West Middlesex University Hospital

Nurses are notoriously suspicious of e-rostering systems, largely due to the perceived complexity of the workforce and the workload and the unpredictable nature of the job. There is an historic, emotive element in the manual development of a roster that is missing in e-rostering. Skill mix and experience are important to fulfill the needs of the service and ensure patient safety. The roster is routinely and frequently adjusted, sometimes several times a day, when service needs based on patient characteristics or nursing availability changes. Historical establishments used in a ward tend to remain unresponsive to the needs for efficient and altered staffing necessitated by advances of technology, the variability of census and admission, discharge and transfer (ADT) activity, also changes in the complexity of patients admitted to hospital.

In January 2005 the decision to introduce the CareWare nurse rostering system to West Middlesex University Hospital was taken. The Trust selected Care Systems to develop an electronic system which would combine rostering, patient acuity / dependency and temporary staffing solutions
to meet patient need. The objective was to ensure accurate and timely deployment of nursing and midwifery resources across the Trust, the three elements, tightly integrated to produce a unique system.

The troubled and lengthy introduction of the rostering software was largely due to the lack of project management resource at the Trust, now recognized to be essential for all large scale information technology projects. Although specialist and complex areas including maternity and theaters are not utilizing the system fully and are under current review, other areas now automate the creation and management of rosters. Imperative to success has been the need for each area to use standardized roster rules and to individualize the planned elements of ward life for their patient group.

The next critical step is to create real time links of the information to ADT and other departmental and clinical systems via HL-7 interfaces that drive the workload systems from each patient event. Once this next step has been taken it will require a concerted and consistent approach to real time
management of the roster by ward managers to ensure accuracy.

In 2006/7 improved roster management contributed, with other necessary and related leadership and staff management initiatives, to a saving of £720,000 on nursing budgets. The reports generated by the system are used by finance and HR, as well as managers, to act on trends in sick leave, monitor the working time directive and annual leave, also to allocate study leave with equity. The reports on sickness management are used to challenge behaviours and spot trends in unplanned leave – the Trust sickness level in 08/09 to September 08 is 3.03 per cent, a figure which represents the second best average in London and 12th best nationally.

West Middlesex University Hospital is one of two acute Trusts in the UK to collaborate with Care Systems, who was then working in partnership with Dr Keith Hurst, a leading researcher working with the Department of Health in many acuity and workload studies, to develop an electronic acuity / dependency system, called AWES (Acuity workload Estimation System). Combined with patient census, Acuity / Dependency determines the need for nursing care in hours by band, allowing the calculation of the headcount of nurses on each shift. A simple assessment of the patient is made – a seven point checklist of patient care needs is recorded on the system daily, calculating the combined needs of the patients in each care setting.

Following the introduction of the system, it was recognized that to truly reflect the changing workload within an area, ADT activities were required to be part of the calculations. The recent upgrade of our initial system to a new event-driven workload estimation system, CareWorks, has provided
the ability to use real time data elements.

The development of a new range of reports will provide valuable trend data for each area. In addition the new reporting system will provide daily, weekly or monthly information which will allow deployment of staff across the site, based on nurse assessed workload rather than emotions, and thus allow for data informed reviews of establishment levels.

With the future introduction of a functioning ESR link, and a mapping of the nursing processes that underlie activity based costing, the possibility of costing nursing care to patient groups or individual patients will be open. Initial data collected by CareWorks, has provided the basis of trend analysis (figure below) which shows that medical workload is seasonal and increasing, care of elderly is increasing, surgery is stable but variable
and pediatrics is stable but seasonal – all of which is consistent with nursing opinion.

The final piece of the puzzle has been the introduction of an in-house nurse bank and a related implementation of CareBank, the integrated bank management system. The drivers for this change were not solely financial, we also needed to ensure that our permanent Trust employees, who are the major part of the temporary staffing pool, were working to the working time directive and that fraud was not taking place. The initiative that allows the requesting of staff following the posting of a duty rota, with attention to the skill mix required, has shown a 20 per cent increase in the number of shifts filled, with positive affects on staff morale and patient safety.

In summary, West Middlesex University Hospital provided an active and significant contribution to the development by Care Systems of a tightly integrated triple system – rostering; patient dependency and workload management; and a temporary staffing (i.e bank) management system.
Together this forms a powerful tool; unique in the UK. A real time Dashboard will be available, and a flexible reporting tool is being developed also, which, together provides data useful for actions at Board to ward level – and on a daily basis or to determine future nursing establishments.

The cost-efficient use of nursing and midwifery resources is key in all healthcare settings from the financial perspective, however patient safety and experience is key to many of the qualitative performance indicators and, importantly, to the patients.