Workforce Education & Wellbeing Committee

09thMay 2018

Report title: / Nursing and Midwifery Staffing Report
March 2018
/ Agenda item:
Executive Director
Author / Liz Lees, Director of Nursing
Adam Brown, Associate Director of Nursing (Workforce)
Report summary / This is a monthly status update for staffing for inpatient areas. It encompasses key indicators including fill rates, CHPPD and incidents
Report Purpose / To appraise workforce, education and wellbeing committee of staffing status for preceding month
Related Trust Objective /
CQC Domain / Safety, well led and responsive
Action
(tick one box only) / Information
Yes / Approval / Assurance / Decision
Recommendation

Impact Assessments

Equalities / Human Rights / No adverse impact identified
Patient & Public Involvement / The report identifies performance against quality standards impacting on the patient population. Actions and learning taken are identified within the report. This report is available on the trust website
Legal / Regulatory / The trust is legally obliged to comply with all CQC Fundamental Standards.
Financial / This report describes staff utilisation in terms of hours not cost
Risk / Risks are managed through mitigations for exceptions

NURSING AND MIDWIFERYMarch 2018 STAFFING REPORT

Introduction

This is the monthly Nursing and Midwifery staffing report outlining:

  • March 2018staffing data submitted viathe UNIFY portal, including Care Hours Per Patient Day (CHPPD)
  • Vacancy and recruitment updatenot available at time of report
  • March 2018 temporary staffing usage and progress against agency,
  • Update on Safe Staffing work streams
  • Enhanced Patient Observation (EPO) – Specials
  • Roster compliance
  • Incident reports on Datix - Staffing shortages
  • Recommendations
  1. March 2018Staffing Data

1.1Fill rate

Nineteen wards reported staffing data for Januarywith an overall fill rate of 100.6% whichincludeenhanced patient observation (5.13%).

The fill rate for registered nurses for day shifts is lower in March than February. In March 2017 there were10 wards with fill rate less than 90%. The use of escalation areas, including endoscopy recovery areas have been a factor in the pressure for staff during the day time. Ward manager supervision shifts have been reduced, as many of the staff are working clinically within the clinical area to mitigate short falls. Furtherdetail of risk mitigation is detailed in section 7 Datix events for short staffing.

March 2017 / February 2017
% of Registered nurse day hours filled as planned / 88.3% of planned level / 90.2% of planned level
% of Unregistered care staff day hours filled as planned / 117.8% of planned level / 108.8% of planned level
% of Registered nurse night hours filled as planned / 100.3% of planned level / 99.6% of planned level
% of Unregistered care staff night hours filled as planned / 115.2% of planned level / 117.6% of planned level
Percentage allocated for Enhanced Patient Observation (Specials) / 5.13% / 6.09%

Figure 1 Monthly staffing level fill rate summaryFebruary / March 2018

1.2Care Hours per Patient Day (CHPPD)

Figure 2 – CHPPD trends

CHPPD is a measurement for benchmarking staffing levels developed following Lord Carter’s workforce review (2016). The range identified was 6 to 15 hours across 25 hospitals that participated in this review.

Utilisation of this metric will increase as guidance from NHSI and the Lord Carter review is shared in coming months. The overall figure is influenced by the higher staff to patient ratios within ED, Critical Care, Maternity and Paediatric services.

In March2018, the overall rate was 7.1 care hours across all patient wards (BHT)

  1. Vacancy and Recruitment Update – March 2018. Not available at time of this report
  2. March 2018 temporary staffing usage and progress against agency
  3. Nursing

During March 2018 a total of 23,409.87 hrs (Increase of 3173.11hrs on February 18) was worked by Qualified Nursing staff (both bank and agency)

The highest booking reasons were;

  • Vacancy –13598.74 hrs (Increase of 458.39 hrs on February 18 figure)
  • Service demand/Bed escalation –4370.66 (Increase of 601.08 hrs on February 18 figure)
  • Sickness – 1381.25 hrs (Increaseof 294.16 hrs on February 18 figure)

3.2.CSW

During March 2018, a total of 14438.25 hrs (Increase of 1212.04 hrs on February 18 figure) was worked by Clinical Support Workers.

The highest booking reasons were;

  • Vacancy – 6355.54 hrs (Increase 519.62 hrs on February 18 figure)
  • Specials – 3839.00 hrs (Increase of 99.25 hrs on February 18 figure)
  • Sickness – 1006.25 hrs (Increase 267.75 hrs on February 18 figure)

NHSI Data

Agency Breaches -Registered Nurse shifts are released to agencies via a cascade for outstanding unfilled shifts in line with the Hertfordshire and Bedfordshire collaborative agenda. Agency breaches are mainly registered against Critical department shifts. There have been some general ward shifts attributed to overrides due to escalation areas been open a total of 4 out of the 20 overrides.

3.3.Temporary Staff Recruitment

Bank staff cleared to work in March 2018;

  • Qualified staff – 4 x RN’s
  • Unqualified Staff - 10 x CSW’s
  • Administration Staff 4 x A&C
  • Other – X 1

Bank RN Recruitment day – successfully recruited 4 x RN’s for bank (Inductions in April/May)

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  1. Safer Staffing

Units / Total Bank & Agency Use % / Post Vacancies WTE RN and CSW / Sickness % / Parenting % / Datix events (Cat; Short staffing) / Fill rate % / Additional Duties / Mitigation
Howard Ward / 41.1% / 9.5 / 5.8 / 4.3 / 2 / 116.5 / 9 / Temporary staff use was 67:33 RN: CSW. RN cover was 49% bank and 51% agency. Additional duties were for EPOand higher fill rate for escalation beds (4 beds)
Whitbread Ward / 39.3% / 7.9 / 6.1 / 6.4 / 7 / 109.81 / 85 / Temporary staff use was 67:33 RN: CSW. Additional duties were for EPO. RN cover was 21% bank and 79% agency.
Richard Wells Ward / 37.7% / 7.6 / 6.8 / 1.8 / 0 / 108.82 / 62 / Temporary staff use was 49:51 RN: CSW. RN cover was 18% bank and 82% agency. Additional duties were to support higher dependency acuity
RussellWard / 32.6% / 6.2 / 8.6 / 0 / 0 / 101.91 / 15 / Temporary staff use was 26:74 RN: CSW. Additional duties were for EPO. RN cover was 47% bank and 53% agency.
ShuttleworthWard / 30.5% / 7.5 / 9.7 / 3.2 / 0 / 93.81 / 8 / Temporary staff use was 58:42 RN: CSW. RN cover was 21% bank and 79% agency. Additional duties were for EPO and seasonal pressure

Figure 3 - Wards with highest temporary staffing use for March2018(data source roster perform 26/02/2018 to 25/03/2018)

The wards in Figure 3are those identified with the highest rate of temporary staff usage. Most wards had an overall staff fill rate>95%, including specials. Unavailability for these wards for this period washigh. Howard ward had four beds open as escalation beds. Within the above wards there are pre-registration practitioners who are undertaking their language testing (IELTS) or OSCE prior to becoming registers with the NMC. The divisions are actively managing sickness absence.

4.1.Nursing Work streams – Work continues with all divisions reviewing nursing and midwifery efficiencies and potential cost improvement plans. Divisional progress will be reported to the newly established TfE Nursing workforce group meetingin April 2018.

4.2.Clinical Time – supervisory shifts - Ward Sister/Charge Nurses are expected to work in a supervisory capacity. In the roster commencing 25/02/2018, 22% of Supervisory shifts were worked; this is a reduction from previous months and is a reflection of service demand (escalation areas) and staff availability. There is some local variation. This Divisional compliance is reviewed monthly at the roster review meetings with Divisional Lead Nurses.

4.3.Establishment Review – Safer Staff report. A full establishment review of all in- patient areas was conducted in June and July 2017. A review of the wards within integrated medicine is underway is due to report in May 2018.

4.4.Recruitment event for RNs, RMs and ODPs. Recruitmentis planned for 12th May2018.

4.5.Agency forecast. Each week senior nurses prospectively review the temporary staff demand and utilisation of staff. This includes trained and untrained staff. Mitigation plans for anticipated short falls are then implemented e.g. reallocating staff, arranging block booking for agency and bank staff.

4.6.Agency Approval guidelines. These have been reviewed and were expected to be ratified in February 2018 implemented in March 2018. This approval is delayed and awaits workforce departmental approval.

  1. Enhanced Patient Observation (EPO).

There was asimilar demand for enhanced patient observationduring March2018(figures 4 and 5).To mitigate any risk associated with unfilled shifts patientsidentified as requiring EPO are reviewed and a risk assessment is undertaken regarding their care needs. Staff are reallocated, to ensure higher acuity wards are supported in care for these patients.

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Figure 4 – Enhanced Patient Observation (Specials) Trends over the last year

Figure 5– Enhanced Patient Observation Total Hours required trends over the last year

  1. Roster Compliance by Wards

6.1.Approval

The latest roster commencing on 21/05/2018 was completed on time by 59% of wards. The future roster approval dates have been agreed and revised with the eRoster team so that reporting is consistent across all departments.Divisional Lead Nurses will be challenged at Roster Review meetings to ensure performance achieves 95% compliance for the next roster period. In last month further measures have been introduced to the divisions to increase compliance.These will be closely monitored and managed by the senior nursing team.

Figure 6– Ward Roster approvals summary

6.2.Key performance Indicators KPIs

BHT eRoster policy sets out a list of KPIs for roster effectiveness, fairness and safety. Figure 7 illustrates compliance against the RAG rates set within the policy.

Those areas with additional shifts reflect the use of EPO, bed escalation cover or higher acuity staffing requirements.

The elevated levels of unused and over contract hours partially reflect the impact of 12 hour shifts against contracted weekly hours. These are reviewed each month with senior nurses for the division in the roster review process.

Riverbank and Meadowbank roster are being reviewed to establish why the fill is reduced. This is possibly due to revision to roster settings that require revision.

Critical Care Unit self-rosterstaff, therefore has a high number of requests.

Units / Unfilled Roster % / Shifts Without Charge Cover / % Requested Duties / Over Contract Hrs (4 wk.) % / Unused Hrs (4 wk.) % / Additional Duties
CAU/ Ambulatory Care / 20.50% / 0 / 6.90% / 0.40% / 1.20% / 38
Harpur / 10.20% / 0 / 2.80% / 0.80% / 0.80% / 67
Maternity / 17.60% / 0 / 12.20% / 1.00% / 2.90% / 6
Tavistock / 18.50% / 1 / 2.20% / 1.20% / 0.90% / 98
Richard Wells / 16.80% / 2 / 10.90% / 1.20% / 2.40% / 62
Arnold Whitchurch / 13.20% / 0 / 9.00% / 1.40% / 1.80% / 0
Howard Ward / 11.40% / 0 / 13.00% / 1.70% / 2.40% / 9
Shand / 14.10% / 1 / 13.80% / 1.90% / 2.00% / 17
A & E / 12.60% / 0 / 4.10% / 2.00% / 1.60% / 87
Elizabeth / 9.20% / 0 / 14.30% / 2.00% / 2.90% / 79
Russell Ward / 13.00% / 0 / 8.90% / 2.10% / 1.50% / 15
Orchard Gynae / 12.00% / 0 / 6.70% / 2.20% / 1.80% / 1
Godber / 11.30% / 0 / 4.10% / 2.20% / 2.50% / 41
Pilgrim / 14.40% / 0 / 8.00% / 2.30% / 1.20% / 49
Riverbank / 26.00% / 0 / 6.90% / 2.30% / 1.60% / 43
Reginald Hart / 12.80% / 1 / 6.60% / 2.40% / 3.50% / 122
Whitbread Medical / 16.60% / 0 / 3.50% / 3.00% / 2.20% / 85
Shuttleworth/SAU / 17.10% / 0 / 9.10% / 3.50% / 2.80% / 8
CCU / 8.80% / 1 / 7.50% / 4.50% / 0.80% / 10
AA Unit / 17.10% / 0 / 3.90% / 4.60% / 1.40% / 42
Crit Care Comp / 3.90% / 0 / 75.70% / 5.90% / 1.50% / 6

Figure 7– Ward roster KPIs for safety and fairness (Ward rosters 26/02/2018 to 25/03/2018)

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Datix events for short staffing

During March 2018, 53Datix forms categorised as ‘short staffing’ were submitted. Three of these were related to medical staff, outpatient areas or non-medical staff so are not included in this report.Within the 50 remaining incidents,allof these incidents were classified as ‘no harm’.

At the time of this report 3 incidents were still being investigated. This is a higher reporting rate as February 2018 where the level was 28.

Only five of the above Datix relate to maternity services. Maternity incidents have raised red flagswithin these that include;

  • 2 x Delay of 30 minutes or more between presentation and triage ,
  • 2 x Delay of 2 hours or more between admission for induction and beginning of process,
  • 1x Delayed or cancelled time critical activity ,
  • 1 x Delay of 30 minutes or more in providing pain relief

This is a reduction for this department since February2017; however the red flags have increased. Staffing levels and safety are reviewed using a situation report every four hours and staff are deployed as required.

More incidents were reported on weekdays (62%). The incident reports rate at night (44%) hasdecreased since last month and increased on day shifts (48%). Four incidents could not be identified as day or night shifts as recorded at time of shift hand over. There were four relate to insufficient staff being available to staff to support enhanced patient observations.

There were a peak of incident reports for Saturday 31/03/2018 where wide spread shortages of staff, this was related to short term absence and requirement to keep escalation areas open. No harms were reported on this date. Forecasting of fill rates had been conducted and reviewed in advance of the Easter weekend. Unfilled shifts were released to agencies earlier than usual for this weekend and also sent to higher cost agencies to seek cover.

Elizabeth ward have reported 8 incidents for March.These relate tostaff shortages partly resulting from staff moves to mitigate risks across other wards, these also include supporting escalation areas. There is no reported correlation to any patient harm for these staffing incidents.

Victoria ward have reported 6 incidents for March. These relate to lower levels of available staff. During this period the planned staffing levels have been increased to support the patient acuity and dependency requirements. There is no reported correlation to any patient harm for these staffing incidents.

Whitbread have reported 7 incidents in March. These relate to shortages of trained staff and on twooccasionsavailability of staff to support EPO requirements. There is no reported correlation to any patient harm for these staffing incidents.

Trust wide staffing levels are reviewed in the operational staffing meetings, three times per day. Mitigations for areas with shortages of staff are implemented and monitored by matrons and senior nurses.

Prospective review to the unfilled shifts on nights are undertaken every day and plans for mitigation enacted. On Thursday and Fridays the weekend staffing is reviewed and plans made to address anticipated short falls in staffing levels. The senior nursing team will monitor the prevalence of out of hour’s incidents each month at the senior nurses meeting.

Ward Managers have further reduced ‘supervisory time’ to 22% and were working within ward numbers.

With winter pressures matrons are often acting down and/or undertaking additional safety/ quality checks in all areas to ensure that patients have care plans and have been reviewed by a senior medic that day.

The remaining incidents relate to short notice changes to staffing levels, partly due to sickness or unfilled temporary staff requests.

The themes from Datix will be discussed at divisional quality meetings.

Figure 8 – Comparison of Datix incidents relating to staff shortages from November to February 2018

  1. Recommendations

To feedback this report at Workforce, Education and Wellbeing Board meeting on 09/05/2018.

Liz Lees

Director of Nursing and Patient Services.

Adam Brown

Associate Director of Nursing (Workforce)

2ndMay 2018

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