Special Health Roundtable “How to Reconfigure Your Workforce to Deal With Staff Shortages”

1. Special Health Roundtable“How to Reconfigure Your Workforce to Deal With Staff Shortages” Highlights 28-30 May 2001

2. Overview • Why Collaborate? • The Roundtable Process • Expectations • Roundtable Agenda

3. Why collaborate? Knowledge Funding Caps Technology Service Demand External Pressure Health Sector

4. Why collaborate? Similar Issues • How to balance elective and emergency bed allocations? • How to set up clinical governance process? • How to reduce length of stay of complex medical patients? • How to increase DOSA rate? • How to find staff?

5. Why collaborate? Isolated Expertise

6. Why collaborate? Shorten Search for Answers HRT

7. Similar Hospitals – Similar Problems – Useful Innovations • The Health Roundtable – 22 Major Teaching Hospitals in Two Chapters • Non-profit membership organisation controlled by CEOs • Focus on operational improvement within existing financial constraints • Share innovative ideas

8. 5. Confirmation 2. Persuasion 3. Decision 3. Decision The Roundtable Process How to speed up action? 1.Knowledge 4. Implementation

9. National shortages of key groups Competing careers with greater status Increasing work pressures -“24-7-365” operation Changing demographics with “baby-boomer” retirement Higher salaries outside Competition from within healthcare sector Decreasing LOS VMO availability Introduction of “safe working hours” Changing work pressures - -“24-7-365” operation Attraction of the ‘Big City’ starves regional centres What Are the Issues? Nursing Medical

10. What You Told Us Increasing Vacancies in:

11. What You Told Us Increasing Vacancies in:

12. What You Told Us Increasing Vacancies in:

13. What You Told Us RANKING OF THE TOP THREE STAFFING CHALLENGES FACED BY PARTICIPATING HOSPITALS

14. Worrying Vacancy Rates

15. Could Lead To:

16. What Others are Saying … Not Just Our Problem • Nurses average age is increasing faster than that of any other occupation. • The number of working RNs under 30 fell 41% percent in 5 years to 1998 • The number of overseas nurses coming into the UK has risen by 48% in 12 months

17. “NURSING AND MIDWIFERY SERVICES FACING CRISIS, EXPERTS SAY” WHO Headquarters -- Crisis result of: • poorly planned workforce policies that do not work, • fragmented health systems and • epidemiological and socioeconomic trends”. “NHS 18,000 nurses short “ The People, 01-21-2001, pp 26 WHO Note for the Press No 1720 December 2000 nursingre-entry program to overcomea shortageof registered nurses in South Australia AAP RUT 13/5/2001

18. Hospitals facing both immediate and long-term shortages of personnel: “today’s shortage is different. It is more than simply traditional stresses peaking at a common time. It is the beginning of along term shortage. It reflects fundamental changes in the relative attractiveness of careers in hospitals, increased competition ... and the aging and pending retirement of ‘baby boomers’” AMERICAN HOSPITAL ASSOCIATION, “Workforce Supply for Hospitals and Health Systems – Issues and Recommendations” Jan 2001

19. Your suggestions for improvement: • Collaborating on placement of overseas nurses as they travel around Australia • Staff exchanges amongst member hospitals • Co-developing educational materials for various job categories • Co-sponsoring recruitment activities for overseas candidates • Share marketing concepts on attracting specialty staff • Sharing expertise in short supply, such as pharmacy drug use evaluation

20. Will this approach be enough? Yes: Focus on recruitment and retention No: Redesign work to fit available talents

21. To Redesign the Work: • How will the roles of hospitals change? • What will be the impact of technology? • Where will care be delivered? • What impact on medical and nursing roles?

22. New Roles Emerging • Hospitalist • Career Medical Officer • Nurse Practitioner • Nurse Clinician • Assistant in Nursing • Patient Care Assistant • Patient Services Assistant • Technician

23. First Nurse Practitioner

24. Staying Ahead will RequireThinking ‘Outside the Box’!

25. 28 May --Presentations by Each Hospital • Common theme – shortages forcing re-thinking of workforce design • Expected increase in problems finding junior doctors • Major issue attracting nurses to the profession • Resistance to changes in existing boundaries across professional groups However …

26. Presentations, continued • Variation in use of Enrolled Nurses and Assistants in Nursing across states – room for redefining nursing and patient care roles • Need to challenge operational practices that prompt staff to leave – inflexible rostering, lack of clerical assistance, advancement blockers • Opportunity to use competency-based training to provide skills where needed

27. Presentations, continued • Some hospitals using career medical officers to provide better continuity of care than relying on junior staff in training, while others have almost no full-time medical staff • Need to clarify service / training role of hospital for junior medical staff • Need to change culture where public hospital role requires juniors while consultants do the work themselves in private hospitals

28. 29 May --“Commission on the Future” • Small groups were asked to evaluate three sentinel conditions • How best to deliver care • Where best to deliver care • Who best to deliver care COAD, AMI, and Hip Replacement

29. COAD Patients • Shift to management in community with limited role for acute hospital • Coordination of care in ambulatory setting • Limit hospitalisation with alternate community-based facilities or home care • Cross-train staff in multi-disciplinary roles

30. Model for the Treatment of Chronic Patients Shift in power base, $$ and status Levels of high profit in practices Skilled Technicians using High technology Community Based 24-7-365 services • Medical Imaging • Pathology • Trauma Mon – Fri 9 - 5 Various levels of health professionals

31. AMI Patients • Provide early diagnosis capabilities at GP or ambulance, supported by central facility • Bypass emergency on arrival with specialist intervention • Manage patient in community as cardiovascular disease patient • Train technical staff to assist with inter-ventional cardiology • Increase telemedicine and telemetry to homes

32. Hip Replacement Patients • Limit role of orthopaedic surgeon to “cutting” with patient management in ambulatory setting by GP/gerontology • Pre-assess, educate, recuperate and rehabilitate in clinic setting, limiting hospital stay to 2-3 days • Use high-volume surgical facilities to achieve high quality & economies of scale

33. The Surgical Patient Patients Community based Ambulatory Care Team Assessment 80% Secondary Care 10% Non-interventional management 10% 3°/4° Care

34. 29 May --Second Session • How to move forward: • Shifting care to the community • Redesigning bedside roles • Redesigning diagnosis and treatment roles

35. Shifting Care to Community • Disease (chronic) specific projects – incremental, test different approaches • Transfer existing activities: Preadmission, follow-up, shared care • Technology – information management sharing, patient access, monitoring telemetry, call centres, GP access to information • Carer networks - assist in monitoring & feedback

36. Linking Care with Community Community GP Tech Patient Carer

37. Redesigning Bedside Roles • Industrial • Lack of unified professional voice • Definition of Nursing • Agreement about priorities • Changes to come from within profession Barriers Clinical Dimensions of Patient Care Administration Housekeeping

38. Redesigning Bedside Roles • Work redesign: question current routines eg showering patients in the morning • RNs, ENs, PCAs: question need for three tiers • Use clerks to answer phones, do data entry • Rethink how to implement 24/7/365 “We have met the enemy and it is us”

39. Redesigning Treatment Roles • Assess & Diagnose common conditions in the primary care setting • The most senior staff available should assess acute presentations • Diagnostic tests, echocardiograms undertaken by technicians • For high volume conditions set clear guidelines and discharge criteria

40. Redesigning Treatment Roles • Train specialists as mentors • Recognise Registrars as key positions • Examine extending medical officers service at hospitals by two years

41. 30 May --Recruitment & Retention Actions • Coordinate overseas nurse placement for “wandering nurses” limited to 90 day placements– organise to rotate amongst HRT Hospitals • Hospitals to designate liaison contact (via HRT) – for medical and nursing vacancies • Member Hospitals update web site to indicate they are collaborating with other HRT hospitals around Aust & NZ

42. Recruitment & Retention ... • Increase sponsorships of overseas staff • Cross registration easing • Focus on UK, Ireland, Canada • Use internal “broker” to handle all job inquiries -- newspapers ineffective • Queensland central recruitment of 200 overseas doctors annually • Offer leave without pay for staff on placements to other hospitals around HRT

43. Recruitment & Retention • Investigate remuneration flexibility in recruitment of specialists • Examine interstate differences in packages • Interest in developing placements for junior specialists at other hospitals • Develop ways to retain 2nd-3rd year residents prior to GP track

44. Recruitment & Retention ... Share: • Educational materials – AiN, PCA, Scrub & Anaesthetic Technicians and Nurse Practitioners (incl definition) • Protocols • Nurse led pre-assessment (incl. Screening tools and pre-admission tests) • Nurse led clinics

45. Action Items: Gemma • Modify HR Process (capturing applicants) • Rotate nurses around country • Expand PCA/EN/Techs • Increase length of contracts for JMO • Work with RBH to rotate specialists • Expand teaching and research roles • Facilitate private rooms for specialists on site • Review role of Interns • Reduce clerical work (with Electronic Record) • Review care roles in working party

46. Action Items: Centauri • Evaluate roles/Skill mix: PSA/EN/RN • Review option of Career Medical Officers • Assess workload of Junior Medical Staff • Test Pre-assessment/pre-admission model for nurse-initiated testing • Understand where and why our staff are going interstate • Make better use of web site • Explore development of Magnet hospitals • Develop medical staff credentialing across hospitals

47. Action Items: Thunder • Identify hospitals for staff exchange • Develop Central point to log job inquiries • Expand programs for patient care assistants • Examine Service requirements for JMO/RMO • Tweak our web site and stay in touch with staff who travel • Redesign Primary/ secondary care roles

48. Action Items: Panther • Expand Assistant in Nursing role • Develop recruitment links with other hospitals • Explore O/S staff sponsorship strategies • Develop Call-centre to support GPs • Redesign work in wards • Foster shift of care to community settings

49. Action Items: Eagle • Review JMO roles – service & training • Expand protocols and care paths • Develop nurse practitioner role • Develop interdisciplinary training between nursing & Medical staff – how to better share roles • Pilot test work redesign in Renal Unit • Improve use of Web site • Improve follow up with GPs -- call centre

50. Eagle continued • Attract GPs back into the hospital as career medical officers • Job sharing • Increase EN Ratio in acute care • Put development of PCA/AiN back on agenda • Share overseas rotation • Provide additional placement for overseas psych nurses coming in October