Safe staffing? There's an App for that...

Ward to board information

The aim of the project was to develop a transparent assurance mechanism to monitor nurse staffing levels from ward to board. The Trust wanted to engage ward nurses with the new development to ensure that any new tool was user friendly, highlighted the necessary areas of concern, provided a platform for professional judgement to be utilised and incorporated an escalation process.

Nottingham University Hospitals NHS Trust (NUH) is the fourth largest acute trust in England; it provides services to more than 2.5 million residents of Nottingham and its surrounding communities. The trust also provides specialist services to between 3 and 4 million people from neighbouring communities. The Trust is based in the centre of Nottingham across three sites; Queen’s Medical Centre (QMC), Nottingham City Hospital and Ropewalk House. NUH has 87 inpatient wards across both QMC and City campuses. The trust has 14,500 staff of which circa 4400 are RN’s and 1800 are HCA’s.

Safe staffing

Maintaining safe nurse staffing levels is a key priority for all healthcare providers and  a variety of methods exist to monitor achievement of this. Some organisations utilise electronic systems whilst others use manual collation of staffing information.

The ability to provide safe nurse staffing levels has certainly been an ongoing priority at NUH. Historically, senior teams relied on manual collation of nurse staffing levels at key points in the day. Although the data would have been known to a small number of operational staff, this data was not visible to the whole trust and failed to provide information or signal where resource or support might be available from elsewhere across the organisation. Neither did it highlight changes to staffing risks as they occurred.

As a senior nursing team we felt the old staffing  collation system was no longer adequate, and not having visibility of an accurate live staffing position was a risk and challenge we were keen to overcome. We wanted to develop a staffing collation method that supported effective deployment of staffing resource to provide support to areas that required it and informed staff, from ward to board, of live staffing data.

App Development

The Deputy Chief Nurse met with the Senior Nurse Lead in ICT to discuss the scope of a live nurse staffing monitoring system and the key requirements of the new system. It needed:

• To be easy and quick to complete
• To be capable of sending automatic alerts for certain risk variables (skill mix, % temporary staffing, etc)
• To allow the professional judgement of the nurse in charge of the shift, in relation to determining safe staffing levels, to be captured
• To red flag process needed to be incorporated into the system
• To make visible nurse staffing levels form ward to board

We considered purchasing an off-the-shelf package to support our  e-rostering system, but wanted to scope the potential of developing our own system in order to prevent ongoing  costly licence fees. However,  ICT very quickly determined that they could develop an App to meet our needs. We were keen that the staffing app met our requirements as oultined above and captured relevant best practice NICE guidance:

• Planned staffing levels determined via the bi-yearly establishment review  - the app captures planned staffing through review of professional judgement of the nurse in charge (did they assess staffing levels as adequate to deliver care to the high standards they strived to achieve?)
• The app prompts completion of a red flag if the nurse determines the ward staffing inadequate
• The app also captures reasons why staffing was not deemed as adequate, along with the actions taken to mitigate staffing shortfalls - a mechanism to capture the cause and response to variations in nurse staffing requirements

Testing, testing..

At NUH all nursing staff have their own mobile device; we hoped to develop a tool that could be used on that. However, the app was designed to function on either a tablet or IPAD rather than the hand held devices, as the user experience of the app was much better.

The Deputy Chief Nurse and the ICT nursing lead met regularly and made changes to the app; by June 2015,  we were happy we had a version ready to be tested by ward teams. At this point, a number of stroke wards offered to test the app and in turn, offered helpful suggestions to improve the app design. By August 2015 we had a version ready to roll out across the inpatient wards. Prior to rollout the planned staffing for every ward had to be locked into the system and a standard operating procedure was developed and circulated.

A rollout programme was devised and training sessions were made available for staff at ward level. Communication with nursing teams was key pre and during the roll out as the app posed a significant change to how nurse staffing data was captured, delegating  responsibility for providing data to ward level. We used a variety of methods to engage with staff including face to face meetings.

Another challenge was ensuring that wards received an appropriate and timely response if staffing shortfalls were highlighted. A workshop comprising various grades of nursing staff, highlighted that responses varied, and directly related to how useful staff felt the app was. It was evaluated positively for those areas that saw a rapid response and were supported to mitigate staffing shortfalls; where areas  did not get a rapid response to staffing shortfalls, there was  less recognition of the app’s potential.

During the rollout period, the ICT developed the reporting element of the app and made this available on the Trust intranet so that all related reports were able to be seen from ward to board. The reports were designed to be user friendly for those staff that would use them and so are available at ward, directorate, division, site and trust level. The App and the reports have been and will continue to be,  subject to further refinements as we utilise staff feedback.

So how does the App work?

The app has the planned staffing for every shift on each ward. At handover, the nurse in charge inputs actual staffing numbers, including any temporary staff, into the ward mobile device. The app reports fill rate skill mix and immediately flag any issues such as high numbers of bank or agency staff,or poor basic skill mix.

The nurse in charge uses their professional judgement to assesses whether the ward or department is safely staffed. If they determine that staffing is not adequate, the app prompts the completion of a red flag. At NUH we use currently use Datix to report red flags; as a Datix report is generated, the senior nursing leaders for the ward/department receive an electronic alert via their hand held device. The staffing app takes less than 10 seconds to complete.

Any staffing changes during the shift are updated to maintain a live accurate position. The app generates a report that can be viewed at Trust, site, divisional, directorate and ward level, allowing rapid response and action to be taken to remedy the situation. The app is supported by a training package, a standard operating procedure and a red flag escalation process which guide staff to take appropriate action.

The staffing app completion  is monitored daily and will continue to be until the process is embedded across the Trust.

The Trust now has a live staffing position available from ward to board. The wards are able to add commentary to support the professional judgement made in relation to determining if ward staffing felt to be safe or not. The project team found that staff, especially less experienced shift leaders, sometimes found it difficult to assess what safe staffing was with a heavy reliance on whether planned staffing numbers were achieved. The project team and senior nurses found that discussing the rationale for any areas deemed not to have safe staffing levels allowed nurses to share experience and assess staffing requirements against the current patient dependency rather than rely on planned staffing numbers alone. The project team felt this was a crucial learning opportunity as shift leaders needed to recognise both when they may not require planned staffing numbers but also when planned staffing levels were achieved but did not match the acuity/dependency of the current caseload of patients.

Red flags

Completion of 'red flags' was monitored by the Red Flag project group and compared to the staffing app information. There was an increase in red flag completion following the roll out of the app, although this was not surprising as the app specifically informs the nurse in charge to complete a red flag if they report ward staffing as not safe.

The site management team had spent at least 2 hours/site/day collating the staffing data manually and this time was released to focus on hospital flow and effective deployment of staff when needed,

Information relating to red flag data and wards that declare they do not feel staffing levels are adequate are reported monthly to Board members, by the Chief Nurse, at the Quality Assurance Committee meetings.

The benefits

• The staffing app provides live, real time planned and actual staffing levels in relation to staffing numbers, skill mix, bank and agency percentage of staff on duty
• The nurse staffing position is visible to all staff within the Trust from ward to board
• The staffing app information ensures that everyone is aware whether or not the organisation has the right number and skill mix of staff on duty for the patients being cared for.
• Allows staff to be focused where the patient need is greatest supporting the delivery of safe care. A number of areas have seen  a reduction in the cost/hr of temporary staffing costs
• Captures in real time the professional judgement of the nurses responsible for giving care
• Allows staff to raise concerns - using red flags if they have staffing concerns
• We are promoting internal staff deployment as the first response, rather than resorting to booking bank or agency staff, which has the potential to reduce temporary staffing expenditure
• Potential patient harm is closely monitored and the Trust continues to make good progress in reducing harm incidences. We have seen a 25% reduction in falls incidences and a 16% reduction in the number of medication incidents