The Trust covers a GP practice population of over 484,000 patients. The Trust currently has a five-year People Strategy to engage with staff and offer more innovative community based services as part of its work within the Sustainability and Transformation Partnerships.
The local Clinical Commissioning Group have contracted the Community Nursing Long Term Conditions (LTC) Services to deliver community nursing services including district nursing, complex care nursing and Health and Social Care coordination. Contract revenue for 2017-18 is through a cap and collar contract with 50% marginal gain to a maximum of 110% delivery. Payments are made per patient contact with a 21-day flex and freeze period. As LTC Services saw a reduction in posts due to lost revenue in 2016-17, the Trust invited Meridian to complete an initial study to identify the areas of potential improvement to maximise contract attainment in year.
The initial analysis consisted of a three-week long study ending in April 2017 which identified the following;
- The current management system lacked control over forecasting, planning and assigning of activity.
- Targets and expectations regarding what represented a fair day’s work were inconsistent across the clusters and within teams.
- The process of allocating work varied between clusters and in many teams leading to avoidable duplication and unnecessary re-work.
- Clinicians in various teams used different ways of working, making it difficult for managers to compare activity within one team against that of another.
The project sold was a 15-week Improvement Programme.
The overall goals of the project were to;
- Deliver a 10% productivity improvement within community nursing, complex care and health and social care co-ordinators.
- Define and agree the optimal percentage split of clinical vs non-clinical time within a net worked day by individual role/post.
- Introduce the definitions of productivity and the language surrounding it.
- Install ‘ways of working’ which reduce or eliminate duplication and re-work.
- Develop, agree and install a work allocation process to ensure equitable workload for all staff within required productivity levels.
- Develop resource planning and capacity management systems and processes.
Meridian worked across 22 Cluster Teams (approximately 131.53 clinical WTEs) within LTC Services. Best practice input and management ownership of the programme was facilitated through a series of executive level meetings, weekly senior management seminars, management training workshops and one-to-one follow-up sessions. During these sessions a new management control system was developed and installed to support the implementation of new ways of working and ensure effective and efficient running of the service to best meet the needs of the population.
The key focus of the programme was to equip managers with the necessary behaviours, skills and controls to obtain maximum contractual income under the CCG Cap and Collar Contract and achieve a 10% productivity improvement.
The changes included the following activities;
- Developed and agreed working norms and frequencies per clinical and nonclinical activity by role and Agenda for Change band.
- Developed and agreed refined targets for face-to-face and telephone contacts with patients per day by role and Agenda for Change band.
- Calculated the number of available clinical days taking into account training, accrued annual leave, sickness and service development activities to better inform rostering forecasts.
- Revised and distributed Standard Operating Procedures to reinforce the correct use of the clinical IT system to ensure consistent and accurate activity capture. – Configured the weekly reporting suite to provide management with greater insight into the rostering data being captured in Health Roster.
- Implemented scheduled review meetings known as Cluster Productivity Huddles to appraise individual/team/cluster productivity with each management level, using bespoke management variance reports.
- Calculated, agreed and communicated the daily, weekly and monthly patient contact volume (target, plan and actual) by cluster to promote achievement of the CCG Cap and Collar Contract.
The new management controls introduced and implemented during the project gave the directorate greater visibility on a daily and weekly basis of individual team and cluster performance along with a more transparent and robust approach to the allocation of clinical caseload to meet the existing CCG cap and collar contract.
The availability of performance data has been tailored and enhanced to meet the need for effective rostering of available clinical resource to plan the allocation of forecasted work. The advent of weekly senior management Cluster Productivity Huddles underpins the requirement for review and follow up on actual activity recorded via the clinical IT system. A “Target v Plan v Actual” review philosophy has been embedded within the clusters to inform more effective management decision making to achieve the Trust’s goal.
By week 9 of the project, the savings were an annualised efficiency of £292,716 due to increased CCG Contract revenue and reduced pay costs during the month of August.
- A savings realisation of £14,299 in August through reduction in contracted pay cost, Bank and Agency spend.
- Increased achievement under the CCG Cap and Collar Contract, resulting in an increased income of £10,094 in August.
- A consolidated and standardised process of forecasting, planning, assigning and following-up.
Unity in terms of clinical activity targets across each cluster and each team, providing a fair and equitable day’s work.
The directorate has been keen to underpin this improvement programme with a strong quality agenda and so all Standard Operating Procedures produced during the project make reference to the importance of clinical governance, particularly in relation to the accurate and timely completion of records of care.