Scepticism was rife last year when nurses were surveyed about whether TrendCare was improving their nursing workload.
A quarter of the nearly 1500 respondents to the New Zealand Nurses Organisation employment survey were aware of having TrendCare or Care Capacity Demand Management (CCDM) at their hospital but reported being uninformed or unimpressed or their workload virtually unchanged as a result.
It appears that confusion and cynicism is still rife five years down the track since the Safe Staffing Healthy Workplaces Unit started developing the CCDM system.
Lisa Skeet, the SSHW unit director, is not that surprised at the NZNO survey results, saying it is still early days for CCDM at the 11 boards it is currently underway in (Auckland DHB will be the 12th and gets underway this year).
CCDM is a sophisticated system developed with the aim of bypassing crude nurse to patient ratios (like those adopted in Victoria or California) and instead using robust patient acuity data to decide base staffing so a ward has the right staff at the right time to safely meet patient demand.
“There have been pockets of success with CCDM. However, it’s still not implemented on the scale where the full benefits of the programme will be seen with DHBs,” says Skeet.
She is calling for patience with only one board – Bay of Plenty – close to full implementation, and it has had a 3–4 year start on many of the other boards.
Nurse perceptions have also not been helped in cases when staff levels stay the same despite CCDM data indicating a ward’s base staffing needs to increase to reflect patient demand.
Calculating what a ward or unit’s base staffing should be is done using the CCDM’s “mix and match staffing methodology” that draws on data from TrendCare – an Australian, nurse-developed software package that Skeet says is the only tool available that provides validated patient acuity data.
The fact that the NZNO survey described TrendCare as an example of “a CCDM” system rather than as a software tool required to gather data to implement “the CCDM” system just further brings home the confusion out there.
TrendCare is a dirty word amongst some nurses, but Skeet points out that TrendCare had been around in district health boards for some time before the SSHW unit started developing CCDM.
“TrendCare makes nursing work visible and the data created shows what is actually happening on the ward,” says Skeet.
“At the end of the day, it is just data and it’s the way that data is used for decision-making in the organisation which actually makes the difference.”
That is one area of mixed success because for CCDM to work, DHBs need to use the data created by the mix and match staffing methodology to inform their annual staff budgeting process.
“That’s still not embedded as business as usual within a number of DHBs we are working with.”
Skeet says the most visible CCDM project to date is the variance response management (VRM) system – with its ‘capacity at a glance’ screens showing how busy the hospital is in real time and the ‘traffic light’ system which sees support swing into action when a ward hits ‘orange’ or worst-case scenario ‘red’.
Skeet says the VRM system is supposed to be there as the fallback ‘plan B’ for a district health board. Plan A is for DHBs to use the CCDM’s mix and match tools successfully so that base staffing is at the right level for patient demand the vast majority of the time and variance response or escalation is rarely needed.
A full, independent evaluation is already underway of CCDM with a final report due at the end of the year – shortly before the DHB/NZNO MECA expires in February and negotiations begin for a new agreement and also prior to the current funding contract for SSHW ending in June 2015. Watch this space.
CCDM research: right staffing = happier staff
Staff were happier and care rationing less likely to occur when staffing levels met CCDM criteria during a nursing shift, a research report released last year found.
The SSHW unit study looking at nurse and patient perceptions of care after shifts which were either understaffed or staffed according to the ward’s CCDM “mix and match” staffing methodology.
Six wards at two district health boards took part in the study and data was collected from 734 shifts over six weeks – of which only 24 per cent met the full criteria of a “design-met” or appropriately staffed shift.
On the 75% of shifts that failed to meet the good staffing criteria nurses were nearly twice as likely to report care rationing – like not answering patient bells within five minutes or mobilizing patients. They were also less likely to be happy (45%) after the shift then if the shift was staffed appropriately (58%). But patients reported little to no difference in perception of their care.
The study also found that all six wards “consistently fell short” in responding quickly to sudden surges in patient demand. The study reports that these findings, and the SSHW unit’s experience of working with DHBs “suggests that DHBs cannot expect to have a lean staffing base and a lean buffer, and expect to maintain safe production in the face of predictable and significant variance between demand and capacity”. The study also says “further investigation will be required to determine if the recommended staffing design is ‘good enough’ as opposed to simply ‘better than’ shifts that do not meet the design level.”
A shift was regarded as ‘design met’ when:
- Actual nursing hours available were within 10% of nursing hours required by patients
- 80% or more of skill-mix staff were RNs (during day shift)
- At least 75% of staff were from the home ward.
I’m here to help – what can I do?” “Here, have our Smart Fives card”
The traffic light system can see ‘gifted’ nurses arriving to help out for an hour or two a ward in strife to find ward nurses too rushed off their feet to brief them.
So the Smart Fives cards – setting out jobs that can be delegated and quickly done by a borrowed nurse (or health care assistant) – initially developed by Bay of Plenty DHB and adopted by CCDM – are there to allow the briefing to be streamlined and snappy.
On one side the card welcomes the helping nurse, names their ‘buddy’ ward nurse and below has a check list of the ‘top 5’ or ‘5 minute’ activities ticked to show what would be most helpful to the ward at that time. The other side of the card has a map of the ward so visiting staff can find what they need and the key codes used. So visiting nurses might be asked to do the ‘obs’ in one room or – if the nurse is familiar with that service or patient type – may be asked to help their buddy with medication rounds. Skeet says the aim of the cards is to help change the culture of nurses feeling uncomfortable about helping out in a strange ward and how they are accepted when they get there.
SSHW history at a glance
- 2007 Safe Staffing Healthy Workplace Unit set up as joint New Zealand Nurses Organisation/district health board initiative to implement 2006 SSHW inquiry recommendations.
- 2009 Bay of Plenty, West Coast and Counties Manukau DHBs demonstration sites for SSHW Unit’s Care Capacity Demand Management (CCDM) tools.
- 2014 15 out of 20 boards have TrendCare – the patient acuity tool that CCDM is built on – 12 are currently actively implementing CCDM at varying stages and four more are interested.
- 2014 Those DHBs that don’t have TrendCare are Capital & Coast (under discussion), Counties-Manukau, Waikato, Lakes and Canterbury.
CCDM three core components
- Mix and Match Staffing (i.e. using ward patient acuity data to match FTE base staffing with patient demand patterns)
- Variance Response Management (i.e. capacity at a glance screen (CAG), ‘traffic light’ system to alert when ward is in need and systems of how to respond)
- Core data set