Day 1 - 2019 CNO Summit

1. Safe Staffing and Productivity
through use of technology and
professional judgement – achieving
the balance
Mike Wright
Executive Chief Nurse

2. Who are we? Where are we?
•Hull Royal Infirmary
•Castle Hill Hospital
•£540m; 9,000
employees
•3,000 RN/M’s
•54 wards – 1,200 beds
•1,000 square miles
•Tertiary centre, major
trauma centre

3. Sentinel events – Safe Staffing
• Feb 2013 - Francis Report published
• July 2013 - Keogh reviews (13 hospitals)
• 2014 National Quality Board and NICE guidance issued (refreshed 2016)
• CQC Reg. 18 Safe Staffing
• Trusts reviewed their nursing and midwifery staffing levels – this led to a
sudden and increased demand, that has outstripped supply since
• Trust Boards, via chief nurses, required to assure each time they meet in
public that N&M staffing levels are safe and appropriate
• September 2016 – Lord Carter’s review – unwarranted variation – Model
Hospital & CHPPD
• 2016 – Wales – legal safe staffing limits
• 2018 – NHSI - Developing Workforce Safeguards

4. The Challenges for a Chief Nurse
•How do I know?:
–all wards are staffed safely?
–that patients are getting the right care?
–that nurses and midwives are practising safely?
–that student nurses are supported/supervised properly
–that the N&M workforce resource is being deployed
effectively?
–that I can be assured and then provide assurance to others
(Trust Board, Regulators, Commissioners)

5. Our story at HUTH
• Started at HEY with ‘Bank Staff’ – 14 years ago
• 2012 - rolled out Healthroster – 54 wards in 12 months
• Gradually enrolled theatres, OPD, AHP’s – now implementing
with medical staff
• Originally printed hard copy rotas – the e-roster was just the
‘recording mechanism’
• Lots of corrections before electronic rotas were locked down,
mostly retrospectively
• Gradual link to payroll
• Now fully live e-roster (with supporting bereavement
counselling for ward sisters!)

6. Continued….
• Before SafeCare – we developed our own in-house ‘safety brief’
• Intention to look at safety/quality risks (less about staffing numbers)
• Grouped wards into ‘zones’
• Ward staff completed their staffing data (planned versus actual),
along with patient acuity data
• Lots of manual inputting/chasing data input
• However, started to give views at individual ward, zonal and
corporate levels
• Safety briefs three times a day – led by a health group nurse director

8. Ward Zones
Beds Beds Beds Beds
19 16 22 27
Shift Shift Shift Shift
Early 3 3 3 3 Early 3 3 2 3 Early 4 4 3 2 Early 4 3 4 2
Late 2 2 3 2 Late 2 2 2 2 Late 3 3 2 2 Late 3 3 4 2
Night 2 1 3 1 Night 2 1 2 1 Night 2 2 2 2 Night 2 2 2 1
Acuity
0
Acuity
1a
Acuity
1b
Acuity
2
Acuity
3
Acuity
0
Acuity
1a
Acuity
1b
Acuity
2
Acuity
3
Acuity
0
Acuity
1a
Acuity
1b
Acuity
2
Acuity
3
Acuity
0
Acuity
1a
Acuity
1b
Acuity
2
Acuity
3
8 0 8 0 0 0 0 16 0 0 11 1 8 0 0 7 1 18 0 0
DNAR
REVIEW
COMPL.
LD DNAR
REVIEW
COMPL.
LD DNAR
REVIEW
COMPL.
LD DNAR
REVIEW
COMPL.
LD
9 YES 0 2 YES 0 12 YES 0 12 YES 0
FALLS
HIGH
RISK
SsKIN
RED
TRAY
I.C. FALLS
HIGH
RISK
SsKIN
RED
TRAY
I.C. FALLS
HIGH
RISK
SsKIN
RED
TRAY
I.C. FALLS
HIGH
RISK
SsKIN
RED
TRAY
I.C.
0 6 10 5 5 0 6 5 3 1 0 17 8 1 0 0 10 8 1 2
SAFE
GUARD
1:1
Self-
Meds
Security
Watch
REVIEW
COMPL.
SAFE
GUARD
1:1
Self-
Meds
Security
Watch
REVIEW
COMPL.
SAFE
GUARD
1:1
Self-
Meds
Security
Watch
REVIEW
COMPL.
SAFE
GUARD
1:1
Self-
Meds
Security
Watch
REVIEW
COMPL.
0 0 2 1 YES 0 0 0 0 0 0 0 0 0 0 0 0
Beds Beds Beds
22 28 134
Shift Shift Shift
Early 6 2 3 2 Early 8 2 5 2 Early 28 17 20 14
Late 6 2 2 2 Late 8 2 4 2 Late 24 14 17 12
Night 4 1 2 1 Night 6 1 3 1 Night 18 8 14 7
2 DCC: 3
Acuity
0
Acuity
1a
Acuity
1b
Acuity
2
Acuity
3
Acuity
0
Acuity
1a
Acuity
1b
Acuity
2
Acuity
3
Acuity
0
Acuity
1a
Acuity
1b
Acuity
2
Acuity
3
9 0 13 0 0 4 6 11 0 0 39 8 74 0 0
DNAR
REVIEW
COMPL.
LD DNAR
REVIEW
COMPL.
LD DNAR
DNAR
Review
LD
8 YES 0 0 43 0 0
FALLS
HIGH
RISK
SsKIN
RED
TRAY
I.C. FALLS
HIGH
RISK
SsKIN
RED
TRAY
I.C. FALLS
HIGH
RISK
SsKIN
RED
TRAY
I.C.
0 5 7 1 0 0 6 7 1 0 50 45 11 9
SAFE
GUARD
1:1
Self-
Meds
Security
Watch
REVIEW
COMPL.
SAFE
GUARD
1:1
Self-
Meds
Security
Watch
REVIEW
COMPL.
SAFE
GUARD
1:1
Self-
Meds
Security
Watch
NO
Review
0 0 2 0 0 0 6 0 0 0 10 1 0
ROTA TOOL
16
C20
Patients Patients
AMBER
Ward Sister:
Staffing
16GREEN
L.D.PASSPORT
PRESENT
L.D.PASSPORT
PRESENT
Ward Sister: SupervisoryWard Sister:
GREEN
ROTA TOOL
Patients Staffing
C30
Patients
20 GREEN
RN + ANROTA TOOL
In-Numbers
RN + AN
L.D.PASSPORT
PRESENT
Staffing
RN + AN
Staffing
C31
26
L.D.PASSPORT
PRESENT
Ward Sister: Supervisory
RN + AN
Staffing
C29
RN + AN ROTA TOOL
RN + AN
In-Numbers
AMBER AMBER
C32
0
ZONE 6 SUMMARY
AMBER
PatientsStaffing
RN + AN
21
C33
121
Patients
Ward Sister:
ROTA TOOL
In-Numbers Ward Sister:
ROTA TOOL
Supervisory:
L.D. PASSPORT
TO REVIEW
22
L.D.PASSPORT
PRESENT
L.D.PASSPORT
PRESENT
ROTA TOOL
Patients Staffing
SAVE

9. C19 C21 C22 C26 C28 CDU
AM BER AM BER AM BER AM BER AM BER AM BER
ED AAU H1 H5 H50 H70 ESSU H10 H11 H110 DL
0 GREEN GREEN AM BER RED AM BER GREEN AM BER AM BER RED RED
C8 C9 C10 C11 C14 C15 C27 CICU
AM BER AM BER GREEN AM BER AM BER GREEN AM BER GREEN
H4 H40 H6/60 H7 H9 H90 H100 HICU
0 AM BER GREEN GREEN GREEN GREEN AM BER GREEN
H30 H35 C16 NICU H130 PAU PHDU H34 H31 H33 L&D CM
GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN
C20 C29 C30 C31 C32 C33
GREEN AMBER GREEN GREEN AM BER AM BER
ZONE 5
ZONE 6
ZONE 4
ZONE 1
ZONE 3
STAFFING AT A GLANCE
ZONE 2

10. Issues
• Gave me great oversight across a large organisation
• ‘at a glance’ data but lots of manual data inputting
required
• However, not ‘live’
• Issues with some wards not declaring all available staff
(fear of being moved) – not transparent/validated
• Issues with Safer Nursing Care Tool gradings; especially
levels 1a and 1b
• The more junior the grade of nurse, the more likely to
over-rate the SNCT level and quality risks

11. SafeCare
• Along came SafeCare (yay!)
• However, in order to make this work – needed to be fully live e-roster,
otherwise information could not be relied upon fully
• Got lots of resistance initially to live e-roster from ward sisters/charge
nurses
• ‘Struck a deal’ with them:
–No longer any manual safety brief (only SNCT updates)
–We will run the safety brief – fed automatically from the e-roster
–We can only understand that your ward has a shortfall and help you if
your e-roster is up to date
–If it’s not up to date we can’t help you
–Allows me to look at skills matches/deficits
• But, staffing numbers are only part of the equation….

12. Why context is important – Example
• Scenario 1:
• 4 x RN’s due on duty
• 4 x RN’s arrive on duty
• Planned v. actual = 100%
• However, only one RN over 1 yr. qualified
• Scenario 2:
• 4 x RN’s due on duty
• Only three turn up!
• Planned v. actual – 75%
• B7 (20 yrs), B6 (15 yrs), B5 (5yrs)
• Which team would you like looking after you?

13. Another example from the ‘Model Hospital’

14. Model Hospital ‘differences’
• The difference between HUTH and the Trust at the top of the
chart is 4 CHPPD
• Extrapolated across a 30 bedded ward = 120 extra hours of
carer per day
• That equals 10 extra 12 hour shifts worth of carer per day (7
day period) over and above what we have at HUTH
• How can this be true?
• Not comparing apples with apples!
• Problem is that numbers ‘trigger on lists’ with regulators
• I’d be more interested in the Trusts with the higher CHPPD to
understand how this is being calculated

15. So, where are we today?
• Safety Brief 6 times a day (7 days per week)
• Good evidence base for decision making/audit trail
• Board Safer Staffing report to every meeting in public
• Review all rota performance metrics monthly with nurse
directors and senior matrons
• Review establishments twice yearly – meeting NQB standards
but we use:
–Healthroster data
–Insights/SafeCare
–Budget performance, use of variable pay
–Model Hospital data
–Shift patterns & overlap
–New roles – e.g. patient discharge assistants
–What’s in and not in the CHPPD calculation
–Overarching Professional Judgement

16. Perceptions
Model
Hospital /
CHPPD
Fundamental
Standards
(EoC)
E-Rota / Safe
Care /
Technology
HR Metrics
Information
Validation
Insights
Budget
Performance
Quality Data
PROFESSIONAL
JUDGEMENT
(you need all of
these things to
make a judgement)

19. Model Hospital

20. Temporary Staffing Approvals Unavailability
Additional Duties Unfilled Duties Hours Balances
Key Roster metrics - Insights

25. How to make sense of all of this –
developed a summary risk rating that covers it all
Risk Rating Description
LOW No staffing related quality concerns
MEDIUM This could mean:
 Although not triggering on quality issues, nursing staff vacancies
are thought to be affecting/possibly affecting the quality of care
being provided.
 Ward is under review/watchful observation by the nurse director
and senior matron.
 Potential risks as a result of high bank/agency usage
HIGH Serious quality concerns where there are evident links to staffing levels

26. An example of how this is used (Board Report)
Ward Professional
Risk
Assessment
Rationale for risk rating Actions
C7 LOW Not triggering any quality indicators and no
staffing issues so deemed to be safely
staffed
C29 LOW Not triggering any quality indicators and
although supporting DME with a RN,
deemed to be safely staffed
C30 LOW Despite 24.8% RN vacancies not triggering
any quality indicators therefore deemed to
be safely staffed
C31 MEDIUM This ward has 29.3% RN vacancies & 6.6%
ML. Actions taken have mitigated the risk &
no quality indicators are triggering currently;
this continues to be closely monitored
Utilising bank and agency, support
from other inpatient wards, 5 beds
currently closed.
C32 MEDIUM This ward has 4.7% RN vacancies & 5.6%
ML; no quality indicators are triggering
Utilising bank and agency, support
from other inpatient wards
C33 MEDIUM This ward has 18.4% RN vacancies & high
ML at 22.9%; the actions taken are
supporting the ward and no quality
indicators are triggering; this continues to be
closely monitored
Utilising bank and agency, support
from other inpatient wards and have
over recruited to non-registered posts
to support

27. Summary
• Need a combination of factors in order to gain full assurance – this is not
just a numbers game – context is essential
• It requires technology, management reports – all overlaid with professional
judgement/oversight/leadership in order to be able to conclude and
manage effectively
• Need to translate this into an overall summary professional view
• Need constantly to check the quality of data and challenge assumptions
• Without the suite of information and technology available to me, I would
not be able to do this!
• It’s about professional conscience and exercising professional accountability
• Continuous journey – the new Developing workforce safeguards will
develop this thinking further across all staff groups
• We have become safer and more productive through a balance of
technology, analysis and professional judgement!

28. Thank You
Any Questions?
Contact: Mikewright411@icloud.com
Mobile: 077 400 85388

29. Rostering for good
Rupert Clarke

30. Content
• Agile Rostering - What on earth?!
• Staffing Pools – Don’t jump in at the deep end
• ‘Flexible’ Rostering – Predictable vs Flexible
• Rostering for ‘new’ staff groups – To AHP or to AHP that is the question..
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31. What is Agile Rostering?
Agile - Definition
1 : marked by ready ability to move with quick easy grace
2 : having a quick resourceful and adaptable character
Agile - Synonyms
featly, feline, graceful, gracile, light, light-footed (also light-foot), lightsome, lissome (also lissom), lithe,
lithesome, nimble, spry
Agile - Antonyms
awkward, clumsy, gawky, graceless, klutzy, lumbering, ungainly, ungraceful
Examples of agile in a Sentence
Leopards are very fast and agile.
the expressive movements of agile ballet dancers
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32. Meet Bob – Bob is not agile rostering!
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32
Little or No contact
with clinical teams –
No patient contact
Produces reports on
a monthly basis – is
always told why data
is wrong!
Always correcting
errors after
finalisation – often
having to deal with
unhappy staff!
Retrospectivechasing
rosterapproval
deadlinesisanever
endingtask
Bob and the system
could do so much
more!!!
Oftenisaskedto
balancenethours
accountsbymatching
thewarddiary
Has never seen blue skies on roster analyser
No engagement with site
team or representation at
daily staffing meeting –
What's a COO?!
Not much meaningful contact with end
users – No understanding of there need

33. What is agile?
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Direct contact with
clinical teams to
understand the
challenges and align the
system to meet them
Information is shared
in multiple streams
and always available
to the right people at
the right time
Finalisation is
normally accurate
and changes could
not have been
avoided.
Allrosterdeadlines
aremetaspartof
customand
practice
Bob is happier and so
are his team!
Alldiarieshavebeen
burntandthesystemis
seenasthesingle
sourceoftruthand
trustedbythe
managersandstaff.
50 shades of blue...
Roster system is a core
operational system used by
site management, on-call and
operational manager to
support delivery
eRoster user stories drive the values
that underpin the change programs for
the whole organisation

34. In Bob’s World..
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35. An Agile World
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36. Employee Life-Cycle (ELC) and Digital Employee Life-Cycle (DELC)
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38. Flexible Staffing Pools
Well established as enhanced nursing care teams, the concept of
flexible staffing pools is not new. The successes of these teams is
variable, with some delivering better patient outcomes along with
substantially reduced temporary staffing spend. Other never really
getting of the ground.
Flexible working pools have some critical factors that constant with
all flexible models:
• Senior clinical sponsorship
• Patient centred
• Requirement based on evidencable patient need
• Underpinned by good process
• Continually reviewed
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39. Key Considerations
• Clinical model – Is there a subset of patients that would benefit from this type of care for your
organisation;
- Dementia and delirium
- alcohol/drug dependency
- sickle cell
- child and adolescent mental health.
• Time requirements - can you model care need on daily, weekly or seasonal patterns. This allows
capacity to map to demand.
• Workforce factors – What people factors need to be consider as part of the model, required skills,
progression, leaderships and administrative support.
• Shift patterns - Patterns that maximise patient care and minimise staff burn out. E.g. Long day and
nights coverage broken into 4 x 3 hour shifts providing patients and staff with variability.
• Tech support – Use the ME App to allocate staff as care requirement flex providing really agile
approach to care. ‘I can the App on the way to work so I know where I am starting my day’
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40. What is Flexible Rostering?
Flexible - Definition
1 : the ability to change or be changed easily according to the situation
2 : willingness to change or compromise
Flexible - Synonyms
elasticity, stretch, stretchiness, whippiness, springiness, spring, resilience, give, bounce, bounciness
Flexible - Antonyms
Fixed, stubborn, obstinate, obdurate, intractable, intransigent, unbending, immovable, inexorable, unadaptable,
unaccommodating
Examples of flexible in a Sentence
I enjoyed the flexibility of the schedule
the government has shown flexibility in applying its policy
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41. Flexible vs Predictable
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41
• Do we mean flexible or predictable?
• What are the characteristics of each?
• What does this mean for the organisation, the
service, the individual and the team?
• How can we be fair in the way we
approach this?
• Can our IT systems accommodate this
approach?
• Is it really one or the other?

42. ‘Flexible’ options available
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Part-time Working
Contracted to work less than the full-time hours for the post on a permanent basis.
Temporarily Reduced Working Hours
An arrangement which enables employees to work reduced hours for a specified period of time to deal with “special circumstances”. This could include a family or
personal emergency, or to undertake a particular course or training or development
Job Share
Two (or more) people undertaking one role on a shared basis. Contracts are inter-dependent
Flexitime
Where the arrival / departure time varies form day to day with core hours specified
Staggered Working Hours
Employees are able to determine their weekly working pattern with specified arrival and departure times on a planned weekly basis. Hours may be staggered on a
permanent or temporary basis throughout the week or just one or two days a week.
Compressed Hours
Compressed working hours allows people to work their total number of agreed hours over a shorter number of working days. For example, you may work full-time hours
but over a period of four days a week instead of the usual five – or nine days in a fortnight
Annual Hours
A contract in which the hours of work are spread unevenly through the year, with fewer hours worked at certain times, for example during the school holiday period
Term Time Only
Employees remain on a permanent contract, either full or part-time, but have leave of absence during the school holidays. School holidays total about 13 weeks in a year
and are much longer than the normal annual leave allowances. Having taken the full annual leave entitlement during school holidays, there remains a potential for extra
weeks unpaid leave to cover all the remaining school holidays
Working from Home
Where an employee meets their contractual obligations working from home on an occasional or temporary basis.

43. Flexibility – Key Considerations
• Involved planning – Create inclusive planning processes
- High request levels/Self-rostering
- Co-defined templates during establishment review
- Rota pattern consultation
- Team Job planning
- Fixed patterns for rostering
• Technological Enablement - Use technology to enable process
- ‘Self-Rostering’ or technology enabled requesting
- Annual leave and study communication
- Training and skills and self ownership
- Commination and sharing, automated
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44. New Groups
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Technical configuration,
operational workshops,
the transfer of
knowledge and skills to
enable you to establish
a solid foundation for
your continued
implementation
Working with you to
ensure that you are in
the best position to
maximise the impact of
your Allocate products
Supporting you to
continue your
implementation and
embed best practice in
the organisation
Using Roster
information to improve
service delivery across
all units and to deliver
continuous
improvement for your
organisation

45. New Nursing and AHP Grade Structure
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Registered
Nurses
RN
Band 7 RN
Band 6 RN
Band 5 RN
Nursing
Associates
NA
Band 4 NA
Unregistered
Nurses
AP
Band 4 AP Band 3 HCA
Band 2 HCA
Grade Type
Category
Registration
CategoryRegistered Unregistered
NA
registered
HCA Grade Type
AHP
Registered AHP
Non registered
AHP
TNA
Non registered
AHP
Pharmacist
Peer Support
Worker
Physiotherapist
Dietition
Occupational
Therapist
Physiotherapy
Asst
Diatetic Asst
Occupational
Therapy Asst

46. How to progress through the NHS Improvement Levels of
Attainment
Background to e-rostering
Lord Carter’s reports into operational productivity in acute (2016)
and mental health and community services (2018) highlighted
unwarranted variation in the use of e-rostering systems
In August 2018 NHS Improvement updated the guidance for
Nursing and Midwifery e-rostering for use across all sectors, with
the aim of enabling trusts to achieve the Carter recommendations
by easily identifying areas of improvement in e-rostering practice
To understand the level of use of e-rostering software and software
suppliers, NHS Improvement conducted a National Workforce
Deployment Software Survey in July 2018 across all sectors and
clinical workforce groups

47. In response to the National Workforce Deployment Software Survey
NHS Improvement reviewed the Levels of Attainment adding
Meaningful Use Standards and published them in November 2018
The results of the above survey highlighted that 59% of the clinical
workforce is deployed via an e-rostering system
Highlights the interdependency with e-job planning levels of
attainment
The expectation is that all clinical workforce groups will ultimately use
an e-rostering system and these standards have been developed for
use across all sectors and clinical workforce staff groups (Long Term
Plan 2021)

48. • Aim of the document is to support NHS Trusts in implementing and using e-rostering
software to its full potential
• NHS Improvement set out five levels of attainment underpinned by meaningful use
standards
• These levels enable trusts to benchmark their progress during the adoption of e-
rostering software
• These set out the processes and systems that need to be in place for trusts to meet
the respective level of attainment
• By adopting these standards, NHS Trusts will have the assurance that they have
implemented the systems and processes related to e-rostering necessary to achieve
their productivity and efficiency gains and have met the highest level of e-rostering
attainment whilst optimising the clinical workforce capacity to demand