Feature / Visual acuity

A new system is enabling Guy’s and St Thomas’ NHS FT to keep a constant track of nurse dependency at both patient and ward level. While it has benefits for ward management and clinical governance, it could also mean much more accurate cost allocation. Steve Brown reports

The recent Francis report was a timely reminder of the need to ensure staffing levels are sufficient to meet patient needs. This means being able to assess that you have the right number of staff – and perhaps in particular the right number of nursing staff on wards – to deliver safe and high-quality care.

Often the focus for such assessments has been at ward level – ensuring a ward has the right nurse numbers and skill mix to meet the collective needs of its patients. But if this understanding can extend to the nursing dependency of individual patients – and, crucially, can be recorded at this level – then significant improvements could be made in the quality of patient-level cost data. And this itself could help inform improvements in the quality and value of patient services. Guy’s and St Thomas’ NHS Foundation Trust has set itself just this challenge.

Different needs

Understanding patient acuity and the resulting nurse dependency is clearly key to ensuring wards have the right nursing staff in place to meet the needs of patients. Different patients need different levels of nursing care and support. Patients in neighbouring beds could have wide-ranging needs, from one-to-one care to  routine support and monitoring.

This is also key in allocating nurse costs accurately to patients. Ward costs are a significant part of healthcare costs. Some analyses of patient-level data put ward costs overall at up to 25% of total costs. This is clearly an average. Ward costs will be an even higher proportion for medical patients, who do not incur the costs of time in theatre.  And within ward costs, nurse time is likely to be far and away the biggest cost component.

A hospital allocating ward costs solely on the basis of length of stay on the ward will in effect be presuming that all patients consume the same level of nursing resource during their stay. This will clearly undermine the resulting patient-level costs and thus the national tariff.

The HFMA’s Acute healthcare clinical costing standards acknowledge this by identifying best practice – the gold standard – as allocating nurse costs on the basis  of length of stay (in hours) weighted by patient acuity/nurse dependency. Allocating costs on the basis of simple length of stay measured in bed days is seen as the baseline approach (see box).

The trick then is to turn this best practice into a practical reality. For most trusts, individual patient acuity data does not exist – or at least not in a simple form that can be imported into a costing system. This has been the case at Guy’s and St Thomas’.

‘The current situation is that every day on a ward, the ward manager reviews the dependency of patients and records this in summary form,’ says Jeremy Brinley-Codd, associate director of finance at the trust. ‘The resulting nurse staffing requirement for this level of acuity is then compared to the planned staff numbers for the shift.’

If this indicates a material variance in staffing levels, an alert is sent to a senior nurse, who can investigate and a decision can be taken on whether more staff are needed (or even if staff could be temporarily reassigned to other parts of the trust to alleviate other pressures).

The trust has taken the Safer Nursing Care Tool – an acuity and dependency measurement tool developed by the Association of UK University Hospitals (AUKUH) – and developed a web-based data collection and reporting system around it.

At the heart of the tool is a classification system that groups patients on the basis of their nursing dependency. There are five levels of care described, ranging from level 0 (patient requires hospitalisation, needs met through normal ward care) through to level 3 (patients need advanced respiratory support and therapeutic support of multiple organs), with level 1 split into levels 1a and 1b. Levels 0, 1a and 1b are typically the levels that would apply to general wards.

The tool uses multipliers to turn the number of patients at the various levels into the required staff needed on the ward.

However, the problem for the Guys’ costing team has been that dependency levels have only been recorded at the ward level. What it required to allocate costs accurately to individual patients was the more granular information – patient-specific nursing dependency.

Minimising workload

Its vision was to develop a system that delivered this information without increasing the administrative burden of nurses and adding further clinical benefits where possible. It has worked with Albatross Financial Solutions to develop just such a system – known as the integrated patient acuity  monitoring system or IPAMS (left) – and is about to run a live pilot.

Under the old process, acuity assessments relating to different patients would be recorded on the ward’s patient information board. At handover to a new shift, the levels of dependency would be totalled and entered into the system to check against current and expected staffing levels. In the new system, the ward manager would instead see a screen on the IPAMS system pre-populated with all the patients currently on the ward (with this data pulled from the patient administration system). By default each patient would be allocated to level 0, indicating they have routine nurse dependency. All the manager has to do is to click on patients for whom this is not appropriate and select a higher acuity level.

To take account of patients who are discharged or admitted part way through a shift, with different acuity levels, the system includes both patients on the listing – enabling the costing team to allocate appropriate dependency weightings on the basis of hours in the ward, if it wants to go to this level of sophistication.

The system has been designed to impose a minimal additional workload on nursing staff. The only hiccup can be where the patient administration system isn’t current, meaning patients listed on the ward aren’t completely up to date. In these cases, the nurse manager has to add in minimum details of the new patients.

However, the system also incorporates additional features to enhance clinical services. For a start it provides an electronic mechanism for making patient-specific notes and passing these on at shift handover. Note-taking by nurses about to start the shift is a common activity. This system means there is a single set of handover notes and an audit trail for the things that are important. A further feature – known as the ‘Big four’ – provides a mechanism for delivering important messages across the whole nursing workforce. So for example if there had been a recall of certain needles, this could be communicated to all wards so that they could check ward cupboards at the start of the shift.

Mr Brinley-Codd says the trust is keen to understand  the impact of better acuity data on its own costs. In theory it could make a significant impact. Considering two patients with the same length of stay who are rated in the existing AUKUH tool as level 0 (normal dependency) and 1b (increased dependency), then allocating nursing costs without an adjustment for acuity could under-allocate costs to one patient by 40% and over-allocate by 40% to the other.

With ward costs accounting for an average 25% of total costs, this could mean that 10% of overall costs are being misallocated to the wrong patient. ‘We need to see how this plays out in practice,’ says Mr Brinley-Codd. However if it makes a material difference, then widespread adoption across the NHS could not only improve local cost data but lead to a tariff that more closely matches payment to the costs of delivery.

Cherry-picking concerns

Concerns have been raised by NHS providers that the current reimbursement system facilitates cherry-picking by private providers. While the healthcare resource group (HRG) tariff system recognises cost differences between different HRGs, the average price paid per HRG does not recognise the different complexity and costs of episodes within a single HRG. NHS providers suggest they often end up treating the more complex cases, yet receive the same tariff as private providers, which treat the lower complexity cases.

Sector regulator Monitor, in its recommendations to the health secretary in March on creating a fair playing field, believes the solution lies in ‘prices that reflect the actual costs of cases treated’.

Taking account of acuity would help in two ways. First, it should mean that HRGs better reflect actual costs – so a more complex HRG should include the higher nursing costs likely to go with it. But it could also help to highlight cost differentials within single HRGs, enabling HRGs to be split to better reflect complexity and cost.

‘We need to see how the pilot works out and then, hopefully, roll out across all wards,’ says Mr Brinley-Codd. ‘But the potential is to have a system that supports clinical practice, gives us more accurate cost data for local management and that could contribute to a more accurate tariff in future.’