This midland-based NHS Trust wanted to relieve the strain on its Acute services by discharging patients from hospital beds and moving activity into Community services.
The services under scope included District Nursing, the Community Intermediate Care Team (CICT), Therapy Teams, Foot Health, and Children’s Services.
In the past there has been no knowledge of the capacity or a forecasted demand of each team within the service. The spread of resources is based on historic information, and not on activity levels.
Meridian was invited by the Executive team to conduct an analysis of a number of service lines and looked at the existing capacity, demand, and current management system of each service.
Meridian expended 60 resource days on an analysis in September 2014. The analysis identified the following;
- Support needed in the role out of an allocation tool – Existing allocation tool does not model capacity and demand
- The existing performance target per banding/team is not monitored or managed
- No evidence of a management reporting system
The foundations already existed in terms of quantification of clinical activity required, however resource hours were recorded manually on paper and not used to highlight capacity.
The programme Meridian proposed focused on the productive use of the staff within the service, enabling them to quantify demand and match resources at a clinically safe and efficient level.
It was proposed that working across 5 service lines with Executives, Divisional Managers, Group Area Managers, Locality Managers and Team Leaders, Meridian would undertake a programme to implement significantly improved management systems and behaviours with the aim of increasing the activities per WTE. This proposal was accepted and the project commenced in November 2014.
The Community Service project lasted for 16 weeks and addressed all of the points from the analysis.
The development of the new system elements were achieved through a combination of workshops and weekly one-on-one coaching sessions. This ensured the project was able to complete all of the deliverables within the planned time scale.
Once the current process work flows were validated and critiqued by the staff themselves, Meridian supported the Trust managers in developing the concept of planning to capacity. All of the participating managers were given the opportunity to contribute to the developments of the controls themselves, as well as to the productivity targets contained within them. This ensured realistic goals and buy in from staff in the working environment.
Both District Nursing and CICT services saw the implementation of two tailored allocation control tools. These allocated the appropriate level of work to each staff. It highlighted the face-to-face demands of the patients within the service, and compared this to the capacity available of the resources working that day. This actionable information assisted the Line Managers when making decisions on acceptance of referrals and the capacity for transfer of activities from Acute into their respective service.
The management team were interested in knowing the demand different types of visits have on their service. Examples include the pressures of End of Life contacts and unplanned contacts on different localities. This information was made readily available through the reports installed. This evidenced the different strains on each of the nine district nursing teams.
A management control system element was installed in the services which worked on a clinic setting basis, to assist in planning and assigning clinic bookings. This ensured clinic slots were filled to the desired target, enabling the management team to have an overview over the available capacity and take action to maximise the utilisation of the clinics on daily/weekly basis. The Administrative bookings team are more aware of planning clinic slots to capacity due to now having a full picture of the week in one report.
This new reporting and review process quickly became standard practice for the services. The weekly reports summarising productivity and highlighting unutilised time became integral to the weekly scheduled review meetings. This allowed the management team to move staff according to the demands each locality, increase the average contacts per clinic, and increase the activity within the community teams to reduce the strain on the acute service.
The new allocation process in District Nursing and CICT has put the Team Managers in a position where they can robustly identify if a “full days work” has been allocated to each person within their team. Through allocating to capacity and reducing the time required to plan and allocate work on a daily basis, CICT has been able to release staff to the Emergency Department. This team divert patients to their service directly, therefore reducing the strain on the Acute. Implementing a tool to forecast the hours required to meet the demands of District Nursing and CICT, will also ensure these services are ‘right-sized’.
The overall outcome of the Therapies service weekly report resulted in a reduction in meetings and other non-patient facing activities. This increased the availability of the staff for clinic time, which consequently led to an increase in the average number of clinic contacts across the week.
The increase in activity within District Nursing has earned the Trust cashed savings of ~£113k annualised and ~£744k has been identified as extra hours of DNs for the month. These savings alone equate to 125% of proposed savings. In combination with the decrease in cost per contact in CICT and therapies, the total annualised saving, for the Trust is a much greater figure.
A skills flexibility matrix has also been installed in Foot Health Service and School Nursing. It has been used to plan training sessions and to increase the skill mix within the team to accommodate overflow of clinics, specifically those which are overbooked due to high DNA rates.