**2.3 Plot**

Expanding on the story structure framework, this section will incorporate a generic narrative mountain structure, breaking down the plot by its background, rising action, climax, falling action, and resolution.

## *2.3.1 Background*

During each quarter, the project team worked with each TSO to produce an implementation plan including a set of targets, infographics, quality checklists, report templates and mentorship support, with PDSA cycles to structure the process [8–10]. Many of these tools required regular, in-depth auditing of data recorded during assessment, treatment, and discharge. Analyses were complemented by attitudinal surveys to front-line practitioners focusing on their perceptions and experiences across each quarter. Services were encouraged to reflect and communicate their learning at the quarterly residential meetings, while critically appraising fellow member's contributions.

#### *2.3.2 Rising action: Events leading up to the main challenge(s)*

Throughout the project, it became clear that an organisation's success in addressing the challenges depended on their relationship with the process of using measurement questionnaires and how deeply practitioners and clients were engaged in responding to feedback. The team later conceptualised this as a development cycle with four distinct evolutionary stages that described the operational depth of practitioners' relationship with measurement: Pre and post-therapy measurement using paper forms; measurement at every session using paper forms; digital measurement at every session using tablets or computers; and digital measurement at every session tracking and sharing outcome progress directly with clients throughout

#### **Figure 2.**

*The evolutionary stages of measurement within SILC TSOs illustrating the development cycle and value to stakeholders.*

the entire therapeutic encounter. It was recognised that services which were further along in this cycle had an inverse relationship with measurement in terms of its input and value towards stakeholders. Those in the later stages were able to maximise the value for clients that in turn benefitted other groups including practitioners, service management, and boards/funders. Conversely, those operating in the earlier stages were limited in their value to certain groups, typically to the boards/funders. **Figure 2** shows a conceptual model of this, including the resulting value for stakeholders.

Conceptual implementation models highlight how the structures and processes that exist within organisations have an influence on the adoption of practice changes during the active implementation phases [8, 10, 11]. Within the SILC project, it was observed that completing paper forms, particularly at every session, generated huge administrative and inefficient burdens for members. This created barriers for practitioners looking to use data as feedback to enhance client outcomes and develop their clinical skills. During the year, most organisations evolved their administrative processes by replacing paper with digital methods, recording via electronic tablets. The services most successful in achieving the optimal rates for each quarterly challenge described understanding measurement as a construct and extension of the client. By focusing on creating the maximum value of measurement for clients, a myriad of other benefits at different stakeholder levels was also reported [19]. Naturally, some services were more equipped than others in accessing the appropriate technologies.

### *2.3.3 Climax: The main challenge(s) reach a high point*

During the project, one of the participating TSOs withdrew due to a turnover in management and evolving financial pressures. Two other services experienced management turnover during the project which, although not impacting on their participation, did require additional input and training from the SILC project team. Practitioner turnover was understood to be common in TSOs [2–4], however, the rate of turnover concentrated at a managerial level had not been anticipated. For services with a complex management structure, this too complicated the sharing of learning and addressing each quarterly challenge. It was discovered that when managers with an on-hand leadership style were absent, this would impact on key aspects of their service operation, including the collection of high-quality data.

Another key challenge regarded the issue of session attendance and unplanned endings. A list of categorical reasons for why a session was not attended was compiled to record each time this occurred. Although the reasons recorded for cancellations were high, this was not the case for those who did not attend (DNA) (no advanced warning given) despite subsequent sessions being attended in approximately half of all instances. The most common reason for cancellations during the second quarter (n = 482) was 'Health Problems' (40%) while for DNAs (n = 160) it was 'Unknown' or 'Not Recorded' (76%). The absence of reasons recorded despite sessions being subsequently attended suggests practitioners either forgot or did not feel comfortable exploring why a session had been missed. This is concerning as DNAs were found to be indicative of an unplanned ending.

Definitions are important and have shown to vary the reported unplanned ending rate [20]. During the project, the unplanned ending rate reduced from 32% at baseline to 27% at the end of the third quarter, however defining and interpreting these rates revealed notable issues. Among the participating members, there were multiple interpretations about what constituted a planned versus unplanned ending. Given its inherently subjective nature and potentially negative connotations, this limited the analysis somewhat. However, the links between session nonattendance and unplanned endings were consistent across all services and tended to occur early in treatment, as described in the next section.

*Evaluating the Efficiency of a Collaborative Learning Network in Supporting Third Sector… DOI: http://dx.doi.org/10.5772/intechopen.84294*
