Taranaki DHB is regularly one of the best performing DHBs in the country for outcomes measurement collection. Outcomes and clinical information projects officer Graham Donlon attributes this to organisational policies, leadership, staff commitment and effective training.

Graham is passionate about collecting measurements and has been a major driver behind the DHB consistently exceeding national targets for HoNOS compliance.

Graham says, “Good health professionals want to help people get better, but how do you know if our service users are improving if you don’t measure change over time? Outcomes measures, such as the HoNOS tools, can help to show if consumers are improving, remain stable or are deteriorating. Good compliance is needed to ensure there is enough data to analyse so we can determine if the measurements capture the impact the service has on people who use it. It is really important clinical information.”

PRIMHD is the Ministry of Health’s national collection of activity and outcomes data. PRIMHD compliance targets are 80 per cent for inpatient units and 70 per cent for community services for the end of June 2014, and 80 per cent for both settings by July 2015.

Taranaki DHB achieves 98 per cent compliance for the inpatient setting and 78 per cent for the community setting. The DHB is regularly one of the best compliance performers in the country since PRIMHD commenced in 2008.

“We’re pretty happy with our compliance. For a mid size DHB we’ve been consistently good, but it could always be better,” says Graham.

Collecting HoNOS

HoNOS is collected on admission and discharge into a service, and every three months for people experiencing mental health issues. In Taranaki, the ratings are completed on three HoNOS tools: HoNOS Adult, HoNOS 65+ and HoNOSCA (for children and adolescents). Adults are rated across 12 areas (called scales) and children and adolescents are rated across 15. The HoNOS tools measure common mental health issues including low mood, self-harm thinking, drug and alcohol use, cognitive issues and relationship issues.

Graham says, “The HoNOS suite captures change from admission to discharge. HoNOS is a great way to monitor whether people are improving under the DHB service because the ratings over time can be compared.”

Graham adds that most people using Taranaki DHB services do improve. When there is no positive change, this should be a flag to review what is happening for the person. 

The road to achieving high compliance targets

The Ministry of Health funds site coordinator positions to manage HoNOS collection within DHB regions. Graham says “having site coordinators to oversee the process gave the collection of HoNOS data a focus it didn’t previously have." He describes the site coordinator role as the oil that keeps the outcome machinery going.

Graham Donlon and Steve Harvey from Taranaki DHB

“Clinicians collect the HoNOS data, team leaders monitor it and I make sure the process doesn’t break down which takes a lot of pressure off clinicians and team leaders,” says Graham.

As site coordinator, Graham runs individual and team training sessions on use of the HoNOS collection tools, provides IT support, and helps managers and clinicians iron out queries and technical problems with HoNOS collection.

Psychologist Steve Harvey believes the DHB’s success with compliance is largely due to Graham’s dedication to training and the support of managers, particularly with training staff to competently use the electronic system.

Graham also distributes regular newsletters and reports to staff, recognises the work of star performers (clinicians whose collections are up-to-date) and visits services on a regular basis to support them with the technical side of HoNOS collection.

The DHB also established an outcomes training group, and champions within teams or professional disciplines to provide support and outcomes knowledge.

“The group trains clinicians and therapists to use the HoNOS tools as objectively and reliably as possible,” says Steve.
 
Graham also facilitates refresher training to remind clinicians and staff of the principles and importance of data collection and of following rating rules.

Graham feels the biggest influence on the high level of compliance gained by Taranaki DHB is the support of leadership across the service. A message from the community service manager and clinical director a few years ago stated that missing HoNOS deadlines was a performance management issue. Line managers had to report staff members overdue with their HoNOS on a monthly basis.

Graham says the memo led to staff lining up outside his office for help with completing overdue tasks and learning more about what was required of them.

“It made a huge difference having senior management championing data collection. In some DHBs, coordinators work their butts off and don’t get buy-in because they don’t have the same support from their management and clinical leaders,” says Graham.

Adult team leader Patrick Morris agrees that senior management involvement changed staff mindset. “It became very clear, from top down, that it was not optional, but a requirement, to collect and input the data.”

Graham says the monthly compliance reports from Te Pou, which show how DHBs fare against other regions, also encourage compliance, because senior managers don’t want to see their region at or near the bottom of the table.

Another significant factor is the continued support from the DHB for the site coordinator role. Graham says many DHBs reduced or dropped the site coordinator role once the Ministry of Health two year seeding funding ran out. Graham says, “In many of those places the culture of compliance hadn’t become embedded and so compliance fell over."

Taranaki DHB funded Graham’s role full time for eight years, but downsized it earlier this year to part time. 

“This is because the DHB believes compliance is at a stage where clinicians don’t need so much support.  I’ve been the go-to person for seven years. Now, with the reduction of time for my role, the onus is on the team leaders and outcomes champions to be the first point of contact for their teams. At this point we don’t know how this change will impact. Only time will tell.”

Graham feels it was probably easier for him to network and develop a profile for the role in a smaller DHB, especially as he had worked in the local sector for many years and already had relationships across the sector, including with local NGOs. Graham says, “This helped me keep an eye on the teams and understand their issues.”   

Challenges of gaining compliance

Graham says using an online tool was quite a change of culture for clinicians.

Te Pou clinical lead Mark Smith says, “ the more you do something like the HoNOS, the faster and easier it becomes. It is a standardised assessment tool, not an extra thing, but part of the standard job of a clinician.”

Graham says many clinicians initially resisted because they felt their role was to support people using the service, not spend time filling in electronic forms. 

“But now they are starting to see that the information is clinically relevant and can be of value within teams and for service users. It isn’t just another thing collected for the benefit of the Ministry.”

Use of outcome measurements

Graham says care plans should be based around HoNOS ratings because the ratings highlight people’s problems. “If ratings have gone down over time and the person has become physically healthy, then this reflects a positive outcome for someone who used to have a major problem in those outcome areas. The HoNOS data shows that, at an aggregated level, most people get better using our services but there are exceptions.”

Graham has been impressed with the way the Mental Health Services for Older People (MHSOP) multi disciplinary team meetings now use HoNOS data as a discussion point for all new referrals and three monthly reviews.

“They are brilliant and their data has really improved since this practice began,” says Graham. The South Taranaki team also utilise it in a similar fashion. A number of other teams have also indicated they are planning to use HoNOS outcomes information in their multi-disciplinary team discussions.

Psychologist Steve Harvey, consultant with the Child and Adolescent Mental Health Service Services (CAMHS), says HoNOS offers a common language.

Steve says, “It provides a way to assess clinical changes through one simple instrument that any clinician can use. Mental health is a team effort these days and HoNOS provides a way for everyone to contribute, plan and review people using a common language."

Steve also finds HoNOS provides a more direct form of accountability. “For example in the past we knew we were getting through waiting lists but we were not measuring outcomes. When the waiting lists were under a certain level, and there were enough discharges, it was presumed things were working well but there was no idea of the quality of the service,” explains Steve.

Patrick uses the HoNOS data for informing clinical judgement and as a tool to generate discussion about discharging, including looking at people who continually score as sub clinical, which means they don’t require support. “We then question why they would still be using the service.”

HoNOS data has also helped with decisions about extension of services. Steve used HoNOSCA data as evidence of the need for a respite house for adolescents, which has now opened.

“The data was also very useful when making a case for a family therapist on the team because the HoNOSCA statistics showed the high relationship between family problems and other outcomes,” explains Steve.

Graham points out that using the HoNOS tools does not provide all the answers. “But it does enable us to ask better questions about the services we provide and their effectiveness,” he concludes.