Care Capacity Demand Management Programme

Care Capacity Demand Management Programme MENTAL HEALTH TRENDCARE SURVEY REPORT July 2014 REPORT TO THE MENTAL HEALTH, ADDICITONS AND DISABILITY ADVISORY GROUP TO THE SAFE STAFFING HEALTHY WORKPLACES UNIT PREPARED BY: SAFE STAFFING HEALTHY WORKPLACES UNIT AUGUST 2014

Acknowledgements Grateful thanks to all the participants, supporters and promoters of the survey. 1

Executive Summary In February 2014 The Safe Staffing Healthy Workplaces Unit established the Mental Health, Addictions and Disability Advisory Group (MHADAG) to ensure the Mix and Match Methodology of the Care Capacity Demand Management Programme was suitable for this setting. In July 2014 the MHADAG undertook a survey of TrendCare users in DHB mental health, addiction and disability services to gain a user perspective on the use of TrendCare, and gain engagement of users to ensure Mix and Match was fit for purpose in DHB inpatient mental health units. The survey attracted 141 respondents who were predominantly clinically based nurses working in acute adult hospital settings. This reflects the focus of attention of the MHADAG at this time. Responses were received from all DHB s currently using TrendCare in the Mental Health setting. The results of the survey indicate the majority of respondents have concerns about the use of TrendCare in mental health services. Almost half of the respondents strongly disagree that TrendCare accurately captures all aspects of their work, with a quarter more somewhat disagreeing. When asked what aspects were missing, many respondents do not believe TrendCare fits the mental health environment. Responses indicated that staff are not aware of, or do not have available all the indicators which reflect their work environment. Many items which were identified as missing are options available in the system. This suggests issues of training or set-up in DHB s and provides an opportunity for review, agreement and training initiatives at a national level. TrendCare was not seen as a tool which enables staff to use their expert clinical judgement about patient acuity, but mainly used by the DHB s to contain costs. From the responses it was apparent that the staffing methodology underpinning TrendCare; that it is not a task orientated system but instead focusses on patient variables that make nursing time consuming; is not well understood. Many staff expect to see every activity undertaken reflected in the indicators as if it were a time and motion study. However many activities are included in the algorithm that contribute to the baseline category timings rather than being individually identified in the indicator list. Almost three quarters of respondents indicated they are confident using the programme and 60% of respondents indicated their training was adequate. However the survey responses did not reflect full use or awareness of the specific features of the program for mental health service provision. When asked for improvement suggestions, the most common response was to make TrendCare more mental health specific, which indicates there is a strong perception the tool does not reflect the reality of the mental health work setting. Throughout the survey there was a strong theme of staff needing to be able to more accurately capture the requirement for multiple staff working with one patient, and particularly in the circumstances of seclusion, restraint and other critical events. A nationally consistent approach and training regarding this aspect would add value to the use of the tool and provide useful information to identify appropriate staffing levels and skill mix to reflect patient need. 2

Recommendations to the Mental Health, Addictions and Disability Advisory Group 1. Work with the TrendCare vendor to run a Train the Trainer workshop focussed on the mental health setting for TrendCare Coordinators and Champions from the mental health setting. 2. Identify and include in national training a consistent way to capture the staffing intensity required to reflect multiple staff providing care at one time to one client. 3. Work with DHB s to identify consistent use of patient types and associated indicators to enable benchmarking. 4. Recommend to all DHB s that there is a mental health member of the DHB TrendCare Steering Group. 5. Recommend to DHB s that following the evaluation of the Mental Health Mix and Match Pilot, the Mix and Match Part One (Work Analysis) is undertaken in all inpatient mental health units that utilise TrendCare. This will enable the capture of a more detailed understanding of staffing activity and therefore assist in the identification of appropriate staffing profiles for patient and staff safety. 3

Table of Contents Acknowledgements... 1 Executive Summary... 2 Background to CCDM... 5 Introduction... 5 Findings... 6 Question 1... 6 Question 2... 7 Question 3... 8 Question 4... 9 Question 5-... 10 Question 6-... 11 Question 7-... 13 Question 8-... 13 Question 9-... 14 Question 10-... 15 Question 11-... 15 Question 12-... 16 Question 13-... 17 Discussion and Recommendations... 18 4

Background to CCDM In 2005 the Safe Staffing/Healthy Workplaces Committee of Inquiry was set up as the result of the Multi Employer Collective Agreement (MECA) negotiations between District Health Boards (DHB s) and the New Zealand Nurses Organisation in (NZNO). The Safe Staffing Healthy Workplaces (SSHW) Unit was established to work on behalf of the parties to develop: a mechanism for nurses, midwives and employers to respond immediately if workloads exceed the determined levels; sustainable solutions to safe staffing issues, developed in a way that has the confidence of nurses and midwives. Subsequently other unions including the Public Service Association have become a party in the partnership. The Care Capacity Demand Management (CCDM) Programme was developed jointly by the SSHW Unit, DHBs and Unions. CCDM is an organisational approach to ensuring that the demand for patient care is matched accurately and effectively with the resources required. CCDM ensures: The right number of staff Who are appropriately skilled In the right place At the right time With the appropriate resources. To meet the patients needs (demand) and deliver safe, effective and efficient care. A fundamental element of the CCDM Programme is Mix and Match; an intervention designed to identify an appropriate number of staff, the optimum skill mix and scheduling underpinned by the use of validated patient acuity information. In New Zealand, TrendCare is the only validated patient acuity system in use in DHB s. In February 2014, the Mental Health, Addictions and Disability Advisory Group (MHADAG) to the SSHW Unit was formed to ensure the patient acuity driven staffing methodology within the CCDM programme is suitable and accessible for DHB Mental Health, Addictions and Disability services in New Zealand. Introduction TrendCare is the most commonly used patient acuity tool used in New Zealand, with 15 of 20 DHB s now using the system. Uptake of TrendCare in Mental Health areas has been variable with a number of DHB s utilising TrendCare in the medical/surgical areas, but not always in the mental health setting. This has been changing in recent times with 12 DHB s now using TrendCare in the Mental Health Units. While the Mix and Match intervention of the CCDM Programme has been tested and validated in medical /surgical areas, the SSHW Unit is aware the mix and match methodology needed testing in the mental health setting to ensure the same degree of reliability and trust by all parties. The SSHW Unit established the Mental Health, Addictions and Disability Advisory Group to ensure the Mix and Match Methodology was suitable for this setting. An important initial step was to undertake a survey of TrendCare users in DHB s to gain a user perspective on the use of TrendCare in mental health, addiction and disability services, and gain engagement of users in this work. The online survey conducted via Survey Monkey ran from 24 June to 13 July 2014 and was distributed and publicised by both DHB and Union parties. The findings of the survey are detailed in this report and recommendations made for the consideration of the advisory group. 5

Findings Question 1 Please select your workplace setting- In alignment with the focus of the MHADAG work on inpatient services, the majority of respondents identified as working in hospital settings. 6

Question 2 Please select the type of service you work in- Service Type Respondents Adult Acute 111 Long stay 3 Adolescent 10 Forensic 9 Forensic Long Stay 7 Geriatric 13 Geriatric Long Stay 1 Intellectual Disability 5 Intellectual Disability Long Stay 7 Paediatric 0 Post Natal 2 Rehabilitation 13 Day Only 0 Total 139 The majority of respondents work in Adult Acute services. 7

Question 3 Please identify your DHB- DHB Respondents Mid Central Health 9 Northland 6 Auckland 7 Waitemata 15 Bay of Plenty 9 Tairawhiti 4 Taranaki 15 Whanganui 10 Hawkes Bay 5 Hutt Valley 11 Nelson Marlborough 19 Southern 31 Total 141 All DHB s who use TrendCare were invited to participate, and all who use TrendCare in Mental Health Services contributed, including Hawkes Bay DHB who are not currently participating in the CCDM Programme. 8

Question 4 What best describes your role? Three other respondents identified themselves as Educators and a further respondent as Nurse Director-clinical leadership. These responses indicate the majority of responses were received from clinically based nurses who were the primary target for the survey. 9

Question 5- When using TrendCare, please indicate to what extent you agree/disagree with the following statements: Note: strongly agree/somewhat agree and somewhat disagree/strongly disagree are grouped together. 127-129 respondents (figures are rounded) a) It accurately captures all aspects of my work, clinical and non clinical. b) It is easy to use Agree Disagree Greatest % response 25% 75% Strongly disagree 47% 64% 36% Somewhat agree 40%. c) I feel confident using this programme 73% 27% d) I have had adequate training in the use of this programme e) The amount of time it takes to enter data is manageable f) It supports me to work efficiently 17% 80% somewhat agree 42%. 60% 40% somewhat agree 36%. 68% 31% somewhat agree 46%. strongly disagree 56%. g) It enables me to use my expert clinical judgement about patient acuity 33% 64% strongly disagree 37%. h) It is used to support patient safety 29% 70% strongly disagree 45%. i) It is used to support staff safety 25% 74% strongly disagree 45%. j) It is mainly used as a way for the organisation to contain costs k) The data is used by my organisation to respond to staffing deficits 73% 24% somewhat agree 39%. 35% 63% strongly disagree 40%. The majority of respondents disagree TrendCare accurately captures all aspects of their work, with almost half of respondents strongly disagreeing with this statement. 10

The majority of respondents agree TrendCare is easy to use, with almost three quarters of respondents indicating they are confident using the programme. 60% of respondents indicate they believe their training is adequate 68% of respondents indicate the amount of time taken to enter data is manageable TrendCare is not seen as supporting respondents to work efficiently, with 80% disagreeing with this statement More than a third of respondents strongly disagree TrendCare enables them to use their expert clinical judgement about patient acuity The majority of respondents do not perceive TrendCare is used to support patient and staff safety, with 45% of respondents indicating strong disagreement. Almost three quarters of respondents perceive TrendCare is mainly used by the organisation to contain costs. TrendCare data is not seen to be used by the DHB s to respond to staffing deficits. These results indicate the majority of respondents have concerns about the use of TrendCare in mental health services. Question 6- If you disagree TrendCare captures all aspects of your work (clinical and non-clinical) as indicated above, what is missing? 81 Respondents. Categories Frequency of response Does not fit mental health 21 Environmental activity 3 De-escalation/monitoring/settling 9 Attending to visitors/phone calls 8 Restraint/seclusion 4 Documentation 6 Teaching /Education 2 Meal distribution/dietary 4 Meetings 4 Outpatient phone calls 2 Covering other wards- security/meal breaks 3 Complex medication administration 4 Smoke free checks/interventions 2 Supporting Students/New Grads/Casual Staff 4 Looking for other staff- e.g. doctors 3 Multiple staff for 1 patient 3 Escort out 2 Physical care interventions 4 Admission 2 Rehabilitation focus 2 Safety/Risk assessment 2 Escort out 2 11

Some additional aspects identified as missing were: Critical events Preparation for reviews/reviews Observations Audits Placing patient under section and advising others of this Projects Room entries Some items noted described what patients are doing rather than what staff are doing, e.g. patients destroying environment. There were also comments which reflected working as a team; however some respondents still see their workload as their own rather than clinical in department hours being a collective of the teams work. Some staff want to see every activity undertaken reflected in the indicators as if it were a time and motion study, when many activities are included in the algorithm that contributes to the baseline category timings. Category timings are averages and will not exactly fit individual patients, but will be made up of unders and overs. Other comments included: TrendCare does not make more staff available there is a lack of options available time does not capture acuity and reflect time spent In common with feedback received from many non mental health users of TrendCare, a number of aspects identified as not captured in TrendCare are in fact able to be captured but it is evident the staff are not familiar with these indicators, or these options may not be available in the current unit set up. Overall, the predominant findings from this question are that many respondents do not believe TrendCare fits the mental health environment, and that staff are not aware of, or do not have available all the indicators which reflect their work environment. 12

Question 7- Do you have access to the TrendCare Clinical Training Booklet for Mental Health? More than half of the respondents indicated they do not have access to the TrendCare Clinical Training Booklet for Mental Health. This is of concern as the booklet provides explanatory information and definitions to support the use of the tool in the mental health setting. Question 8- Are there adequate staffing areas on the staff allocate screen to capture clinical hours not included in Clinical in Department? Responses to this question were relatively evenly split between staff who consider there are adequate options and those who don t. 13

Question 9- If not, what is missing? 42 Respondents. Identified by multiple respondents Escort out (patients/other staff) (4) De-escalation/monitoring/settling/ Supervision of communal areas (3) High needs/specialing/close observations (3) Admission (2) Restraint/seclusion (2) Identified by 1 respondent Attending to visitors/phone calls Meetings Outpatient phone calls/medication Smoke free checks/interventions Multiple staff for 1 patient Environmental /housekeeping activity Special relief Clinical review Dealing with other peoples patients Speaking with family Liaison between clinical teams Observations on patients in main hospital Sensory modulation Clinical supervision Room entries Audits Triaging crisis calls after hours Liaison with external agencies (e.g. police) Delivering off site programmes Five respondents replied they don t have access to the staff allocate screen, which means they are not able to record all of their activities and are reliant on the shift coordinator to account for them. One respondent was looking to record overtime/annual leave/higher duties allowance in TrendCare and three others made reference to safe staffing. Responses included a combination of areas that may be captured on the staff allocate screen and activities that would be captured in the Clinical in Department section. There are a number of items identified as missing that are available in Trend care, or that are included in the baseline category timings for mental health patient types in Clinical in Department. 14

Question 10- Are the indicators available to you sufficient to reflect the overall care provided (Note: TrendCare indicators are not a list of tasks but average timings for care provided based on patient categories) Question 11- If not, what is missing? 55 Respondents Categories Frequency of response Multiple staff for 1 patient 5 Not Mental Health specific 5 Rehab focus 2 Specialling 4 Environmental 2 Room entries 3 Time with family 2 Intellectual Disability Client indicators 2 Forensic Client indicators 2 Lengthy medication administration 2 Documentation/Administration 2 Other items noted were:- level of danger and abuse, safe staffing, monitoring for disinhibited behaviours and drug use, dealing with elevated clients and responding to phone calls. A number of indicators identified as missing are indicators currently available in the TrendCare system which suggests this may be an issue of training or set up. As with Question 6, the understanding that TrendCare is not a task orientated system which itemises every activity 15

undertaken, but rather focusses on patient variables that make nursing time consuming, is not widespread. From the responses it is apparent some staff expect to see every activity undertaken reflected in the indicators as if it were a time and motion study. This suggests there is not a clear understanding that many activities are included in the algorithm that contributes to the baseline category timings and that selecting additional indicators do not always change the timing categories. Question 12- If you could make one improvement to the use of TrendCare in Mental Health, what would it be? 90 Respondents contributed to this question Categories Frequency of response Make more Mental Health specific 19 Don t use it 15 More mental health 7 indicators/variables Address minimum staffing levels 2 Identify level of risk/safety issues 3 Training/information 6 Add narrative section 4 Allow staff to set timings 2 Reflect actual acuity 7 The most commonly identified improvement was to make TrendCare more mental health specific, which indicates there is a strong perception the tool does not reflect the reality of the mental health work setting. The need for senior management to more fully use the information staff are entering, and respond to predicted staff deficits was identified. A requirement to allow time for complex oral medication administration and reflect time spent with patients allocated to other staff were additional improvements identified by respondents, as were the need to identify whanau participation and reflect real time staff demand and variance. 16

Question 13- Are there other aspects of the use of TrendCare in Mental Health you would like to see the Mental Health, Addictions and Disability Advisory Group address? 53 Respondents Categories Frequency of response No 10 Stop using TrendCare 3 More mental health focus 4 Address staffing levels 4 Training/information 3 Add whanau/family domain 2 Include input from clinical staff 3 Add (electronic)assessments/alerts 3 Improve consistency of use 2 There were no frequently identified additional suggestions which stood out as aspects of the use of TrendCare staff would like to see the MHADAG address. 17

Discussion and Recommendations The majority of the 141 respondents to the survey were clinically based nurses working in acute adult hospital settings which reflect the focus of attention of the MHADAG at this time. Responses were received from all DHB s currently using TrendCare in the Mental Health setting. The results of the survey indicate the majority of respondents have concerns about the use of TrendCare in mental health services. Most respondents did not agree TrendCare accurately captures all aspects of their work, with almost half of respondents indicating strongly disagreement. TrendCare was not seen as a tool which enables staff to use their expert clinical judgement about patient acuity. TrendCare is seen to be mainly used by the organisation to contain costs and not used to respond to staffing deficits. The majority of respondents do not perceive TrendCare is used to support patient and staff safety, with 45% of respondents indicating their strong disagreement. The majority of respondents agree TrendCare is easy to use, with almost three quarters of respondents indicating they are confident using the programme and 60% of respondents indicating training is adequate. This contrasts strongly with the information collected about the use of TrendCare and the understanding that TrendCare is not a task orientated system but instead focusses on patient variables that make nursing time consuming. In common with other care settings, many staff expect to see every activity undertaken reflected in the indicators as if it were a time and motion study, when many activities are included in the algorithm that contributes to the baseline category timings. Category timings are averages and will not exactly fit individual patients, but rather are based on timing studies which include the scope of care provided. Many items which were identified as missing are options available in the system. This suggests issues of training or set-up. As most TrendCare Coordinators do not come from a mental health background this may indicate a lack of awareness of the functionality which would be of use to the mental health setting in DHB s and provides an opportunity for review and agreement at a national level. It may be useful to invest further in the training of TrendCare Champions from the mental health setting together with some mental health focussed training for the TrendCare Coordinators so that in collaboration they can improve the use of TrendCare in mental health settings in DHB s. While not noted in high numbers in any of the responses to any particular question, across the survey there was a strong theme of needing to be able to more accurately capture the requirement for multiple staff working with one patient, and particularly in the circumstances of seclusion, restraint and other critical events. There was also a strong sense of being unable to reflect the team approach of providing a calming/monitoring presence for a number of clients who are allocated across the team workload, and the de-escalation activity that routinely occurs. The most common improvement suggested was to make TrendCare more mental health specific, which indicates there is a strong perception the tool does not reflect the reality of the mental health work setting. 18

The responses provided sufficient information to support the following recommendations to the Mental Health, Addictions and Disability Advisory Group: 1. Work with the TrendCare vendor to run a Train the Trainer workshop focussed on the mental health setting for TrendCare Coordinators and Champions from the mental health setting. 2. Identify and include in national training a consistent way to capture the staffing intensity required to reflect multiple staff providing care at one time to one client. 3. Work with DHB s to identify consistent use of patient types and associated indicators to enable benchmarking. 4. Recommend to all DHB s that there is a mental health member of the DHB TrendCare Steering Group. 5. Recommend to DHB s that following the evaluation of the Mental Health Mix and Match Pilot, the Mix and Match Part One (Work Analysis) is undertaken in all inpatient mental health units that utilise TrendCare. This will enable the capture of a more detailed understanding of staffing activity and therefore assist in the identification of appropriate staffing profiles for patient and staff safety. 19