Improving Value for Money

by Steven Course, Chief Finance Officer, Nynn-Hui Chang & Marco Aurelio, QI Team Improvement Advisors

Often the rationale for undertaking QI has focused on doing the right thing, with the main focus not on the financial gain resulting from the improvement work. However increasing pressure on NHS budgets and rising patient demand is putting a strain on the system to deliver more with fewer resources. With this in mind a priority for some of our QI work within the trust going forward is what we’ve called improving value for money.  One of the ways we’d like to tackle this at ELFT is through the use of QI methodology to deliberately redesign systems to eliminate waste and improve efficiency.

One team currently using QI to tackle an aspect of waste is the Salary Overpayments project team, comprised of colleagues from finance and human resources (HR). Last year the trust had 229 overpayments totalling £369,000. This represents a significant amount of unnecessary waste in the system not only financially, but administratively from staff needing to recover the overpayments.

The team aims to reduce salary overpayments by 30% by April 2018 and are using QI methodology to do so. Early on the team used data from trust finance systems to begin to understand where and why overpayments were happening within the trust. Interestingly what they found was that the majority or late payments were caused by late submission of staff change or leavers forms.

Why is this? What were users of this system in this case saying? To develop their knowledge around, the team sent out a survey to some 500 staff to understand what some of the barriers to submitting change forms were and what might be done to help. Some key themes that emerged included lack of clarity around the process for submitting forms, confusion over the date for form submission to payroll and difficulty in using the online forms among others.

The team were able to use the great insight from the survey to begin to develop a whole host of potential change ideas to the system including the re-introduction of positive returns, changes to the intranet, new guides and help documents and changes to the London field weighting on change forms.

While the team are in the early stages of testing some of these, they are keen to more fully understand the user experience around submitting change forms. To do this they’re looking for a few volunteers who regularly submit staff-change and leavers forms to join a focus group to explore this.

So if you’re interested in being part of this drop us an email to elft.qi@nhs.net

To find out more out about developing a value for money based system please take a look at some of the following resources:

• Increasing efficiency and enhancing value in health care – Nolan et al.
• Value creation systems – Swenson et al

Recruitment Timeline

Please learn more about this completed ELFT QI project from the adjacent poster.

ELFT staff, service users and carers can access full details of this project on QI Life.

The project code is 100754, please log onto your QI Life account before clicking the logo below.

Recruitment Timeline

This projected was presented at the 2017 Annual QI Conference. The project aimed to reduce the time it takes to hire to 35 days by December 2016.

QI Project Story: Improving the disciplinary process at ELFT

ELFT’s human resources department has already seen a reduction from 107 days to 52 days in the time taken from start to completion of the process, but other challenges lie ahead. Read this blog by the HR team on how this Quality Improvement project is developing.

The specific aim of the project was to reduce the length of time taken to conclude 80% of disciplinary processes in 115 days or less.

There has been an increasing focus on the application of systematic methods for quality improvement in healthcare, with a growing body of evidence suggesting benefits across clinical settings. The approach adopted by East London NHS Foundation Trust (ELFT) incorporates extensive efforts to engage and involve staff and service users, build improvement capability at scale and embed continuous improvement efforts into daily work.

ELFT has been using quality improvement to tackle complex quality issues such as violence on in-patient wards, patient waiting times and community-acquired pressure ulcers. We chose to focus on Disciplinary Processes as there was a wealth of data available to us and a real desire in the Trust to improve the process and reduce the amount of time taken in resolving disciplinary issues and also the over representation of BME staff in the process.

The team used quality improvement to guide their work through not only the design and implementation phases of their project, but also to ensure sustained levels of engagement from all of those who were involved. The specific aim of the project was to reduce the length of time taken to conclude 80% of disciplinary processes in 115 days or less.

To achieve this, a number of change ideas were tested including reducing the preliminary report to a one page document, introducing a meeting between the commissioning manager, line manager and HR, pairing experienced investigation officers with non-experienced investigation officers, among others. The combination of a number of change ideas including offering a hearing date at the outset of the process culminated in a reduction of time it takes to conclude a case from 107 days to 52 days.

In the year prior to the project, the average number of days that staff were suspended was 104 with an average cost of £296 per day. By reducing the length of time that a case took to be heard by 50 days resulted in a saving of £429,200 in a year based on a case rate of 29 per year.

In the three year period up to November 2015, 16% of cases that progressed to a hearing resulted in no case to answer. Between January 2016 and January 2018, only 2% of cases resulted in no case to answer, which shows improvement.

We have introduced an agreed outcome process where staff admits the alleged misconduct; they can agree to accept a written warning without the need to go to a formal disciplinary process.

Agreed outcome represents 19% of the disciplinary cases. Whilst there is a significant increase in the number of disciplinary cases overall, we can say that there has been a shift in the organisation’s culture in terms of taking formal disciplinary action against medical and dental staff. We can also conclude that the number of cases that result in no case to answer has reduced significantly from 16% to 2%. Also, 19% of cases avoided going to a formal hearing as a result of the agreed outcomes process.

However, there is still a disproportionate effect of disciplinary processes for black staff which has increased, whilst the proportion of white staff has remained the same. In terms of the internal processes, we have centralised employee relations activity to improve the consistency of disciplinary sanctions. We are also in the process of rolling out a fair treatment process to triage disciplinary cases before they progress to formal investigation. The Trust are moving towards a performance culture by implementing performance rating for agenda-for-change staff, as part of the appraisal forms to enable managers to have performance conversations.

We have also reviewed and re-launched the Trust Disciplinary Policy and Procedure, significantly reduced the number of suspensions and, where practicable, assigned staff to have alternative duties. Previously we had 89 suspensions and now we are reporting 51 suspensions. Additionally, we have seen a reduction in the number of cases reaching an employment tribunal. At the last report there were 13 live employment tribunal cases compared to 5 currently.

Ethnicity and disparity

Whilst ELFT has a culture of inclusion supported by a highly diverse board, including BME female CEO and Chair, it also faces similar challenges to other London Trusts across a range of Workforce Race Equality Standard (WRES) indicators.

A review of all employee relations cases in the past three years was undertaken alongside the project with the aim of reducing the number of BME staff over represented in Disciplinary processes.

Lessons Learned

We learned through analysis of 3 years’ worth of employee relations data that it was black or black British nurses in band 5/6 positions who had been with the organisation for over 3 years that were more likely to be disciplined than other staff. This helped us learn about the importance of deep analysis of data to understand the differences between types of staff who are being disciplined.

We have also learned that the project team and change team set up are crucial to the success of the project, ensuring the right people are in the team and that they have some ground work as a team about how they will work together as well as what they will be doing.

The project team trialled changes to see if they worked before incorporating them into policy, by trialling changes that were outside of policy which had implications for further process so had to be clearly identified and communicated, particularly to staff side colleagues.

Another valuable lesson is that you don’t always get what you expect – it was anticipated that a reduction in overall cases would impact positively on the number of BME staff being disciplined. However, whilst cases have reduced, the ratio has not shifted in the way we would expect. Therefore, a more targeted aim statement will be developed in the next iteration of the QI work on disciplinary and a new driver diagram developed to support this.

Finally, we learned that it is important to support staff by giving them time and space to focus on QI work.

Learning about QI in Canterbury, NZ

By Mason Fitzgerald, Director of Corporate Affairs

On a recent trip back home to New Zealand, I had the pleasure of spending a day with colleagues at the Canterbury District Health Board (the commissioner and main provider of acute, mental health and community services in the South Island).

Read more

Active QI Projects – June 2019

This is the monthly report generated from Life QI, showing all active projects within all the directorates.

Quality Improvement for Non-Clinical Teams

While there is a growing body of evidence confirming the benefits of quality improvement in clinical settings, there has been little exploration of or published literature on applying a systematic approach to improvement in non-clinical areas. Learn more in this article by Dr Amar Shah, Marco Aurelio and Mason Fitzgerald.

Click on the image to access the resource.