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Integrated KPI Board Report
March 2018
Page 1
Integrated KPI Board Report for
February 2018 (unless otherwise stated)
Executive Sponsors
Jane Hayward
Director of Transformation
Date of Board Meeting
29 March 2018
5. Well Led Ward Staffing Report
February 2018
March 2018
Page 26
The following highlight report (in fulfilment of the National Quality Board (NQB) expectations on trust
board awareness of safe staffing) focuses on any ‘hotspot’ areas in February 2018 which the board needs
to be aware of in each Division. The report is based on review of the overall staffing figures, daily staffing
reports and staffing incident reports.
The report concludes with a specific focus on the band 4 HCA model in place in the inpatient areas. It
details the approach used (with a ward by ward breakdown of the models) and serves to provide assurance
around the evaluation and monitoring of clinical standards linked to the amended registered/unregistered
skill mix.
The table below represents the high level summary of the planned and actual ward staffing levels reported
for February 2018. This is the information which has been uploaded and will be for public display via NHS
choices from early April 2018. Detailed ward by ward information is also included as part of this KPI report.
From May 2016 Care Hours Per Patient Day (CHPPD) showing average care hours per patient for SGH, PAH
and CMH has been included as part of the Model Hospital dashboard and is included in this report. Costs
per ward have also been included in the model hospital dashboard since December 2016.
Staffing position for February 2018
February 2018 Day
Night
Care Hours Per Patient Day
(CHPPD)1
Site Name
Average fill rate - registered
nurses/ Midwives (%)
Average fill rate - care staff
(%)
Average fill rate -
registered nurses/
Midwives (%)
Average fill rate -
care staff (%)
Reg. midwives/
nurses Care Staff
Total care
hours per
patient
SOUTHAMPTON GENERAL HOSPITAL
79.2%↓ 123.0%↑ 91.3%↓ 134.2%↑ 5.1↔ 3.3↑ 8.4↑
COUNTESS MOUNTBATTEN HOUSE
92.6%↑ 129.7%↓ 104.4%↑ 115.7%↓ 3.3↔ 4.0↓ 7.3↓
PRINCESS ANNE HOSPITAL
81.4%↓ 67.6%↓ 103.6%↑ 78.0%↓ 6.0↓ 2.0↓ 8.0↓
NB: Arrows indicate changes against the previous month and do not represent either a positive or negative performance position.
Whilst it can be seen that we were not able to staff many clinical areas with our planned level of registered
staff due to current vacancy levels, we maintained our staffing levels at or above minimum safety levels.
This was achieved by regular review of trustwide staffing on a daily basis, the regular movement of staff,
using our nursing/midwifery bank and agency and through reassigning non-ward based staff from other
services to support the ward areas.
1 CHPPD, split into registered nurses/midwives and health care support workers is calculated using this
formula:- Actual hours worked_
Patient count at midnight
5. Well Led Ward Staffing Report
February 2018
March 2018
Page 27
‘Hotspot’ areas for nursing/midwifery staffing in February 2018 Key metrics show that staffing and capacity challenges continued to be extreme during periods in February,
with high volumes of patients within the emergency department and critical care and impacting the
downstream ward areas. Consequently acuity and dependency remained high across the trust and staff
sickness impacted on a number of areas.
Exceptions by Division are detailed below: Division A Surgery – The surgical ward vacancies continued to improve slowly, with a conscious over-recruitment of
support staff and an increase of staff at supervisory level.
Cancer Care – Registered nursing vacancies at CMH are improving with a very successful targeted
recruitment event.
Critical Care – All critical care areas have seen a continued rise in occupancy and flow throughout February.
This has led to challenges in staffing the fluctuating levels of activity. The overall registered nurse vacancy
has reduced to 8.8% (29 FTE) across the 4 units.
Division B
The Divisional registered nurse vacancy position remains significant at 20.9% (98.5 FTE) but has improved
in February. Focussed work continues on recruiting additional support staff to various areas of the division
to support overall staffing levels.
The division’s daily staffing challenges have remained consistent in February with some shifts remaining at
‘critical’ levels. Key mitigating actions and daily senior nurse focus have supported the ward teams to keep
patients safe; golden key release is monitored carefully in order to ensure that high cost agency is only
used for true ‘break glass’ eventualities however February has seen a further rise in the number of requests
to maintain safety.
Following consultation, all the divisions’ matrons are now providing a core hours, evening and weekend on
site service and one element of their role is to lead safe staffing planning and decision making.
ED and AMU - The registered vacancy position within the Emergency Care group reduced in February and
is now at 10% (19 FTE). The trustwide capacity challenges have continued in February and have been
particularly focussed on ED and AMU activity. This was reflected in continued requests for high cost agency
for break glass safety reasons.
Emergency medicine wards & Medicine for Older People – Registered nurse vacancies are now at 31.6%
(77 FTE) and this is reflected in the need to use high cost agency for break-glass safety reasons and an
increase in staff moving from across the hospital to support. Medicine continues to over-recruit
unregistered staff which really supports the risk associated with the RN vacancy rate.
Division C
Child Health - RN vacancies across child health fell to 13.6% (44 FTE) nurses. This level of vacancy
continues to impact on the ability to open the beds closed over the summer.
Maternity & Neonates– Vacancies for midwives have remained stable this month and a further cohort of
newly qualified midwives is expected to start in March.
5. Well Led Ward Staffing Report
February 2018
March 2018
Page 28
Division D The overall Divisional registered nurse vacancy position increased to 3.8% (111 FTE) with a pipeline of 12
registered nurses to start in the next 3 months. Staffing of the continued use of uncommissioned beds
(particularly in cardiothoracics and neurosciences) to support the capacity challenges has resulted in an
increased usage of high cost agency.
T&O and Neurosciences remain areas of focus with registered nurse vacancies of 39% (49.5 FTE) and 29%
(42 FTE) respectively, an increase for both areas in the month. High vacancies are being managed with
staff doing bank shifts, over recruitment of band 3 and 4’s and deploying staff across wards, however there
has been a resulting increase in the number of shifts escalated to high cost agency for break glass safety
reasons.
------------------------ Staff continue to reference the ‘red flags’ identified in the NICE guidance on safe staffing when completing
adverse event reports (AER) linked to staffing. These red flags highlight when patient care has potentially
been impacted due to staffing shortfalls. These AERS are reviewed, actioned and mitigated in real-time to
reduce the risks. They are also themed monthly and identified actions taken forward linked to the
reporting on safe staffing and the trust risk register. Care group and divisional reports are also available to
enable focus on trends in incidents being reported from each clinical area.
In February there were 90 staffing incident reports in total covering 7 different staff groups. This is a rise
on the previous month but is at the average level for the last year and is a decrease on the 110 incidents
reported in December. These incidents have been rated from near miss to moderate (5) impact. Of these
incidents, 60 were related to nurse staffing, a slight rise on the 52 reported in January. There were 6
Midwifery incidents reported for the month. Hotspot areas identified through the reporting are being
closely reviewed by the divisions.
In addition to the existing system, in August 2017 we introduced the capability to report red flag incidents
in real-time on the safecare acuity/dependency system in healthroster. Following a rostering and safecare
masterclass in January this facility has now been rolled out trustwide and the red flags will be reviewed at
the daily staffing meetings.
------------------------ The overall vacancy level for ward staffing (registered, unregistered and other support roles) was
maintained in February and now stands at 410 FTE (12.9%). There is a slightly improved registered nurse
position in February. The current vacancies are 365 FTE (17.6%) registered vacancies and 14 FTE (1.5%)
unregistered vacancies. A further trustwide recruitment event for unregistered staff takes place in March.
It should also be noted that 58 FTE registered overseas nurses are currently working as unregistered nurses
as they await the results of their English language testing (IELTS) requirements and competency
requirements stipulated for NMC (Nursing and Midwifery Council) registration.
This month has seen our first candidates pass the OSCE (Objective Structured Clinical Examination)
required by the NMC for registration.
The annual cycle for the recruitment of the newly qualified registrants (adult/child) continued with an open
day held on February 22nd. More than 100 attended the event, a reduction on the previous year, but this is
likely to be due to the spread of the recruitment process where we now hold 3 open days per year and
allow qualifying students to apply for positions up to 18 months before they qualify. The event had a really
5. Well Led Ward Staffing Report
February 2018
March 2018
Page 29
vibrant atmosphere and was well evaluated. Interviews will be taking place in April and social media has
been used to further spread the impact of the event and increase the awareness of the application process.
Graph 1 below details the breakdown of temporary staffing cover across the last year.
Overall use rose in the month, with the increase mostly in bank fill. The proportion of bank to agency usage continued to increase as planned with 26% of the temporary staff usage filled by agency compared to 38% 12 months ago. High cost agency usage rose by 4 FTE with 11 FTE (196 shifts) in February 2018 for break glass safety
reasons. This equates to 2.8% of the total temporary nursing staff usage. Shifts escalated to high cost
agency remained unfilled in a number of cases and all measures were taken to manage staffing across the
trust to ensure safety was maintained.
Daily escalation processes continue to support the most effective deployment of staff in real-time with the
use of ‘safecare’ acuity/dependency data embedded as part of the daily staffing reviews.
Graph 1:
5. Well Led Ward Staffing Report
February 2018
March 2018
Page 30
Graph 2 – Ward Staffing - Predicted vacancies
5. Well Led Ward Staffing Report
February 2018
March 2018
Page 31
Review of the Band 4 HCA model in the inpatient areas
The band 4 model is used to maximise the contribution of the unregistered nurses by providing additional training, competency assessment and supervision to enable them to provide enhanced levels of nursing care alongside registered nurses. Staff in these role have either attained (or are working towards) the foundation degree in healthcare and associated competencies that are supported through this route or they are staff who have an overseas equivalent qualification in nursing but are not eligible or don’t wish to pursue full registration with the NMC. This has enabled UHS to offset the ongoing vacancy levels with registered nurses whilst maintaining the overall care hours per patient day provided to our inpatient wards. This is closely balanced to ensure there remains an appropriate level of registered nurses on each shift to coordinate and direct the overall delivery of care on the ward and support the more complex, technical and patient management aspects of care. In critical care areas and theatres specifically, patients are only admitted calculated on the appropriate number of registered nurses being available. Latterly the band 4 role is also being used to support registered nurses from overseas who have not yet completed all of the requirements to gain registration with the Nursing and Midwifery Council (NMC) but who are actively pursuing registration. On registration they automatically transfer into a band 5 registered nurse post. Currently 49 areas utilise a band 4 nursing model alongside the registered nurse complement of staff. An additional 20 areas are deemed not appropriate for this model of staffing either due to the size of the ward or the complexity of the speciality and skill requirement of the registered nurses (see breakdown of ward areas and models in place). Quality nursing metrics, as presented through the Clinical Quality Dashboard (CQD), are monitored monthly within each division. These include:
Pressure Ulcers
Falls prevention
Medication errors
Nutritional assessment
Infection prevention
Home before lunch There have been no indicators of reduction in quality in the areas that have adopted a band 4 model. Indeed metrics in most of these areas have improved over the period of time that the band 4 models have been in place Additionally, complaint reviews, serious incident reviews and reviews of adverse events related to staffing have identified no issues related to the band 4 model of staffing or linked to these roles themselves. When initially introducing the model in areas a pre and post evaluation process has been put in place to robustly review the quality metrics to ensure the staffing model has had no adverse effects. This post evaluation review is due to take place across the medicine wards and respiratory HDU and to be repeated in the medicine for older person wards in the next 3 months.
5. Well Led Ward Staffing Report
February 2018
March 2018
Page 32
As part of the post evaluation review carried out previously in medicine for older people, a staff survey was undertaken. This reported that the model was seen to be very supportive and integral to the ward, with individuals in the role valued as part of the team. A number of the individuals were regularly named on friends and family feedback (FFT) and received recognition from a wide range of patients. It was felt that the role has contributed to an improvement in staff morale by enhancing the overall staffing complement. In summary, the introduction of the band 4 model (whilst managed carefully to ensure an appropriate balance of registered staff are available) has supported the total staffing model in the inpatient areas within UHS. It should be noted that divisions report that any challenges around quality have been due to overall staffing shortfalls rather than the introduction of the model of band 4 staffing. Impact and review of the roles will be maintained through the annual staffing reviews completed for each area and through specific post evaluation reviews in some areas.
