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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
Notes de l'éditeur
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.