new structure and the range of functions described in this document. Terms of Reference, with membership and functions of the proposed committees and meetings will be prepared. 
34. That a Newsletter is established to inform staff of service developments, priorities and core activities, and provide a vehicle for inter-service communication. 
35. That the MHS Manager will support the development of a MHS Procedure Manual for clinical and administrative staff, that is open to continual evaluation and improvement, to outline standards and practices to support consistent quality and safe practice. 
36. That to reduce variation and support quality clinical practice, care pathways and clinical pathways are developed and implemented across the service; their use is monitored and evaluated, and these pathways are subject to continual improvement. ?
37. That the size of community MHS clinics is carefully considered to ensure that they have been established with adequate critical mass to minimize safety risks. If necessary, visiting satellite services several days / week will be established to ensure safe care. 
38. That community team clinical activity targets be established to support focused clinical services, and a service-wide target is set to deploy 20% of clinical time into coordinated community development and capacity building activity to support a MH system of care. 
39. That the MHS consultation and liaison team allocates at least 20% of their clinical time to providing secondary consultation, support and advice to hospital (Tier 2) services to assist them to provide MH services to patients presenting less severe mental health problems. 
40. That existing collaborative clinics are studied and evaluated to inform the planning and future development of new clinics and more integrated systems of mental health care.

Stream 2: Building an Integrated System of Mental Health Care in RCH

Once the MHS redevelopment is established and consolidated, the focus of service development will turn to strengthening an “Integrated MH System of Care” at RCH. Currently, mental health services in RCH are provided through several departments or service units. These different departments comprise a loosely-coupled system of mental health care, as there is no coordination of “mental health care” activities, and there are no structures or agreements to support coordination.

The RCH IMHP Review Report (2007) contains a proposal for a common vision, principles, governance arrangements and proposed structures within RCH that will enhance coordination and support more consistent service delivery in mental health care.

Many RCH departments currently provide primary MH care (e.g. psychosocial support, preventive education and early intervention), and secondary specialist MH care (e.g. child counselling, psychological interventions, psychotropic medication and parent counselling) through individual paediatricians, psychologists, social workers, nurses, educators and counselors, although there is wide variation between departments in the resources allocated to this and the services they provide.

The psychological and social aspects of healthcare are important determinants of illness and recovery. This dimension of healthcare is a critical component of holistic care, as children have minds as well as bodies, and these minds are stressed and distressed by pain, illness, disability and threat to life and wellbeing. Therefore, the Integrated Mental Health Program will initiate the following activity to facilitate the development of a more coherent and integrated system of mental healthcare at RCH:

1. The MHS will develop a process to map Tier 1, Tier 2 and Tier 3 psychosocial services; identify how these are funded; advocate for more funding for mental health care and initiate a dialogue with the Health Department to explore greater equity in funding and distribution of these services across RCH to better match resources with need.
2. The MHS will also work with other RCH departments to support them in providing Tier 2 mental health services. We will collaborate to develop and trial assessment tools, models of care, and interventions that strengthen psychosocial care delivered by other departments.
3. The MHS will also undertake mapping of specialist MHS consultation and support to these Tier 2 and 3 services with a view to developing optimal service arrangements, and referral pathways for appropriate patient groups.
4. In addition, the MHS will explore the development of interdepartmental multidisciplinary programs for clients with complex mental health needs, whose needs are not well met by any single department or unit. This includes services for clients with Eating Disorders, Autism Spectrum Disorders and other areas that have potential for strategically enhancing clinical care, research, education and teaching in the hospital. 
5. The MHS will develop a proposal for the Hospital that outlines an “RCH system of MH care” to facilitate a broader discussion to develop an agreed direction for future development. It is recommended that a Steering group be established to construct a work plan and undertake projects with potential to strengthen such a system at an appropriate time. 

Conclusion

The MHS will focus first on strengthening a more focused, businesslike efficient and effective specialist mental health service within RCH using the objectives described here, and then work towards building a more integrated and effective system of mental health care within the Royal Children’s Hospital as outlined above.

This will require structural and cultural reform to build a culture and practice of consumer and family focused quality mental health care that is continually evaluated and improved, in partnership with all relevant stakeholders. The framework for quality improvement activity within the MHS will be developed to be consistent with directions within the overall RCH.

This will emphasize outcomes of safety, effectiveness, appropriateness, acceptability, access and efficiency, within a learning organization framework and a broader commitment to the use of translational clinical science to provide the best possible treatment and care. Overall direction will also be influenced and modified by the Victorian Mental Health Plan.