TAMESIDE HOSPITAL NHS FOUNDATION TRUST Report to Public Trust Board meeting of 26 th March 2015 Agenda Item 8c Appendix A Title Sponsoring Executive Director Author (s) Purpose Previously considered by 6 Month Acuity & Dependency Review Mr John Goodenough Director of Nursing Anne Allison, E-Rostering Project Manager To note/receive n/a Executive Summary In-line with the Hard Truths Commitments regarding the publishing of Staffing Data, and NICE Guidance, the Trust Board are required to receive and review a 6-monthly Acuity and Dependency Report. The aim of this report is to provide the 6-monthly review of data collected during January 2015. Related Trust Objectives Risk Assurance risk impacted upon Legal implications/regulatory requirements Financial Implications 1. All patients receive harm free care through the Trust s Patient Safety Programme. 2. To improve the quality of patient care through the implementation of the Trust s agreed Quality Strategy. 3. To improve the patient experience through a personalised, responsive, compassionate and caring approach to the delivery of patient care. CR734: Nurse vacancies, leadership and Nursing staffing recruitment across medicine and the ability to provide safe care. AF3480: Failure to meet CQC registration requirements relating to staffing. AF3482: Failure to ensure adequate staffing levels to ensure patient safety and quality of services NHS England monthly requirement to publish and report Staffing Data None Has a quality impact assessment been undertaken? How does this report affect Sustainability? Yes where applicable in plans The Trust are required to ensure staffing levels are adequate to meet patient safety and quality. Action required by the Board The Trust Board are requested to receive this update Page 1 of 12
1. Purpose In-line with the Hard Truths Commitments regarding the publishing of Staffing Data, and NICE Guidance, the Trust Board are required to receive and review a 6-monthly Acuity & Dependency Staffing Report. 2. Background/Introduction The National Quality Board (NQB) issued guidance in November 2013 to optimise nursing, midwifery and care staffing capacity and capability: 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. This was in response to the Robert Francis QC Report, and also encompassed the findings of Sir Bruce Keogh s review of hospitals with high adjusted mortality rates, the review of safety by Don Berwick and other similar sentinel national reports. The guidance clearly sets out the expectations and requirements of Trust s to meet the Hard Truth s commitments, with clear guidance from the Chief Nursing Officer for England Jane Cummings, and Professor Sir Mike Richards. In addition to this, NICE (National Institute for Health and Care Excellence) published further guidance in July 2014 with regard to staffing levels in adult inpatient wards: Safe Staffing for nursing in adult inpatient wards in acute hospitals. Undeniably there is world-wide evidence within the literature that ensuring the appropriate numbers of skilled staff safeguards a safe, quality, caring experience for patients. 3. Current Position At Tameside Hospital, a significant amount of work has been undertaken to ensure we meet the requirements set out within Hard Truths and can provide assurance to our patients, our staff, the Trust Board, our regulators and the general public of Tameside & Glossop. The journey has been huge, both in terms of organisational change, staff effort and financial investment, despite significant overarching operational and financial pressures. The table below summarises our journey to-date: Date Sept 13 Action Taken Major review of nursing establishments following Keogh review and CQC recommendation: 440,499 investment to support front line nursing teams - increases to Bands 2 Band 6 staffing. Significant increase in supporting specialist nursing & governance infrastructure VTE Specialist Nurse, Dementia & Frail Elderly Specialist nurse, 3 x band 7 Patient Safety Officers, 2 x band 7 Divisional Governance Lead posts and Clinical Effectiveness - 325,000 Nov 13 Additional investment of 388,883 to support additional staffing in view of issues relating to ward environmental layout and patient mix on Elective, Trauma, Ward 45 and Ward 46 Dec 13 Corporate Matron post created for Patient Experience & Quality - 43,822 Jan 14 Jan 14 279,020 investment to create additional Band 7 posts and facilitate Ward Manager supervisory time 6-monthly Acuity & Dependency Review undertaken 2014 789,611 investment to increase staff numbers and skill mix in A&E. 156,182 investment following a review and remodelling of the Healthcare Assistant role in A&E May 14 Gap Analysis undertaken against Hard Truth s commitments and Action plan to Page 2 of 12
meet requirements. Commenced monthly reporting of Planned v Actual staffing levels Reported publically via NHS Choices and Trust public website Monthly Board reporting commenced of staffing levels Public display of Planned & Actual staffing at ward level Escalation process for staffing concerns revised and re-launched June 14 Aug/Sept 2014 Nov 14 Jan 14 6-monthly Acuity & Dependency Review undertaken: Acts as a sense check to assess whether current staffing levels are adequate and appropriate. Triangulated against Nurse Sensitive Indicators and professional judgement. Report to Trust Board Gap analysis undertaken against NICE guidance and action planning commenced to meet guidance standards. Report to Trust Board Additional Ward Clerk support provided on the wards at weekends to nursing teams with additional admin & clerical support - 13,000 Business case developed to meet NICE guidance re: Nurse: Patient ratios: 500,000 investment agreed to meet NICE recommendations 4. Acuity & Dependency Review January 2015 The review of nursing establishments is complex and any method of determining staffing has limitations. There is no one solution to determine safe staffing and therefore triangulation of methods is essential. Using the combination approach will provide greater confidence in the decisions taken. The setting of establishments should triangulate from different sources: Workload measurement based information (acuity/dependency and activity) using a validated tool. Analysis in conjunction with patient safety & quality indicators Benchmarking with other organisations. Professional consultation/judgment by senior nurses and Chief Nurse/Head of Midwifery. The Trust is currently utilising the Safer Nursing Care Acuity & Dependency tool to further understand what the optimal staffing levels are for individual areas. This tool has been endorsed by NICE following the publication of their guidance Safer Staffing for nursing in adult inpatient wards in acute hospitals July 2014). The tool, when allied to Nurse Sensitive Indicators (NSIs), also offers nurses a reliable method against which to deliver evidence-based workforce plans to support existing services or the development of new services. The Acuity & Dependency Review is undertaken twice yearly (January and June) to enable the identification of trends across seasons and in response to changing demographics and healthcare needs. During January 2015 we carried out data collection on each ward for a period of 20 days in order to ensure a consistent approach. Utilising the Safer Nursing Care Tool, multipliers are used to calculate recommended staffing levels according to actual patient acuity and dependency. The results of this review are illustrated in Appendix 1, 2, 3 and 4, and are for the 15 adult inpatient areas detailed in the reports. Page 3 of 12
4.1 Results The results for each ward are illustrated in Appendix 1 4: Appendix 1: Shows the reported dependency levels for each ward Appendix 2: Illustrates the number of staff required according to patient Acuity v the Funded establishment, by ward. Appendix 3: Shows the variance between funded staffing and staffing required according to dependency. Appendix 4: HeatMap illustrating staffing variance and mapped against nursing care indicators and incidents. 4.2 Analysis (Appendix 3) identified: 4 areas are within an acceptable 10% variance (Ward 30, 43, MAU and WHU) 5 areas sit with a 10.1 20% variance 6 areas have a variance >20% No areas demonstrate staffing above 10% variance These results highlight areas where a more detailed analysis and review needs to take place by triangulating the data against other risks, complaints and patient care indicators. 4.3 Triangulation of Data A HeatMap has been produced (Appendix 5) to map patient care indicators against ward staffing and dependency data. The table below summarises the findings for the areas who sit outside of the 10% variance: Key: + = Over staffed = Under staffed Ward/Dept Variance Comment Ward 41-10.6% RN staffing at night <90% of planned levels during review period. Number of falls & drug errors higher than average Ward 31-11.8% RN staffing on day s <90% of planned levels during review period 1 incident of C-Diff Elective Surgical - 12.7% - 14.4% RN staffing at night <90% of planned levels during review period. Number of falls & drug errors higher than average 1 incident of C-Diff No significant issues identified Average number of complaints during review period (2) Ward 45-18.0% Ward 40-20.5% RN staffing on day s <90% of planned levels during review period Moderate number of complaints, drug errors and falls No significant issues identified Average number of complaints during review period (2) Page 4 of 12
Ward 5-21.5% Trauma - 25.0% Ward 42-29.3% Ward 44-31.7% Ward 46-37.5% RN staffing on day s <80% of planned levels during review period Number of falls & drug errors higher than average Number of complaints during review period high (5) and this area was one of only 2 areas reporting the development of a grade 2 pressure ulcer during this period. Planned staffing levels good during review period High number of falls reported (9), but no other significant issues. Planned staffing levels good during review period High number of falls reported (8), 2 complaints & 1 drug error. Planned staffing levels good during review period This area reported the highest number of falls during the review period (11). The only incident of MRSA was reported in this area, plus 1 grade 2 Pressure Ulcer (a total of 2 were reported in all areas during review). No complaints reported 4.4 Discussion The analysis has demonstrated that a significant number of our ward areas did not have the budgeted staffing levels to meet the acuity and dependency of the patients they provided care to during the review period. These reviews are undertaken at a point in time, it is therefore important to consider the findings over a longer period to determine the prevalence of increased patient dependencies. The table below shows the changes to patient dependency over the past 12-months based on all patients assessed during each review period: Review Date Level 0 Level 1a Level 1b Level 2 Level 3 Jan 2014 45% 19% 36% <0.1% - June 2014 48% 16% 36% <0.1% - Jan 2015 35% 16% 48% 1% - The above illustrates a reduction in the number of Level 0 patients and an increase in Level 1b and Level 2 patients. This suggests the patient mix admitted to our wards in Jan 2015 were significantly more acute and/or dependent, requiring higher levels of nursing care, intervention and support than previous reviews had identified. When reviewing the Nursing Care Indicators, there has been little change when comparing results between studies, although there has been a significant increase in the number of complaints reported (see below). This needs to be considered however; against the assertive work we have done to accurately capture these against incident reporting. Date Complaints Drug Errors Falls MRSA C.Diff Grade 2 Pressure Ulcers June 2014 9 12 81 0 2 2 Jan 2015 39 13 79 1 2 2 Page 5 of 12
Further work is required Divisionally to review the areas that sit outside of the +/- 10% variance and triangulate with other safety metric data to identify any risks to patient care. The outcomes from this work will be reported through Divisional Governance structures and via Senior Nursing and Staffing Forums in order to provide further Board assurance. 4.5 Impact of NICE Guidelines In July 2014 the National Institute for Health and Care Excellence (NIC) published guidance in relation to nurse staffing levels: Safe Staffing for nursing in adult inpatient wards in acute hospitals. This report highlighted that patient care may be compromised in areas where nursing staff were required to care for more than 8 patients during the day and 10 patients at night. Further analysis of the acuity and dependency data has been undertaken to map the trust s position against NICE guidelines, and illustrate the impact; should these recommended minimum staffing levels/ratio s be applied across our inpatient areas. The results of this remapping are shown in Appendix 5 & 6. If staffing establishments were increased to meet NICE guidance only 5 areas would sit outside the +/- 10% variance for understaffing, and 10 would be satisfactory, whereas currently only 4 areas are satisfactory. 4.6 Recommendations The table below outlines the recommendations and required action as a result of this latest Acuity & Dependency review: Recommendation Action Responsibility Completion Date Review ward areas who sit outside of the +/- 10% variance. Triangulate with safety data to determine actual/potential risks. Develop action plans to mitigate/address known risks Divisional Teams May 2015 Gap analysis of NICE guidance completed: Trust Board to be appraised of quality, safety and cost implications and potential options for implementation. Consider implications of implementing NICE Guidelines. Decide whether any increase to nursing establishments is required. Trust Board April 2015 Further analysis of additional staffing data/information in-line with NHS England Hard Truths Reporting requirements and NICE guidance recommendations. Report to be provided to Trust Board and disseminated Divisionally to ward teams Anne Allison May 2015 Further establishment reviews required for those areas not captured during this review. Establishment reviews to be undertaken in: Critical Care Maternity Children s Divisional Teams June 2015 Page 6 of 12
Patient Beddays Appendix 1 Dependency Levels by Ward January 2015 700 600 500 400 300 200 100 0 Acute Stroke and Short Stay 0 0 0 0 3 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 520 0 0 0 0 2 0 Elective MAU Surgical Trauma Ward 30 Ward 31 Ward 40 Ward 41 Ward 42 Ward 43 Ward 44 Ward 45 and Stroke Rehab Ward Ward 46 Womens Health Level0 Level1a Level1b Level2 Level3 Page 7 of 12
Appendix 2 Dependency vs Current Staffing - January 2015 80 70 60 50 40 30 20 10 0 Acute Stroke and Short Stay Elective MAU Surgical Trauma Ward 30 Ward 31 Ward 40 Ward 41 Ward 42 Ward 43 Ward 44 Ward 45 and Stroke Rehab Dependency 24.537 28.481 70.659 29.745 56.732 19.656 35.091 39.757 35.96 42.167 24.698 35.156 38.01 35.795 17.506 Current Staffing 20.2 25.28 67.8 26 45.4 20.7 31.4 33 32.5 32.6 26.6 26.7 32.2 26.04 16.3 Ward 46 Womens Health Dependency Current Staffing Page 8 of 12
Appendix 3 % Variance - January 2015 (Current Staffing-Dependency)/ Current Staffing 100.0% 75.0% 50.0% 25.0% 5.0% 7.2% 0.0% -25.0% -50.0% -21.5% -12.7% -4.2% -14.4% -25.0% -11.8% -20.5% -10.6% -29.3% -31.7% -18.0% -37.5% -7.4% -75.0% -100.0% Acute Stroke and Short Stay Elective MAU Surgical Trauma Ward 30 Ward 31 Ward 40 Ward 41 Ward 42 Ward 43 Ward 44 Ward 45 and Stroke Rehab Ward 46 Womens Health Page 9 of 12
Appendix 4 Acuity & Dependency - January 2015 Funded- Dependency Complaints Drug Errors Falls MRSA C.Diff Pressure Ulcers - (Grade 2 only) Registered Staff - Day Shift Registered Staff - Night Shift Care Staff - Day Shift Care Staff - Night Shift Elective -12.7% 2 2 7 0 1 0 97.4% 86.9% 109.3% 130.6% Surgical -14.4% 3 0 3 0 0 0 105.4% 118.6% 122.9% 166.3% Trauma -25.0% 5 1 4 0 0 1 96.8% 99.2% 124.3% 122.5% Ward 30 5.0% 3 0 3 0 0 0 99.2% 95.7% 110.8% 106.9% Ward 31-11.8% 2 0 0 0 1 0 87.7% 95.9% 103.0% 119.8% Ward 40-20.5% 2 0 3 0 0 0 94.3% 94.6% 115.9% 116.4% Ward 41-10.6% 2 2 6 0 0 0 93.6% 88.2% 120.6% 192.1% Ward 42-29.3% 2 0 9 0 0 0 94.9% 93.5% 121.4% 166.3% Ward 43 7.2% 2 1 4 0 0 0 100.2% 102.6% 151.5% 173.3% Ward 44-31.7% 2 1 8 0 0 0 100.2% 103.4% 137.9% 162.4% Ward 45-18.0% 1 1 5 0 0 0 83.3% 103.9% 114.9% 114.2% Ward 46-37.5% 0 1 11 1 0 1 91.4% 96.5% 116.2% 117.1% MAU -4.2% 8 3 6 0 0 0 98.8% 84.5% 92.0% 119.1% Ward 5-21.5% 1 1 7 0 0 0 78.6% 101.7% 112.3% 101.0% CCU N/A 0 0 0 0 0 0 96.3% 101.2% 60.4% N/A ITU N/A 0 0 0 0 0 0 99.6% 94.2% 91.9% N/A Women's Health -7.4% 4 0 3 0 0 0 87.8% 115.6% 96.0% N/A Total 39 13 79 1 2 2 Key: Funded Dependency Complaints Drug Error Falls +/- 10% = Green 0 = Green 0 = Green <4 = Green +/- 10% - 20% = Amber 1 = Amber 1 = Amber 5 7 = Amber +/- 20% = Red 2 = Red 2 = Red >8 = Red MRSA C Diff Pressure Ulcer Staff Fill Rates 0 = Green 0 = Green 0 = Green >90% = Green 1 = Amber 1 = Amber 1 = Amber 80% - 90% = Amber 2 = Red 2 = Red 2 = Red <80% = Red Page 10 of 12
Appendix 5 100.0% % Variance - January 2015 (Proposed Staffing-Dependency)/ Proposed Staffing 75.0% 50.0% 25.0% 9.8% 8.7% 4.7% 4.6% 17.4% 0.0% -25.0% -4.2% -14.8% -2.3% -15.9% -4.8% -22.9% -17.6% -7.7% -19.7% -7.4% -50.0% -75.0% -100.0% Acute Stroke and Short Stay Elective MAU Surgical Trauma Ward 30 Ward 31 Ward 40 Ward 41 Ward 42 Ward 43 Ward 44 Ward 45 and Stroke Rehab Ward 46 Womens Health Page 11 of 12
Appendix 6 % Variance Comparison - January 2015 100.0% 75.0% 50.0% 25.0% 0.0% -25.0% -50.0% -75.0% -100.0% Acute Stroke and Short Stay Elective MAU Surgical Trauma Ward 30 Ward 31 Ward 40 Ward 41 Ward 42 Ward 43 Ward 44 Ward 45 and Stroke % Variance % Variance (Proposed Staffing) Rehab Ward 46 Womens Health Page 12 of 12