The Trust serves a GP practice population of over 703,000 patients within the locality of focus, the East locality. The organisation provides more than 70 services and is forecasting a 26.7% growth in the over 65 population by 2021.
Four local Clinical Commissioning Groups (CCGs) have contracted the Community Nursing Short Term Conditions (STC) and Nursing Long Term Conditions (LTC) to deliver community nursing services including district nursing, therapies and specialist nursing. Contract revenue for 2017-18 is through block contracts which include key deliverables, providing additional revenue payment in exchange for further service development.
Following on from a successful programme of work within the neighbouring West locality, the Trust commissioned Meridian to complete an initial study to identify the potential areas of improvement to resource utilisation and capacity management within this locality.
The initial analysis consisted of a three-week long study within East locality Community Nursing ending in October 2017 which identified the following;
- Clinicians across the service were on average working at or above their target for patient contacts per worked day according to analysis of the clinical IT system (CIS) and eRoster.
- There was unwarranted variation in use of CIS system functionality to track and record the allocation of caseload.
- The current management system provided a suite of reports on forecast capacity and completed activity which were not seen as informative, did not cross reference multiple data sources and were not routinely used to inform management decisions.
- Personal targets and expectations of what represented a fair day’s work were consistent across the localities and within teams. However, these were not linked in any way to CCG contractual targets.
- There was a lack of understanding around the impact of telephone contacts and what should be recorded as contractual activity.
- The process of allocating work varied between clusters and in many teams leading to avoidable duplication and unnecessary re-work.
The analysis highlighted the difference in customs and working practices between East and West localities within the Trust, identified widespread levels of high productivity and underlined the limited visibility and informed proactive management of capacity within the teams. As a result, the organisation commissioned a 12-week Improvement Programme.
The overall goals of the project were to;
- Install and further refine the management controls developed during the original West locality programme in both LTC and STC teams
- Undertake a Training Needs Analysis for CIS and work with organisational leads to develop a refined SOP for CIS Utilisation to ensure accurate and timely completion of clinical records of care and complete data capture for contractual revenue purposes.
- Work with the Performance & Business Intelligence Team to develop an integrated Performance Reporting Dashboard for community nursing services
- Undertake a Training Needs Analysis for HealthRoster to refine, agree and implement guidance and rules associated with correct use of HealthRoster including assignment of clinical time, training and absence to ensure accurate data feed for the dashboard.
Meridian worked across 19 Locality Teams within LTC Services and 12 Locality Teams within STC Services. This involved approximately 350 WTE managerial, clinical, therapist and administrative staff.
Working in partnership with colleagues from the West, best practice input and management ownership was facilitated through a series of executive level meetings, weekly senior management seminars, management training workshops and one-to-one coaching and follow-up sessions. The management control system was installed and further refined to incorporate best practice and allow for local variations in clinician role. This approach supported the implementation of new ways of working to 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 effectively manage capacity across the teams and ensure the consistent allocation of a fair day’s work, improving staff wellbeing and minimising unwarranted variation.
The changes included the following activities;
- Working with Learning and Development to develop a Flexibility and Skills Matrix, setting out the expected competencies per post.
- Identification of widespread underreporting of telephone activity as a patient contact; training workshops and crib sheets used to address this.
- Revised and distributed SOPs to reinforce the correct use of the clinical IT system to ensure consistent, accurate activity capture and identify training needs to improve quality.
- Configured and installed the weekly reporting suite to provide managers with greater insight into data being captured in Health Roster.
- Implemented weekly “Productivity Huddles” to appraise individual/team/locality 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 locality to promote achievement of the CCG contracts.
- Agreed and implemented HealthRoster KPIs to improve rostering accuracy and drive proactive management of annual leave and training.
The refined HealthRoster and CIS Utilisation SOPs implemented during the programme standardise the activity and recording of the teams. When combined with the installed management controls, the directorate has pan East and West locality visibility on a daily and weekly basis of individual team and locality performance. This also provides a more transparent and robust approach to allocation of clinical caseload to meet the existing CCG contracts and maintains an equitable distribution of workload.
Collaboration with the Trust’s Performance & Business Intelligence Team and IT system providers has explored the specifics behind creating an automated dashboard which draws upon live system feeds. A template has been created and work is underway to configure the automatic system feeds to populate the dashboard.
The implementation of weekly 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 localities to inform more effective management decision making to achieve the Trust’s goal.
The directorate has been keen to standardise working practices across the East and West localities and ensure best practice is shared. As a result, all Standard Operating Procedures produced during the project have been disseminated pan East and West localities and nominated West locality representatives have cascaded updates