TRUST POLICY AND PROCEDURES FOR ROSTER MANAGEMENT FOR NURSING and MIDWIFERY

Transcription

1 TRUST POLICY AND PROCEDURES FOR ROSTER MANAGEMENT FOR NURSING and MIDWIFERY Reference Number CL OP Version: V1 Status Final Author: Anne-Marie Davies Job Title: E-Rostering Project Manager Version / Version Date Author Reason Amendment V1 May 2011 Anne-Marie New Policy History Davies V2 November Libby Keep Review and minor 2014 amendments Intended Recipients: All clinical nursing staff, All Divisional Matrons, Divisional Directors of Nursing, Divisional Directors General Managers Training and Dissemination:, Divisional Meetings and team briefings. To be read in conjunction with: Trust Annual Leave policy Trust Policy For Managing Heath and Attendance Trust Employee Friendly Policy Trust Policy and Procedures for the Booking, Deployment and utilisation of temporary nursing staff Parenting Leave and Pay Policy Trust Procedure For Dealing With Deductions And Overpayments Trust AFC Handbook In consultation with : Director of Human Resources, Nursing Executive Team & Divisional Nurse Directors, Joint Professional Advisory Committee (JPAC), Matrons, Trade Union RC. EIRA stage: Stage 1 Completed Procedural Documentation Review Group Assurance and Date July 2011 Approving Body and Date Approved Trust Management Team August 16 th 2011 Date of Issue November 2014 Review Date and Frequency December 2017 Contact for Review Executive Lead Signature Approving Executive Signature Director of Patient Experience and Chief Nurse Director of Patient Experience and Chief Nurse Director of Patient Experience and Chief Nurse Trust Policy for all staff using roster management v1 Page 1 of 22

2 Table of Contents 1 Introduction and Background Purpose and Outcomes Definitions Used Key Responsibilities / Duties Director of Patient Experience and Chief Nurse Error! Bookmark not defined. 4.2 Director of Human Resources Divisional Nurse Directors... Error! Bookmark not defined. 4.4 Matrons Senior Sister or Senior Ward or area employees Human Resources MAPS team E-Rostering Project Team Implementing this policy Principles Governing Roster Creation Principles Governing the Approval of Rosters Principles Governing the Updating of Rosters Principles Governing the Finalisation of Rosters Principles Governing the Creation and Amendment of E-Rostering System Information Monitoring Compliance and Effectiveness Appendices Process for Creating an Effective Roster Roster Creation and Annual Leave How to Calculate the Number of Staff that Can Be On Annual Leave at Once Quick reference guide to Responsibilities for key E-Rostering Tasks E-Rostering Process Map Timeline for making specific shift requests Trust Policy for all staff using roster management v1 Page 2 of 22

3 POLICY AND PROCEDURES FOR ROSTER MANAGEMENT 1 Introduction and Background The purpose of this policy to set out the agreed governing principles that apply to the production of off duties (rosters). It supports the applicable guidance, policies and procedures as set out on the front page of this document, that are agreed within the Trust and is not intended to supercede them. This policy has been developed to be used in conjunction with an electronic rostering system (referred to as MAPS) although the principals are also applicable to those inpatient clinical areas that are not currently live on the system. MAPS is a computerised rostering system also referred to as E-Rostering that is specifically designed for managers to roster staff to an agreed duty requirement. It will store data providing visibility of a person s availability and contractual obligations. This policy is for use by all areas live on the system or who are in the process of completing the implementation. The main aims of the E-Rostering system are: To improve the utilisation of existing staff and reduce temporary staffing expenditure by giving Managers clear visibility of usage of staff contracted hours. To help managers and employees ensure that everyone has an equal and fair ability to request specific shifts and planned absences such as holidays, training days etc. To provide transparency and clarity around working times so that all staff are managed equitably and fairly and that staff take their rest breaks. Implicit in this policy is the Trust s support for the principles embedded in Improving Working Lives (IWL) and the European Working Time Directive (EWTD) regarding work life balance, flexible working and employee friendly practices. As stated in the Trust s Employee Friendly Policy all requests for employee friendly arrangements will be balanced with the Trust s ability to maintain safe and effective patient care. 2 Purpose and Outcomes To ensure safe and appropriate staffing for all departments using fair and consistent approach to rostering (creating off duties). To provide a fair and safe roster (off duty) which is published and approved in a timely manner. To minimise clinical risk associated with the level and skill mix of nurse staffing levels. Trust Policy for all staff using roster management v1 Page 3 of 22

4 To improve monitoring of sickness and absence by department and / or individual, generating comparisons, identifying trends and priorities for action. To improve planning of clinical and non clinical working days and non effective days e.g. annual leave, sickness and study leave. To ensure that the required number of inpatient beds are safely staffed to meet elective and emergency demand. To provide effective management of all staff groups and nursing / midwifery / AHP staff establishments, across wards and departments. 3 Definitions Used EOL Employee Online a module of the MAPS system which provides staff with an electronic mechanism to request shifts, request non effective periods and check timesheets are correct for pay. EWTD European Working Time Directive Finalisation The process by which each worked roster is completed and approved for pay. IWL Improving Working Lives KPI Key Performance Indicator. A defined measure used to assess the performance of an activity MAPS E-Rostering System Unavailability - A period of time recorded in MAPS which is not part of a shift. For example annual leave, study day, office day, sickness Personal Pattern A set pattern of agreed shifts that is specific to an employee. Roster Perform A module of the MAPS system that provides management information based on the information recorded in the system. Restriction A time bound restriction recorded against an employee that indicates the agreed times of day and days of the week which they can be rostered to work. Working Pattern A set pattern of agreed shifts that is applicable to one or more members of staff. 4 Key Responsibilities / Duties 4.1 Director of Patient Experience and Chief Nurse The Director of Patient Experience and Chief Nurse is responsible for: Ensuring that the Divisional Directors of Nursing have effective processes and procedures in place to enable their wards and areas covered by this policy to apply the principles that have been agreed. Ensuring that the Trust has the resources required to provide the relevant training and support so that this policy is sustainable. Representing E-Rostering issues to the Trust Executive team Trust Policy for all staff using roster management v1 Page 4 of 22

5 4.2 Director of Workforce Management The Director of Workforce Management is responsible for: Ensuring that this policy is considered when making changes to any aspects of HR policy that may impact on staff rostering. Divisional Nurse Directors DND s are responsible for: Ensuring that this policy is enforced in their areas of responsibility. Monitoring relevant reporting Key Performance Indicators (KPIs) to understand the reasons behind any issues and use them to inform an action plan to rectify issues where necessary. Using the Roster perform /Safe Care module to monitor ward / Divisional Performance and escalate issues. 4.3 Matrons The Matron is responsible for: Ensuring that their wards/ areas produce safe and fair rosters in line with the procedures guidelines and timelines outlined in this policy. Ensuring that where the relevant Matron is / will not be available to approve a roster that this responsibility is delegated to another Matron preferably within the same Division Reviewing the worked roster, including the Senior Sister or s timesheet prior to finalisation. Ensuring any non compliance with this policy is investigated and where necessary escalated to the DND for the area. Where staff are redeployed during staff shortages that any agreed moves are reflected in the relevant roster. 4.4 Senior Sister or Senior The Senior Sister or is responsible for: Producing rosters in line with the processes and timescales outlined in this policy. The tasks of creating and updating rosters for approval and finalisation may be delegated by the Senior Sister or to nominated trained members of staff. The Senior Sister or still maintains responsibility even when delegated to nominated members of staff. Ensuring that their staff are aware of the principles set out in this policy and are able to make reference to it on their ward/ area. Completing the relevant change forms for new members of staff or staff leaving in a timely manner. Trust Policy for all staff using roster management v1 Page 5 of 22

6 The final decision to reject staff requests for specific shifts or annual leave and ensuring this is reflected in the applicable roster. Agreeing any shift changes requested by staff are acceptable to all individuals concerned. Ensuring the relevant competencies are correctly assigned to each applicable staff member and that these are reviewed at the appropriate time intervals. For informing the E-Rostering Team of any changes to shift competencies. Making changes on MAPS to work patterns or restrictions within a staff member s contracted hours, as a local agreement that does not form part of the work contract, as agreed with the staff member. This may be due to a temporary circumstance and the only reason for actioning this change on MAPS would be to facilitate accurate auto-rostering. This process does not obligate the staff member to work to these patterns for longer than has been agreed. Ensuring that working patterns and any applicable restricted hours are reviewed regularly or as set out in an Employee Friendly Agreement that an individual may hold. Informing HR MAPS team of any changes to a staff member s hours or employee friendly arrangements that have been agreed by both parties to form part of their work contract. Using the available KPIs and reports to ensure rosters are created and worked are fair, safe and effective. Ensuring that designated unpaid breaks are facilitated. As part of the role of the nurse in charge of each shift it is expected this will be monitored and adhered to, Ensuring that there are adequate trained and nominated staff to be able to use MAPS to adhere to this policy. Ensuring that blue timesheets are completed accurately where necessary. 4.5 Ward or area employees Rostered ward staff are responsible for: Ensuring they are able to use Employee On Line (EOL) either by attending EOL training or to update themselves via the resources on the Trust intranet. Making requests for annual leave or specific shifts or days off via EOL in a timely manner. Exceptions to this rule should be for temporary reasons i.e. EOL system failure. Request books must not be used within areas where the roster is electronic. Ensuring that their finalised timesheet is correct in EOL before the monthly pay deadline. Individual staff are responsible for taking and appropriately managing their leave in line with the Trust annual leave policy. Trust Policy for all staff using roster management v1 Page 6 of 22

7 Staff members should use their EOL accounts to check their timesheets at the end of the month, in order to ensure that any enhancements or overtime / additional hours are correctly recorded. Failure to do this could result in under or overpayments, which will be subject to Trust procedures for recovery. Informing their Senior Sister or as soon as is practicable of any errors on their finalised timesheet in order for them to review and make the necessary changes on MAPS. 4.6 Human Resources MAPS team The HR MAPS team is responsible for: Actioning changes to staff contracts or new additions on MAPS. Ensuring that requests are sanctioned by the correct member of staff. Administering these requests in order of priority in a timeframe suitable for the production of the roster which it affects. (Excepting occasions where the receipt of change form is after the effective date). Ensuring that change forms received tie with the Trust change form or new starter form. 4.7 E-Rostering Team The E-Rostering Team will be responsible for: Ensuring that all roster templates are recorded correctly and that any changes are approved by a member of staff with the right level of seniority. Ensuring all requests for additional duties are approved by the relevant member of staff and recorded on the system in a timely manner. Ensuring that enough relevant training is provided for the users of MAPS and EOL. Ensuring that key metrics are reported to the Safer Nurse Staffing Group monthly. Ensuring the accuracy of resources available on the Trust intranet regarding MAPS Ensuring that the team is available for support and guidance on system operational issues. Ensuring that MAPS rules and patterns accurately reflect the principles outlined in this policy. Updating core reference information in MAPS so that it accurate. Trust Policy for all staff using roster management v1 Page 7 of 22

8 5 Implementing this policy. The following rostering process steps are covered in this section : a) Create roster (open and close for requests, allocate duties) b) Approve (partially and fully) and publish the roster c) Update roster with any alterations as they are known. d) Partially finalise roster as worked (optional) e) Fully finalise roster 5.1 Principles Governing Roster Creation The following five steps should create a roster that is safe, cost effective and provide a good work / life balance with developmental opportunities. The process steps and the employee role responsible are outlined in Appendix One and Appendix Two. a) Assemble all necessary information. b) Know and understand the policies and best practice for planning rosters. c) Plan the roster. d) Obtain approval for the roster. e) Publish roster on wards/departments All rosters will be created to the following standards: Rosters will be created by the Senior Sister / or by a member of staff nominated by the Senior Sister or Senior. All rosters will commence on the same date as shown on the Trust Intranet. All rosters must commence on a Monday and run for a 4 week period. Rosters should be created no more than 4 roster periods in advance of them coming into effect so that staff have adequate time to make requests via EOL.. Employees will still be able to request annual and study leave before this time. An example is shown in Appendix six. Rosters should be closed for requests no later than 7 weeks in advance of the roster start date. This should allow up to 8 weeks in which to request shifts in advance of the closing date (15 weeks in advance of the roster start date). See Appendix six Rosters must be completed and approved 6 weeks in advance of the start date. This will enable staff to better manage their personal arrangements, allow opportunities to fill vacant shifts internally or to give the Flexible Staffing Office more time to fill any authorised vacant shifts. Shifts given a high priority on MAPS must be filled first, i.e. nights and weekends. Night duty shifts and weekends must be covered by Trust staff. Exceptions to this should be approved by the Matron. It should not be routine to use bank/agency permanently on night shifts. Mandatory shifts should be allocated to staff before optional ones are utilised. Trust Policy for all staff using roster management v1 Page 8 of 22

9 If any of the staff are working non standard shifts such as late starts this should be entered to reflect agreed changes. Ward administration staff and Housekeepers hours should also be entered as appropriate Creating a roster and staff working restrictions Staff with an agreed flexible working agreement in place will have their pattern incorporated into the E-Rostering system where the system is implemented in the area that they work in. All requests for flexible working must be made with reference to the Trust Employee Friendly Policy and will be dealt with in accordance with that policy. Staff who have restrictions on the hours they are available to work as result of an Occupational health assessment will have these restrictions represented in MAPS for the time that they are applicable Skill Mix and Shift Staffing Guidelines for creating a roster All rosters should be composed to adequately cover 24 hours, where appropriate, utilising permanent staff proportionately across all shifts. Each area should have an agreed total number of staff and skill mix for each shift, agreed with the Matron concerned. Agreed numbers and skill mix must be achievable within the ward budget. These will be represented in the ward demand template on MAPS. Each area should have an agreed level of staff with specific competencies on each shift, e.g. the ability to take charge, IV designated staff, as agreed with the Matron. In areas where the workload is known to vary according to the day of the week staff numbers and skill mix should reflect this. The roster of any senior staff must be compatible with their commitment to the site rota. There should be a designated nurse in charge who has been identified as having the required skills and competencies for a co-ordinating role. Senior ward staff should work opposite shifts. Senior Sisters or s should generally work 4-5 week-day short shifts per week or the prorated equivalent for part time staff. This requirement may be altered to reflect service needs in areas where shifts are longer and a higher level of senior cover is required. E.g In the Accident and Emergency department. Student nurses should be rostered with their mentor where possible and 2 days per week as a minimum. If their mentor is unavailable an associate mentor should be allocated. Student nurses should not be allocated to work night shifts in their first semester. Student nurses should not work more than 3 x Long days in one week, or more than one weekend in four weeks. Shift patterns should maximise social time when possible e.g. staff should have two consecutive days off. Trust Policy for all staff using roster management v1 Page 9 of 22

10 Weekend shifts are defined as Friday Night, Saturday day or night, Sunday day or night and Bank Holidays. The following shifts will be available: Day Shift (D) hours with 1 hour unpaid break Night Shift (N) hours with 1 hour unpaid break Short 'flexi' day time and twilight shifts - where applicable hour shifts with 30 minutes unpaid break. The majority of day time shifts will be 12.5 hour Day (D) shifts. General roster planning rules: All staff will have a minimum of 11 hours rest between shifts. This rule cannot be opted out of. The maximum working time per day will be 11.5 hours. All shifts over 6 hours will have an unpaid break incorporated within the shift. All staff will have a minimum of 1 weekend off in every 4 week roster. All staff will be able to request up to 4 shifts (including days off) per roster. Rules for day planning time shifts: Up to 3 Day (D) shifts to be worked in a row. Up to 4 Day (D) shifts in 7 days. Up to 13 day (D) shifts in 4 weeks. Up to 4 short flexi shifts in a row. Rules for planning night shifts: No more than 4 consecutive night shifts. Up to 7 night shifts per 4 week roster for staff who work 'internal rotation'. Up to 36 night shifts in 12 weeks for staff who wish to work mostly or all nights. This means that the equivalent of 1 week in 12 of not working nights. This will be prorated for part time staff. Where more than 1 night shift is planned they should be followed by a rest day and a day off. Where a single night is worked then staff can return on days after one rest day. The auto-roster will be used to allocate to these rules unless a variation is agreed. e.g. 3 day shifts in a row can be given unless a variation is agreed. Trust Policy for all staff using roster management v1 Page 10 of 22

11 Any agreement to vary from these rules should be documented using the "employee e- rostering rules" pro-forma. All agreements will have a review period of a minimum of 6 months. This will be monitored by the Matron as part of the monthly performance management proforma. It should be noted that these rules are for the planning of rosters and do not exclude staff working outside of them where there are unplanned service needs Creating a roster and staff breaks Rosters must have shifts created on the system that comply with the Trust s agreed shift and break policies. All shifts longer than 6 hours must include at least a 20 minute unpaid break and preferably 30 minutes. Breaks should not be taken at the beginning or end of a shift, as their purpose is to provide rest time during the shift Creating a roster and study leave Ensure that the necessary number of study leave days is used in each roster. Calculate the mandatory study leave requirements for staff. These may include induction, link nurse training, away days, updates. Produce roster ensuring staff have required mandatory training recorded Creating a roster and staff requests A staff request may be for annual leave, specific shifts or days off on a date and study days. Requests for annual leave, specific shifts / days off will be considered with the needs of the service at the forefront of any decision. Equity for other staff members must be taken into account when accepting or rejecting requests. Indication must be given in the Notes field as to whether requests made are essential or desirable. A maximum of 20% of shifts / days off can be requested per roster per person. A shift request must be for one short shift, long day or day off only. When reviewing the percentage of requests made by employee personal patterns are not to be considered as requests. All requests should be made no later than seven weeks prior to the roster start date. Any requests made after this time should be of an emergency nature and subject to the Senior Sister or s approval. If the maximum requests have already been made by the same staff member, he / she will be asked to prioritise their requests and the most important 20% will be considered. Annual leave must be booked or cancelled before a roster is created. Annual leave requested after this can only be given if staffing levels permit, near to the day and only if the reasons for this late application of leave are exceptional. See Appendix 2 for further details. Trust Policy for all staff using roster management v1 Page 11 of 22

12 5.2 Principles Governing the Approval of Rosters A completed roster must be reviewed by the Senior Sister or and Matron prior to being published. It is expected the matron will have received training from the Eroster team/allocate to ensure they are familiar with the Erostering system. The Senior Sister or must review an unapproved roster by checking the analysis data and ensure it fits within the defined parameters. Once they are happy with the roster then they must partially approve it. They must then take responsibility for informing the Matron that it is ready for them to review and give final approval. The Matron must review the partially approved roster and highlight: o Any potential unsafe shifts. o Any of the agreed parameters that have been exceeded. o Any duties within the agreed demand that have not been filled by permanent staff, broken down by number of shifts, hours and potential approximate cost (based on Bank pay scales). The Matron will approve the roster unless any issues have to be raised with the DND. If the Matron rejects a roster then they should work with the Senior Sister or to make changes so that it will be approved. Once the Matron approves the roster it can be published. A single copy of the published roster is printed on the ward / area for all rostered staff to view at least six weeks prior to the roster start date. Any changes made after the roster has been published must be agreed with any staff involved and will be clearly marked for audit purposes. The Senior Sister or should make the decision whether any extra time worked by the staff member should be given in lieu another time, or whether the extra hours should be paid for. This should be done in consultation with the individual involved. 5.3 Principles Governing the Updating of Rosters Once a roster has been published any changes to it are referred to as updates. The following guidelines should be adhered to when updating a roster. Updates should be made by the Senior Sister or or nominated roster updater. It is considered good practice to amend any change(s) to the roster as they occur. It is the responsibility of the Senior Sister or, or designated roster updater, to amend off duties with non-effective shifts i.e. sickness, absence and additional duties or unpaid leave. A finalised roster must accurately reflect the actual roster that was worked. Information that will affect pay should be input in the month in which it is accrued. This includes shift enhancements, additional hours, overtime, details of sickness, maternity leave and other non effective periods. If off-duty days follow on from sick days, the ward / department must be kept informed of recovery and, unless notified, off-duty days can be reclassified as sick leave. Trust Policy for all staff using roster management v1 Page 12 of 22

13 Where a staff member is off sick then the sickness reason should be recorded accurately on MAPS as this feeds information into the Electronic Staff Record (ESR). Sickness hours recorded should correlate with contracted hours. The reason and amount of any leave taken should be recorded accurately on MAPS as this feeds information into the Electronic Staff Record (ESR). Shift changes should be kept to a minimum and should only reflect unavoidable changes following the approval of the roster. Changes should not occur as a result of more requests after the cut off date, other than those that are deemed exceptional circumstances. All changes should be made with an equal grade, and with consideration for the overall skill mix of all shifts being changed. Changes may occur as a result of service needs and with agreement of the individual(s) concerned. Staff allocated to a student should ensure that their student either changes with them or is allocated to another suitable member of staff, and that this is reflected on the roster. Any time claimed back, must be recorded in MAPS and approved by the Senior Sister or. 5.4 Principles Governing the Finalisation of Rosters The act of finalising a roster means that it has been checked for accuracy and that each listed staff member can be correctly paid as a result if the information recorded in it. A finalised roster must accurately reflect the actual duties worked. Senior Sister or or their nominated deputies should aim to finalise a roster in a timely manner so that staff can check their timesheets in EOL and have adequate time to discuss amendments with the Senior Sister or. All rosters must be fully finalised after the last day of the month and before the 6 th of the next month. Rosters not finalised by this date will mean all staff from that unit will only receive their basic pay. Any enhancements or overtime will be paid the following month A roster may be part finalised as it is worked. This is considered good practice as it allows staff members to check their EOL timesheets as the roster progresses and any errors can be corrected in a timely manner. The Matron will ensure that the roster is complete and that the Senior Sister or has finalised it ready for payroll processing before the 6th of each month. Once the roster is finalised the roster will locked and no further changes can be made on the system without contacting the E Rostering Team. Changes that affect pay can only be made up until the 8 th of the month after they occurred. Any further amendments must be made using a blue timesheet, which should be sent to Payroll for processing before the 8 th of the month. If overpayments occur as a result of inaccurate recording in MAPS, the instance will be investigated and the money recovered in line with the Trust Procedure for Dealing with Deductions and Overpayments. If underpayments occur as a result of inaccurate recording, the instance will be reviewed and any payments owed to the staff member will be paid the following payday. Trust Policy for all staff using roster management v1 Page 13 of 22

14 5.5 Principles Governing the Creation and Amendment of E-Rostering System Information A quick reference guide is contained in Appendix 5 showing who is responsible for updating ward information or fixing system issues Changes to ward set up Changes to shift templates can be requested by the Senior Sister or Charge Nurse and must be sanctioned by the relevant Matron. These changes include permanent or long term temporary increase / decrease of mandatory or optional shifts or changes to shift patterns. Additional duties can be requested by the Senior Sister or and must be sanctioned by the relevant Matron. An additional duty is an ad-hoc shift that can be created to accommodate unexpected circumstances. The E-Rostering Team will make any requested changes to templates in a timely manner. Any changes requested by other staff will be referred to Senior Sister or or Matrons for verification. The addition of budgetary information for each ward is the responsibility of the IT department System Access Control The MAPS system may only be accessed and updated by staff who have attended and completed the relevant training. All requests for training must be agreed with the Senior Sister or that the member of staff reports to. Access will not be given unless agreed by the Senior Sister or even if the member of staff has booked training. Access levels to the system are monitored and created by the Trust IT Systems team and are subject to the normal governance policies that apply to the protection of personal data. Where a member of staff moves from one area to another any access to MAPS should be reviewed to ensure it is still relevant to the member of staff concerned. Where the member of staff is deemed to no longer need the same level of access the Senior Sister or will contact the E Rostering Team to determine the appropriate course of action Changes to Staff details Change forms or new starter forms should be sent to the HR MAPS team in advance of the creation of a roster in which the changes take effect. This should be done using the MAPS change form. Where a staff member moves from one ward to another it is the responsibility of the receiving ward to ensure that any unused hours recorded on the system are zero on the date that the change comes into effect. Exceptions to this must be agreed with the relevant Matrons, Senior Sister or and the staff member involved Staff seconded to another post on an E-Rostering ward must be communicated using the HR MAPS change form so that the correct changes can be made. Any changes to staffing must go through the normal channels. Trust Policy for all staff using roster management v1 Page 14 of 22

15 New nursing staff have a supernumerary period. This should be allocated on an individual basis. New nursing staff should work with their preceptor / mentor during the supernumerary period, to ensure that their induction is completed and objectives are planned. After this they should plan to work with their preceptor 1-2 times per week to complete objectives and competencies. Any new starters or change to contracted hours should be inputted on to MAPS in advance of their effective date by the HR MAPS team, following receipt of the MAPS change form in dictating a new starter or change Completion of blue timesheets Timesheets printed on blue paper are used to identify staff who are usually paid via the MAPS to payroll process. Blue time sheets should be signed by the Senior Sister or in the area that the member of staff is usually posted to. The reason for completing the blue timesheet should be indicated in the appropriate tick box in the top right hand corner. The quantity and reasons for completing blue timesheets are monitored by the Project Board. A blue time sheet should only be completed in the following circumstances: Where a member of staff who is set up on MAPS has worked a non-effective period of time that should attract an enhancement to their basic pay but MAPS is unable to process this information. Where a technical issue prevents enhancements being paid correctly. Where a member of MAPS rostered staff works extra hours in an area where MAPS is not implemented. Where an error has been made on MAPS which affects the staff members enhanceable pay and the deadline for pay processing has passed. Where this is the case the timesheet should also be signed by the Matron.. Where a member of staff has worked extra hours or an enhanceable shift which is not on their base ward and is as a result of short term operational requirements. Trust Policy for all staff using roster management v1 Page 15 of 22

16 6 Monitoring Compliance and Effectiveness The following metrics will be reported to the Safer Staffing Group and escalated where necessary via the Director of Patient Experience and Chief Nurse. Monitoring Requirement : 1. Timeliness of roster partial approval: 2. Number and percentage of unused contracted hours By Division (on MAPS only) 3. Number of blue timesheets submitted per month per Division submitted and the reason that they have been created. 4. Timeliness of roster full approval Monitoring Method: 1. For each monthly roster partially approved in line with 6 week timeline by ward and Directorate. Presented as % completed within time guidelines. 2. The number of unused contracted hours remaining at the end of each 4 week roster also shown as a percentage of contracted hours. 3. Number of blue timesheets submitted and the reason they have been created. Report Prepared by: 4. For each monthly roster fully approved in line with 6 week timeline by ward and Directorate. E Rostering Team from MAPS information and the report regarding number of timesheets by Pay Services Monitoring Report presented to: Frequency of Report Reported to Safer Nurse Staffing Group Monthly Trust Policy for all staff using roster management v1 Page 16 of 22

17 Appendices Appendix 1 Process for Creating an Effective Roster Process Steps Use the Trust standard roster dates. Responsibility Roster Co-ordinator Staff to make shift requests (max. 20% shifts) on Employee Online, including requests for annual and study leave up to one week prior to roster publication date. Annual leave requests are not included in this 20%. Close the roster to requests and review requests. Approve any non-effective periods. Run the auto-roster (this will try to fill in the expensive / difficult to fill shifts (e.g. nights / weekends) first and create a balance). Ensure that there is a nurse in charge for each shift, manually move shifts as necessary. Fill remaining staff hours with vacant shifts, adjusting duty times where necessary. Review roster analysis data, ensure good balance of staff across the 4 week period, all staff hours are used, cover allocated and there is an even balance of popular and unpopular shifts amongst substantive staff. All Staff Senior Sister or Charge Nurse / designated deputy Roster Co-ordinator Roster Co-ordinator Roster Co-ordinator Roster Co-ordinator / Senior Sister or Charge Nurse Partially approve the roster and inform the Matron that it is ready for full approval. Matron reviews analysis data, if there are gaps in the roster try to cover them by moving nurses or responsibilities between teams / wards. Allocate any vacant shifts to bank, in line with the Trust Policy and Procedures for Booking, Deployment and Utilisation of Flexible Nursing Staff. Consider moving less urgent tasks to another shift and if it is necessary to deploy temporary staff, ensure that they are rostered for the most cost effective shift, as long as it is safe to do so. Publish roster once approved by the Matron Senior Sister or Charge Nurse Matron / DND Senior Sister or Charge Nurse or from Matron if reasons for deployment varies from those listed in the Temporary Staffing Policy or budget is exceeded. Roster Co-ordinator Trust Policy for all staff using roster management v1 Page 17 of 22

18 Appendix 2 Roster Creation and Annual Leave The following statements are to be used within the context of the Trust Leave policy and Agenda for Change Terms and Conditions of Service. Annual leave is allocated in hours for all members of staff. Each ward should calculate how many staff must be given annual leave in any one week (See Appendix Three). An agreed number needs to be set and adhered to. Staff should be made aware of the need to maintain this number constantly throughout the year. Should this number not be met, by way of requests, the Senior Sister or will allocate leave following discussions with the staff concerned and in line with Trust policy. No holiday bookings should be made until the Senior Sister or has approved the annual leave requested. This request should be made via EOL and approved through MAPS. The Senior Sister or must ensure that these requests are approved or rejected in a timely manner. Half term weeks and school holidays present additional problems. The total amount of leave whether annual or study leave etc should not be increased because of the well-recorded difficulties in obtaining additional staff. Discussions should be encouraged between those requesting half terms off so that each member of staff has an equal chance of being granted annual leave. Annual leave requests for school holidays will be shared equally amongst those requesting. If annual leave is not booked and is to be taken ad-hoc, it is an individual s responsibility to ensure it is used before 31st March. Any annual leave not used by 31st March each year will be forfeited except in exceptional circumstances such as the staff member being off sick. Carrying over leave must be authorised by the Matron with the exception of maternity leave. Annual leave must be booked or cancelled before a roster is planned. Annual leave requested after this can only be given if staffing levels permit, near to the day and only if the reasons for this late application of leave are exceptional. Staff on rotational programmes should take annual leave proportionate to each placement. Please refer to policy for further details and information on Special Leave. Every effort should be made to have days off surrounding the leave. Trust Policy for all staff using roster management v1 Page 18 of 22

19 Appendix 3 How to Calculate the Number of Staff that Can Be On Annual Leave at Once The recommended guideline of allowed non effective time is as follows: Annual leave between 11% and 17% Sickness no more than 5% Study leave no more than 2.5% Total = no more than 22.5% To calculate how many staff can be absent at any one time for annual leave purposes the following algorithm can be used Ward X has WTE nursing staff Ward X has 8.27 WTE HCA s Total staff WTE 11% of staff on annual leave at any one time is x 0.11 = 1.37 WTE nursing staff 8.27 x 0.11 = 0.91 WTE HCA s Minimum total 2.28 WTE on annual leave at any one time 17% of staff on annual leave at any one time is x 0.17 = 2.11 WTE nursing staff 8.27 x 0.17 = 1.41 WTE HCA staff Maximum total 3.52 WTE on annual leave at any one time. NB: If the % of staff off on annual leave at any one time exceeds 15%, the allowable % on study leave should drop to keep establishment unavailability at or below 22.5%. Although the calculation allows for fluctuation in leave patterns (e.g. more may request time off during school holidays), the allocation of leave should remain as consistent as possible throughout the whole year and sanctioning of annual leave should not leave the department understaffed. Please note: This number is based on WTE s in post, therefore as staff join and/or leave you will need to recalculate the above. It must be remembered that this only a guide for Ward/ Area Managers, as many issues will arise in the clinical setting which will affect the compliance to one or more of the standards. However even though these standards are flexible the overall amount of short term absences for an identified clinical area must not be exceeded. It should be noted that recent functionality improvements in the MAPS system allows for the maximum number of staff on leave can be set as a system rule which will feed into EOL. With agreement with the Senior Sister or these rules can be set in the system. Trust Policy for all staff using roster management v1 Page 19 of 22

20 Appendix 4 Quick reference guide to Responsibilities for key E-Rostering Tasks Task Responsibility Authorisation / Approval Account creation and access rights IT Helpdesk E-Rostering Team Account reset or queries IT Helpdesk Request from user Hardware issues IT Helpdesk Request from user Adding new staff to MAPS / EOL HR MAPS Senior Sister or of ward Amending contracted hours HR MAPS Senior Sister or Amending / creating new postings / transfer to other wards Creating or amending work restrictions HR MAPS Senior Sister or Creating or amending personal patterns Senior Sister or Creating or amending shared patterns E-Rostering Team Matron Creating or amending templates E-Rostering Team Matron Creating new shift types E-Rostering Team Matron Senior Sister or Agreed with Staff member Agreed with staff member Management of shift rules E-Rostering Team Senior Sister or Management of competencies (staff) Senior Sister or Agreed with staff member Management of competencies (shift) E-Rostering Team Senior Sister or Net hours reset E-Rostering Team Senior Sister or Partial approval of roster Senior Sister or As set by access control Full approval of roster Matron As set by access control Finalisation of roster Amendments to roster (pre-finalisation) Amendments to roster (post finalisation) Senior Sister or Senior Sister or E-Rostering Team As set by access control As set by access control Senior Sister or Trust Policy for all staff using roster management v1 Page 20 of 22

21 E-Rostering Process Map E-Rostering Process At least 7 weeks to start date 6 weeks to start date 4 wk roster period 8 th 14 th of +/-20 th of of month 27 th of month month month Finance Project Team Payroll Ward Staff Senior Nursing Complete MAPS form to indicate new starter or change to existing contract/ward Send form to payroll Put in requests for annual leave or unavailability. This can be done manually or via Employee Online Receive MAPS form from Nursing Snr Matron to inform Project Team by of changes to template Process MAPS change form Add any additional duties or changes to shift template Ensure all rules and restrictions are processed Process electronic roster Receive ESR Trust Change/New Starter form Check for gaps in roster and seek alternative options to fill If the roster is not approved, the ward staff will not be able to view it on Employee Online Approve roster when completed (single tick) Cross check MAPS and ESR details Occasional requirement to approve rosters in the absence of Senior Matron Verify roster (double tick) Process amendments to roster in real time (e.g. overtime, sickness recording) Complete all amendments (e.g. sickness etc.) No amendments to be made after this date on the E-Rostering system Check Employee Online system to verify that shift details are correct. Inform Ward Matron prior to 8 th of discrepancies 8 th of month upload MAPS data to ESR Check that all wards are finalised and finalise those not done. Subsequent overtime amendments to be made on blue form Send blue forms to payroll for processing Receive blue forms or manual timesheets (for temporary staff or non ESR linked rosters) Process changes to hours on ESR Process pay run Pay feed imported automatically from hub to Agresso Extract from ESR goes to hub Payday 27 th of month. Current month basic plus previous month s overtime and enhancements Trust Policy for all staff using roster management v1 Page 21 of 22

22 Appendix 6 Timeline for making specific shift requests This diagram shows the number of rosters in advance that can be created for each area and the cut off times for making requests for Timeline for requesting specific shifts and days off specific shifts. Annual leave may be requested further in advance but should be made no later than the date the relevant roster closes. Excludes requests for leave which can be requested further in advance of the roster being closed Start of current roster 1 End roster 1 End roster 2 End roster 3 End roster 4 Start roster 2 Start roster 3 Start roster 4 Start roster 5 End roster 5 Roster 1 Current Roster 2 Roster 3 Roster 4 Roster 5 Publish 'roster 5' 6 weeks -(see a) Earliest date for creating Roster 5 1 wk 7 weeks (see b) Close 'roster 5' for requests 9 weeks (see c) Maximum time for making shift requests (see d) Weeks until roster starts Notes: a - Rosters should be published 6 weeks before coming into effect b - Rosters should be closed for requests 7 weeks before coming into effect c - This gives staff a maximum of 9 weeks to make requests for a roster which comes into effect in up to 16 weeks d - Rosters can be created up to 16 weeks before coming into effect : There should be a maximum of 4 future rosters created after the current one as shown Trust Policy for all staff using roster management v1 Page 22 of 22