Cross Chapter Health Roundtable Redesigning the Workforce to Meet Emerging Needs

1. Cross Chapter Health Roundtable Redesigning the WorkforcetoMeet Emerging Needs 15-16 September 2005 Stamford Plaza, Auckland NEW ZEALAND

2. Key Principles Every system is perfectly designed to produce the results it gets.(D. Berwick)

3. OverviewChallenges, Trends & Predictions

4. Challenges to secure asustainable health workforce • Demand - Changing Demographic & Disease Trends • Time – a larger workforce faster • Technology & Empowered Consumers • Shrinking labour pool • Competition from other sectors • A global market • Work/life balance AND • Workforce planning and data • Connection between the health and education and training sectors • Funding for vocational training, undergraduate, • Postgraduate and clinical education, • Traditional professional, industrial and educational roles John Ramsay Chair, Australian Health Workforce Officials Committee

5. Challenges - shortages • Medical - GP and specialist shortages, • Nursing - predicted 40,000 shortfall by 2010 • Allied health - shortages across a range of professions including hospital pharmacists • Dental – public sector, rural and remote • ATSI - shortages identified in recent reports John Ramsay Chair, Australian Health Workforce Officials Committee

6. Insanity “Doing the same thing again and again, but expecting different results” -- Benjamin Franklin Should we expect an increase in hospitals, specialists, allied health, and funding to treat more patientsas we have in the past? Or should we develop alternative ways to meet patient needs?

7. Overview of Briefing Materials • Rough indicators only – problems with data comparability • Wide variation in vacancy rates – suggests that shortages are not system-wide • Limited planning to anticipate trends • Some seem powerless, while others seem more proactive • Our approach – focus on things you can change

8. 1A Appraisal & Performance 2A Defining Roles 1F Working Safely 2 Attracting Staff 1B Competences 1 Using Staff Skills Effectively 1E Working Environment 1C Role Redesign - Innovative new and amended role 2B Recruiting 1D Work Design & Planning Out of Hours & Work time Directives PDSA Data Workforce Improvement Themes 3G Pay and Reward 3A Career Framework • Retaining & • Developing Staff 3F Partnership and Staff Involvement 3B Education and Training 3E Induction 3C Enhancing Roles 3D Flexible Working

9. The percentage of Medical FTE vacancies reported ranged from 0.5% at Vulcan to 10.9% at Asklepios. 6 Hospitals predict an increase in vacancies by 2008 The highest vacancy rates - Emergency Physicians (6.1%) and Junior Medial Staff (5.5%)

10. Nursing vacancies reported as a percent of total Nursing FTEs ranged from 2% at Falcon to 15% at Athene 6 health services reported the use of nurse practitioners, (Achilles with 3)

11. The highest percentage of vacancies for non medical / non nursing staff was for biomedical engineers & sonograpahers Other categories with large vacancy rates -midwifery, psychiatry, speech and language therapists. Few health services were able to forecast increase or decreases in vacancies for non medical and nursing staff in 2008 The disciplines with the most critical shortfalls in staffing availability over the next three years were Nursing, Junior Medical Staff and Allied Health

12. Lowest vacancy rates as a percentage of total FTEs

13. WORKFORCE PLANNING • Several health services reported having processes or systems to forecast future emerging needs for the workforce for future planning (Highlighted in green below) • Dionysis – for allied health have a system for annual review

14. Recruitment Innovations: An opportunity exists for collaborating on the placement of overseas staff as they travel around Australia & New Zealand

15. Recruitment issues & innovations Major recruitment issues • insufficient staff being trained, • covering 24/7 • competition from the private sector • Difficulty in attract and retaining senior staff • Limited Career Path Recruitment innovations • Candidate care teams to assist with relocation (Fury) • A range of coordinated programs and working party (Achilles) • Clinical leadership program (Falcon) • Establishment of an Allied Health Recruitment and Retention working party (Achilles) • AH Clinical progression program (Demeter)

16. Vulcan and Athene anticipate recruiting 70-80 new OS trained medical staff this financial year • Opportunities exist to improve training for OS trained graduates • Dionysis and Vulcan have a clinical privileging granting process which is different for OS trained doctors • Dionysis and Vega have different credentialing and evaluation processes for OS trained Allied Health recruits

17. Retention: Panther had the highest number of strategies fully implemented Best implemented Least implemented

18. Retention Issues & Innovations Major retention issues • Remuneration, • Workloads, • Career development, • After hours work, • Competition with the private sector • Recognition and support Retention Innovations • Clinical training and education centre (Fury) • Clinical Leadership program (Falcon) • Flexible working arrangements (Vulcan & Achilles) • Clinically led management structure (Polaris) & Clinical / management partnership (Asklepios) • Allied Health Recruitment and Retention party (Achilles) • Allied Health Reclassification structure and improved pay (Dionysis)

19. Redesign: Rostering to cover off peak widely implemented

20. Redesign: Computer based clinical protocols scarcely implemented

21. Redesign Issues & Innovations Major redesign issues • In ED - Allied Health ability to access community based services out of hours + appropriate skills to work in ED • Utility of highly skilled allied health staff to deal with demand • Attracting skilled and experience allied staff to drive model of care and clinical practice changes • Surgical - Allied health - Ability/resources at pre-admission to provide education/intervention • Allied Health entrenched work practices – fragmented and poorly coordinated • Work practices are fragmented and poorly coordinated Redesign innovations • Nurse initiated x-ray (Poseidon) • Nurse practitioners in ED (Polaris and Achilles), • GP led accident and medical centre 24/7 (Electra), • Nurse led event driven discharges & allied health trigger tool (Achilles), • Allied health education sessions to drive down LOS for specific surgical DRGs, • E-referral system (Vulcan)

22. Other Innovations

23. “Work Structuring” at Waitemata District Health Board • Redevelopment of North Shore Hospital and the creation of a new sub-district general hospital in West Auckland – Waitakere • Underlying philosophy Healthcare is a complex, adaptive system. • Outcomes of the system are the consequence of the complex interaction of the different components, more than the properties of the individual components

24. Healthcare is a non-linear system and needs a whole of system solution linear, mechanistic, non-adaptive system. Adaptive, organic system • Work Structuring - Whole-system solutions from the bottom up • Aligns the work structures with meaningful ‘whole tasks’ in patient care, in accordance with the natural properties of the system.

26. Outcomes from Work Restructuring • A 15-20% improvement can be expected in a number of system measures: • Reduction in staff turnover • Reduction in sick leave and absenteeism • Reduction in average length of stay • Reduction in patient complaints • Reduced overall system costs Qualitative improvements include: • Dramatically improved morale and motivation of the healthcare workforce • Significant improvement in the quality and safety of clinical care • Dramatic improvement in the quality of patient ‘service’ and the emotional and psychological aspects of care • Better outcomes for patients and their families

27. Redesign/extend roles one of NHS’s High Impact Changes (No10) • Redesign / extend roles in line with efficient patient pathways to attract and retain an effective workforce • Redesigning roles & matching to skills and competencies • Improve patient care, reduce waste, improve working lives, reduce errors and mistakes.  Outcome • Reduce time clinicians spend on administrative tasks • reduce staff turnover and agency costs • improve clinical quality through increases in direct clinical care time and timely interventions through reducing time to diagnosis and treatment. 

28. 5 Examples Workforce Substitution • Certified Nurse Anaesthetists • Advanced Neonatal Nurse Practitioners • Endoscopist Substitution • Highly Specialist Medical Admissions Clinical Pharmacist • Advancedpractitioner radiographers See Changing Workforce Program review PDF Modernisation Agency

29. 1. Certified Registered Nurse Anesthetists (CRNAs) • Problem Description - Shortage of anaesthetists limits OT throughput • Solution Design • 2-3 year intensive training course Department of Anaesthesia, approved by the relevant authority • Two Nurse Anaesthetists are supervised by one Senior Anaesthetist (remains on the floor during all procedures). • OR has 6 operating rooms so 6 CRNAs, 3 Senior Anaesthetists and 1 supernumerary Anaesthetist • OR employs 20-30 CRNAs who work 12 hour shifts, 7 days per week. • Nurses undertaken all aspects of routine anaesthesia including induction, anaesthesia maintenance, fluid and circulatory management and anaesthesia reversal. • Legislation 1986 made CRNAs first nursing speciality to get Medicare reimbursement rights.

30. Nurse anaesthetist outcome data • Nurse Anesthetists (CRNAs) administer approx 65% of all anesthetics give to patients each year in the US • "CRNAs are the sole anesthesia providers in approximately two thirds of all rural hospitals in the US, enabling these healthcare facilities to offer obstetrical, surgical, and trauma stabilisation services. In some states CRNAs are the sole providers in nearly 100% of rural hospitals."

31. 2. Advanced Neonatal Nurse Practitioners Problem Description • Shortage of medical residents (SHOs) means other senior neonatal staff required for Nursery SUMMARY of Role Substitution • provide many of the duties previously done by SHOs • throughput of babies (activity level) higher • no evidence yet presented but reduced admissions from home born should provide space for more transported babies • figures indicate Length of Stay (LOS) reduce by 24 hours approx • provide a career path for neonatal nursing staff • provide nurse-led clinics etc for community education

32. 3. Endoscopy Alternatives Problem Description • Upper and lower gastrointestinal endoscopy essential investigation for stomach and bowel disease and early detection of gastrointestinal cancers • Waiting list increasing with proactive bowel screening programmes • Number of trained endoscopists to increase or new ways of working needed. Solution design • Pilot showed possible to train individuals from a variety of backgrounds to perform flexible sigmoidoscopy competently, thereby increasing the endoscopy workforce numbers

33. Endoscopies are traditionally carried out by doctors. I’m the first nurse endoscopist at this Trust . There are about 300 of us in the country and the numbers are rising. I trained at Hull University and had to complete 200 procedures, all assessed by a consultant, and complete four written assignments based on all aspects of the care and management of a person undergoing an endoscopy. Now that I have qualified I have my own lists, although there is always a doctor in the department as well. Hammersmith http://www.hhnt.org/staff/endoscopist.htm

34. 4. Highly Specialised Medical Admissions Clinical Pharmacist Problem Description • Medication histories, prescribing decisions and allergy documentation were often incomplete or inaccurate • Many patients were also having problems obtaining and taking their medication. • Audit identified many clinically significant gaps in junior doctors clerking affecting many patients. Solution Design • highly trained, experienced clinical pharmacists • actively participate in the ward rounds and in taking full medication histories • identify medication related problems early in the patients stay • improve communication with patients, carers and primary care • write up discharge medications • prevent unintentional changes in medication following discharge.

35. 5. Advanced practitioner radiographers Problem Description • Long waiting times for radiology procedures • Shortage of radiologists (either supply or funding to employ) • Role to work autonomously • release Consultant Radiologists from some roles (allow them to specialise in other modalities) • two-year foundation degree to provide them with the necessary expertise to work in radiology • on-the-job training for three days a week • undertake a proportion of the plain film radiography examinations, including referrals from minor injury unit, GP, and outpatient clinics • comprehensive radiographer led barium service • radiographer led Barium Follow Through service

36. Reduced waiting time radiology

37. Thought Starter Presentations

38. Idea Screening • Feasibility • 1. Is it real? • Enough patients? • Evidence that it works? • 2. Is it worth it? • Likely financial benefits • 3. Can we do it? • Clinical champion available? • Minimal opposition? • Low risk? • Available expertise?

39. First Step PROJECT AIM • How much improvement for patients (Percent) • in what specific area (Start small) • by when, (Month/year) Focus on patient for maximum buy-in Example: Decrease percentage of Diabetes patients with HBA1C levels above 9 by 50% by December 2005

40. Workforce planning inputs& workplace • Recruitment & retention • Attrition • Age and gender profile – participation rates • Hours worked • Safe hours • Work/life balance John Ramsay Chair, Australian Health Workforce Officials Committee

41. Career decision making by doctors invocational training study • Survey of all doctors in vocational training in 2002 • 4,271 useable responses (54%) • Representative across disciplines – 17.4% general practice (32% rural pathway), 15.6% surgery, 15.5% adult medicine,11.3% anaesthesia, 9.5%, emergency, 8.4% psychiatry, 6.4% paediatrics • Limitations: self reported survey, snapshot • Strength: evidence where little previously existed Paul Gavel, National Health Workforce Secretariat November 2003

42. Factors Affecting Choice of Discipline • Male trainees rated the more important • factors as: • perceived financial prospects, • opportunity for career advancement • job security • influence of mentors/consultants • work experience since graduation • perceived prestige and intellectual content • procedural work, research and teaching Female trainees rated the more important factors as: • hours of work • appraisal of own domestic circumstances • opportunity to work flexible hours • type of patients typical of discipline • helping people • number of years required to complete Paul Gavel, National Health Workforce Secretariat November 2003

43. Choice – other notable differences Urban background rated the more important factors as: • perceived prestige of discipline • influence of parents/mentors • perceived job security and career prospects • opportunity for procedural work • GPs rated the more important factors as: • interest in helping people • appraisal of own domestic circumstances • opportunity to work flexible hours • number of years required to complete training • experience of specialty as a medical student (Gavel 2003)

44. More Flexibility around Training Required • Issues around flexibility: part time training and job sharing • longer times to complete training to allow for life experiences (having children etc) • ability to choose hours of work and location of training • ability to change easily between programs • Satisfaction and stress linked to hours worked - ‘too many’ hours – average worked was 57.3 per week, - ‘about right’ – average 48 per week • 70% plan to practice full time; but 52% of • female trainees plan to work part time 43% of trainees dissatisfied with time for family, social and recreational activities (Gavel 2003)

45. Future Practice Locations • Positive association between rural background and positive rural training experiences and a preference for rural practice • 9% indicated nothing would induce them to practice in a rural location • Highest rated factors that could influence to practice rural - money and family circumstances • States – a third of SA trainees do not plan to practice in SA (NSW and Vic also lose; around 5-7% of trainees) (Gavel 2003)

46. Vocational Learning Environment- Most satisfying aspects of training • Quality and content of the program • Supportive relationships with supervisors, consultants and peers • Supportive training environment • Opportunities afforded by the program • Enjoyment gained from doing the program (Gavel 2003)

47. Vocational Learning Environment - Dissatisfying aspects of training • Poor quality training, teaching and supervision • Inadequate structures and procedures • Non-supportive relationships with supervisors • Lack of guidance • Rural training requirements • Discrimination • Training costs (Gavel 2003)