This redesign project focused on optimising outpatient clinics responsible for managing clozapine—a high-risk medication used to treat schizophrenia—within the South Western Sydney Local Health District (SWSLHD) Mental Health Service.
The initiative aimed to enhance compliance with clinical guideline monitoring requirements, ensuring higher rates of adherence. Additionally, the project sought to standardise clinic operations and processes, strengthening them through improved clinical governance frameworks. A key outcome of the redesign is an enhanced experience for both staff and consumers engaged with these clinics.
Challenges in clozapine service delivery
Schizophrenia is a chronic mental illness that significantly affects an individual’s perception, thoughts, behaviour, and overall functioning. Clozapine is the most effective pharmacological treatment for schizophrenia, offering substantial improvements in quality of life. However, due to its potential for serious and life-threatening side effects, clozapine requires ongoing, intensive clinical monitoring within specialised outpatient settings.
As of May 2024, approximately 650 consumers across SWSLHD were attending one of five dedicated clozapine clinics. This number has steadily increased and is expected to continue rising. However, clinic staffing levels have not kept pace with this growth.
Over time, each clozapine clinic has developed independently and reactively, without a unified strategic approach or overarching purpose. This has led to considerable variability in clinic operations and processes. Governance structures are inadequate, with limited accountability for service quality and patient safety. Mechanisms for escalating clinical risks and concerns are poorly defined and inconsistently applied.
Current clinic practices fall short of full compliance with clinical monitoring guidelines. Additionally, feedback from both staff and consumers highlights dissatisfaction with the overall experience and functionality of these clinics.
Designing solutions for sustainable improvement
The redesign process began with extensive diagnostic activities to identify key issues and determine their root causes. These activities were led by the project team and supported by a multidisciplinary steering committee established to oversee governance and strategic direction. The team undertook an extensive service review and facilitated workshops and focus groups to ensure staff, consumer and carer perspectives and experiences were accurately captured.
To inform best practice, the team conducted literature reviews, as well as reviewing guidelines from other jurisdictions. A site visit to a high-performing clozapine service in another state was also undertaken to inform best practice.
The team logged, themed and analysed issues identified during the diagnostics phase, forming the basis for root cause analysis and solution development. Stakeholders were actively involved in co-designing the solutions, with recommendations endorsed by the steering committee. Two key solutions are being codesigned with plans for implementation in the next six months:
- The development of a comprehensive model of care to enable standardisation and consistency; improve governance and accountability; ensure evidence-based and best practice care; provide enhanced consumer and carer experience; increase staff satisfaction and support; maximise efficiency and resource optimisation; and facilitate innovation and adaptability
- Creation of new Electronic Medical Record (eMR) templates to enable consistent and high-quality documentation, which are being co-designed with clinic coordinators and medical officers. As of March 2025, development is well underway, with the templates scheduled for pilot testing at one clinic site in May 2025.
This collaborative and structured approach ensures that the redesign is grounded in real-world experience, addresses root causes, and is driven by subject matter experts.
View this project's poster from the Centre for Healthcare Redesign graduation May 2025.
