Table of Contents
1. Purpose of this report 3
2. Expectation 1 3
3. Introduction 3
6. Family health 5
7. Integrated Adult Care 5
8. Surgery 5
9. Acute and Emergency Care………………………………………………………………………5
10. Recommendations 5
11. Action requested of the Trust Board 6
12. References 6
13. Bibliography 7
NURSING AND MIDWIFERY ESTABLISHMENTS REPORT (Summary)
July 2016
1. Purpose of this report
The previous January 2016 report summary on this topic was presented to the Trust Board in July, 2016. That report advised the Trust Board of the latest developments in relation to the National Quality Board’s[1] Ten Expectations for nursing and midwifery staffing levels, specifically expectations 7 and 1.
The purpose of this July 2016 report summary is to confirm on-going compliance with the requirements to:
· publish monthly aggregated nursing and care assistant staffing levels, in accordance with NHS England’s, The NQB’s and the CQC’s requirements; and
· Evaluate Nursing establishments in Adult wards twice each year and report these findings to the Trust board.
At its meeting in January 2015, the Trust Board approved uplifts to nursing establishments. An update on the impact of this uplift is provided in the report.
2. Expectation 1
The National Quality board set out an expectation that Boards request and receive papers on establishment reviews. Carried out at least every six months, establishment reviews are critical to ensuring that the right people, with the right skills, are in the right place at the right time. They provide the opportunity to evaluate staffing capacity and capability over the previous six months, and to forecast the likely staffing requirements of wards for the next six months, based on the use of evidence based tools, and a discussion with ward, service and team leaders. Boards should sign off establishments for all clinical areas, articulate the rationale and evidence for agreed staffing establishments, and understand the links to key quality and outcome measures.
3. INTRODUCTION
As part of Expectation 1, the Trust holds SCNT audits a minimum of every six months in January and July. This 4 weekly review, twice yearly, covers two distinctly different periods in the Trust calendar. The summer period, where one would assume the trust caters for clients in a lighter climate over the summer holiday months against the colder, more hazardous winter climate with the traditional winter pressures.
The audit currently covers 36 Adult In-patient areas within the whole Acute and Community sphere and this has not changed since January, although the Care Group areas currently reported on have changed since January 2016.
As part of this audit, the author will make comparisons between the current July audit and the audit from January 2016. The audit approach remains the same except for the scoring tool used within the community settings. This has been tweaked to give a more accurate picture.
4. BUDGETED AND ACTUAL WTE STAFF
As part of the overall audit, the established and actual budgets for each of the 36 areas are recorded and totalled. They are then compared against the SNCT’s recommended WTE budget once data from each area’s bed occupancy and in-patient acuity are recorded and input on a daily basis. Comparing the overall totalled budgets required to currently run the 36 identified areas against the total budget required to run the same areas last January, incredibly, the overall available established budget reduced by 22.9 WTE staff. The actual WTE staff available for both audits remains the same. However, over the same time period, the trust has managed to cap Agency use by introducing a Neutral Vendor system. Bank staff usage is also closely managed and regulated by the Temporary staffing team.
When reviewing the SNCT recommended WTE totals against the total Trust Established budget WTE, they now mirror each other closely overall. The author believes this is due to the audit data recording becoming electronic and the tweaking of the audit tool for application in community areas. Individually, 19 of the 36 areas report lower recommended SNCT WTE totals against current department budgets. Of the 17 areas over reported, the author believes traditional ward bias may account for over scoring of their own patient acuity. Again, being constantly in that pressurised environment may perhaps make the ward feel heavier than actual.
The author suggests that more work in this area would provide even more accurate data. Perhaps a team of unbiased staff could carry the mantle of reporting acuity over the next audit due in January 2017 and that the cost of achieving the results would be most beneficial to the trust.
In summary, there seems to be sufficient evidence to warrant a further review of individual established budgets. This would require a collaborative approach between the Executive Team, Care Group leaders and Finance staff. Anecdotal evidence shows this is happening in a sporadic manner following feedback from the monthly staffing reports but more impetus is required. For example, Wards 33 and 34 amalgamated into one area last December but to date, the budgets remain separate and misaligned to current ward status. The author argues the fact that more work is needed to make budgeting more free flowing and in alignment with the free flowing changes occurring within the Trust and this will become clearer when the author discusses number of beds and bed occupancy later in the report.
5. BEDS AND BED OCCUPANCY
In January, the number of beds available to the 36 areas was 871 compared to this audits total of 852 beds. Again, total bed occupancy with those previous 871 beds was 92.29% compared to the 88.13% occupancy of this audit. The author will argue that this reduction is due to reduced community area bed occupancy. Bed occupancy in the main acute ward areas has remained constant with the previous audit suggesting the traditional change in seasonal bed occupancy is less obvious and acute ward areas percentages remain constant throughout the year without respite. This is further backed up by patient flow statistics that show comparable figures to Januarys audit and in some cases, have in fact increased in July. The author would suggest that this picture has had an influence on the current rise in sickness statistics.
Capacity within the acute ward areas could potentially rise significantly. AMU’s at Durham and Darlington are not currently running on full capacity but acute ward areas are. AMU areas could increase current capacity but only if patient flow increases between acute wards and the rest of the trust. Only 3 out of 9 surgical areas managed to achieve greater than 90% bed occupancy in July, whilst only 50% of the community wards and hospitals achieved greater than 90% occupancy. It would appear the use of “Guest” facilities could be better managed within the Surgical ward areas. NerveCentre would be a valuable tool to achieve bed occupancy status quite reliably as it has been utilised within this audit. Reduced bed occupancy was very noticeable within wards at Bishop Auckland and outlying community hospitals such as the Richardson, the Weardale and Sedgefield. Sedgefield was actually closed to admissions for a short period of time during this audit and this is also noticeable in the audit data.
It would appear from the evidence, that efficient WTE numbers of staff against numbers of beds within the community areas requires closer scrutiny. The safer staffing level ratios of one nurse to every eight beds (1:8) appears to be used in its purest form. For example, Chester-le-Street, Richardson and Sedgefield have 23, 24 and 22 beds respectively but they are all identically budgeted to 24 beds using the 1:8 ratio. Beds at Weardale have recently been reduced from 20 to 16 in number, possibly to fit the 1:8 ratio approach formula. A change that has not yet been financially adjusted to budget.
The author would argue that the Trust now has the technology to better utilise the 1:8 ratio in a more efficient and accurate manner and approach each departments bed situation individually. Moreover, a move to more real-time budgeting of these changes would lead to unused budget funds put aside and frozen. Introduction of the new Trust standardised shifts would also emphasise a need to re-review and re-align budgets to current circumstance.
6. Family health
Obstetrics and Gynae Services, both at Ward 62 DMH and Ward 9 UHND are currently underutilised. Both running on less than 75% bed occupancy. Furthermore, neither achieved greater than 90% bed occupancy during January 2016. It would appear justifiable to review these services under the circumstances and look for further service improvement or realign budget against current services.
7. INTEGRATED ADULT CARE
As previously stated, bed occupancy in the community areas is not currently optimal. Better utilisation is required to increase patient flow. However, in theory, 100% utilisation of two of the four currently available community hospital beds and 100% utilisation of the ward based community beds could possibly achieve the same results as currently achieved within all four community hospital areas.
8. SURGERY
As previously stated, bed occupancy within the surgical care group could be better utilised. Budget anomalies within that care group in areas such as Ward 12 Orthopaedics remain prominent and “guest” patient flow could be reviewed.
9. ACUTE AND EMERGENCY CARE
As previously stated, the majority of acute and emergency care beds are always greater than 90 percent utilised. Ward 2 UHND and Ward 44 DMH are the only exceptions. This could perhaps be explained with bed closures within Ward 2 and respiratory services deviating from the normal 1:8 ratio due to the N.I.V. capacity. AMU services could flex, but only if patient flow within medical services as a whole improves.
10. Recommendations
. The key recommendations relate to:
· The review of Community hospitals should be expedited to ensure the provision and occupancy of long term beds meets the demands placed on acute ward beds, especially during the winter pressure months. Currently, we have staffing issues, empty beds and a reticence to transfer patients out to outlying community areas that do not suit family in the face of continuous acute bed demands.
· The review of outlying wards at BAGH such as Ward 4, Ward 16 and Ward 17 should be expedited. Again, this would ensure the provision of additional beds to meet the demands placed on acute ward beds during the winter pressure months.
· Review of Trust wide Obs and Gynae Services to better utilise bed occupancy and increase efficiencies.
· Monitor Acute and Emergency Care services to ensure sickness/absence does not increase over the coming winter months.
· Review bed occupancy within AMU and SAU services and see if services could increase to further reduce pressures within the ED departments of both UHND and DMH. The trust has just received negative media attention around the issue of waiting times.
· The Trust wide review of the ward budget model on a ward by ward basis utilising the 1:8 safe staffing alongside new systems technology and the introduction of new standardised shifts. Collaborative approach between care groups and finance.
· Introduce a new methodology around budgets and the real-time alteration to changes in circumstances such as bed closure whether permanent or temporary. This is imperative to ensure we report accurately to NHSI etc.
· Review of “guest” patient flow processes within the surgical care group wards or a re-alignment of budgets to match current bed occupancy.
· Assemble independent team to carry out acuity scoring in the 36 identified areas for the January 2017 audit. This will further improve on the accuracy of current reported SNCT WTE recommendations for each area.
11. ACTION REQUESTED OF THE TRUST BOARD
The Trust Board is requested to:
· Receive this report, and;
· Decide if any if any further actions and/or information are required.
Noel Scanlon
Executive Director of Nursing
October 2016
12. References
Department of Health (2000) Comprehensive Critical Care: A Review of Adult Critical Care Services. London: DH
Hurst, K. (2003) Selecting and Applying Methods for Estimating the Size and Mix of Nursing Teams - A Systematic Review commissioned by the Department of Health. Leeds: Nuffield Institute for Health.
National institute for Health and Clinical excellence (2014). Clinical guideline 1: Safe staffing for nursing in adult in patient wards in hospitals. London, Department of Health.
National Patient Safety Agency (2009) Quarterly data summary. Issue 13: Learning from reporting - staffing. How do staffing issues impact on patient safety? London. NPSA
NHS Commissioning Board (2012) Compassion in Practice, Nursing, Midwifery and Care Staff.Our Vision and Strategy. Leeds: NHSCB
Rafferty, A.M. Clarke SP, Coles J, Ball J, James P, McKee M, Aiken LH (2007) Outcomes of variation in hospital nurse staffing in English hospitals: a cross sectional analysis of survey data and discharge records. International Journal of Nursing Studies, 44,(2), pp 175-182
RCN (2010) Guidance on safe nurse staffing levels in the UK. London: Royal College of Nursing
13. Bibliography
Ball, J.A & Washbrook, M. (1996) Birthrate Plus: A Framework for Workforce Planning and Decision-making for Midwifery Services. Cheshire. Book of Midwives
Department of Health (2013) The Cavendish Review : An Independent Review into Healthcare Assistants and Support Workers in the NHS and social care settings. London: DH
Department of Health and Human Services (2011) Safe Staffing - User Manual Nursing Hours per patient day Model. Tasmania: Department of Health and Human Services
Department of Health (2000) Comprehensive Critical Care: A Review of Adult Critical Care Services. London: DH
Hurst, K. (2005) Developing and Validating the AUKUH’s WP&D System.Commissioned by AUKUH Directors of Nursing.
Scott, C. (2003) Setting Safe Nurse Staffing Levels. London: RCN
Smith, S. Casey, A. Hurst, K. Fenton, K. Scholefield, H.A. (2009) Developing, testing and applying instruments for measuring rising dependency-acuity’s impact on ward staffing and quality. International Journal of Health Care Quality Assurance. 22, (1), pp 30-39
[1] National Quality Board 2013 - How to ensure the right people, with the right skills, are in the right place at the right time - A guide to nursing, midwifery and care staffing capacity and capability