Efforts to solve trolley crisis and staffing numbers in our hospitals go on and on ...
says the trolley crisis is being tackled but believes the crisis is exacerbated by the inability to retain staff.
‘The public has invested significant resources in our hospital’
Reduced numbers on trolleys in CUH demonstrates that the crisis is being tackled, but of course much more needs to be done, writes
In order to understand the patient-flow difficulties that manifest themselves in our emergency departments, it is necessary to appreciate that the contributory factors reside in our processes in our acute hospitals and in community services.
Accordingly, the resolution of these patient-flow challenges requires a focus on multiple factors such as collective leadership in our hospitals and community services, the creation of a shared passion that we will resolve impediments to patient flow and a commitment to a change management programme that will incrementally exploit opportunities for improvement.
There is no quick-fix solution to this, perhaps the most complex of problems in our health service and this is the story of what we are doing to address the challenge of patient flow in Cork University Hospital (CUH) where to date over 200 change initiatives have been implemented with evidence of success over the past six months.
The implementation of these change initiatives began over four years ago with an acknowledgement that the internal processes in the hospital were not fit for purpose and were in need of urgent attention.
In response, hospital leadership undertook a week-long study of the flow of roughly 1,400 patients (there are in the region 65,000 patients per year attending our emergency department).
The application of science and analysis to understanding the impediments to patient flow coupled with the use of ‘lean-management techniques’, resulted in a body of work that was focused on addressing inefficiencies in patient flow.
These individual change initiatives were largely implemented by redirecting existing resources in the hospital to improve, for example, the flow of patients to assessment units for a decision to be made on admission or discharge, to the implementation of new processes to reduce pre-cardiac surgery inpatient numbers to a minimum with considerable savings in bed days.
Where necessary, additional resources were invested in establishing new services such as an ortho-geriatrician service that streamlines the flow of orthopaedic trauma patients out of CUH to the South Infirmary University Hospital, where the rehabilitation service is located or to another community setting. The full range of initiatives is at www.cuh.hse.ie.
In 2017, leadership in CUH decided that priority would be given to a series of initiatives that are embodied in Project Flow ’17 (PF’17) that set specific targets to reduce trolley numbers in the emergency department but also critically to improve the patient experience time for patients attending the emergency department.
One of the most important aspects of PF’17 is it focuses on the contribution that every member of staff in the hospital has to play in optimising patient flow.
However, the resolution of the difficulties in the flow of emergency patients cannot be dealt with by changing processes in the hospital alone and must incorporate a programme of work with our community partners.
In April 2017, a weekly systematic review of every patient in the hospital who was over 14 days as an in-patient commenced (the average length of stay in CUH is six days which is considerably shorter than any comparable similar sized hospital in Ireland) and this has effectively created 10 beds by reducing the number of such patients.
These meetings have highlighted many of the challenges that the health system faces in working to place patients appropriately in alternative community settings such as community hospitals, nursing homes and in the home setting with homecare packages.
The development of a shared leadership commitment to improving the system of discharges from acute hospitals to community settings is possibly the greatest challenge that the HSE faces and given that 3% of patients in CUH occupy 30% of bed days, there is a compelling argument that additional beds are needed in community settings rather than in acute hospitals.
In any event, a range of types of beds ranging from intensive care to community placements are required and the forthcoming Bed Capacity Report is critically important in this debate.
What then has been the change in patient flow as measured by the number of patients on trolleys in the Emergency Department in CUH at 8am since the implementation of PF ’17 and other many individual change initiatives?
The target set in the Plan was for an ambitious 50% reduction in the number of patients on trolleys each day in emergency departments. These targets have been achieved on a consistent basis over the past six months.
The number of patients on trolleys in emergency department in CUH remains at an unacceptable level. However, the progress made in the implementation of PF’17 in the second half of 2017 and the implementation of 200 individual change initiatives provides encouragement that this most intractable of problems can be managed to a level that provides the public and the Exchequer with assurance that it is getting value for the very substantial additional investment that has been made in additional staff, promotional opportunities and increased resources.
Of note, the trolley count for the second half of 2017 averaged 12 per morning which represents a 50% performance improvement over the first half of that year.
Our plan for a continued, sustained improvement programme that will be embodied in Project Flow ’18 is now being finalised that will set ever more challenging targets for our performance in 2018.
The experience in CUH suggests that additional resources of themselves will not resolve the challenge of optimising patient flow for emergency patients. Additional resources must be invested commensurate with change in process in our individual hospitals and community settings.
The public has invested significant additional resources in our hospital and community services since Health Minister Minister Mary Harney declared in 2006 the Emergency Department problem a “national emergency”.
They deserve our collective leadership commitment to demonstrate that this seemingly intractable problem can be resolved not by more of everything but by a commitment to continuous change.
Patients paying the price of low nursing and midwifery wages
A total of 98,981 people were on hospital trolleys in 2017, a crisis exacerbated by the inability to retain staff, says
THE two words I associate with this new year are ‘hope’ and ‘courage’ or, in Irish, ‘dóchas’ agus ‘misneach’.
These two words resonate with nurses and midwives. Hope and courage are integral to our interactions with patients: we impart treatment plans, advise on care, encourage them to continue with difficult treatments, and see with hope the end of illness and recovery.
But hope is in short supply in the improvement of working conditions for nurses and midwives.
The dawn of 2018 was a mirror image of Januarys past: overcrowded hospitals, long waiting lists, shortages of nurses and midwives, and patients being cared for in inappropriate circumstances.
The INMO has been counting admitted patients on trolleys since 2004. The count relates to the number of patients admitted for hospital care, but for whom beds are not available.
In 2013, this count was extended to include additional in-patients on wards/inappropriate areas, as this had now become a reality. Unfortunately, just this week, we expanded it to include children on trolleys. This was due to children admitted without appropriate inpatient bed areas being available.
Without this count, there would not be a public awareness of the problem.
The count is a barometer of a problem that is not improving, and reminds policymakers and employers that they have to do more to prevent complacency.
It is not okay to have a growing problem. One patient overnight on a trolley is too many, never mind the 98,981 who were on trolleys in 2017.
Patients deserve better access, and staff in these departments and in overcrowded wards deserve a healthy and safe place of work.
Listening to all the various commentators over the past number of weeks, each with their own version of the cause of the problems and the variety of solutions, it is clear there are many reasons why this is a constant feature of our health service.
We know the causes: poor planning, reconfiguration that reduced capacity, moratoriums on employment, reduced frontline posts, and reduced bed capacity. The perfect storm.
Undoubtedly, the capacity of our acute hospitals will have to be increased significantly and hospital care must develop and advance in a planned and interlinked manner.
I am concerned that we will be in the same place in January, 2019 as in January, 2018, unless, by some miracle, the SláintecCare report recommendations for health-care reform are prioritised for implementation in 2018.
However, the HSE service plan, announced in December, 2017, does not provide for this reform and the HSE will wait for the Department of Health to come forward with the plan and the funding, and, until then, will sit on the fence and cry ‘funding does not allow’.
Increasing capacity will require a major increase in the employment of nurses and midwives. The current employment figures remain stubbornly below 2007 levels, when hospital activity was lower.
To get to the baseline this year, agreement had been reached with the HSE to grow the nursing and midwifery workforce by 1,224.
This has, despite many plans and recruitment initiatives, proven impossible, as the recruitment rate is almost matched by the numbers leaving. Total starters in 2016 were 2,872 across nursing grades. Total leavers were 2,861. That’s a gain of 11.
It is abundantly clear that we have a recruitment and a retention problem. Heading into 2018, we know there is only one untried solution to turn this tide.
The pay of nurses and midwives, which falls well behind that of colleagues with equivalent entry qualification in the public service, must be improved.
The INMO submission to the Public Service Pay Commission (PSPC) provided the evidence that links pay to the problems with recruitment and retention.
The evidence across the main destination countries for Irish-trained nurses is that Ireland ranks lowest in the international comparative standard exchange rate — purchasing-power parity — when it comes to nurses’ pay.
Likewise, when comparisons within these countries were made between the nurses’ salary and that of other allied health professionals (AHP), the relative salary is equal, marginally above and, where lower, it is very slightly lower.
Whereas, in Ireland, the difference is significant and four times lower than the AHP comparator in all cases.
So, misneach? Where will it surface? Well, the Public Service Pay Commission has the evidence: it is tasked with examining the submissions and presentations made to it and reporting to the Government by May/June.
I hope all parties — the HSE, the Department of Health, and the Commission members — will have had the courage to confirm that recruitment and retention in nursing and midwifery grades will not be corrected without pay improvements.
When the Government receives the report from the PSPC, I hope they have the courage to break the cycle of low pay in nursing grades, and use the protections within the public service stability agreement, which confirms that the output from the PSPC work will not give rise to any cross-sectoral relativity claims, to set fair and equal pay for the female-dominated professions of nursing and midwifery.
If not, I know INMO members have the courage to pursue the correction of this cycle of low pay. I know the Executive Council and INMO team have the courage to lead.
I sincerely hope the process under the Public Service Stability Agreement, fully engaged in by the INMO and its members, delivers, so that all energies can then be focused on implementation, which would be a courageous and hopeful start to the next chapter for nursing and midwifery pay in 2018.
