In 2013, a Monash Mental Health team began

focusing on the hospital system psychiatric walk-in service.

Led by Dr. Melissa Casey,

the Monash team was responding to troubling signals: a

significant increase in adults arriving in crisis in the emergency room,

a growing relapse rate indicated by shortening intervals between those arrivals,

and awareness that the system didn't know

exactly how many patients were seeking mental health services,

and importantly,

clinician frustrations for spending so much time filling out so much paperwork.

The focus was on containing the damage.

People were coming in crisis and many were suicidal, so that made sense.

But medicating or containing people until a crisis was passed was

not the reason any Monash clinician had originally gone into mental health.

Casey's team decided to concentrate on

service redesign based on better understanding the patient experience.

Unlike most other design-thinking projects,

data mining from Monash's existing IT systems

was originally front and center, not ethnography.

The plan was to complement this data analysis with participant observation by shadowing

clinicians and counting how much time and effort they

actually spent with patient concerns, not with paperwork.

But the original effort was digging through the existing data.

We believe that Monash Mental Health,

now called the Agile Clinic,

provides an important counter-argument to

the quantitative versus qualitative dichotomy we often accept.

It points out how either research methodology can support the design-thinking process,

as well as illustrating ways the two research approaches might work together.

To develop any sense of what was happening at the front-end of mental health,

Melissa and her team had to merge data from three on-link IT systems.

This type of data mining task might have daunted

the most courageous and committed clinician but not Dr. Casey.

Melissa is a rare breed.

Her team selected a sample of patients and followed

their journeys across all three experiences: phone,

emergency room and outpatient mental health.

Focusing on a 12-month period,

team members began with the phone database,

looking at each patient's engagement.

They linked those patients with the emergency room system,

and for every person who engaged with both,

they found the overlap with the standard mental health database.

Having pulled together all this engagement data,

the Monash team followed a suggestion offered by a consultant,

using a timeline to lay out each patient's interaction in sequence,

which led to creating journey maps for each patient's mental health experiences,

for 60 different patients.

Those timelines triggered an aha moment.

The story of one particular patient,

Tom, provides a case in point.

Following a suicide attempt,

Tom was referred to Monash's adult mental health service

by another hospital's acute psychiatric ward.

Just two months later,

Tom was readmitted to the hospital with another overdose.

During that period, the timeline revealed the patient experience significant activity.

Tom had 13 different case managers,

70 touch points and 18 hand-offs,

again, over two months.

What he hadn't experienced,

it seemed, was treatment that made any difference.

When the team shared Tom's story with Monash's head of mental health,

Dr. David Clarke, Dr. Clarke said,

there was no care there.

And the timelines, overall,

assured clinicians that their existing system was

not providing the patient experience they wanted to deliver.

Indeed, the data indicated that about half of

the 5,000 mental health patients coming into

Monash emergency rooms annually were being discharged

to general practitioners without any real psychiatric care.

In addition, Tom's information was recorded in

five different information management systems and 15 different patient records.

The clinicians' sense of overwhelming paperwork was well-founded.

Given this deep, deep understanding,

the team asked, "What should be the purpose of any new system?"

For an answer, they reached back to their roots in psychology to

Erik Erikson's argument that a good and wholesome life is being able to live,

love, and work, and decided to make that the basis of any new Agile Clinic's purpose.

Getting patients on a recovery journey to live, love, and work.

Armed with this purpose,

the team captured insights.

One, all roads lead to the emergency room.

If the team wanted to impact outcomes,

members would need to design a system that

incorporated what happened at the first face-to-face contact,

which was rarely with a mental health clinician.

Two, many adults arrive in crisis and receive, primarily, crisis treatment.

Examining the nature of the care revealed an important gap.

Here, at the front-end,

emergency medical services, often drugs,

were available, but there was little connection to longer term therapies,

as Dr. Casey explains.

Say a patient intended to kill himself and took an overdose,

he or she would go into the emergency department

and be treated for that particular incident

rather than the underlying mental health condition

that has predisposed him to vulnerability.

She would be treated and then discharged.

And again, those discharges were usually to general practitioners,

not psychologist or psychiatrist.

Hence, people were coming back frequently,

but the underlying mental health disorder wasn't

being treated even if specific biological issues were.

The third insight was the realization that Monash needed to focus

on what patients needed now and how clinicians could immediately help

versus spending time discovering,

rediscovering and analyzing the patient history.

The patient-mapping revealed that returning patients

were being assessed over and over again.

Rather than talking with patients about their current issues,

clinicians were asking them a set of very similar questions.

And the fourth insight was if the paperwork burden

was truly a serious inhibitor to delivering patient care.

The staff was indeed inundated with paperwork.

Over the years, regulatory changes had led to new forms

because each regulatory or procedural change had brought pressure for a new form,

rather than a systemic redesign merging all the forms.

The result was a massive disruption of any clinician's ability to focus on the patient.

The staff was deeply involved,

but too much in paperwork.

Monash Looks at What Is

Design Thinking for the Greater Good: Innovation in the Social Sector

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