Royal Liverpool and Broadgreen University Hospitals NHS Trust
Doc.GOV/14/47
Safe staffing report: Executive Summary.
Purpose
To present the safe staffing reportfor July 2014.
Presented by: Lisa Grant: Chief Nurse.
For assurance / For information /
For decision
INTRODUCTION & BACKGROUND OF REPORT
The safe staffing report has been developed in response to the recommendations of the National Quality Board in its publication:
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 [NQB 2014].
This publication provides guidance and structure to Trusts in responding to the recommendations outlined in the Governments ‘Hard Truths report’ which was a response to the recommendations outlined in the Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry [Feb 2013].
On the 15th of July the National Institute for Health and Care Excellence [NIHCE] published their safe staffing pathway “Safe staffing for nursing in adult inpatient wards in acute hospitals”. This has been produced as a response to the issues highlighted in the NQB guidance [Francis report, Hard Truths report, Berwick report] and provides nurse leaders with a framework by which nurse staffing should be addressed. It is clear within the framework that the pathway should not replace professional judgement but should be used as guidance. There are no recommendations for minimum staffing rather guidance on how to agree the staffing that is required.
Most of the guidance is already implemented to varying levels in the Trust. The key recommendations are:
- To assess nurse staffing on a daily basis ensuring the skill mix and number of staff are able to meet the needs of the patients in their care. We currently do this in the daily staffing huddles.
- To review skill mix based on patient need looking at the hours of nursing time per patient per day and the bed utilisation of the ward. This is more a time and motion approach and recommendations are that we undertake this every 6 months. We are currently reviewing our staffing utilising the safer nursing care tool which looks at patient dependency and the next report will be presented at Trust board in September.
- To implement and monitor red flag events and record requirements on a daily basis. We currently report by ward each month on a number of KPIs and these are robust and in line with the evidence based safer nursing care tool [nurse sensitive indicators]. The suggestions in the guidance for red flags are:
- Any unplanned medication omission, any delays of more than 30 minutes in administering pain relief.
- Any evidence that patient MEWS have not been recorded in line with their plan.Any gaps identified with the utilisation of intentional rounding.
- Less than 2 registered nurses on any shift and any shortfall of 25% or more of the planned staffing [we currently have this set at 20%].
July staffing report key findings.
Areas in July where staffing fill rates below 80% were recorded are:
- 5B Both RGN and HCA on days.
- 9A HCA on nights.
- 10Z HCA nights.
- 9HDU HCA nights.
Comparison from the previous month
There were three wards in June and four in July with lower than 80% fill rates however the overall trust level fill rates remain high.
Ward highlighted in June that still have some reductions in fill rate in July are:
- Ward 5B was highlighted in June as having a low fill rate for HCAs on days.
- 9HDU reported reduced HCA cover on night duty due to long terms sickness.
Reviewing staffing
The ward staffing is reviewed daily and any gaps in planned shifts are shared and cover is arranged where possible. The Chief Nurse has had 1:1 meetings with every Ward Manager and Matron to review nursing numbers and layouts of the ward. This has helped to triangulate all the data we have available and gives the opportunity to discuss staffing using professional judgement.In terms of setting establishments the trust has used evidence based tools such as the Association of UK University Hospitals [AUKUH] acuity dependency tool, and the professional Judgement model. The skill mix required on each ward in terms of the number of registered and non-registered staff has been set up on the E roster system and this is used to monitor shift ‘fill rates’. A full establishment review will be provided for the September board meeting then every six months thereafter.
Supervisory elements: At this current point in time there are no supervisory elements to the report. There are plans to release our ward managers to their full supervisory roles commencing from August, once we have recruited to the agreed backfill posts to facilitate this. Some ward managers currently have more supervisory capacity than others.
Facilitating planned and unplanned leave
All ward establishments have been planned using evidence based tools and professional judgement. The agreed skill mix is then provided with an extra 22% uplift to allow for release of staff for mandatory training, study leave and to cover short term sickness. Long term sickness poses significant challenge as the 22% uplift does not always cover this. Maternity leave is covered with 50% backfill for wards and this is helpful however can pose some challenges in cover.
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Royal Liverpool and Broadgreen University Hospitals NHS Trust
Full report
Section one: Fill rate data
The trust has submitted its third safe staffing data on Monday the 11th of August.The tables below are a copy of the data that was submitted to UNIFY and what will be uploaded to NHS Choices. Areas where shortfalls have been identified will be discussed in more detail below. Please note that planned hours are those that have been agreed are required for safe staffing and on which our establishments are set.
July safe staffing overview
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Royal Liverpool and Broadgreen University Hospitals NHS Trust
Reviewing and publishing of the data
It is important to know that that the report will be published by site and this will include the fill rates in the table above.
For the purpose of this report we will, by exception, highlight the following:
- Every ward where fill rates have fallen below 80% in month [80% and below has been chosen as an internal measure and is not mandated]. This will be highlighted at day shift and night shift level and by RNs/Care staff.
- A full workforce and quality dashboard to review any impact upon performance and patient satisfaction which will be triangulated with the gaps in fill rate for these wards.
- A clear outline of what is being done to address any risks both in the short term and the medium term.
Triangulating staffing data with patient safety and quality metrics
The completion of the monthly staffing has been undertaken manually by Matrons and checked against off duty and agreed skill mix for each ward. This ensures the planned shifts are accurate and that true variances are picked up. This was undertaken by Sue Sadiq Assistant Chief Nurse. Summary findings for the month of are:
- Of the 40 wards reviewed [the remit is for every inpatient designated ward to be included] there are 4 areas where less than 80% fill rates were identified across at least one shift [Day or Night].
There needs to be some investment in developing an IT solution to this report and E Roster is currently being explored as an option. There are currently some inconsistencies in E roster that make it unreliable as a report currently. Progress has been made with this and we are currently testing the electronic data against the manual data currently provided to ensure E roster is accurate.
National Quality board report recommendations
One of the key requirements for this report is that the wards highlighted as under the acceptable fill rate [80%] are reviewed against a number of workforce and quality metrics. This has been completed for the three wards in June and highlighted on the table on page 6.
- % Fill Rate Days RGNs/HCAs and % fill Rate nights RGNs/HCAs
- % Vacancies based on the whole time equivalent establishment that has been approved previously.
- % Sickness which is always one month behind but provides and overall indication of sickness in the previous 12 months.
- Harm Free hospital care from the most recent safety thermometer submitted.
- Ward Quality Indicator results [WQI formerly known as NQI] 3 Month performance. This is indicated by the RAG rating for the past 3 months to provide an indication of overall performance.
- The most recent ward Quality Audit [WQA] which is our in depth ward based quality audit.
- Falls where moderate to severe harm has been recorded in month.
- Grade 2- 4 hospital acquired pressure ulcers reported in month.
- Ward based complaints received inJune. It must be noted that these complaints often originate from another time and are not a real indication of performance in month.
- HCAIs reported in month.
- FFT score in month.
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Royal Liverpool and Broadgreen University Hospitals NHS Trust
Key for NQI.
R = Red rating [Less than 75%].
A = Amber rating [75.1% -89%].
G = Green Rating [90%].
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Royal Liverpool and Broadgreen University Hospitals NHS Trust
Ward 5B has now opened four extra beds and so the skill mix plan has been amended accordingly. The vacancy rate therefore looks higher in July. It must be noted that these have been recruited into and most will start in employment in the months of August and September. The vacancy factor has a direct impact upon fill rates in July. The sickness and absence rate compounds this [18.35%].The ward is still in transition in terms of acuity of the patients utilising the new beds and has been assessed daily by the Matron in terms of safe staffing. This is discussed as part of the daily staffing huddles held with all Matrons and senior nursing team.
There were 2 complaints received into the Trust in July and these are currently being reviewed. These were both informal complaints. The ward performance has seen a dip the monthly quality audits though however the ward has delivered some real improvements and is being supported to sustain these. The issues highlighted in the audits on the whole related to poor documentation, this could be due to the low fill rate. Staff will continue to be supported by the patient safety team and the quality audit teams.
Overwhelmingly patients that we have spoken to have been extremely positive about the care they receive and praise staff for their hard work.
9HDU reported a lower fill rate for HCAs on night duty. This is due to sickness. Performance on the ward is very good and there are no concerns regarding quality of care. There was one formal complaint received in July and this is currently being investigated. There was no formal patient feedback in July and this will be addressed to ensure patients have the opportunity to comment on their care.
Ward 10Z reported a low fill rate for HCAs at night. The ward remained safely staffed at all times and there are no concerns regarding performance. Again this ward does not get regular feedback form patients so this will be addressed. It is a small 8 bedded bone marrow transplant unit.
Ward 9A reported a low fill rate for HCAs on the day shifts. This is due to long term sickness. The ward has remained safe for all shifts and there are no concerns regarding performance.
Report summary and recommendations
The completion of the safe staffing report has been extremely helpful in that it has provided an opportunity to review all aspects of staffing, quality and safety. There are a number of issues highlighted in the report that are already being addressed. The questions this report wanted to answer was:
1. What are the fill rates for our wards based on the skill mix that was agreed in the last establishment review?
2. What are the gaps and why are they there?
3. Has there been any obvious impact on quality and safety?
4. What are we doing about the issues we identify?
Fill rates on the whole were good and the overall Trust figure is high. This may be a result of the improved daily reporting of staffing and much more transparency regarding actions taken.
Patient feedback is important and the Trust will address any areas where feedback is low.
Action required
All areas identified as having shortfalls are already being reviewed and monthly updates on vacancy fill rates are provided in the board report and quality performance report.
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