“It is important that nurses, midwives and DHB management realise that this is a long-term process.”
These words in the foreword to the 2006 Safe Staffing/Healthy Workplaces Committee of Inquiry report by chair Diana Crossan have proven somewhat prophetic.
It is a decade on since the joint union and DHB inquiry committee went out to listen to the concerns of stressed nurses and anxious employers about ensuring safe staffing levels in the country’s public hospitals. As a result it recommended setting up the Safe Staffing Healthy Workplaces (SSHW) Unit and, amongst a raft of other recommendations, for the unit to develop and rollout a toolkit of best practice safe staffing tools across the DHBs.
In 2009 the unit began testing and evolving the toolkit, now known as the Care Capacity Demand Management (CCDM) programme, with the core tools really only finalised in 2012/2013. And to date only one hospital – Tauranga in the Bay of Plenty, where many of the more high-profile tools were created and honed – is close to completing implementation of the programme across all its acute care wards. Another ten DHBs have implementation up and running at various levels, and four more are at the very early stages. Others are not even off the block.
Worth the wait
It is probably not surprising then that upping the implementation momentum is fairly high on nurses’ priorities in the latest NZNO and DHB contract negotiations.
It is also fortunate that the final evaluation report on CCDM, released earlier this year, concludes the programme is worth the wait and recommends that all DHBs implement it (see sidebar for summary of evaluation findings and recommendations).
“This programme provides a safe level playing field for front line hospital staff in the drive to provide efficient and effective health services,” says the executive summary of the evaluation report by the New Zealand Institute of Community Health Care.
CCDM aims to ensure a ward has the right staff at the right time to safely meet patient demand by analysing historic and robust patient acuity data gathered by TrendCare. Developed by an Australian nurse leader, TrendCare is patient acuity and workload management software that is an essential component of CCDM.
The evaluation shows that once the ward workload and staffing analysis component of CCDM is done, evidence that the skill mix, rosters and model of care need to change to better meet patient demand consistently emerges.
The suite of CCDM tools also includes systems for responding to unexpected demand – be it in orthopaedic ward or emergency department – with the busy ward in need made visible through Capacity at a Glance (also known as Hospital at a Glance) screens spread across a hospital campus, often including the staff café.
Can’t just ‘pick and mix’
Twelve tools make up the CCDM programme and the evaluation report’s lead author, nurse and midwife Dr Chris Hendry is clear that all 12 are necessary to ensure safe staffing.
She says as part of the evaluation the team went through each tool and process to see whether the programme could be stripped back to a bare minimum of tools.
“But to be honest every single bit is a very important part of the whole.”
Julie Robinson, director of nursing at pioneering Bay of Plenty DHB, which developed the first Hospital/Capacity at a Glance screen, says there can be a tendency for some DHBs to just “take the toys” like the “nice screens”.
“But you can’t just pick one bit and hope that it will be successful,” she says.
Hilary Graham-Smith, NZNO’s associate professional services manager and representative on the SSHW Unit’s governance group, agrees that DHBs can’t just take a ‘pick and mix’ approach to the CCDM programme and endorses Hendry’s finding that the complete programme needs to be implemented in a systematic way.
Robinson says she is a firm advocate for CCDM amongst her DHB colleagues but always reinforces that it’s not a quick fix.
“It’s a whole of system change,” notes Robinson. And taking a whole of system approach to staffing, the model of care, patient flow and variance response management is “incredibly challenging”. She says these changes don’t happen overnight, emphasising that it not only takes time but also a good partnership with NZNO and a commitment to being open and transparent.
Openness and transparency required
Transparency includes not being afraid to discern whether there is a mismatch between a ward’s workload and its current staffing. And not being afraid to share the result – whether it is ‘too few’, ‘too many’, the ‘wrong’ skill mix or ‘just right’ – with the staff involved.
“Nurses know what is going on – there’s no point in hiding data,” says Robinson. “Because fundamentally they are the ones there every day; they know what it’s like and they know what’s going on.”
The evaluation report notes that boards risk nurses becoming sceptical if the whole CCDM programme is not maintained and monitored or there is an inadequate response to meeting patient demand. It also notes that some boards appear fearful or reluctant to carry out ward-by-ward workload analysis in case ‘costly’ understaffing emerges.
“I think some people are a bit concerned what it might show-up, but in actual fact you may find you are using that FTE (full time equivalent staffing) anyway,” predicts Robinson.
Robinson, who is also the DHB directors of nursing representative on the SSHW Unit’s governance group, says Bay of Plenty DHB has now carried out the workload analysis and FTE calculation in all bar one of Tauranga Hospital’s acute inpatient wards.
The workload analysis showed that the base staff for the orthopaedic ward needed to be boosted – but its use of TrendCare acuity data meant it had already been plugging the workload gap with casual staff. So creating permanent nursing positions for the ward was virtually cost neutral over the year because the casual pool costs went down.
Likewise, when the analysis found too many FTE in its AT&R (Assessment, Treatment and Rehabilitation) ward it shifted some of that nursing resource to the two surgical wards shown to be in need of more nursing power.
Graham-Smith believes a vital ingredient for this re-engineering of rosters or base staffing is that is based on patient acuity data from a validated acuity-measuring tool.
“Nurses nurse patients, not beds – identifying your staffing resource based on just how many beds are full is not going to cut it.”
Momentum needed to keep nurse buy-in
But to get this accurate data on patient need, their nurses need to build time into every shift for entering patient data into the electronic TrendCare tool.
TrendCare pre-dates CCDM and a 2013 NZNO survey showed that nurses were somewhat sceptical about whether TrendCare alone was making a positive impact on their workload. There has also been some confusion between the wider suite of CCDM tools (using TrendCare data) and TrendCare as a standalone tool.
Graham-Smith says entering TrendCare data can appear to be adding another “onerous” task in an already “fraught environment” but it does not take a huge amount of time and nurses will embrace it if they can see it making a difference.
“That’s the critical thing – nurses have to see the results. They have to see that doing this additional step actually works for them.”
Hendry agrees: “If you start measuring things then people get excited but if nothing is happening to the measurements then people just lose interest and then the measurements aren’t as reliable”.
Graham-Smith adds that nurses understand that DHBs are fiscally stretched. “But more often or not they bear the brunt of it and their patients suffer as well. And that’s not a tenable situation for nurses – they don’t like having their safety and their practice compromised like that.”
So even if their ward’s workload and base staffing analysis doesn’t lead to immediate change, the nurses need to be able to see and discuss the results and to also know that a concrete plan of action is underway to remedy any shortfall.
Hendry also points out that one very visible way of showing TrendCare measurements in action every day is by using the Capacity/Hospital at a Glance screens that show the ‘busy-ness’ of every ward and unit across a hospital.
“And if you don’t have something like that simple screen up, then you wouldn’t have a nurse in the café glance up at the screen and see that ‘x’ ward is desperate and busy and her ward is not so busy. She then goes back to her charge nurse and says ‘I think we can give some nursing time to that ward’.
“That’s what I think is the beauty of this programme – it allows decision-making and management between services, rather than being a centralised system,” says Hendry.
Robinson says the screens and other variance response tools play a vital role in showing up unexpected bottlenecks in patient flow on any given day on a ward-by-ward basis.
Early on, Bay of Plenty realised that if a medical ward, for example, was super busy first thing in the morning then ED was often quiet at that time and transferring some ED staff to the ward for just two hours could help clear the bottleneck and smooth the workload before ED demand built up.
But Robinson says such staff shifts – and the handy “smart five” cards setting out jobs that can easily be delegated and quickly done by a ‘borrowed’ nurse – are probably used less now. “Because the more you get your base roster right, the less you should have to – in the main – move people.”
Getting to a point in time where safe staffing mechanisms are embedded in the system and unsafe staffing is the exception and never the rule, is where everybody wants to be.
But it is not always an easy task. The evaluation report acknowledges that the actual human and IT resources required to implement and establish CCDM were underestimated and this was exacerbated by the programme still evolving as it was being introduced. Hendry believes how the programme was presented – with gimmicky names that didn’t call a ‘spade a spade’ and the lack of a simple one-page summary for busy people at the ‘coalface’ – also didn’t help sell the programme. “I don’t think the potential had been fully understood.”
So hospitals, wards or units that are ‘early adopters’ and good at rolling things out have progressed, while others have floundered. “It’s probably become a bit stuck in areas where they are more resistant to embracing a new way of doing things,” says Hendry.
“Because basically CCDM questions the model of nursing care. There’s more of a move to a team-based nursing care provision.”
Hendry says it also questions the skill-mix. “It actually asks if there should be more in the skill-mix. And if so, when, where and what sort of other skill do you need to add to the mix?” That might mean health care assistants, extra clerical staff cover, or changes to cleaning staff and orderly rosters.
CCDM also questions roster lengths and staffing numbers and asks whether the right staff are in place at the right times; if there are enough staff, or too many.
“These are big things for charge nurse managers to have to manage,” says Hendry.
Hendry believes there needs to be strong support and change management capability amongst charge nurse managers and the evaluation report recommends that DHBs and unions step up and provide training to help them meet this challenge.
Top-level commitment needed
The evaluation report says the challenge is worth it, as the potential outcome of having the right person with the right patient at the right time is good for both patients and nurses
“I know there are people around the country who think it’s just about the union wanting to grab more of the pie – but it’s nothing like that, not remotely,” says Graham-Smith.
“Our agenda is exactly the same as the Safe Staffing HW Unit – and the people on the governance group – we want to see staff being able to work safely to deliver all of the care a patient needs on a given shift and not having to ration care, which is what occurs when you are not adequately resourced.
“Definitely we would like to see improvement in the pace and scale, but at the same time we have to acknowledge it’s a massive change programme and it is quite complex.
“And it is very much dependent on commitment at the top level of DHB leadership and for them to take the nurses along with them on that journey.”
“I can’t understand why you wouldn’t want to do it!” is the view of Julie Robinson, a convert to the difference that the Care Capacity Demand Management system can make.
To her it is simple – it’s an evidence-based method, staff feel listened to and valued and, at the end of the day, patients get better care.
Now it is just a matter of convincing all parties – from the Ministry, Minister and DHB executive to the nurse on the ward floor – that the evaluation report has it right, and after a decade of waiting it is time to step up the resources and commitment to ensuring safe staffing becomes an embedded reality.
Findings of the CCDM Evaluation Report*
- The CCDM programme provides a safe level playing field for front line hospital staff wanting to provide efficient and effective health services.
- The full CCDM programme is the first step in a nationally consistent, fair and valid process to review and realign the nursing and midwifery workforce in hospitals to more truly reflect patient acuity on the day.
- CCDM provides a nationally standardised and professionally agreed set of tools to monitor and respond safely and immediately to unexpected changes in variance between workforce availability and patient demand (acuity).
- While CCDM provides an deal suite of tools and activities to meet the safe staffing outcomes called for by nurses a decade ago, the patchy implementation of the programme in DHBs to date has made the results *difficult to quantify.
- The staffing diagnostic tools used to analyse workload and FTE staffing on a ward have the potential to identify under-resourcing of staff at ward level, which some DHBs feared would be costly and this has been put forward as a reason for the slower uptake of the base staffing calculation in particular.
- The few budgetary findings to date indicate that CCDM is relatively cost neutral as the reduction in the use of casual staff, the increase in flexibility of existing staff, combined with roster re-engineering and changes in skill mix, balanced out any increases in nursing FTE required.
- As at September 2014, only 51 of the 85 potential wards had undergone a workload analysis and only 19 had implemented recommended changes. In almost every case evidence emerged that the skill mix, rosters and model of care needed to change to better meet patient demand
- If the ward/hospital/DHB does not continue to maintain the CCDM programme, monitor its performance and respond appropriately to the patient care demand on the day and over time it runs the risk of being viewed by nurses with scepticism.
Summary of the CCDM Evaluation Report* main recommendations
- All DHBS should implement the Care Capacity Demand Management (CCDM) programme.The focus should firstly be on completing the rollout for all nurses and midwives in hospital wards in the current participating DHBs.
- DHB chief executives should make the SSHW Unit a permanent structure and ensure it was appropriately resourced to facilitate and assist the rollout of CCDM.
- The Ministry of Health and DHB chief executives should negotiate and manage a national licence with the current validated patient acuity tool provider i.e. TrendCare.
- The SSHW Unit should focus on refining and streamlining the CCDM tools to make the implementation process more effective, more efficient, and simpler to describe.
- DHBs and unions should provide change management training for staff prior to CCDM implementation, as in order to effectively implement CCDM, nurse managers require “a significant level of leadership and managements skills”.
- *The report, An evaluation of the implementation, outcomes and opportunities of the Care Capacity Demand Management (CCDM) programme, and its recommendations are yet to be fully discussed or endorsed by the SSHW Unit governance group or the other stakeholders, including DHB chief executives. An action plan is to be decided on shortly.
The full report is available on the website of the Health Improvement and Innovation Resource Centre www.hiirc.org.nz.
Safe Staffing timeline
2003–2004 NZNO Fair Pay campaign for DHB nurses raises idea of piloting nurse- to-patient ratios as answer to concerns about unsafe staffing.
2005 Nurse-to-patient ratios dropped when national DHB pay jolt settlement made.
Safe Staffing Healthy Workplaces (SSHW) committee of inquiry begins instead under independent chair Diana Crossan.
2006 SSHW report released along with action plan
2007 SSHW Unit created
2009 Bay of Plenty, West Coast and Counties Manukau DHBs are demonstration sites for SSHW Unit’s still-evolving care capacity demand management (CCDM) tools.
2015 CCDM final evaluation report released (based on 11 DHBs)
SSHW Unit now actively working with 14 DHBs in various stages of implementing CCDM, with the latest to join being Auckland and Hawke’s Bay and the 15th (Capital & Coast) due to start next year.
NZNO seeking more action from DHBs in implementing CCDM as part of current pay negotiations