Safe Nurse Staffing Levels Executive Summary June 2017 The purpose of this report is: 1. To provide an assurance with regard to the management of safe nursing and midwifery staffing for the month of June 2017. 2. To provide a summary report of quality metrics for the month of June 2017 as indicators of patient safety 3. To provide context for the Trust Board on the UNIFY safer staffing submission for the month of June 2017. East and North Hertfordshire NHS Trust is committed to ensuring that levels of nursing staff, which includes Registered Nurses, Midwives and Clinical Support Workers (CSWs), match the acuity and dependency needs of patients within clinical ward areas in the Trust. This includes ensuring there is an appropriate level and skill mix of nursing staff to provide safe and effective care. These staffing levels are viewed along with reported outcome measures, registered nurse to patient ratios, the percentage skill mix ratio of registered nurses to CSWs, and the number of staff per shift required to provide safe and effective patient care. No Topic Measure Summary RAG 1. Patient safety is delivered though consistent, appropriate staffing levels for the service. Unify RN fill rate The Unify submission for registered fill % decreased in June with the average day fill % for registered nurses falling from 96.3% in May to 95.7%. Care hours per Patient Day - CHPPD Overall CHPPD static at 7.3 in June 2. Staff are supported in their decision making by effective reporting. % of Red triggered shifts Increase in % of Red Triggered shifts from 6.13% to 6.51% 3. Staffing risks are effectively escalated to an appropriate person 4. The Board are assured of safe staffing for nursing % of shifts that remained partially mitigated Red flag reportable events and DATIX report Board reports and discussion covering overview of safe staffing levels 3 of the 211 initially triggered red (0.09%) shifts remained partially mitigated. This is the same number of partially mitigated shifts as May Red flags continue to be used to escalate staffing issues in the organisation. The Safer staffing team have developed the NICE red flags to make them more user friendly and meaningful to the nursing teams. These are being piloted for 3 months from the 19 th May. The overall RN fill rate decreased slightly due to an increase in sickness and decrease in temporary staffing RN fill. The CHPPD delivered in June remained static due to a slight decrease in bed occupancy across the wards. 1 P age
1. Patient safety is delivered though consistent, appropriate staffing levels for the service. The following sections identify the processes in place to demonstrate that the Trust proactively manages nurse staffing to support patient safety. 1.1 UNIFY Safer Staffing Return The Trust s safer staffing submission has been submitted to UNIFY for June. Table 1 below shows the summary of overall fill %, the full table of fill % can be seen in Appendix 1: Table 1 Overall Unify Return fill rate Day Night Average fill rate + Average fill rate + Average fill Average fill registered registered rate + care rate + care nurses/midwives nurses/midwives staff (%) staff (%) (%) (%) 95.7% 91.5% 94.4% 108.2% The Unify submission for registered fill % decreased in June with the average day fill % for registered nurses falling from 96.3% in May to 95.7%. Factors affecting Planned vs. Actual staffing Ashwell was escalated above their planned 24 beds to 28 beds for the whole month of June; their planned staffing level for the Unify return is reflective of their 28 bed shift plan. There are a number of other contributory factors which affect the fill rate for June. This, along with the summary of key findings by ward, can be seen below: Ward 11 The wards at Mount Vernon were merged in April following a review of the service model for these wards. The combined Oncology ward will be known as Ward 11 for the purposes of this report. Ward 11 ran below their planned patient numbers in June, therefore although their fill rate is below 90% the CHPPD delivered meets the required level of care. Senior Nurses, Matrons and Specialist Nurses Senior Nurses, Matrons and Specialist nurses worked clinically to support wards where staffing fell below the minimum safe levels. 10B, 5A, 5B, 6A, 8B, 9A, 9B, AWU-W, Ashwell, Barley, and SSU Had a high number of patients requiring enhanced care which resulted in increased CSW fill. ACU - Continues to support the reactive opening of the Cardiac Cath Lab as an escalation area when required. To ensure this increased activity is supported most efficiently additional temporary staffing is only resourced when current staffing levels cannot support activity. No additional staff resource was required in June for the opening of escalation beds. Swift RN day fill is recorded as 87.9% in June, the average bed occupancy was however 74.93% as at the 23:59 census period. Staffing levels were managed appropriately to the occupancy. CHPPD is 6.76 which is above the planned service model therefore we are assured that staffing is maintained appropriately. Due to lower planned staffing levels at night there is less flexibility to reduce staffing at night in line with occupancy. SAU - Since the relocation of SAU in November the service adjusted staffing to meet service need as activity is lower in the early part of the day, but remained higher into the evening and night. In the interim, additional CSW shifts were used to support the activity of the service at night and RN use during the day was reduced which has resulted in a lower fill rate during the day and a higher than 100% fill rate at Night. The new service plan has been approved and was implemented on the 15th June. SAU will therefore align to their new service model for the month of July. 2 P age
Michael Sobell House - RN day fill is recorded as 83.7% in June. The average bed occupancy for June was 76.88% as at the 23:59 census period. Staffing levels were flexed to reflect bed occupancy. This is demonstrated by 7.85 CHPPD whichh is above the planned service model therefore we are assured that staffing is maintainedd appropriately. Due to lower planned staffing levels at nightt there is less flexibilityy to reduce staffing at night in line with bed occupancy. Pirton RN day fill is recorded as 89.2% in June. The average bed occupancy for June was 89.39% as at the 23:59 census period. Staffing levels weree managed appropriately to reflect the bed occupancy as the delivered CHPPD of 6.41 is above the planned service model. It has also been noted that the Stroke wards tend to have reduced bedd occupancy during the day; therefore CHPPD is greater during the day. In addition to the planned ward staff, the Stroke wards have support from the specialist Stoke Nurses which iss not currently reflected in the Unify return. Work is on-going to capture the care hours provided by the Stroke Nurses and Therapistss on this ward. 9A The RN Day Fill was slightly above 100% in June duee to an enriched skill mix to match patient acuity on specific days, the use of CSWs was balanced to reflect this. Care hours delivered were assessed each day and were appropriate too the patientt needs. The Enhanced Nursing Care Team (Specialling team) continues to mitigate the risk and reduce the need to cover those patients requiring specialling with temporary staff. It was recommended in the December Establishment Review to increase the Establishment of o the ENC Team by 9.56 WTE to get to zero Agency for enhanced care. The team will be fully recruited to by August 2017. The impact in terms of care hours delivered by the Speciallingg Team andd reduced reliance on Agency staff can be seen in the Chart 1 below. Daily patient ward rounds are conducted by a senior member of the team. Patients are risk assessed to identify requirements for bay watch which allows patients p requiring some additional support and observation to be cohorted inn a bay, for which 1:11 care is not deemed necessary. Although the number of care hours required by those patient requiring specialling increased from May to June, we have seen greater utilisation of bay watch on the wards therefore reducing r our need for additional staff cover. Chart 1 3 Page
1.2 UNIFY Care Hours Per Patient Day (CHPPD) From 1 May 2016 each Trust is required to report the number of Care Hours per Patient Day (CHPPD). This figure is calculated: The total number of patient days over the month (Sum of actual number of patients on the ward at 23:59 each day) / Total hours worked in month (Total hours worked for registered staff, care staff and then combined) This is a standard calculation indicating the number of care hours provided to each patient over a 24 hour period. The table below shows the CHPPD for June, this indicates overall CHPPD remained static at 7.3 in June. Table 2 Average Care Hours Per Patient Day Care Hours Per Patient Day (CHPPD) Trust-wide Registered midwives/ nurses Care Staff Overall Total 4.7 2.5 7.3 CHPPD is used to inform the bi-annual establishment reviews and the results are reported monthly on the Unify return. When benchmarked against similar trusts the CHPPD for the Trust fall within expected thresholds. A full list of CHPPD by ward can be seen in Appendix 2 of this report. Additional analysis of how the organisation uses CHPPD to inform productive and effective use of staffing is on-going and was included in the Trust s Nursing Establishment review in December. The NHS Improvement Model Hospital Portal includes the CHPPD metric and will be used to Benchmark CHPPD against other Trusts for the April Establishment Review. 2. Staff are supported in their decision making by effective reporting 2.1 Daily process to support operational staffing Three daily staffing meetings and twice weekly look ahead meetings continue to support the organisation in balancing staffing risk across the Trust. Each ward is rated as red, amber or green for each of the early, late and night shifts. This record is held electronically in the Staffing Hub which provides a central point to access the E-Roster and NHSP teams. The record is also shared with the Operations Centre and provides assurance on nurse staffing levels in the organisation. 2.2 Staffing levels and shifts that trigger red The number of shifts initially triggering red remained the same in May and June (211 shifts). The percentage has however increased due to the fewer numbers of days in month and removal of Ward 11 from this report. Table 3 below shows the % of shifts that triggered red in month. 4 P age
Table 3 % of shifts triggering red Month Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 % of shifts that triggered red in Month 5.44% % 4.42% % 8.57% % 7.72% % 5.14% % 4.35% % 6.02% % 5.32% % 6.40% % 7.44% % 5.91% % 6.13% % 6.51% % Comparison of red triggered shifts between June 2016 and June 20172 showss an increase of 1.07% in the number of shiftss triggering red r in month. Out of the shifts triggering red, 3 of the 211 that initially triggered red ( 0.09%) remained only partially mitigated. This is the same number of partially mitigated shifts ass May. Shifts triggeringg red, and those that remained a challenge to mitigate, are exploredd below. Chart 2 below shows the % of shifts triggering red in month; following the spike in August the % shifts triggering red has shown a slight linear increase in the following months. This is multifactoria l, these reasons include, sustained levels of vacancies and sickness and controlled use of agency and are discussed in section 2.3. It is worthh noting however that the trend on shifts remaining red has declined. Chart 2 Chart 3 below showss the number and % distribution remained red after mitigating action was taken. of red triggered shifts and those shifts tha 5 Page
Chart 3 Shifts initially triggering red & remained red A list of all the shifts triggering red can be found in Appendix 3. Eleven wardss triggered red on 10% or more of the shifts in month which is an increase from May where seven wards triggered red on 10% or more of shifts. One ward triggered red on more than 20% of their shifts. Further analysis has shown that although annual leave was low, high levels of sickness and sustained high vacancy levels on these this ward together with the use of escalation bedss contributed to a high percentagee of red triggered shifts. Generally, red shifts are mitigated by moving staff between wards to balance staff numbers and skill mix. Table 4 below shows the shift breakdown for each of these wards. Table 4 Wards triggering highh number of red shifts Ward Early Late Night Ashwell SSU AMU-A 8B 10A Gynae Barley 7B 6B Child A&E Pirton Swift 7 2 4 5 4 4 2 1 3 2 0 12 11 7 7 4 8 7 10 5 8 3 3 1 2 1 5 0 3 0 3 0 6 INITIAL REDS R Number of o shifts where staffing initially fell below agreed levels 222 144 133 133 133 122 122 111 111 100 9 % of shifts where staffing fell below agreed levels and triggered a Red rating 24.44 15.56 14.44 14.44 14.44 13.33 13.33 12.22 12.22 11.11 10.00 In addition to the reactive daily support, this informationn is provided to ward managers and matrons to ensure proactive robust supportive measures can be put in place moving forward. 2.3 Summary of factors affecting red triggering shifts Several key factors have impacted the incidence of red shifts, these include: Temporary Staffing Fill Temporary staffing demand decreased slightly in June, agency usage decreased by 2.5% and bank filled hours increased by 2.5%. The percentage of unfilled hours remained static at 19.3% in June. Unfilled RN shifts increased by 0.7% although the demand decreased. There was no overall increase in temporary staffing fill; therefore theree has been no overall improvement in red triggered shifts. 6 Page
Sickness Sickness rate increased slightly from 6.5% in May to 6.7% in June (taken from e- Roster) and remains above the 4% budget position. Specialling requirements impact on the care hours required on a ward on a shift by shift basis. If the specialling needs are not covered this may cause the ward to trigger red. 3. Staffing risks are effectively escalated to an appropriate person Shifts that fall below minimum staffing levels are escalated to the divisional staffing bleep holder who moves staff to balance risk across the division. Where the individual division is unable to mitigate independently this is escalated to the Divisional Heads of Nursing to balance risk across the organisation. 3.1 Red Flags Red flags are NICE recommended nationally reportable events that require an immediate response from the Senior Nurse Team. Red flag events signal to the Senior Nurse Team an urgent need for review of the numbers of staff, skill mix and patient acuity and numbers. These events are considered as indicators of a ward requiring an intervention e.g. increasing staffing levels, facilitating patient discharge or closing to admissions for a temporary period following discussion and agreement with the operations centre and the executive on call. The Safer staffing team have developed the NICE red flags to make them more user friendly and meaningful to the nursing teams. These are being piloted for 3 months, and commenced in May. Red flag notification is sent to a centralised staffing e-mail address and escalated at each of the 3 daily staffing meetings with feedback required prior to each meeting. The Nurse in Charge of the ward will try to resolve Red Flags with the help of the Divisional bleep holders who will act on escalated open issues to help resolve them. Feedback from the wards has found the new red flags much more appropriate to the issues they need to escalate on a shift. Chart 4 below shows the distribution of red flags by type. This shows that the shortfall in care hours was the most common flag raised. Matrons are expected to visit any ward that has raised a red flag within an hour to ensure any risk is mitigated. Chart 4 Red Flags raised by Type 50 45 40 35 30 25 20 15 10 5 0 Red Flags raised by Type Total 7 P age
Chart 5 below indicates the red flags by day of the week; this shows that Mondays, Wednesdays s and Fridays were the days where staffing was most likely to t be escalated as needing an interventionn in June. This data is being interrogated over a period of time in relation to what might affect staffing on particula days of the week. Chart 5 - Red Flags Day of Week Red Flags by Day of Week Sunday Saturday Friday Thursday Wednesday Tuesday Monday 4 11 15 16 202 22 28 0 5 10 15 20 25 30 Total 4. The Board are assured of safe staffingg for nursing across the t organisation The overall RN fill rate decreasedd slightly due to an increase in sickness and decrease in temporary staffing RN fill. The CHPPD delivered in June remained static due to a slight decrease in bed occupancy across the wards. The maintenance of safe staffing levels on wards in June was supported by: Continued daily monitoring and ward RAG rating of staffing levels across inpatient wards Matrons review and response to Red Flag events at the three Daily Staffing meetings with mitigations fed back to the wards via SafeCare in real time Regular patient acuity audits completed by Matrons Working with cap compliant agencies Working with agencies to identify long line agencies to support areas with high vacancies Controlled release of unfilled shifts to agencies Additional support provided by e-roster,, NHSP and Temporary Staffing management to assist wards with staffing challenges Active management by the Divisional / Duty Matron and support from Matrons and Heads of Nursing within the Divisions to review staffing requirements on a daily basis for identified wards Divisional Heads of Nursing, Matrons, Specialist Nurses and the Education Team working clinically where needed The introduction of the e-roster operational support service in the evening to cover the handover of the night shift and support the Duty Matron with the mitigationn of red shifts at night The e-roster team visiting all Red wards to ensure that the planned mitigations have taken place and escalatee to Matrons where appropriate 8 Page
Appendix 1 Day Night Ward name Average fill rate + registered nurses/midwives (%) Average fill rate + care staff (%) Average fill rate + registered nurses/midwives (%) Average fill rate + care staff (%) 10B 99.7% 87.3% 96.9% 101.3% 11A 93.5% 82.5% 96.9% 98.5% 11B 98.7% 85.9% 99.1% 100.0% 5A 93.2% 86.5% 87.6% 145.0% 5B 98.0% 94.4% 96.8% 120.2% 6A 99.7% 92.8% 97.6% 107.0% 6B 93.7% 88.8% 98.6% 103.4% 10A Gynae 99.5% 96.3% 93.7% 100.6% 7B 98.2% 89.4% 91.6% 93.3% 8A 97.0% 94.0% 95.8% 99.9% 8B 94.4% 121.5% 95.0% 209.7% 9A 103.4% 101.8% 100.1% 119.5% 9B 96.4% 106.3% 98.6% 115.3% ACU 91.5% 83.6% 85.6% 96.7% AMU A 93.9% 89.9% 93.8% 99.1% AMU W 98.6% 102.9% 97.8% 134.0% Ashwell 99.1% 104.5% 100.1% 126.8% Barley 97.0% 97.4% 101.1% 125.0% Bluebell 95.3% 50.1% 82.7% #DIV/0! Critical Care 1 100.0% 100.0% 100.0% 100.0% Dacre 101.8% 80.7% 97.9% #DIV/0! Gloucester 98.3% 89.0% 94.9% 85.6% CLU 100.5% 92.2% 100.3% 96.8% Mat MLU 97.4% 92.9% 96.8% 101.6% Michael Sobell House 83.7% 79.3% 103.8% 111.0% Pirton 89.2% 93.6% 95.7% 100.0% SAU 84.2% 96.4% 97.7% 130.9% SSU 98.1% 113.7% 92.4% 130.8% Swift 87.9% 88.2% 86.9% 90.1% Ward 11 85.2% 61.9% 62.5% 13.7% Total 95.7% 91.5% 94.4% 108.2% 9 P age
Appendix 2 Care Hours Per Patient Day (CHPPD) Ward name Registered midwives/ nurses Care Staff Overall 10B 3.10 2.32 5.42 11A 4.10 1.62 5.72 11B 3.83 2.59 6.42 5A 3.14 1.91 5.04 5B 3.49 2.74 6.22 6A 3.24 2.50 5.75 6B 4.02 2.82 6.84 10A Gynae 4.94 2.52 7.46 7B 3.35 1.77 5.12 8A 3.23 2.24 5.47 8B 3.24 2.30 5.54 9A 3.17 2.53 5.70 9B 3.17 2.32 5.49 ACU 5.26 1.57 6.83 AMU A 7.69 4.61 12.30 AMU W 3.90 3.66 7.57 Ashwell 2.93 2.81 5.74 Barley 3.78 2.76 6.53 Bluebell 7.10 1.36 8.46 Critical Care 1 17.28 2.45 19.73 Dacre 6.99 0.96 7.95 Gloucester 3.07 2.53 5.61 CLU 30.84 6.64 37.47 Mat MLU 29.28 8.91 38.19 Michael Sobell House 4.92 2.93 7.85 Pirton 4.19 2.21 6.41 SAU 6.07 3.44 9.51 SSU 3.28 2.74 6.02 Swift 3.78 2.98 6.76 Ward 11 5.87 1.98 7.86 Total 4.7 2.5 7.3 10 P age
Appendix 3 Speciality Ward Early Late Night INITIAL REDS Number of shifts where staffing initially fell below agreed levels % of shifts where staffing fell below agreed levels and triggered a Red rating Care of the 9A 1 1 0 2 2.22 Elderly 9B 1 1 0 2 2.22 Stroke Barley 4 8 0 12 13.33 Pirton 2 8 0 10 11.11 General 6A 1 3 1 5 5.56 10B 2 2 0 4 4.44 Respiratory 11A 1 7 0 8 8.89 7AN 0 0 0 0 0.00 Cardiology ACU 0 1 2 3 3.33 AMU-A 4 7 2 13 14.44 Acute SSU 2 11 1 14 15.56 AMU-W 2 2 0 4 4.44 Renal 6B 1 10 0 11 12.22 DTOC / gastro Ashwell 7 12 3 22 24.44 ED A&E 1 1 2 4 4.44 UCC 1 1 0 2 2.22 30 75 11 116 8.06 8A 1 4 0 5 5.56 General 8B 5 7 1 13 14.44 SAU 0 7 0 7 7.78 Surgical Spec 11B 0 3 2 5 5.56 7B 2 7 3 12 13.33 5A 2 1 2 5 5.56 T&O 5B 3 4 1 8 8.89 Swift 0 3 6 9 10.00 ATCC Critical Care 1 0 0 0 0 0.00 ASCU 0 0 0 0 0.00 13 36 15 64 7.11 Gynae 10A Gynae 4 4 5 13 14.44 Bluebell 1 1 0 2 2.22 Paeds Child A&E 3 5 3 11 12.22 NICU 0 0 0 0 0.00 Dacre 2 2 0 4 4.44 Maternity Gloucester 0 0 0 0 0.00 Mat MLU 0 0 0 0 0.00 Mat CLU 1 0 0 0 0 0.00 10 12 8 30 4.17 Ward 10 0 1 0 1 1.11 Inpatient Michael Sobell House 0 0 0 0 0.00 0 1 0 1 0.56 TRUST TOTAL 53 124 34 211 6.51 11 P age
Appendix 4 Speciality Ward Early Late Night FINAL REDS Number of shifts where staffing initially fell below agreed levels % of shifts where staffing fell below agreed levels and triggered a Red rating Care of the 9A 0 0 0 0 0.00 Elderly 9B 0 0 0 0 0.00 Stroke Barley 0 0 0 0 0.00 Pirton 0 0 0 0 0.00 General 6A 0 1 0 1 1.11 10B 0 0 0 0 0.00 Respiratory 11A 0 1 0 1 1.11 7AN 0 0 0 0 0.00 Cardiology ACU 0 0 0 0 0.00 AMU-A 0 0 0 0 0.00 Acute SSU 0 0 0 0 0.00 AMU-W 0 0 0 0 0.00 Renal 6B 0 0 0 0 0.00 DTOC / gastro Ashwell 0 0 0 0 0.00 ED A&E 0 0 0 0 0.00 UCC 0 0 0 0 0.00 0 2 0 2 0.14 8A 0 0 0 0 0.00 General 8B 0 0 0 0 0.00 SAU 0 0 0 0 0.00 Surgical Spec 11B 0 0 0 0 0.00 7B 0 0 0 0 0.00 5A 0 0 0 0 0.00 T&O 5B 0 0 0 0 0.00 Swift 0 0 0 0 0.00 ATCC Critical Care 1 0 0 0 0 0.00 ASCU 0 0 0 0 0.00 0 0 0 0 0.00 Gynae 10A Gynae 0 0 0 0 0.00 Bluebell 0 0 0 0 0.00 Paeds Child A&E 0 0 0 0 0.00 NICU 0 0 0 0 0.00 Dacre 0 0 0 0 0.00 Maternity Gloucester 0 0 0 0 0.00 Mat MLU 0 0 0 0 0.00 Mat CLU 1 0 0 0 0 0.00 0 0 0 0 0.00 Ward 10 0 1 0 1 1.11 Inpatient Michael Sobell House 0 0 0 0 0.00 0 1 0 1 0.56 TRUST TOTAL 0 3 0 3 0.09 12 P age
Appendix 5 NHSP hours YTD report 13 Page