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How many more staff do you need to improve the quality of care?
- 1. How many more staff do you need to improve the quality of care? How many more staff do you need to improve the quality of care? A challenge to the conventional thinking that to achieve better quality automatically means more staff. Mike Davidge, Director NHS Elect 22 October 2014
- 2. How many more staff do you need to improve the quality of care? The context
- 3. How many more staff do you need to improve the quality of care? The systems response
- 4. How many more staff do you need to improve the quality of care? The impact
- 5. How many more staff do you need to improve the quality of care? If you had to justify hiring extra staff, what would you say?
- 6. How many more staff do you need to improve the quality of care? Three assumptions 1. To provide quality care we just need to have the right amount of staff. 2. We are already working 100% efficiently – we can’t do any more. 3. We have to use the roles we have, it’s too difficult and too time consuming to do anything else.
- 7. How many more staff do you need to improve the quality of care? Assumption 1 “To provide quality care we just need to have the right amount of staff” What does right amount mean? Nurse staffing levels according to NICE
- 8. How many more staff do you need to improve the quality of care? “There is no such thing as a safe level without knowing about the nature of demand.”
- 9. The Safer Nursing Care Tool Evidence-based easy to use tool which uses acuity and dependency to help plan for future workforce requirement. What are the benefits? • Review impact of actual staffing levels on the quality and care delivered • Determine ward team size and mix easily and quickly • Benchmark against similar wards and departments Turn data into graphs and reports.
- 10. How many more staff do you need to improve the quality of care? Ward staffing Patient demand per patient Direct nursing time per patient Employed nurses per patient Employed nurses per ward (a) Acuity (b) Dependency (c) Daily living (a) Number of tasks (b) Frequency of tasks (c) Time to do tasks Average Average Average (a) Non direct care time (b) Working week (c) Non working time (d) Shift overlap (a) Ward size (Pt No’s) (b) Occupancy
- 11. How many more staff do you need to improve the quality of care? The flaw of averages
- 12. How many more staff do you need to improve the quality of care? Variation in patient acuity 0 2 4 6 8 10 12 14 16 18 20 01 Jun 09 03 Jun 09 05 Jun 09 09 Jun 09 11 Jun 09 15 Jun 09 17 Jun 09 19 Jun 09 23 Jun 09 25 Jun 09 05 Jun 09 07 Jun 09 09 Jun 09 13 Jun 09 15 Jun 09 19 Jun 09 21 Jun 09 23 Jun 09 27 Jun 09 29 Jun 09 04 Jan 10 06 Jan 10 08 Jan 10 12 Jan 10 14 Jan 10 18 Jan 10 20 Jan 10 22 Jan 10 26 Jan 10 28 Jan 10 Daily acuity score Daily Score on CCU St Elsewhere's NHS Trust Daily score Mean (7.5) Lower (0.0) Upper (16.3) Staff level (11.9)
- 13. How many more staff do you need to improve the quality of care? Variation by day 7.95 7.82 4.22 4.71 7.99 9 8 7 6 5 4 3 2 1 0 Monday Tuesday Wednesday Thursday Friday Average Acuiy Score Daily average Acuity score on CCU St Elsewhere's NHS Trust
- 14. How many more staff do you need to improve the quality of care? Understand the variation in demand and set your levels accordingly. Key Point
- 15. How many more staff do you need to improve the quality of care? Assumption 2 We are already working 100% efficiently – we can’t do any more.
- 16. How many more staff do you need to improve the quality of care? Systems thinking Input Process Outcome Staff time and resources The care plans and protocols staff follow The effect on the customer Source: “Evaluating the Quality of Medical Care”, Donabedian A, 1966
- 17. How many more staff do you need to improve the quality of care? How much time did staff spend with patients? % Direct Care Time Initial survey results 60% 50% 40% 30% 20% 10% 0% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 % direct care Range 25% - 49%
- 18. How many more staff do you need to improve the quality of care? What else were staff doing? Activities other than direct patient care 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Motion Discussion Other Admin Handov ers Medicine Mgt Personal Hy giene Patient Flow percentage of time
- 19. How many more staff do you need to improve the quality of care? "The tools of VMPS have helped us eliminate waste and non-nursing activities that took nurses away from direct patient care. Our nurses spend more than 90 percent of their time at the bedside, compared with a national average of less than 50 percent.” Charleen Tachibana, Chief Nursing Officer, Virginia Mason Medical Center So what is possible?
- 20. How many more staff do you need to improve the quality of care? Never assume that all staff time is being used effectively. But also don’t blame the staff for this situation! It is the system WE have created or allowed to persist that is the cause. What is the direct care percentage in your wards and services? How could you increase that by removing unnecessary tasks and activities?
- 21. How many more staff do you need to improve the quality of care? Assumption 3 We have to use the roles we have, it’s too difficult and too time consuming to do anything else.
- 22. How many more staff do you need to improve the quality of care? Two organisations have started to think differently and use workforce in a different way...
- 23. How many more staff do you need to improve the quality of care? In these examples the focus is on uncovering the demand for skills instead of which role, and then working to understand the capacity of the workforce to provide those skills:
- 24. How many more staff do you need to improve the quality of care? 5 Boroughs Partnership NHS Foundation Trust Psychiatrists, Psychologists, Qualified Nurses, Therapists, Health Care Assistants and House keepers, all have agreed on the generic skills needed by patients to agreed points across the inpatient adult mental health pathway.
- 25. How many more staff do you need to improve the quality of care? The context • Current mental health trust the result of a merger • Relocation of inpatient mental health service • No ‘lift and shift’ • Multi-disciplinary workforce: Psychiatrists, Psychologists, Registered Nurses, Therapists, Pharmacists, Healthcare Assistant and Housekeepers
- 26. How many more staff do you need to improve the quality of care? The diagnosis The team collated and reviewed data that: • Captured the size and shape of the existing workforce (payroll data) • Uncovered the demand placed upon workforce (patient flow data) • Identified how the workforce were utilised (scheduling data)
- 27. How many more staff do you need to improve the quality of care? What they found Each crisis was different and required a tailored response. The service struggled to provide the right health worker at the right time to meet the individual or family’s presenting emergency. Most people had complex health and social care issues. BUT the skills needed to provide the assessment tended to be more generic than originally expected.
- 28. How many more staff do you need to improve the quality of care? The solution “From this diagnosis, the team created a workforce plan that matched the skills and competencies needed by patients to agreed points across the pathway."
- 29. How many more staff do you need to improve the quality of care? The results Workforce agree on the generic skills needed to support inpatients. Use shift skills and competencies requirements when allocating temporary staff thus reducing costs. Recognition that role broadening is important to improve the patient experience. Staff engagement increased and turnover reduced from 14% to 1.9%. Provide CPD based on patient needs.
- 30. How many more staff do you need to improve the quality of care? Nottingham CityCare Partnership Qualified nurses, social workers, occupational therapists and physiotherapists are all trained in each other’s disciplines up to the level of a general assistant practitioner.
- 31. How many more staff do you need to improve the quality of care? The context • Convert an existing team into a new crisis response service • Challenging target response times • Multi-disciplinary team covering health and social care – nurse, physiotherapist, occupational therapist and community care officer • Wider team support
- 32. How many more staff do you need to improve the quality of care? The diagnosis Staff recorded what their patients actually required in terms of input.
- 33. How many more staff do you need to improve the quality of care? What they found Each crisis was different, and required a tailored response. The service struggled to provide the right health worker at the right time to meet the individual or family’s presenting emergency. Most people had multifaceted health and social care issues. BUT the skills needed to provide the assessment tended to be more generic than originally expected.
- 34. How many more staff do you need to improve the quality of care? The solution The team decided to establish a workforce development approach to give each individual a basic grounding across the four professions. The national assistant practitioner competency framework offered a set of core skills. Each professional assessed their colleagues’ competence to practice core skills within his or her own discipline.
- 35. How many more staff do you need to improve the quality of care? The results Individual confidence levels have improved. Deeper understanding of each other’s profession and contribution. Release of resources: More can be done in a single visit and less time is taken in referring between disciplines.
- 36. How many more staff do you need to improve the quality of care? It’s not as hard as you think! • Understand the nature and pattern of demand on multi-professional teams and set your capacity accordingly • Work to remove the unnecessary tasks that waste staff time • Focus on skill management rather than staff mix to meet changing demand • Unleash the knowledge of existing teams. • Put patients needs at the centre of changes you make
- 37. How many more staff do you need to improve the quality of care? Panel Debate Panel Chair: Margaret Edwards: Vice President, McKesson The Panel: Mike Davidge: Director, NHS Elect Robert Sumpter: Workforce Consultant, McKesson
- 38. How many more staff do you need to improve the quality of care? The three assumptions • Did you recognise them? • What other assumptions are you making and are they just as invalid? • Focus on what patients need first then use the whole team to meet that need • This is not an instant solution but you do need to get started
- 39. How many more staff do you need to improve the quality of care? Shared learning • Write up your next steps from what you have learned today on your postcard • Provide your email address to receive a digital summary of today's session
- 40. How many more staff do you need to improve the quality of care? Thank you
Editor's Notes
- Pose the question Discuss with your neighbour Allow 2 minutes
- Did any of these play a part in your answer to the question posed just now? We are going to explore each of these assumptions in turn to see how valid they are
- Create nicer slide using the following material http://www.nice.org.uk/guidance/SG1/chapter/1-Recommendations). The recent NICE3 consultation indicates that where a registered nurse is caring for more than 8 patients during the daytime, safe staffing is unlikely to be achieved. In terms of satisfaction with current job, nurses who reported the worse staffing (e.g. 1 nurse to 13 patients) were more likely to report emotional exhaustion. Thus the basis for suggestions of a 1:8 ratio also see http://www.theguardian.com/healthcare-network/2014/jul/21/nhs-staffing-mistake-minimum-levels and http://www.theguardian.com/healthcare-network/2014/aug/19/nurse-staffing-nice-guidelines-fall-short-nhs
- By demand we mean the type and volume of patients that staff are dealing with. There are a number of tools that attempt to translate patient demand into numbers of staff required I’m going to use one tool as an example to illustrate some of the dangers
- The Safer Nursing Care Tool was developed by the Association of UK University hospitals together with Leeds University. The NHSI created an online version. The screen shows a flyer produced by NHSI team What does it do? Senior Nurse categorises patients each day according to the acuity of their condition (intensity of nursing care required). Tool uses Leeds University ‘Multiplier’ to convert acuity score into nurse staffing requirement. Provides data in WTE This is a perfectly sensible idea and some of you in the audience today may be using this tool or a similar one. However there are a number of assumptions required to get from an assessment of patient acuity to the number of nurses. Let’s have a look at these.
- Why have I highlighted the use of averages? Because variation from the average affects what staff are able to do
- Switch to the Steyn Excel model to show the impact of variation on waiting or workload This is not a model of staffing but it does show the principle Relate waiting number to staff overload, unused capacity to staff idle time
- Point to make: Even when you attempt to factor in patient acuity, you need to know about variation. Responding to demand requires thought, at what level do we set our capacity? I have used the Steyn model to illustrate this. Now let’s return to SNCT data to show the effect of this. Show the charts for 2 Nottingham wards showing variation in acuity by day. Challenge to the audience: What level of staff would you regard as safe?
- Nurses scored the ward over a 4 week period Monday to Friday. We have 4 scores for each day of the week This chart shows the average score each day. Not all days are equal? What about Saturday and Sunday?
- Back in the 1960’s an Ameican physician Avedis Donabedian created a deceptively simple quality model. It goes something like this: I: Input - The staff time and resources used in creating the services you run P: Processing – The care plans, protocols and policies your staff use to care for patients O: Outcome – The effect on the patient of how you use staff and how reliably you follow procedure This brings us back to the point in the SNCT model that translates patient acuity into nurses required per patient. What they do with their time is crucial. The SNCT tool uses an average direct care time and applies it to all wards. Is this right?
- Some data from the initial Productive Ward work by NHSI. A twofold variation in direct care time across 21 wards. This makes the assumption implicit in all staffing calculators that there is a fixed factor to convert patient demand into nursing time a fallacy. More importantly, if you can increase the percentage on your wards or other services then you can cope with more patients or use less staff safely. How can you do that? Well let’s see what those nurses were actually doing.
- The most common is Motion. This is almost all complete waste. Why did nurses spend one minute in every six looking for stuff or walking to get it? Discussion too would contain a high level of waste.
- We saw in the PW data that wards varied in their direct care time. All the wards improved after implementing PW, some more than others and got to 50%-60% direct care time. So is 60% the limit of what can be achieved? Not according to VMMC Think about that. To provide the same level of nursing care VMMC need just over half the nurses of the average American hospital.
- More direct care time means a better patient experience
- Point to make We make things difficult for ourselves because we default to working with what we already have in terms of existing roles and job titles rather than starting creatively from what the patient needs in terms of skills and competencies each time they come into contact with the service. Back to variation: instead of providing more capacity all the time we could flex capacity and capability. Then we need less overall.
- This mental health trust merged in x bringing together x other geographical sites. The trust is preparing to relocate its inpatient mental health service into a new development in 2015. The trust does not want to ‘lift and shift’ its workforce into the new build, but align workforce to newly redesigned patient flows. The existing workforce component consists of Psychiatrists, Psychologists, Registered Nurses, Therapists, Pharmacists, Healthcare Assistant and Housekeepers.
- The team came together led by the Service Lead to: Collate and review data that: Captured the size and shape of the existing workforce (payroll data) Uncovered the demand placed upon workforce (patient flow data) Identified how the workforce were utilised (scheduling data)
- The team came together led by the Service Lead to: Collate and review data that: Captured the size and shape of the existing workforce (payroll data) Uncovered the demand placed upon workforce (patient flow data) Identified how the workforce were utilised (scheduling data) Unleashing their experience of delivering the service the workforce met and created a matrix, matching the skills and competencies needed by patients to agreed points across the pathway. Uncovered the quality priorities of patients and workforce
- Agreement across the workforce on the generic skills needed to support inpatients and that role broadening is important to improve the patient experience When using temporary workforce service leads now understand skills and competencies requirements needed for each shift and as a result ‘like for like’ shift fill is not always thus necessary reducing costs Influenced new CPD provision that includes competencies that will enabling staff to positively support patients wishing to make use of social media as part of their recovery.. Staff engagement has increased and turnover reduced from 14 to 1.9%
- In 2009 Nottingham CityCare Partnership redesigned an existing intermediate care team into a new crisis response service. The target response time was a maximum of 4 hours, and the transfer to services for ongoing support was 48 hours. The health component consisted of a nurse, a physiotherapist and an occupational therapist. The local authority provided a community care officer to address social care needs. A number of health and social care support staff worked alongside the professional staff as part of the wider team.
- Both these case studies show the vital importance of understanding your demand before settling on a solution. It also shows that cross-training does not have to be expensive. Is this a useful idea I can take away? WRONG question. The take-away idea is to understand your demand first. Then agree skills and competencies based on what you actually need to provide for your patients
- Two very different services were facing similar challenges but they applied these principles to create a quality and cost-effective solution.
- Margaret to chair the debate 10 minutes