EXECUTIVE SUMMARY Report to Trust Board Date Tuesday 28 July 2015 Agenda Number 2.5 Agenda Item Nursing Acuity and Dependency Audit Report Sponsor Debbie Bennion, Interim Director of Nursing Prepared by Debbie Bennion, Interim Director of Nursing Presented by Debbie Bennion, Interim Director of Nursing 1. Purpose and Key Issues The purpose of this paper is to present to the Board, the nursing acuity and dependency audit completed for 20 consecutive days in June 2015. The Nursing dependency and acuity audit will be completed twice yearly; this is designed to (a) provide assurance that the agreed staffing establishments are sufficient to meet patient need and (b) propose changes where required Key issues include: The Trust has a clear validated process for monitoring acuity and dependency of patients in order to provide assurance that staffing establishments are set against patient need; This report includes all adult inpatient wards with the exception of maternity, ICU, paediatric and special care baby unit; and The context of the report and the questions this may raise for Board. 2. Supporting Information Appendix 1: The Safer Nursing Care Tool (SNCT) was used to capture the acuity and dependency data. Appendix 2: Safe Nursing Care Tool (SNCT) data collection form June 2015. This spreadsheet details the levels of dependency, acuity and patient flow data for the period 1 st June 2015 to 20 th June 2015 inclusive. Due to the size of the spreadsheet, this is attached as a separate document. Appendix 3: Planned v Actual staffing report June 2015. This spreadsheet details the planned versus actual staffing levels for each ward for the period 1 st to 30 th June 2015 inclusive. Appendix 4: report June 2015. This spreadsheet details the substantive v temporary staffing for each ward for the period 1 st to 30 th June 2015 inclusive. 3. Controls and Assurances 3.1 The Safer Nursing Care Tool (SNCT, Appendix 1) was used to capture the acuity and dependency data. This tool was developed by the Association of United Kingdom Director of Nursing Page 1 of 13
University Hospitals (AUKUH) and is the only evidence based methodology currently available. The evaluation of the nursing acuity and dependency audit and ward staffing establishments uses a number of tools and methods to assess current staffing levels and skill-mix. These include acuity, dependency, bed occupancy and patient flow information (number of admissions, discharges and transfers). 3.2 This report compares the actual funded whole time equivalent (wte) nursing staff (registered and health care assistants) with the assessed whole time equivalent needed during the 20 day acuity/dependency audit. The audit figure is a baseline against which to set nursing staffing levels, wards have varying degrees of activity therefore nursing professional judgement is vital to ensure that establishments are adjusted appropriately under these circumstances. Established levels of absence are built into the SNCT formula used to calculate levels of care and allows a 22% uplift for annual leave/ study leave. The report will include a summary of context narrative to provide rationale regarding the data. 3.3 The acuity and dependency scores were calculated three times a day by the nurse in charge of the shift, the 12 mid-day audit was used for the purpose of this report The results were reviewed by Senior Nurses/Matrons in order to further add professional judgement to this report. The acuity and dependency audit is not used in isolation as experience tells us that acuity / dependency is often higher than the staffing levels, but adjustments are not required as both the seniority and experience of staff on duty enable them to manage safely. Therefore when reviewing the data it is important to take into account the skill mix, strength of ward leadership as well as activity, patient acuity and dependency; The acuity and dependency tool is not currently validated for use in medical admissions wards and a model is currently being developed therefore the data for MAU will need further refining when the tool has been released by the Shelford national audit team. The acuity and dependency tool is being further developed by the Shelford national audit team to better reflect the complexities of caring for older people in acute care wards 3.4 This report will be presented twice a year at Board meetings. 4. Legal and Regulatory Implications The legal implications have been considered and none have been identified. 5. Equality and Diversity Implications The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. No adverse or positive impacts have been identified from this report. Director of Nursing Page 2 of 13
6. Patient, Public and Staff Involvement The Trust ensures that patients, the public and staff are involved in the decision-making process when appropriate. This paper is published on the Trust website on the Safer Staffing web pages 7. Cost Implications The Trust aims to support optimal quality and safety and financial effectiveness whilst promoting safe staffing through maximizing the use of our own resources. 8. Potential Risk to the Organisation Failure to address staffing effectively will place the care of our patients at risk and could damage the reputation of the Trust 9. Board Prompts Does the attached information and commentary provided explain the results of the 20 day June acuity and dependency audit? Does the commentary sufficiently explain the current position, this issues that need to be addressed and the next steps? Is the Board satisfied that the staffing report has the right information on which to base a judgment about assurance? Is the Board assured that the methods the Trust is using are open to external scrutiny? 10. Recommendations The Board is asked to RECEIVE and APPROVE the report. 11. References Source Webpage: NHS Institute for innovation and Improvement, January 2014 (please see Appendix 1). Source webpage: National Quality Board (NQB) 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, November 2013. 12. Strategic Objectives The Trust s Strategic Objectives are reviewed by the Board on an annual basis. This paper supports the achievement of the following strategic objectives: X Highest quality X Flexible & multi-skilled workforce X Sustainable services X Efficient & effective Integrated health & social care X Local provider of choice Director of Nursing Page 3 of 13
13. Principal Risks The Principal Risks have been identified through the Trust s risk management processes. They are updated as they are identified by the Risk Management Committee. This paper supports the mitigation of the following principal risks: Financial planning & management Clinical records management Strategic & business planning X Leadership & management X Workforce numbers X Unsafe behaviour X Workforce skills X External demands Procedural management Partnership arrangements Equipment & facilities arrangements Communication Director of Nursing Page 4 of 13
Nursing Acuity and Dependency Audit Results June 2015 Appendix 2 ( SNCT audit data) details the levels of dependency, acuity and patient flow figures for the period 10 th to 30 th June 2015. Bed occupancy (at 12 midnight) is not included in these figures but commentary is detailed below. Those areas which show a +ve difference in funded establishment (wte) to audited need are defined as areas having more nursing staff than required for the average of the audit period. Those areas which show a -ve difference in funded establishment (wte) to audited need are defined as areas having less nursing staff than required for the average of the audit period. NDDH (Acute wards) The audit results indicate that during the audit period there were; Five wards had between 1.51 and 8.32 wte staff more than they required to deliver safe and effective care based on the acuity and dependency assessment. Six wards had between 0.49 and 7.42 wte staff less than they required to deliver safe and effective care based on the acuity and dependency assessment. Staff from the wards with more nursing staff than they required for this period would have been redeployed to wards with a greater need on a shift by shift basis, when a need based on professional judgement has been identified. Ward Difference in actual wte to audited Occupancy Data from PAS at 12 midnight Comment ASU -0.49 94.6% Staff were also covering the stroke outreach service. Planned v Actual staffing report for June 2015 demonstrates, actual staffing hours were 105.18% of Elizabeth - Bideford report demonstrates 8.49% were temporary -1.03 98.3% Planned v Actual staffing report for June 2015 demonstrates actual staffing hours were 99.81% of planned report demonstrates 16.13% were temporary Capener -6.63 85% Planned v Actual staffing report for June 2015 demonstrates actual staffing hours were 109.63% of report demonstrates 14.31% were temporary Staff scored most patients at level 1a or 1b this needs further clarification, se Director of Nursing Page 5 of 13
recommendations. Alex (Elderly Care Medicine) +8.79 98.6% Planned v Actual staffing report for June 2015 demonstrates actual staffing hours were over 108.79% of report demonstrates 20.37% were temporary During the audit period, the ward relocated with a net reduction of 19 beds. Staff were supporting the move and redeployed on a shift by shift basis to support staff on other wards Fortescue -3.97 87.2% Planned v Actual staffing report for June 2015 demonstrates, actual staffing hours were 98.95% of planned report demonstrates 9.61% were temporary Staff from Alex ward were redeployed to Fortescue to support staff Glossop -5.40 97.3% Planned v Actual staffing report for June 2015 demonstrates actual staffing hours were over 112.8% of This increase in staffing related these patients requiring enhanced observation. report demonstrates 11.76% were temporary During the audit period there were a number of highly dependent patients, appropriately scored at level 2 Lundy +6.84 87.6% Planned v Actual staffing report for June 2015 demonstrates, actual staffing hours were 110.85% of planned report demonstrates 11.91% were temporary MAU +7.59 71.5% This result should be viewed with caution as the audit is not specifically designed for assessment units. A National audit tool has been developed for assessment units but not yet released for use. Staples (female surgery) Planned v Actual staffing report for June 2015 demonstrates, actual staffing hours were over 105.21% of report demonstrates 21.85% were temporary +1.51 85.7% Planned v Actual staffing report for June 2015 demonstrates, actual staffing hours were 105.28% of report demonstrates 14.63% of registered nurses were temporary Director of Nursing Page 6 of 13
Tarka +8.32 85.3% Planned v Actual staffing report for June 2015 demonstrates, actual staffing hours were 99.59% of report demonstrates 15.11% were temporary Victoria -11.20 (based on ECC monitored patients as Level 2). -4.83 (based on Level 0). -7.42 (based on Level 1a). 99.1% This result should be viewed with caution as nursing staff have scored patients who are undergoing ECG monitoring as level 2 patients. It is believed that these patients should be scored at a level 0 or 1a. Please see recommendations for further commentary. Planned v Actual staffing report for June 2015 demonstrates actual staffing hours were over 120.73% of report demonstrates 23.19% were temporary Community Hospitals The staffing review and recommendations presented to Executive team seventeen months ago by the former Director of Nursing, were across the organisation. At that point in time the recommended staffing levels for the acute wards were accepted and funding approved. The recommendations for the community hospital staffing levels were accepted in principle but funded establishments were not amended as the services were part of wider rationalisation and scrutiny process. However in the interval of time the rationalisation process has not been fully agreed and completed; this therefore remains the subject of discussion. Final agreement of funded establishment will conclude once quarter fours rationalisation of acuity, professional judgement and staffing recommendations has concluded; this is anticipated to be with the Executive team in November 2015 for their consideration and will then come to Board. The wards teams are meeting any staffing gaps and enhancing care as required for patient safety based on previous set staffing levels and acuity/need/risk as assessed on a day to day basis. When community hospitals are viewed, the audit results indicate that during the audit period there were; Eight wards had less staff than required to deliver safe and effective care based on the acuity and dependency data. Some of these are in the lower range and the adjustment would seem proportionate to the acuity lift and the changes in the staffing recommendations re lone RN working and 1.8 ratio. Four wards had more staff than they required to deliver safe and effective care, based on the acuity and dependency of patients Director of Nursing Page 7 of 13
During the period of review of the data, there continued to be a complexity of bed flexing and a dynamic bed base state through a change process in Eastern area. Future data and assessment will reflect/capture this dynamic state in order to validate the way teams and rosters are aligning to bed reductions and increases at times of winter and other pressures. Northern Community Hospitals Ward Difference in actual wte to audited Occupancy based on beds open Comment Willow +2.66 92.2% Planned v Actual staffing demonstrates, actual staffing hours were 103.57% of report demonstrates 32.9% were temporary South Molton +2.04 78.5% Planned v Actual staffing demonstrates, actual staffing hours were 103.07% of report demonstrates 15.99% were temporary Holsworthy -2.73 85.3% Planned v Actual staffing demonstrates, actual staffing hours were 100.52% of report demonstrates 8.86% were temporary Eastern Community Hospitals Ward Difference in actual wte to audited Occupancy based on beds open Comment Doris Heard -0.91 98.1% Planned v Actual staffing report for June 2015 demonstrates, actual staffing hours were 98.14% of Geoffrey Willoughy report demonstrates 26.72% were temporary +4.42 71.9% Planned v Actual staffing report for June 2015 demonstrates, actual staffing hours were 88.25% of report demonstrates 15.23% Director of Nursing Page 8 of 13
were temporary Honiton -3.14 92.8% Planned v Actual staffing report for June 2015 demonstrates, actual staffing hours were 112.32% of report demonstrates 26.4% were temporary Okehampton -1.46 94.1% Planned v Actual staffing report for June 2015 demonstrates, actual staffing hours were 109.04% of Ottery St Mary -6.75 at level 2. Level 2 patients as level 1a would give a difference of -6.55. report demonstrates 28.37% were temporary 97.3% Planned v Actual staffing demonstrates actual staffing hours were over 96.81% of report demonstrates 15.67% of registered nurses were temporary Seaton -2.65 96.9% Planned v Actual staffing demonstrates actual staffing hours were 99.91% of report demonstrates 16.51% of registered nurses were temporary Sidmouth -3.26 92.2% Planned v Actual staffing demonstrates actual staffing hours were over 109.93% of report demonstrates 38.82% of registered nurses were temporary Twyford -2.81 98.4% Planned v Actual staffing demonstrates actual staffing hours were over 102.86% of report demonstrates 9.73% of registered nurses were temporary Blackdown -1.12 94.7% Planned v Actual staffing Director of Nursing Page 9 of 13
demonstrates actual staffing hours were over 101.62% of report demonstrates 14.25% of registered nurses were temporary Budlake +0.45 92.3% Planned v Actual staffing demonstrates actual staffing hours were over 107.27% of Recommendations for further action Acute and Community report demonstrates 25.25% of registered nurses were temporary Methodology for calculating bed occupancy to be reassessed by Performance Team as several wards appear to have low occupancy rate for this period. Senior Nurse / Matrons will review and discuss with individual ward managers on a daily basis the dependency and acuity scores of the wards who are demonstrating wide variation in scoring. Acute Benchmarking with other Trusts indicates that the scoring of Victoria ward in relation to the number of patient undergoing ECG monitoring which were scored as level 2 patients should be scored as level 0. The Director of Nursing is awaiting confirmation from the Shelford Team. The bed reconfiguration project team are reviewing the surgical and medical bed base in light of the bed occupancy figures. Data for MAU to be refined using the new national audit tool once this has been released for use from the national audit team. The ED establishment has been reviewed in the light of NICE guidance published on 16 th January 2015. Further validation has taken place, based on the RCN methodology. This will be reported on at the November Board. From July 2015, a band 7 nurse has been allocated on a daily basis to oversee staffing and embed more fully compliance with safer staffing and e-roster performance. This is currently monitored via the weekly tactical meetings. Community Rebalance community hospital establishment once final configuration of community hospitals is agreed. Future planned developments of this report Incorporate further analysis of patient flow and occupancy data; Report six monthly nurse sensitive indicators using statistical process control run charts Director of Nursing Page 10 of 13
What is it? Appendix One Additional background information about the Safer Care tool The Safer Nursing Care tool - Linking Staffing to Quality Outcomes The Safer Nursing Care Tool (SNCT) is a robust valid evidence-based easy to use tool which uses acuity and dependency to help plan for future workforce requirement. It is a natural extension to the original Association of United Kingdom University Hospitals (AUKUH) Patient Care Portfolio project. What are the benefits? Helps to review the impact of actual staffing levels on the quality and care delivered to the monitoring of nurse sensitive indicators (NSIs). Helps NHS teams determine or evaluate ward team size and mix easily and quickly. Teams can benchmark their staffing and NSIs against similar wards and departments internally and externally. When linked to NSIs will also offer nurses a reliable method against which to deliver evidence-based workforce plans to support existing services or the development of new services. It will also help to define establishment levels, skill-mix and training and development of staff to provide high quality patient experience. Who is it aimed at? Acute general adult inpatient services Ward based staff providing a functional tool that gives them an output that they can use to inform them of staffing levels and their care processes Matrons, nurses and divisional managers to help identify risk and enable them to influence and apply resource where applicable. Board level to provide assurance that staffing is based on actual workload and linking it to quality outcomes. Uses evidence to ensure that financial resources are used appropriately across the organisation. The Safer Nursing Care Tool is free to all NHS trusts in England. However, we require each trust to nominate a Safer Nursing Care Tool lead, who will receive information about access to the tool. We recommended that a lead is nominated before your organisation embarks on using the tool. Source: Webpage NHS Institute for innovation and Improvement Jan 2014. Director of Nursing Page 11 of 13
Appendix Three Director of Nursing Page 12 of 13
Appendix Four Director of Nursing Page 13 of 13