2016 and Beyond

The Report of the Safe Staffing COI

• Represented a shared commitment by the District Health Boards (DHBs) and the New Zealand Nurses Organisation (NZNO) to work together to agree on: – a mechanism for nurses, midwives and employers to respond

immediately if workloads exceed the determined levels

– Sustainable solution to safe staffing issues, developed in a way that has the confidence of nurses and midwives

Step COI Elements Purpose CCDM tool/process/ structure that achieves this

1 Forecasting patients To enable organisation to accurately predict elective and acute

demand (whole of service level and unit/area/ward level)

Central CCDM Council

Local Service Councils

Core Data set

Integrated Operation

2 Smoothing the planned workload To remove as much variability as possible from the patient

forecast

Work analysis

Core Data Set

Integrated operations

3 Patient generated staffing Generate a basic acuity based evidence driven staffing plan Work analysis

FTE staffing calculation

4 Non-patient generated staffing Accounting for time required to keep ward functional, sustain

quality and safety and to support staff to acquire new skills and

knowledge

Work analysis

FTE staffing calculation

Local Service councils

5 Estimating the effect of moderating factors Consider contextual factors –

Leadership, team culture, physical environment, technology,

equipment and work design

Work analysis

Local Service Councils

Variance Indicator Scoring

6 Provision for leave Base staffing must account for entitlements –annual, sick,

parental & special leave using historical data of actual rates per

service and staffing group to ensure accuracy

Work analysis

FTE Staffing calculation

7 Fine tuning and budgeting Test the staffing plan against the forecasted demand well ahead

of implementation. If any mismatch is identified take steps well

in advance to decrease demand or increase capacity

Core Data Set

Central CCDM Council

Local Service Councils

FTE staffing calculation

Integrated operations

8 On the day Professional judgement and credible data are the basis for

intelligent decision making to match the right staff with the right

skills & competencies to deliver the right care to the right

patients

Integrated operations

Variance Management System

9 Incident responsiveness A detailed workable response plan activated by system data and

professional judgement to manage inevitable unexpected surges

in demand

Variance Management System

Integrated Operations

10 Review Review of the forecast and staffing plan by monthly, weekly,

daily by shift

Integrated Operations

Variance Management System

First three demonstration sites 2009:

Counties Manakau (does not currently have a validated patient acuity system)

Bay Of Plenty (Model site)

Westcoast (has currently suspended programme)

Second Intake 2010: Northland

MidCentral

Nelson

Third Intake Sites: 2011/2012 Tairawhiti (Fit Approach –RTC/CCDM)

Taranaki

Southern

Fourth Intake Sites 2012 Waitemata

Fifth Intake Sites 2013 Lower Hutt Whanganui South Canterbury

Sixth Intake 2014 ADHB

Seventh Intake 2015 Hawkes Bay

Eighth Intake Capital &Coast

Eligible & under discussion Wairarapa

Not currently eligible Counties Manukau (Demonstration site) Waikato Lakes Canterbury

Timing of Involvement

• Committee of Inquiry (2006)

• Health & Disability Services Standards (2008) – “Consumers receive timely, appropriate and safe services from

suitably qualified/skilled and/or experienced service providers” (2.8)

– “There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery” (2.8.1)

• Health & Safety Act (2016)

• NZ Health Strategy (2016)

– “value & better performance”

Mandate for Safe Staffing

“The CCDM programme provides a comprehensive infrastructure for a whole of hospital approach to managing its nursing & midwifery workforce to better meet the needs of patients.” (p.74)

CCDM has enabled a level of trust in and transparency of workforce management at the bedside which has not been previously experienced.” (p.14)

“CCDM plays an integral role towards achieving a safer workplace for staff and care venue for patients.”(p.14)

2015 CCDM Evaluation Findings

Overall feedback tells us that our patients have a better experience of care since CCDM was introduced and this is reflected in the many stories we hear of the benefits of nurses feeling able and willing to go the extra mile and in many cases to contribute that discretionary effort that makes all the difference. DHB CE

This programme is an

investment with real

benefits and not a just

cost. DHB CE

The Local Data Councils are an enabler for our wards, and the staff are grateful

for a place to discuss ideas, and local solutions to the

problems that they face on a day to day basis.

Operations Manager

As the Operations Manager the CCDM work has been invaluable in the way that we have developed our Integrated Operations Centre, we now have so many tools to support us in our work. We are able to be very transparent around what our decisions are based on

Operations Manager

“Better quality care is less expensive care. It is more efficient and less wasteful. It is the right care at the right time. It should also lead to fewer patients being harmed or injured”

“Quality frameworks can serve as a way of shifting the focus of the health system from managing and delivering outputs to improving patient experience and outcomes”.

The Care Capacity Demand Management system (CCDM) is one QI

initiative that stood out during our visit to BOPDHB and

demonstrates a number of elements that are necessary to develop,

implement and evaluate QI initiatives.

Exploring the links between Quality Improvement Strategies and Organisational Outcomes in Four New Zealand District Health Boards. Report prepared by the Ministry of Health, the Treasury, and the Health Quality & Safety Commission 2016.

CCDM is a Quality Improvement Initiative

Social Processes

Technical Processes

CCDM

• Slow patchy implementation

• The utilisation of only some of the tools and processes

• Staff change management readiness

• Limited ongoing resourcing of the programme

• There is national expectation of increase pace and scale however constraints & enablers are at the local level.

Not So Good News

Common success factors across most or all of the DHBs, included • alignment to strategic goals • executive and clinical leadership • culture and capability • measurement and results, and • consumer engagement and patient experience

Advice for others: • Do not underestimate the amount of time it takes for changes to bed in &

benefits to be realised. • Investment in analytical capability and data systems was often identified as a

key enabler. • Attribution of savings, efficiencies or improved outcomes to specific

programmes can be problematic in cases where multiple QI initiatives are introduced .

• Quality improvement programmes can vary in their financial impact, either at the organisational or programme-specific levels.

Quality Improvement Enablers

All programme components need to be fully implemented.

The identified required changes need to be put in place.

To Achieve all the Expected Outcomes of CCDM

The fundamental shift

It is critically important to the integrity of the entire process that once the staffing requirements have been matched with the forecast workload, this is the basis on which budgeting decisions are made. Budgets must fit staffing requirements, instead of staffing being made to fit budget requirements. To do otherwise is inappropriate and undermines the goal of safe and effective healthcare delivery. COI Page 68

Plan Do Study Act

2008-2009

• Revised COI Recommendations

• Extensive Literature search

• Developing thinking

2009 • 3 Demonstration • Sites • Testing tools and

process • Incorporating

learnings

2009-2015 • Programme

components set • Further testing • and improving • Incorporating

DHB innovation

2016 • Further refinement • 3 main drivers

• Evaluation recommendations

• Request for greater clarity of DHB progress from funders-National DHB CEO Group

• Pending MoH Copyright

CCDM Programme Progression

CCDM Copyright

Software

1. Staffing Methodology Software

Previously Now

Excel spreadsheet for work analysis & FTE calculation

Purpose built software

Time consuming data entry Less personnel time - improved cost benefit to DHB

Risk of failure or corruption Fast, secure, simplified, robust

Limited ward profiling for work analysis

Greater depth of data inputs (WA) provides for better and more useful analysis

Variable processes across DHBs Improved process based on PDSA

‘Staffing Methodology’ is one of three CCDM programme components. It includes the work analysis and FTE calculation conducted in all Wards/units.

Software Preview

2. CCDM Progress Reporting

Previously Now

Programme consultant monthly reporting to SSHW Unit Director & Governance Group

Programme consultant monthly reporting to SSHW Unit Director & Governance Group & quarterly to DHB CEs

Limited input to report from DHB Councils & separate Union reporting

Inclusive, clear process for all parties to agree progress and areas for further work

No regular feedback loop back to DHB Councils

Greater opportunity for regular specific feedback

Subjective method of reporting progress

Objective reporting against achievement of milestones

Funder not readily able to make comparisons or accurately assess progress over time

Greater clarity of CCDM programme implementation across the sector

CCDM Programme Milestones

There are organisational and ward level milestones. Organisational are shown below.

Milestones have been weighted according the interdependency between milestones with emphasis placed on business as usual.

Category Deliverables Milestones %

Organisational Supported patient acuity system Dedicated coordination resource 20%

Organisational Supported patient acuity system Effective interface with other IT systems e. roster, patient management, CaaG 20%

Organisational Supported patient acuity system Latest upgrade implemented 10%

Organisational Supported patient acuity system Business rules in use 20%

Organisational Supported patient acuity system Dedicated governance for patient acuity system 10%

Organisational Supported patient acuity system Established process for quality audits 10%

Organisational Supported patient acuity system Established programme for staff training/updates 10%

Organisational Operational CCDM Governance Permanent governance (or Council) for CCDM is established 10%

Organisational Operational CCDM Governance All members have received CCDM Programme education 10%

Organisational Operational CCDM Governance Documented TOR reference agreed and reviewed annually 10%

Organisational Operational CCDM Governance Membership includes all agreed and required stakeholders 20%

Organisational Operational CCDM Governance The governance group meets regularly e.g. monthly 10%

Organisational Operational CCDM Governance Reports from Local Data Councils are reviewed by Council at each Council meeting 10%

Organisational Operational CCDM Governance Progress against documented annual CCDM Plan is reviewed at each Council meeting 10%

Organisational Operational CCDM Governance Last Council meeting attended by 80% of the members, including the partners 20%

Organisational Effective core data set use A core data set is defined and agreed by the Council including the measures advised by SSHW Unit 20%

Organisational Effective core data set use The core data set is reviewed by Council at each Council meeting 20%

Organisational Effective core data set use The core data set is used to evaluate the effectiveness of CCDM over time 20%

Organisational Effective core data set use Findings from the core data set are actioned 20%

Organisational Effective core data set use The core data set informs the annual CCDM Plan 20%

Organisational Effective organisational VRM Churchill exercise completed or agreed this is not required 10%

Organisational Effective organisational VRM Electronic display of care capacity and patient demand visible to clinical/operational staff in real

time, 24/720%

Organisational Effective organisational VRM Variance indicator scoring system displayed electronically for all wards/units 10%

Organisational Effective organisational VRM SORs are effective in responding to variance 20%

Organisational Effective organisational VRM IOC established under the management of a suitably qualified and experienced person with

responsibility for patient flow 24/7.20%

Organisational Effective organisational VRM IOC meeting using a MDT/whole of hospital approach to CCDM 20%

3. Programme Standards

Previously Now

A number of different documents used – Over the Line, Business as Usual

Single set of Standards

Annual process of self assessment Annual process of bipartite assessment

Over the line assessment format ‘new’

Standards format already familiar to DHBs

Consensus on progress attained challenging

Clear guidance on how to meet the criteria for attaining the Standards

Supported by new DHB Progress reporting framework – gaps and attainment already known

Programme Standards Preview

4. Variance Indicator Scoring

Previously Now

SSHW Unit recommend indicators and DHB have tailored

SSHW Unit recommend 7 evidenced based indicators

Significant variation between DHBs with scores

Standard, consistent and supported by evidence

Variation between wards within the same DHB so difficulty interpreting variance indicator scores and responding appropriately

Greater understanding and transparency of variance for wards and at operations level

DHBs build system to display customised score/colours on Capacity at a Glance screens

DHBs build system to display customised score/colours on Capacity at a Glance screens

Variance Indicator Scoring is part of Variance Response Management (one of three CCDM Programme components). Variance indicators are designed to flag care capacity variance in the moment during a shift.

5. Core Data Set

Previously Proposed

SSHW Unit recommend minimum ‘safe six’ data set

Collective agreement on expanded data set (still includes safe-six)

Definitions vary between DHBs

Definitions to be set

Not all of the safe six collected in every DHB

DHB to have some choice to select DHB/service relevant measures

Safe-six not provide enough information to assess CCDM Programme impact

Additional measures improve evaluation of CCDM Programme impact

Large data sets difficult to arrange and display for ease of analysis

Safe six increased to 15 measures that are evidenced-based

Data sets not consistently reported from floor to board

Data set can be reported from floor to board

CCDM –World Famous!

WORLD FAMOUS

For Supporting NZ Health Care to Provide:

Quality patient care Quality work environment for staff The best use of the health resource

So Are We There Yet………………

2016 and Beyond