This is a service that has recently been taken over by a London based Mental Health Trust. It provides health care within the community, outside of Hospitals. The contract was awarded 5 years ago and is due out for tender in late 2015. There may be an option for the trust to renew the contract if they can demonstrate better performance to commissioners.
In the past there has been no knowledge of the demand and the capacity of each team within the service. The spread of resources is based on historic customs, and not on activity levels.
Contract performance is not good. This is a combination of breaching on some waiting list targets and overspending. The trust acknowledges that savings need to be made.
The trust is to re-configure Community Services into 4 locations. District nursing currently sits at 6 locations across 2 districts. Other Clinical Services, which includes Adult and Child Therapies, and Dietetics, all sit at 1 site.
Meridian was invited by the Executive team to conduct an analysis of a number of service lines and specifically asked to look at the existing capacity, demand, and current management system of each service.
Meridian expended 48 resource days on an analysis in August 2014. The analysis identified the following;
- Lack of control over Band and Agency spend.
- A paper-based allocation system that utilises 18 resource hours a day across the District Nursing service line.
- No clear performance target per Banding or Team.
- No evidence of a management reporting system.
- Low compliance with their clinical record database.
The programme Meridian proposed focused on the productive use of the Health Care Professionals (HCP) within the service, enabling them to understand and quantify demand and match resources at a clinically safe and efficient level.
The foundations already exist in terms of clinical activity quantification, and for collating worked resource hours. The programme will bring these to the fore and help managers to utilise them to set and report activity ratios per HCP, team, and service line.
It was proposed that working across 7 service lines with Executives, Directors, Divisional Managers, Team Managers, and Team Leaders, we will undertake a programme to implement significantly improved management systems and behaviours.
This proposal was accepted and the project commenced on Monday the 25th of August 2014.
The Community Service project lasted for 17 weeks and addressed all of the points from the analysis.
Engagement with the management team across 7 service lines occurred through a series of 11 productivity training workshops and weekly one-to-one coaching to deliver the programme. This ensured we were 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, together we began to develop on the concept of planning to capacity and forecasting.
Meridian quickly installed a weekly audit in the District Nursing service line to measure activity being input on the clinical record against the actual activity carried out in the teams. The objective was to improve compliance of the HCPs in recording their clinical work.
Working with the management team, we set and agreed a series of ‘performance targets’ and ‘planning norms’ which would be used to measure the performance of the team on a day to day basis.
A caseload management tool was installed that encompassed an electronic caseload with the ability to plan and allocate work.
- Making allocation a quicker process frees up time for the nurses to carry out more contacts and improve clinical compliance.
- Work is allocated across the team fairly and to capacity.
- Aim to increase utilisation and reduce the need for bank and agency hours.
In addition, the tool allows each District Nursing team to forecast the volume of work they have on a six week rolling basis, and informs on the hours required to deliver that particular service.
This new process was agreed and implemented through the initial workshops and quickly became standard practice for the service. In addition to variance reports, which were reviewed by management in weekly scheduled review meetings, keeping hours in line with workload generated decisions for movement of substantive posts across the teams and reduction in agency and bank hours.
An Operations Dashboard was developed for service lines in other Clinical Services. This included Intermediate Care, Nutrition and Dietetics, Community Physiotherapy for Adults and Child, MSK, and Podiatry. This allowed total transparency within the individual services for the number of visits they have planned and the time that is required to complete the visits. Furthermore it shows the utilisation for each Nurse based on the type of activity they plan and the hours that will be required. It highlights members of staff who have capacity to take on urgent or emergency referrals that some of these services receive on a daily basis.
The new allocation process in District Nursing has continued to systematically remove bank and agency hours for the following day by highlighting where it is not needed. Team Managers are in a position where they can robustly identify if a “full days work” has been allocated to each person within their team. Where there is an excess of hours bank and agency has been removed.
Through allocating to capacity, reducing time required to plan and allocate work on daily basis, the productivity of the District Nursing service has seen an increase of 28% over the course of the project. This is alongside clinical compliance which has improved from 66% to a high of 90% by the end of the programme. Implementing a tool to forecast the hours required to meet the demands of the service, will ensure the service is ‘rightsized’. The total actual value of the financial improvement in District Nursing is £1,180,000 annualised.
The other Clinical Service lines now have the ability to review the plans for the following week, and look at the required hours compared to the hours available. This identified an urgent need to increase the utilisation of staff across these 6 service lines, where there is an identified saving of ~£40,000 per week. The principle suggestion put forward was to move the services from a 5 day working week to a 7 day working week to enhance the service offering.
In addition to increased activity per whole time equivalent, the increase in compliance with the clinical database, and improving the offering to a 7 day service, has not only produced savings for the Trust, but will certainly aid the Trust’s case for renewal of the Community Services contract when presenting to commissioners.