How busy is busy? What does rushed off your feet really mean? How can you tell which ward is on the verge of being so busy that patient care is at risk?

Nurses at Bay of Plenty District Health Board have helped develop a simple electronic tick box tool that instantaneously flags a ward’s ‘busy-ness’ across the whole hospital.

Director of the Safe Staffing Healthy Workplace (SSHW) unit, Jane Lawless, says this is something New Zealand hospitals have never been able to do before.

“Before, people were stuck with the language of ‘we’re busy’, ‘we’re very busy’ or ‘we’re, really, really busy’. That doesn’t have a lot of meaning to people who are trying to adjust resources or respond to problems,” says Lawless.

The Bay of Plenty DHB is a model site for the SSHW unit’s care capacity demand management (CCDM) project (see CCDM sidebar). The DHB developed the electronic tool as part of its nurse-led variance response management (VRM) system.

Julie Robinson, the DHB’s director of nursing, says the tool is a flag that gives a more objective and consistent picture of how busy all its wards actually are.

“You are probably aware that in the past the squeaky wheel got the attention, as opposed to other areas that just got on and worked well as a team and did their best on the day.

“Now, everybody’s information is visible in a more objective way.”

The whole hospital can tell at a glance when a surge is about to hit a stretched Emergency Department or a ward is at risk of having too

few nurses for too many complex patients. This allows managers a chance to intervene early and shuffle staff and divert patients before the pendulum swings too far and patient and staff safety is put at risk.

For Robinson, the beauty of the VRM tool – which is a whole-of-hospital tool, not just for nurses – is that it is a nurse-led initiative developed and piloted by staff rather than imposed from above.

Mate, are you mad?

Maurice Chamberlain is a nurse service leader who was involved from the start in the safe staffing pilot site for the CCDM initiative, which led to the development of the still-evolving VRM system.

The former clinic nurse manager says his biggest bugbear in the past was the frustration of management just not getting it when his ward was “busy” and he called for help.

“You’re short on staff and you ring someone up and they say ‘have you considered overtime’ and you sit there and say ‘oh my goodness – mate, are you mad?’,” laughs Chamberlain.

“Of course you have! All you want to know is if there is anybody out there who can help, as you’ve run out of options.”

Now a senior nurse leader, he is proud of the nurse-initiated VRM system and the work nurses put into developing its cutting edge electronic tool – known as the Care Capacity Variance Board – often nicknamed VRM.

Chamberlain says one of the first steps along the way was Jane Lawless leading them in a “Winston Churchill” style war game, complete with tiny nurses and patients that they shuffled around the table to emulate a real-life day in the hospital.

“It really highlighted how areas worked in isolation. The only person who had a real idea of what was going on was the duty manager.”

Then work began in 2010 to brainstorm and develop a list of safe staffing risk factors that the clinical nurse manager could tick off to get a risk or ‘busy’ score for that shift.

Alongside this work was another Safe Staffing unit project, using the SSHW unit’s “mix’n’match” analysis tool to help work out the staffing resource and optimum skill mix of nurses to health care assistants required for each ward. Another part of the VRM system includes the board’s standard operating procedures (SOP)

An essential element for the tool is having TrendCare or another electronic patient acuity/workload management system that forecasts patient numbers and acuity and then schedules clinical staff to meet that demand.

The nursing brainstorm team drew on international and existing models to create its own unique list of risk factors for each service that fitted neatly on a single computer snapshot screen.

Boxes to tick

It is still a work in progress, but the resulting tick-box tool can quickly signal when the reality of the day doesn’t match what was forecast.

Variance risk factors include:

• A nurse caring for more than six patients during a day shift.

• Meal breaks being delayed or missed.

• A ward falling short of its TrendCare scheduled staffing levels.

• All beds being filled.

• Anticipated care rationing.

• Too high a proportion of bureau staff.

• Absent admin support staff.

• Breach of the skill mix.

• The shift leader making a professional judgment that the workload is unsafe.

Each risk factor box ticked is worth one point – except for the tick box for whether there are excess staff that shift, which subtracts one point from the score.

The total variance score is then matched against a ‘traffic light’ colour code that shows at a glance what the current state of ‘busy-ness’ is, from a minimum of minus one to a score of seven or more that puts you firmly in ‘code red’ territory.

In Chamberlain’s words, being in mauve is when you can give up a bed or staff member, green means good or “please leave us alone”, yellow is when its “just starting to hurt and work is being affected”, orange is when care-rationing has begun, so people are being put at risk, and finally, red is “when the wheels have really fallen off” and care and safety are being compromised.

Each colour code matches a plan of action and expectations of how staff should respond. This applies not just to nurses but to medical, allied health, and admin staff from the ward unit, all the way up to the chief executive.

“Otherwise, it would be just a colour for the sake of a colour. For example, if one of my areas goes orange, there’s an expectation that I will attend on the floor, the clinical nurse manager is on the floor, and the nurse educator is on the floor,” says Chamberlain.

The unique part of the tool is that it is electronic, so once the clinical nurse manager or shift leader enters the score, their ward’s colour code comes up on the VRM’s hospital status at a glance on computer screens all over the hospital.

Work on turning the paper-based check list into an electronic tool began in late 2010. Chamberlain says the DHB was lucky to have a “very willing person with the right skills”, so the tool was created in-house in record time by the board’s IT department.

Lawless says this is part of what makes the tool such a “remarkable innovation, as it was so home grown.”

Traffic light hits orange…

Once management spots a ward or unit going into “yellow”, the DHB can launch into targeted early intervention mode. This may involve, for example, sending extra clinical staff into ED for just an hour or two rather than for a whole shift to help the ward get over an influx of patients and return to green status.

“Otherwise, you are robbing Peter to pay Paul, and it just doesn’t work,” says Chamberlain.

Early intervention like this a few weeks ago saw the ED turned back from the brink of “red” in two hours flat.

Robinson says ED was an area used to quietly soldiering along and its workload was “not particularly visible before.”

“I think ED was initially surprised that people turned up to help them – they are so busy caring for patients that they forget they are part of a whole system.”

The department must regularly crack the six-hour-turnaround government target, but the variance tool has helped it draw significantly closer to that goal than ever before (see ED sidebar). Addressing surges in ED earlier rather than later has been shown to be better for the whole hospital system.

The tool isn’t perfect, but it is seen as a giant leap forward. The results of the soon-to-be-released evaluation research report, commissioned by the SSWH Unit, will be used to further refine the nuances of the safe staffing tool.

Lawless says it is important to get the tool subtle enough to signal the significant difference between code yellow (three to four ‘ticks’) and orange (five or six ‘ticks’).

She says it is a “huge breakthrough” for nurses to objectively indicate that if patient care is being rationed, people are missing their breaks, and the agreed skill mix is breached, then they really are “busy”.

Or as Chamberlains put it: “The potential for this tool is huge. It’s absolutely massive … I sometimes I feel we have just scratched the surface.”

Snowed-under ED now swamped with help

Tauranga Hospital’s ‘busy’ emergency department used to often find itself at 150 per cent capacity on a daily basis.

It would soldier on as more and more patients built up in the waiting room, the corridors, and even the ambulance bays. Responses to calls for help from the wider hospital were sometimes haphazard thanks to confusion over what overloaded actually meant …

In the past year, ED clinical nurse manager, Marama Tauranga, says she has been in the novel situation of turning away offers of help.

The introduction of the new variance and “hospital at a glance” tools has made the ED workload and triage surges visible to the whole hospital as never before.

Tauranga says while the VRM tool is no ‘magic pill’ – the department is still to reach the government’s target of 95% of ED patients turned around within six hours – it has “absolutely” made a difference and had an “amazing impact”.

“Prior to VRM, we had a state (where) we would often be 150 per cent occupied on a daily basis. That means people in corridors, people in our ambulance bay, and our ‘did not wait’ (DNW) figures were through the roof on a daily basis.”

Nowadays, she says it’s rare to have patients in the corridor and its DNW figures were at least 40 per cent better than they were.

Prior to the electronic variance tool, the department already had its own traffic light system and overload plan but it wasn’t well understood by the wider hospital, says Tauranga. An overloaded ED might report it had gone ‘yellow’, but that didn’t necessarily mean much to the duty manager.

“We didn’t feel like we were getting the response we required because we weren’t speaking the same language.”

When the SSHW unit came along and work began on a hospital-wide variance tool, things started to change. Now, every shift, Tauranga or the shift co-coordinator takes a ‘barometer reading’, in league with consultants on the floor. With the touch of a key, the ED’s status is visible on every computer in the hospital.

If the ‘hospital status in a glance’ tool and ED ‘worm’ shows a triage surge on the way, the team re-checks its variance colour and has “huddles” with its consultants every two hours to ensure it doesn’t flip into the next variance level.

The ED worm is a statistical tool hat that shows the ED attendance forecast for the day and then tracks it minute by minute against the actual patients registering at triage.

“One indicator we know that trips us over the edge is if we get more than eight patients at triage registered within an hour when the ED is already 75 per cent full. That can actually cause the ED to be over 100 per cent occupied.”

Tauranga says ED staff were surprised to find the ED didn’t descend into ‘red’ as often as expected, as process improvements have led to better patient flow hospital-wide.

“After midday, when we are already humming along and fairly much full, if you then get a couple of hours of patient surges coming, then you can flip into yellow.

“We don’t really get too fussed. We might not ask for help from the wider hospital as we might be able to ride that surge and use our own plan [including Tauranga and the nurse educator going onto the floor if necessary] and move back into green within a short space of time.”

Now the ED doesn’t even have to ask for help for the phone to start ringing. People are attuned to keeping an eye on the ‘ED worm’ and ED colour code.

“You aren’t in a silo any more. Someone might ring and say, ‘Noticed you’ve had two hours worth of surge. Are you guys okay? Is there anything we can do?’”

ED has even had the embarrassment of turning junior doctors away who turned up offering help on hearing about an ED surge. A text appeal now only goes out to junior doctors on the wards if okayed by the shift co-coordinator.

While VRM may not be the ‘magic pill’, it is helping ED step close to meeting the elusive 95% six hour target.

Tauranga says the department is now tracking in the “early 90s” and is making steady progress thanks to VRM, the new standard operating procedures (SOP), and the daily integrated operating centre or “state of the nation” meeting involving representatives of all staff from clinicians to security.

Safe Staffing Healthy Workplace Unit

The SSHW Unit is a joint New Zealand Nurses Organisation/District Health Boards initiative set up in 2007 with central government funding. It was set up to implement the 2006 NZNO/DHB Safe Staffing Healthy Workplaces Inquiry recommendations.

The inquiry itself followed a push by NZNO in early 2004 for New Zealand to pilot a model of the Australian state of Victoria’s patient-nurse ratio model as part of national pay talks for DHB nurses. In the end, NZNO pulled the ratio pilot off the negotiating table in return for the historic “fair pay” deal and SSHW committee of inquiry.

In 2009, Bay of Plenty was one of three DHBs selected by the SSHW Unit as demonstration sites to trial practical ways of implementing the unit’s care capacity demand management (CCDM) tools. A positive independent evaluation of the unit’s work to date lead to the 20 DHBs agreeing to fund the unit’s work until mid-2013, allowing a roll-out of the still-evolving safe staffing tools to three more DHBs.

NZNO pushed in its latest pay talks for a faster timetable for rolling out CCDM tools across all DHBs but settled for a “commitment” from boards to the CCDM programme.

Care Capacity Demand Management

Care capacity demand management (CCDM) is viewed as a more sensitive and subtle way of measuring safe staffing levels than the blunter instrument of simple patient to nurse ratios.

CCDM is built on patient acuity. Rather than measuring how many physical beds are available on any given day, CCDM forecasts how much care the patients filling those beds are likely to need.

It uses a mix of staff feedback, electronic workload management tools like TrendCare, on-the-ground analysis, and historical data to establish base staffing numbers and clinical skill mix. It then forecasts future patient demand and schedules the clinical resources required to meet the forecast need.

Care capacity itself is way of measuring the nursing resource needed to meet patient demand and ward need on any forecast day. The Variance Response Management tool is a systematic way of measuring and signaling when patient and staff safety are at risk because the on-the-day patient demand and clinical resources do not match what was forecast.

Staffing “efficiencies” under discussion

In February, the New Zealand Nurses Organisation put out a press release concerned that the Bay of Plenty DHB was signaling it may disestablish nursing positions due to budget pressure.

In answer to a query from Nursing Review in late March, NZNO industrial advisor Lesley Harry said it was “in discussions with the DHB to find ways to make efficiencies without cutting nursing positions”.

When Nursing Review asked Director of Nursing Julie Robinson in late March about the earlier NZNO concerns about nursing job cuts, she declined to comment.

Robinson was quoted in the Bay of Plenty Times in late February saying that staff had been asked to identify efficiencies but this would “never” be at the expense of patient safety or care.

In the NZNO press release in late February, Harry said it was ironic that the board was a safe staffing demonstration site and that any cuts to nursing numbers was “completely contrary” to the DHB’s agreement to implement a programme that manages the staff requirements according to patient need.


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