National Forum Productive Programmes Care Capacity Demand Management (CCDM) and RTC. 10 th May 2013 Lisa Skeet Director Safe Staffing Healthy Workplaces Unit

Safe Staffing Health Workplace Research Findings at BOPDHB Staff on wards participating in RTC were particularly likely to express that the level of trust and commitment in the organisation is growing. Our overall finding was that there was a significant difference in the way the staff in the RTC wards talked about the organisation and rated safety, quality and efficiency than other areas and also these staff recommended faster roll out. The safe staffing healthy workplace workforce analysis showed that in one week 3a only recorded approximately 180 episodes of care rationing where as 3b and HIA who are only just beginning to implement the programme recorded approximately 1000 each. Care Rationing: Is defined as any time that a patient does not receive an aspect of care that professional consensus judged to be in their interests.

Releasing Time To Care is not: A project - it is a culture change A political tool – particularly in regard to the “not enough resource” question A cost cutting tool – though as a consequence savings are made

THE FIT APPROACH Releasing Time to Care & Care Capacity Demand Management

Safe Staffing Healthy Workplaces Committee of Inquiry  Recommendations  Description of the goals  No road map to achieve the changes 2007-mid 2009 Establishment of SSHW Unit by Minister of Health (3 years)  Engagement with DHBs & NZNO  Focus on escalation planning Mid 2009-end 2010  Re-assessment of sector status  Three demonstration sites established  Trialling of tools and resources  Evaluation  Emergence of CCDM approach On-going commitment from DHBs & Health Unions  Roll-out of CCDM to DHBs  Broaden to multi-disciplinary approach  Integrate with other sector activity -productivity -innovation -collaboration -quality -shared information Safe staffing healthy workplaces Care Capacity Demand Management

Care Capacity Demand Management Base staffing design (Mix & Match) Responding to variance (Variance Response Management) Naming & knowing normal (Safe Six Data Set & KHWD Groups) Naming & knowing normal (Safe Six Data Set & KHWD Groups) Forecasting & Planning

TrendCare Work-stream-System platform for CCDM

Focus of Mix & Match Uses Patient acuity to determine FTE Determines skill mix Determines responsive schedule Determines budget Includes realistic allowance for non clinically available time

Mix and Match Part 1: Work Analysis A Work Analysis is: o Concentrated data gathering o Noting real time work (all activities) and Care Rationing o Each staff member notes down everything that they do in15 minute blocks, for their entire shift. o Data collection continues for 2 weeks o All nursing staff involved in delivering patient care will be included, e.g. CNM, RN, EN, Students and Bureau.

The Data Collection sheet 99 AM 7am 4p m Mo n Nov 1st

Information gathered Utilisation, NHPPD -care required verses nursing hours available Ward activity (admits, discharges, transfers) Skill mix Work activity Bureau use & redeployments Staff hours worked Breaks rationing Care rationing TrendCare data – variance, hours required Patient numbers Rostering pattern of ward

Well Organised Ward Shift Handovers Admissions & Discharge Management Patient Observations Ward Round Nursing ProceduresPatient Hygiene Productive Ward Executive Leader’s Guide Knowing How we are Doing Meals Medicines Patient Status at a glance Project Leader’s Guide Ward Leader’s Guide Toolkit

Well Organised Ward - WOW

What is an Activity Follow It is an eight hour detailed recording of activities a member of the nursing staff undertakes It captures the task at hand and the location where it is performed e.g. what the nurse is doing & where she is doing it, These pieces of information are recorded every minute during the hour

Care Capacity Demand Management Base staffing design (Mix & Match) Responding to variance (Variance Response Management) Naming & knowing normal (Safe Six Data Set & KHWD Groups) Naming & knowing normal (Safe Six Data Set & KHWD Groups) Forecasting & Planning

Where to start VRM IDENTIFY In any given moment how can we identify what our situation is ? Capacity exceeds demand – We can assist other units Optimal productive functioning – all care completed with minimal delay -manageable workload Undesirable - quality of care compromised –on trajectory to compromised staff and patient safety and creating inefficiencies Unacceptable compromise of quality and safety – trajectory to failure Intolerable –unjustifiable risk – failure

Where to start VRM QUANITIFY In any given moment how can we describe to others what our situation is ?

District Hospitals

Event Report

Click on event Daily report

Care Capacity Demand Management Base staffing design (Mix & Match) Responding to variance (Variance Response Management) Naming & knowing normal (Safe Six Data Set & KHWD groups) Forecasting & Planning

Care Capacity Demand Management CCDM ESSENTIAL METRICS SAFE SIX CARE RATIONING – are patients receiving all of the care they require? HARM – are adverse events or outcomes occurring? STAFF SATISFACTION – are staff satisfied with what they were able to achieve ? DISCRETIONARY EFFORT- is the work effort to maintain service levels reasonable? PRODUCTIVITY –is the budget being maintained ?FLOW – are flow and volumes being achieved?

Knowing How We Are Doing Improve patient safety Improve patient experience Improve staff wellbeing Improve efficiency of care

Ward Variance Response Management (VRM) Agree a set of ward level metrics that describe the ward landscape both in the moment (Variance Response Indicators) and overtime Agree and establish service normal's and tolerances Receive, review and analyse ward level data and information that reflects the wards functioning ensure Effectiveness of metrics provide the picture Make appropriate recommendation to the DHBs permanent CCDM council to support a cycle of constant quality improvement. Support the ward staff with ‘plan- act- study do’ The KHWD(Local data Council) Teams Purpose in CCDM

In addition to CDS the KHWD team will Own the mix & match process for the service Choose clinical champions Be part of the set up and ward prep Actively support the team through data collection Receive the completed reports Organize feedback sessions for staff Compose a response for the Fit Council Develop unit/service level response strategies Own the VRM System for the ward/service Discuss status markers from the screen over the month looking for patterns Identify areas of strength and weakness with system design Identify areas for development within the tools of the VRM system Discuss redeployment for the month both in & out Compose a monthly report for Fit Council on service successes and identify areas where Fit Council assistance is required.

The CCDM Council ED Medical services Paediatrics Surgical services Mental Health Maternity The structure below illustrates the function of this council system whereby each service has its own KHWD council that reports to a CCDM Council. This structure enables the DHB to continuously refine and redesign tools and processes that allow it to more consistently match demand and capacity on the day and over time.

RTC/CCDM There are fundamental and complimentary differences between the two programmes. RTC focuses primarily on the resourcing and organisation of the work environment and the review of all systems and processes with the ward. The goal being to reduce the amount of non clinical time that is required to maintain the context of care. RTC therefore does indeed ‘release’ time that is currently being utilised inefficiently and makes this available for direct care. CCDM has a different goal and methodology based around identifying the direct and indirect clinical care that will be required by a particular patient group; thus CCDM does not free up time because the care hours are as assessed.

Summary Synergises/Benefits KHWD group/Local data council/safe six metrics Well Organised Ward organises the physical environment and ensures appropriate resources are available Work analysis helps informs which process modules are a priority. Work analysis provides robust baseline data for RTC process modules

RTC/CCDM Two sides of the same coin RTC focuses on systems/process and the environment within the wards CCDM focuses on right staff in the right place - (numbers, skills and schedule) with a organisation wide approach. Both focus on right care and right use of resources (productive & efficient)