Developed by: Rachael Smith & Jayne Duffy The Calderdale Framework A Facilitation Tool for a Flexible and Competent Workforce Developed by: Rachael Smith & Jayne Duffy The Calderdale framework is a proven transformational workforce development tool which empowers front line staff to make positive contributions to improving services for their patients. It originated in the UK and has been taken up as the preferred workforce development tool in Queensland, Australia.

The right person, doing the right thing at the right time, RIGHT! Implementing The Calderdale Framework leads to staff development (at all levels) with a focus on patients needs. It complements other service and quality improvement methods which generally focus on processes (e.g. productive ward) – it is lean for the workforce. This means the patient is seen by the most appropriate person, who is competent, at the right time – in reality this means less duplication, fewer hand offs and better care.

The Calderdale Framework: “a transformational tool for a competent & flexible workforce” CF is the result of evaluation & further development of Saunders original Functional Model of Delegation. Developing a competent & flexible workforce using the Calderdale Framework R Smith & J Duffy, IJTR 2010; 17(5):254-262 www.calderdaleframework.com (Please refer to reading/reference list for further articles) Development of the Calderdale Framework started in 1996, as a result of a clinical need – this was to assure the quality and consistency of care provided by Rehabilitation Assistant s who were working in a new community based service. It is rooted in the scholarly work of Saunders who set out the key issues of managing delegation. However it has undergone considerable development and testing and is applicable across different professional groups and agencies, and can be used to develop hybrid support staff, new types of worker (e.g assistant and advanced practitioners) and skill sharing across professional boundaries – all to make services better for patients. An academic paper has also been published describing its implementation – this gives a clear account of each stage involved, and a randomized controlled trial of its effectiveness is being published in Australia

Why Bother ….! ? The National Challenges Demographic challenges –workforce and patients Fiscal challenges Safety and quality challenges –Francis, Keogh, Berwick, Cavendish Modernising medical careers = early specialisation- GAPS in less ‘sexy’ areas Five Year Forward Plan -INTEGRATION Add national issues driving change – e.g. Demographics – ageing population, increasing demand plus policy directives e.g. Liberating the NHS, Francis Report, Cavendish report, Keogh report etc

Why Bother….! ? Local Challenges: Longstanding medical and non medical staffing recruitment difficulties Reduction in numbers of junior doctors Changing demands of the service Ability to offer career development opportunities Regular rotation of junior doctors impacts on continuity of care Add your specific local drivers and direction of travel.

What does this mean to us? INCREASING DEMANDS ON OUR SERVICES PATIENT DRIVEN SERVICE PROVISION MAINTAIN QUALITY & PRODUCTIVITY WHILST CONTROLLING OR REDUCING COST ENSURE REGISTERED PRACTITIONERS ARE FREE TO UNDERTAKE TASKS ONLY THEY MUST DO IMPROVE SKILLS BASE OF THE WORKFORCE TO PROVIDE FLEXIBILITY & CONTINUITY So what does all this mean for us : There will be increasing demands on our services as people liver longer, treatments become more complex and technology advances. However we must make our services more patient driven – do we meet our patients needs? How would we like to be treated? We must maintain /improve quality , improve our productivity, and work within budget. One part of this is to ensure the highly valuable skills of the registered practitioners are used for those who need them, whilst developing non registered staff. It will also be increasingly important to develop out own local workforce as the workforce shrinks (grow your own)

HEYH response: Development of both Assistant Practitioners and Advanced Practitioners is a regional priority. Regional steering group being formed to ensure consistency and rigour. Investment in Calderdale Framework methodology to support this.

So how can we do this? Service Improvement Initiatives Workforce development and new ways of working using The Calderdale Framework. Service Improvement techniques such as lean methodology (and in UK the productive series) are familiar to most of us and these focus on improving processes to reduce waste and add value. The Calderdale framework is to applies these principles to our workforce– which means looking at new ways of working, including new roles. It is a huge opportunity! – and you have the opportunity to be involved in shaping the services of the future.

Calderdale Framework: 7 stages Focus on Engagement Focus on Potential to Change Focus on Embedding Focus on Risk Focus on Staff Development Focus on Best Practice Focus on Governance

2 Service Analysis Captures ‘as is’ in detail Captures ideas to improve What is the service? When & where delivered? Staffing How well are patients needs met ? What could be different? This is an annotated example of Service analysis , using the Orthopaedic Early Discharge Service as an example, This service support the early discharge patients following elective orthopaedic surgery (hip/knee replacement), so they come out of hospital by day 2-4 post op. Examples of The broad functions carried out are triage, assess, plan, treat and so on. Service analysis breaks these down further - for example treatment is broken down to exercise, mobilise, stretches ….. Each of these are broken down into their components (e,g each exercise, each type of stretch, each type of equipmet and so on). Who does what is noted – it becomes clear where there is duplication (waste). It is important to ask how well patients needs are met now and in the future. Staff can then start to identify potential changes to improve the service (based on use of the workforce). What functions and tasks are carried out? Who does what now?

KNOWLEDGE BASED RISK ANALYSIS FREQUENCY RULE BASED TRAINING 3 Task Analysis KNOWLEDGE BASED RISK ANALYSIS FREQUENCY TRAINING IMPLICATIONS RULE BASED The decision tale used in task analysis is based on the skill, rule and knowledge framework (Rasmussen). He identified that tasks & functions require different levels of performance. Skill based performances are learnt over time with practice, and are largely automatic. Rule based performance requires more cognitive processing as application of known rules guide the task. Knowledge based performance occurs where new rules are having to be formulated in order to successfully complete the task, and demands in depth knowledge gained through training or experience. The level of performance required needs to be considered as it impacts on the cost of training as well as the potential risk of delegating or sharing a given task. Frequency of the task is important to considered as infrequent tasks will may not be cost effective to teach (and competence will not be retained) SKILL BASED

Stages 2 & 3 - ‘New Ways of Working’ Tasks mainly knowledge & rule based & highly specialist Remain with current profession Registered Practitioners consider Skill Sharing/Advanced Practice Tasks mainly knowledge & rule based Allocate to Assistant Practitioner Tasks rule & knowledge based with protocols available This gives you a simplified explanation of how using stage 2 & 3 of the Calderdale Framework enables decisions regarding role boundaries, and level of worker required for a given task to be made. Tasks which require performance at skill & rule level are less likely to escalate to requiring knowledge based performance and are also less costly in terms of training. These are most appropriate to delegate to support staff. Tasks which require more rule and knowledge based performance are more appropriate to consider for skill sharing (given that gradaute professions have a similar level of education and can therefore assimilate new knowledge without a great additional cost in training with rules being provided to underpin this). Tasks which can are rule based with some knowledge can be allocated to assistant practitioners (with protocols to guide performance and scope). Finally there are always a few tasks which are highly specialist which stay with the current type of worker. Delegate to support worker Tasks mainly skill & rule based

Assistant Practitioner Definition: ‘An assistant practitioner is a worker who competently delivers health & social care to & for people. They have a required level of knowledge & skill beyond that of a traditional healthcare assistant or support worker. The Assistant Practitioner would be able to deliver elements of care and undertake clinical work in domains that have previously only been within the remit of registered professionals. They may transcend professional boundaries. They are accountable to themselves, their employer and more importantly the people they serve’. Skills for Health 2009 NOTE: this slide can be removed if your project is unlikely to involver the development of Assistant Practitioners. The assistant practitioner role provides one means of meeting the workforce challenge (i.e. a shrinking workforce and growing ageing population). This worker is able to undertake elements of care that were only previously done by registered practitioners and therefore require training to equip them with the knowledge and skills required. Skills for Health set out standards for Assistant Practitioners in 2009 The assistant practitioner role is seen as a training role, that will take up to 2 years to complete. The standards identify that staff already working at level 4 career framework are expected to fulfil the AP standards, particularly in terms of the training requirements.

Advanced Practitioner definition : ‘An Advanced Clinical Practitioner is a professional who has acquired the expert knowledge base, complex decision making skills and clinical competencies for expanded practice the characteristics of which are shaped by the context and/or country in which s/he is accredited to practice.’ (HEYH Advancing Clinical Practice task & Finish Group 2014)

Benefits of The Calderdale Framework For Organisations Consistency & Safety Reduction in Risk Efficient & Effective Improved Productivity Flexible Competent Workforce Improved Patient Experience Employer of Choice Provider of Choice For Teams & Individuals Builds Effective Teams around the Patient Personal & Team development needs- Links to KSF (in UK) and PDP Clear Roles & Responsibilities Safe Skill Sharing Transferable Skills Job Satisfaction These are the benefits of developing a competency trained workforce using The Calderdale Framework. (focus on the benefits you are seeking). Evidence from both UK (Smith & duffy 2010) and Australia support the above benenfits.

Hybrid Support Worker Jack’s wife , Margaret said, “ Under the direction of the therapists, Cath the rehab assistant undertook speech and language therapy exercises and movement exercises. To the relief of both of us Jack’s speech returned and his walking has improved, giving him more independence. Thank you to all.” Margaret This give a real life example of a competency trained Rehabilitation Assistant who is competent to work across Physiotherapy, Occupational Therapy ,Speech & Language Therapy & Dietetics. They work in patients homes, to rehabilitation plans designed by therapists. This negates the need for the patient to come into a clinical setting and be seen by several different staff. The patients outcome was not compromised, and satisfaction was high.

Assistant Practitioner (New type of worker) Nicky Byrne, team leader (MacMillan Rehab) said: “ Michelle is now competent to take her own non complex caseload, including elements of assessment (to protocol) previously done by Health Professionals. This means patients are seen quickly by one person and complex cases have access to the specialist skills they need” This is an example of the value of a level 4 (Assistant Practitioner ) working in a MacMillan Community team with cancer patients. The team is able to work more efficiently with the right person, doing the right thing at the right time right!! This is role is seen as the biggest potential growth area for the future and is a new way of working – the worker undertakes some tasks which were previously only carried out by a registered practitioner (e.g assess, plan & treat). In 2008/9 the team were predicted to see 250 new cases, in reality they saw just over 500 new case – this is an example of the positive impact a trained and well supported Assistant Practitioner can have.

Health Professional Skill Sharing (level7) Nicky Hill, Emergency Department Occupational Therapist said “ Competency training was completed around tasks that are traditionally uni-professional, to allow Health Professionals to share skills in order to complete all aspects of the assessment & treatment. This enhances the patient experience and journey by reducing the number of disciplines involved, subsequently speeding up the assessment & discharge planning process” OT News May 2010; 18(5):25 This is a short excerpt from Nicky’s publication in OT news. She is describing the real benefits to patients when registered practitioners effectively share their skills. The Calderdale framework was used to identify what could be shared, develop competencies, train and support staff in the new ways of working. 18

Health Professional Advanced Practice (level 8) Physiotherapy led outpatient orthopaedic clinic: First assess Order X rays and scans & tests –read & interpret these. Prescribe Inject List for surgery, Refer on Give advice Review & monitor. This is a short excerpt from Nicky’s publication in OT news. She is describing the real benefits to patients when registered practitioners effectively share their skills. The Calderdale framework was used to identify what could be shared, develop competencies, train and support staff in the new ways of working.

NEW WAYS of WORKING:STAFF VIEWS “ Confidence and skills increased” “Allay fears of role erosion” ” “Still ensuring quality services” “Enables health professionals to focus on more complex interventions” “ Beneficial for patients- they don’t have to wait for another assessment” “ Able to apply new knowledge and skills with real benefit to patients” These are comments from health professionals following use of the Calderdale framework to develop effective skill sharing. Initially some had been sceptical and concerned – however the end result was they positively embraced the new way of working and saw benefits for their patients and themselves. “ Increase knowledge of wider initiatives and policies”

The Combinations are Limitless …… ‘alternative approaches are needed to develop a sustainable workforce that is flexible enough in its work practices to manage the complex changes facing the NHS’. Gita Milhora, Kings Fund UK Please refer audience to website www.calderdaleframework.com