In November 2016 Meridian were invited to conduct an outline study within the Community Nursing Service of the Shetland Health and Social Care Partnership. This was to include the Non-Doctor Islands service delivery and also that of those practice nurses employed by the HSCP.
Meridian were tasked with an analysis of the above service to look at levels of demand in comparison with current capacity, existing work allocation, follow up, discharge planning and the management control systems currently in use.
At the time of this analysis the management team felt that the pressures amongst the different Shetland teams varied greatly. Staff struggled at times to manage visits across the busier bases as opposed to some of the more rural areas where staff were used as station fill and often had no more than one visit per day to attend to.
The Executive team invited Meridian to conduct an analysis to assist them in understanding how much resource they needed to adequately deliver services whilst remaining within their existing budget and make financial savings where possible.
During the analysis Meridian spent 25 resource days during which time they;
- conducted 10 “Day in the life of” studies with staff
- performed 2 Supervisory studies with clinical team leaders
- observed 65 contacts across live studies
- met with various nursing managers, clinical leads and Executives
Meridian identified a number of improvement opportunities to enable the HSCP to continue to deliver the right quality of care, correct type, duration and frequency of contact, whilst meeting their other operational targets. A clear opportunity existed in the provision of improved controls for managers. There was no clinical recording system in use by the Service.
Meridian proposed an increase in F2F time achieved through;
- Introduction of MCS Concepts
- Clear Service Definitions
- Planning – Norms & Targets
- Assigning – Daily Allocation
- Flexibility – Skills
- Managing Variance – Active Management
- Ensuring correct resources are moved within teams to match the identified need
Meridian projected an opportunity of between 5.6 and 10.9 WTE
In November 2016 Meridian embarked on a 12-week program with the Health Board. The core objectives of the project were to implement consistency of practice across each of the community nursing bases, create an equitable and more robust method of allocating work for the community nursing teams and enable a simplified method of follow up for both the district nurses and their supervisors. In turn, this methodology was designed to improve the productivity of the clinicians within those teams.
In addition, the project sought to assist those working on the non-doctor islands to identify the split of their time between nursing, social care and other activity and to enable a better consistency of practice amongst practice nurses across the board managed GP surgeries.
A programme of workshops delivered at both District nurse and Clinical Team lead levels allowed input by all attendees upon the development and creation of the necessary controls required to meet both the Health Board’s and the project’s objectives.
These sessions allowed participants to challenge their current working practices and processes and develop a system better suited to the desired way of working. This was particularly key, in the design of a clinical recording system, bespoke to the service.
During workshops, time was taken to identify and quantify each discrete activity undertaken with patients, to identify the skills of each clinician to deliver these activities, to understand the skill mix across the teams and to develop and agree activity ‘norms’ and service definitions which were subsequently agreed and implemented.
Each workshop was followed by 1:1 sessions with the participants to reinforce the training. Those unable to attend sessions due to geographical constraints and clinical need were caught up with on a 1:1 basis to ensure everyone had an opportunity to take part.
Follow up sessions helped embed topics covered and ensured service and team managers received direct input from Meridian to help them progress from concepts discussed to their practical applications.
From these workshops and agreements made, Meridian and the team developed a work allocation control to facilitate a fair and equitable distribution of work. Supervisors can allocate a clinician’s day in advance where planned visits existed and thereby see on a daily basis where capacity exists across the teams. These controls also allow district nurses to easily see if work has been completed thereby removing the risk of a patient being missed on a busy day.
From sessions with the clinical supervisors and service manager Meridian developed a management dashboard to permit the data recorded by clinicians to be easily evaluated and allow a view of where each team and the whole service are performing against their targets.
On the non-doctor islands, Meridian developed a control enabling resident nurses to record, when seeing a patient/client, the purpose for which the visit had been initiated. This will enable the Health Board to now separate nursing requirements from other activity.
For practice nurses, Meridian ran a series of workshops to determine working practices of each. Within sessions, Meridian determined individual nurses’ skill sets and types of interventions undertaken within each practice and the slot length allocated for each appointment types. This analysis identified, as expected, significant discrepancies between each of the board practices highlighting the different levels of service which could be expected by members of the public and also the different levels of demand placed upon the nurses according to which practice they worked in. Further analysis was conducted into the volume of appointments delivered.
The programme objectives were achieved. Key achievements were;
- Clear definition of activities and expectations -Skills Flexibility and Norms agreed across service
- Allocation process is embedded, performance against target being measured
- Additional assignments identified and allocated to staff members
The bespoke designed allocation and activity recording system enables the teams to quantify and measure the demand and capacity of the service. This unprecedented level of data is now available to the HSCP to identify excess capacity, and permit informed decisions around service delivery and cost savings.
A particularly important feature of the new system enables spare capacity to be easily identified and can be used to deal with urgent work or where some teams are particularly under pressure.
Service information provided by NHS Shetland identified a surplus of 4.6 WTE (based on 5 months-worth of data capture) within the staff in post across all areas. Vacancies were at 5.2 WTE at project inception.