The client Community Services Organisation (CSO) was created on 1st March 2008 and operates as a separate business unit within the PCT and was working towards Foundation Trust status. The CSO serves 600,000 people where it is responsible for improving the health and well being of its local population. The CSO employed over 2500 staff with a budget of over £140 million. The CSO provides an Out of Hours GP service, Adult services, Children/Young people’s Services, Community Hospitals, Healthy Lifestyles, Sexual Health and Family Planning.
Although the CSO had recently completed a LEAN project, the community nursing services still lacked the robust reporting tools, systems and processes that would give the managers the necessary information with regard to productivity, demand and capacity planning. No information was readily available on a weekly, fortnightly or monthly basis to inform managers of the activity completed in each work stream. It was felt that the work completed by the LEAN change agents would dovetail with the proposed Meridian project. However, it was widely agreed that with the absence of this management information the CSO was unable to evaluate where and how improvements could be made and how to proactively improve the reference costs and the utilisation of resources.
By completing a three week analysis of the current systems, processes and training within the four work streams, Meridian’s productivity specialists were able to identify problems and solutions within the CSO that could provide the necessary information with regards to reporting on productivity, capacity planning modelling which would provide a cost effective service.
Community Nursing – All Work Streams
During the analysis phase Meridian staff, while working with the client’s staff, conducted a number of observations .
The results for each service are as follows:
- District Nurses: 32% Direct Face to Face Contact + 17% Travel.
- Occupational Therapy: 32% Direct Face to Face Contact + 24% Travel.
- Intermediate Care: 31% Direct Face to Face Contact + 16% Travel.
- Health Visiting: 30% Direct Face to Face Contact + 11% Travel.
There was very limited historical data available; nevertheless, Meridian staff collated statistical data for the calculated activity over the 2007/08 financial year which demonstrated the calculated reference cost per visit for each work stream:
- District Nursing £24.59 Occupational Therapy £37.91
- Intermediate Care £40.50 Health Visiting £52.01
Total contacts for each area were calculated at:
- District Nurses 285,485
- Occupational Therapy 40,039
- Intermediate Care 126,111
- Health Visiting 60,877
Total contacts all areas were 512,512.
Project Objectives and Elements.
- Community Nursing Four Work Streams.
- Develop, agree and implement capacity planning tools and resource planning tools.
- Increase utilisation of resources.
- Reduce reference costs by visit.
- Provide new system training through a workshop environment.
- Develop and agree project governance.
- Deliver management workshop training to improve management behaviours
Working with the Senior Management and the purposely created Business Change Teams, Meridian Productivity staff were able to develop, agree and assist in implementing the following face to face targets for each work stream:
- District Nursing 70% Including Clinical Travel
- Occupational Therapy 65% Including Clinical Travel
- Intermediate Care 60% Including Clinical Travel
- Health Visiting 65% Including Clinical Travel.
During the four project phases, Meridian staff worked closely with the CSO staff operating at the point of execution to develop, agree, implement and perpetuate a reporting tool which measured, on a weekly basis, the direct and indirect activity achieved by each individual and team within. each work stream.
The reporting tool gave each manager timely information on a weekly basis upon which to act within their weekly review meetings. Planning norms were developed from the reporting tool data and the norms are used by the managers in planning and allocating the work from the case load.
Once the reporting tool was installed the CSO senior management team and Meridian staff agreed time scales to collect data in order to populate the capacity planning tool. The capacity planning tool was also developed, agreed and signed off by all relevant staff within the Business Change Teams.
Once the capacity planning tool was implemented, an accurate staffing model was developed by team and band which was aligned to the demand for the service. Work then began to restructure the team sizes and bands within each team to meet that demand. Furthermore, at the beginning of the project a vacancy management process was agreed and implemented, which gave the project team timely information on where the spare capacity could be realised quickly once the capacity tool was completed.
The output from the capacity planning tool indicated that a number of vacant nurse positions were surplus to requirement and it was agreed they would be removed from the budget through natural attrition. New business opportunities that had been sourced could now be staffed without a recruitment exercise. Consequently, this had the effect of increasing productivity and decreasing the cost per visit for each work stream. Projected annual visits across all four services have increased by 122% of 2007/08 calculated figures. Bank and agency cost were reduced from the 1st April – 31 August 2007/08 figure of £139,753 to 1st April – 31st August 2008/09 to £112,932, a total reduction of £26,820. Similar ongoing improvements would continue to be measured through the project review team which remained in place when Meridian’s full time work with the Trust ended.
In Occupational Therapy, the overall number of people waiting for a ‘priority two’ assessment visit reduced from 470 to 303. The waiting time for people in one of the counties for priority two visits reduced from 62 weeks to 24 weeks and the waiting time for people in the same county for a priority three visit reduced from 72 weeks to 30 weeks.
The continuous improvement initiatives instigated mean that each work stream has an ongoing programme of evaluating and implementing strategies to remove barriers to lost productivity. The potential solutions to some of the causes of lost productivity that are being evaluated across all the services are:
- A universal approach to completing patients notes.
- New protocols and procedures for the patient discharge criteria.
- Review of the frequency of patient discharge reviews.
- Review how work is assigned and allocated
- Replicate processes across other teams where certain teams have a good productivity level.
- Planning work load four weeks in advance.
- Installation of case load tracker to manage throughput of open and closed cases.
- Weekly measurement of completion of non-core tasks, i.e. activity for which the services do not get paid.