EXECUTIVE SUMMARY FRONT SHEET Agenda Item: Meeting: Quality and Safety Forum Date: 09.07.2015 Title: Monthly Board Report- Publication of Nursing and Midwifery Staffing Levels June 2015 Exception Report Author: Deputy Chief Nurse Executive Lead: Chief Nurse Other meetings presented to: Purpose In response to the National Quality Board and the Chief Nursing Officer Publication of How to ensure the right people, with the right skills, are in the right place at the right time: A guide to nursing, midwifery and care staffing capacity and capability the Board will receive a monthly exception report detailing staff capacity and capability. The Board will be advised of actions taken to address staffing shortfalls and to ensure the continuous safe delivery of quality care to patients. This report will be published on the Trust website on a dedicated patient friendly safe staffing area site. Link to Strategic Priorities Deliver safe, appropriate and effective patient care Efficiency driven by innovation, teaching, research and education Be efficient and financially stable Executive Summary Decision Approval Information In response to Hard Truths Commitments Regarding the publication of Staffing Data - NHS England and Care Quality Commission, UHNM has been preparing to ensure that the Board can receive assurance against the requirement to take full responsibility for the quality of care provided to patients through collective responsibility for Nursing and Midwifery, staffing capacity and capability. This report outlines Summary of June 2015 publication of planned versus actual staffing numbers available on a shift by shift basis for Stoke and County sites Actions taken to ensure safe staffing levels on every ward Details of further National Guidance and Trust response on the delivery of safe staffing Key Recommendations Board to receive and agree staffing assurance report format for the University Hospitals of North Midlands Board to receive actions taken to maintain safe staffing levels and address shortfalls Support further considerations associated with delivery of safe staffing levels 1
Corporate Impact Assessment (please tick any which are impacted on / relevant to this paper) Financial Legal Workforce Quality Implications Implications Implications Implications 2
Monthly Board Report- Publication of Nursing and Midwifery Staffing Levels June 2015 For approval 1. Introduction In June 2014 the Board received the first monthly report on the Trust publication of Nursing and Midwifery Staffing Levels at UHNM. This is a national requirement for all Trusts providing in patient care and is received by the Board to provide assurance that there are adequate staffing levels across the organisation on in patient wards As an NHS organisation we have a duty to ensure our staffing levels are adequate and the Nursing and Midwifery Council (NMC) endorse this responsibility within the Code of Professional conduct. Demonstrating sufficient staffing is one of the six essential standards that all health care providers must meet to comply with the Care Quality Commission (CQC) regulatory standards. 2. Nurse Staffing Levels June 2015- Summary Publication of staffing data On the 13 July 2015 UHNM submitted nurse staffing information on the UNIFY website for the County and Royal Stoke sites. The information was collated for the month of May and included all wards across UHNM except day case wards and our Clinical decisions unit. The information submitted was: Total monthly planned hours for: Registered nurses and midwives for all day shifts Care staff for all day shifts Registered nurses and midwives for all night shifts Care staff for all night shifts Total monthly actual hours for: Registered nurses and midwives for all day shifts Care staff for all day shifts Registered nurses and midwives for all night shifts Care staff for all night shifts The table below provides a summary of UHNM results for June 2015, with the overall fill rate for RN being 94% Planned v Actual Hours Worked Royal Stoke University Hospital Changes from the previous month Registered Nurse 88.9% Nursing Assistant 93.4% Royal Site Total 91.1% Planned v Actual Hours Worked County Hospital Registered Nurse 97.16% Nursing Assistant 103.96% County Site Total 100.18% In all a total of 55 ward areas submitted data (44 Royal Stoke, 11 County). 3
3. Exception report In the absence of national guidance on appropriate staffing thresholds an internal indicator has been of 90% compliance against delivery of planned hours has been applied The following exception report following data validation, reviews those ward areas that demonstrated <90% of the overall planned hours for registered nurses versus the actual staff hours available and cross references the data against objective measurements to provide assurance on the delivery of safe care. For the month of June 2015 at the Royal Stoke site a total of 12 (out of 44 wards) in-patient adult wards fell below the threshold of 90% compliance of their total planned hours for registered nurses. Several of the critical care units fell below 90% of the planned hours but for these units flexibility in staffing generally reflects patient acuity and bed usage. Each area has been reviewed against independent quality metrics including: Number of Complaints June 2015 Ward Quality Report June 2015 measures harm free care looking at nutrition, infection prevention, medication incidents, pressure area care, clinical monitoring and patient experience Percentage of patients recommending the ward through the friends and family test Red flag events Inpatient Ward Area Division Planned v actual hours worked (Registered Nurses) Complaints Ward Quality Report- % harm free care % patients recommending ward Red flag events 233 Medicine 80.8% 0 100 100 0 79 Medicine 86.6% 0 100 80 0 223 Specialised 84.8% 0 100 100 0 232 Specialised 85.2% 0 95.65 No results 0 3 Specialised 87.0% 0 100 100 0 217 Women & 216 Women & Critical care areas NICU Women & 79.7% 0 NA No results 0 85.3% 1 NA No results 0 71.9% 0 NA NA 0 PICU Women & 72.9% 0 NA NA 0 CCU Surgery 64.8% 0 100% NA 0 SSCU Surgery 82% 0 100% NA 0 Cardiac ICU Specialised 85.2% 0 100% NA 0 Women, Children s and Diagnostics The Child Health Directorate have reviewed their fill rates as they constantly reported failure to meet the 90% target. Ward 217 has had a number of staff leave over a short period and have a high maternity leave rate, resulting is a higher vacancy rate than normally seen in that area. However the fill rate has shown some improvement this month. June was a very difficult month for all the areas as there was unprecedented levels of activity unusual for Child Health and far exceeding the usual occupancy of 60% for this time of the year. In response to this demand there has been Daily / hourly reviews of staffing to support acuity and there has been movement of staff across the directorate to support areas. Some staff 4
have given up supernumerary time to support the ward areas. Vacancies are out to advert and a good level of response has been noted. Within the Paediatric intensive care, if the beds are not fully utilised, staff are transferred to ward on shifts so the fill rate does not impact on patient care. This is also pertinent to the other critical care areas. Medicine Within one of the wards there was a high level of sickness and support has been given to support the manager in managing the sickness, Skill mix has been slightly amended to ensure more junior nurses have additional support. The nursing outcomes do not support any concerns around patient outcomes. Recruitment is on-going. Specialised The beds on Ward 3 at County are currently not fully utilised and as a result some of the staffing resource is being allocated to other wards on a shift by shift basis. This suggests that the staffing levels do not meet requirements but it actually reflects good practice and full utilisation of a staffing resource across the organisation. Within the others areas there is an ongoing recruitment programme, and some staff have been recruited.. Surgery The main deficits are within the critical care areas. There has been successful recruitment to vacancies in this area and new staff will start over the next 3 months. The beds within the critical care areas are flexed on a daily basis to ensure staffing meets the acuity required. 4. Percentage of nursing staff hours filled by agency staff Agency use on both Stoke and County sites is reported and monitored on a monthly basis to assess the percentage of planned nursing hours delivered by agency staff. Nurse vacancy levels at County are higher than those experienced at Stoke site and future reports will focus on the actions taken to ensure continuity in nurse staffing levels across both sites and strategies going forward to reduce reliance on temporary staffing. This process is centrally controlled and monitored on behalf of the Chief Nurse via the Directors of Nursing and applied by the Associate Chief Nurses in the operational divisions through the Standard Operating Procedure for requesting and obtaining nurse agency resource. UHNM has a robust recruitment strategy in place to ensure that nurse staffing levels are buoyant and can meet service needs requirements and that our planned nursing hours wherever possible are provided by nursing staff employed by UHNM. Divisions are now finalising plans to reduce the use of agency staff in the next months. Percentage of planned hours filled by Agency for June Royal Stoke University Hospital 8.8% and this is a slightly higher percentage of agency filled hours than April and is inclusive of all wards. The critical care areas are the highest users of agency staff currently County Hospital 21.2% this is a marked increase from the May position of 15.8% This process is closely monitored through the Divisional Associate Chief Nurses who ensure that agency resource is spread across existing nursing establishments so that permanent Trust staff can be released to support escalation capacity 5
The largest usage of agency staff at the Stoke site was in the following areas: Critical Care Unit- Surgery Ward 210 - Respiratory Medicine Ward 103 Surgery The largest usage of agency staff at the County site was in the following areas: Ward 1 - Medicine Ward 10- Medicine Ward AMU - Medicine Staffing levels 5. Midwife to Birth Ratio s Midwife to birth ratios for the month of June 2015 have been merged for both County and Stoke sites and are as follows: University Hospital of North Midlands - 1 midwife to every 1.29 births The new model for midwifery services across Stoke and County site is now fully operational in alignment with the agreed TSA model leaving an established Midwifery Led Unit at County site. Workforce models for midwifery services at both the Royal and County site have been developed in accordance with national guidance and NICE Safe Staffing recommendations for midwifery staffing. To date feedback on the changed services has been positive and Midwifery staff transferred to Stoke are settling well in their new working environment Midwifery to birth ratio s do fluctuate slightly month on month with starters and leavers; planned establishment for midwifes at the UHNM is compliant with Safer Childbirth recommendations and the amalgamation of services provides additional flexibility to utilise our resource of midwives more effectively. 6. Further Guidance on Safer Staffing In November 2014 NHS England produced further guidance Safer Staffing: A Guide to Care Contact Time in support of existing guidance (NQB, NICE Guidance and NICE endorsed safe staffing toolkits) to provide a suite of toolkits for organisations to use in making decisions to secure safe staffing for patients. UHNM took part in the pilot scheme for Care Contact Time and contributed to feedback informing the development of the national guidance. In addition to the NQB requirements to publish monthly analysis of actual staff each month versus planned, the Care Contact Guide sets out the additional recommendations; Trust Boards should consider undertaking a contact time assessment to provide a baseline indication of the construction of care provided Because nurse contact time may vary across specialities data collected should be considered alongside other indicators such as - Planned v actual staff numbers - Quality Metrics aligned to care provided - Undertake temperature checks on contact time in the following circumstances- quality indicators falling, care model has changed, change in skill mix or introduction of new technology - Within specialities on a six monthly basis as outlined in the NQB guidance and NICE Guidance Board report should include how delivery of care contact time will be incorporated into ward leadership training and development strategy Further to the above recommendations UHNM has undertaken a baseline assessment of Care Contact hours for each ward area across Stoke and County sites. The results of this audit can be used as a baseline for future reviews which will be performed in conjunction with other tools when there is a change in ward circumstances or a trend in decreasing patient outcomes / patient satisfaction is noted. The average direct contact time for Registered Nurses was 69.7% and 66.8% for Nursing Assistants. There is no 6
national benchmark to judge these results against, however it is an increase in the direct contact time noted when work commenced on the productive ward initiative several years previously. Nurses are also encouraged to report red flag events resulting from staffing issues. At the moment if the nurse in charge identifies deficits in staffing levels they are supported to complete a DATIX form so issues can be monitored. The specific red flag indicators are: Unplanned omission in providing patient medications Delay of more than 30 minutes in providing pain relief Patient vital signs not assessed or recorded as outlined in a care plan Reduced staffing numbers for more than 8 hours Less than 2 registered nurses present on a ward during a shift During June there were 2 red flag events reported, both relating to delays in treatment which ultimately did not impact on patient outcomes. Neither event was reported on a ward identified with poor compliance with fill rates. 7. Conclusion The average fill rate for Registered Nurses and Nursing Assistants has fallen during June and the predominant reason for this can be linked to staff sickness, maternity leave and vacancies. However it is also connected to the work being undertaken in the Divisions to ensure that the staffing resource is efficiently and effectively managed so there are less areas reporting fill rates greater than 100%. There is no indication that the patient experience or episodes of harm have increased across the wards. Systems are now being introduced to capture red flag incidents through the DATIX system, although these will be captured automatically from the safer care tool when electronic roll out has been completed 8. Next Steps 1 Further analysis of the contact hours information to identify the principle reasons for the variation between wards and identify areas of ward management and organisation that could be improved 2 Improved use of key performance indicators from the e-rostering system to ensure that all wards make most effective and efficient use of staffing resources 3 Continued roll out of the safer care tool. 7