Emergency Care WorkforceEmergency Care Workforce Literature Review

Prof John Buchanan

Catherine Raffaele

Workplace Research Centre

University of Sydney Business School

Catherine Raffaele

Guiding questions + structure of the sessiong q

› What does the literature reveal ?- Lessons from research + WRC processing of it

› What is the most useful way of defining challenges?- ECI small group discussion => insights + suggestions for improvement- ECI small group discussion => insights + suggestions for improvement

What options appear to be worthy of more detailed consideration?› What options appear to be worthy of more detailed consideration?- ECI’s considered recommendations after a further round of consultation

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Outline for todayy

› Method› Findings from the literature› Findings from the literature

- Specifics

- Understanding the connections, not just specific ‘problems’

- External environment

- Immediate operational context

L b- Labour management arrangements

› Small group discussion (after the break)› Small group discussion (after the break)- Three ‘sphere of influence’

› Reporting back => input into recommendations from the lit review

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Key messagesy g

› ED workforce problems are systemic + not isolated› ED workforce problems are systemic + not isolated

› Ideally need to shift the trajectory of evolution, but change is possible y j y , g pwithin current trajectory

Th h di i ‘ h f i fl ’ h ECI› There are three distinct ‘spheres of influence’ open to the ECI

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Methodologygy

› The literature review consisted of two linked parts:- A literature search

- E D workforce in UK, USA, Canada and NZ (+ Aust).

- future of the health workforce- future of the health workforce.

- skills eco-systems and workforce development.

- workforce engagement and sustainability

- Literature discovery interviews with key stakeholders and experts (n=33).

› A reference group advised on the above

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Literature Search

Included Literature English language

The following specifications were determined prior to the search:

Included Literature English languagePeer reviewed journal articles‘Grey’ literature (e.g. policy reports and discussion

papers)Published researchUnpublished research that is available to the public (e.g.

downloadable from an organisation’s website)Literature from 2000 onwardsLiterature from 2000 onwards

Cover all occupational groups- Most comprehensive documentation on doctors,

d i lli d h l hpoorest documentation on allied health

Excluded Literature Not English languagePre 2000 literature unless deemed to be seminal and stillPre-2000 literature unless deemed to be seminal and still relevantLiterature outside of scope

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Key Problemsy

› Access Block and overcrowding

Literature and Interviews indentified:

› Access Block and overcrowding› Increased complexity from ageing population› Ageing ED workforce› Recruitment + retention difficulties

- high level of part time work misrepresents actual FTE available

› Intern/trainee burden on ED› Intern/trainee burden on ED› Insufficient time and prioritisation of skills development› Concerns about non-technical skills: eg leadership, team work› Uncertainty about optimal staffing ratios, staff mix for patient safety› Limited funding to implement initiatives

R l d i l f t h ll› Rural and regional areas face greater challenges

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Lessons from successful interventions

› Importance of team leadership + training in team work for physicians

Numerous examples:

› Importance of team leadership + training in team work for physicians, nurses + allied health (North American Studies)

› Effective recruitment and retention programs for nurses (Alberta Canada)

M l i f I i E (M li Q l d)› More learning for Interns in Emergency (Molie, Queensland)

Successful initiatives addressed SYSTEMIC problemsSuccessful initiatives addressed SYSTEMIC problems

› Problems not seen as ‘isolated issues’

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Our key findingy g

› Systematic approaches

Need to ‘move beyond the fragments’

› Systematic approaches- Dynamic system modelling has been found to explain common problems in service

industries- The simulation results show that service organizations are vulnerable to a wide

f lf i f i th t t d th i l I h thrange of self-reinforcing processes that can act as death spirals. In each case, the short-term benefits of an action, whether overtime, corner-cutting, service standard erosion or hiring, can trigger harmful long-term effects that either lead to insufficient capacity, drive away customers, or reduce the organization’s budget, forcing further service capacity erosion. (Oliva and Sterman, 2010)p y ( , )

- Alternative is the nurturing of “virtuous cycles” ~ key to this is the maintenance of a reserve margin of capacity.

- Skills ecosystem analysis has identified that a range of practices can systematically combine to lead to skills atrophy or growth in a range of industries (e.g. IT, manufacturing and health care)

› Lack of evaluated systemic interventions

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Systemic factors shaping ED workforces todayy p g y

(a) External environment(a) External environment- Social, economic + policy changes

(b) Immediate operational context- Physical design, links to rest of hospital + external social services

(c) Labour management arrangements- How labour requirements are defined + organisedHow labour requirements are defined + organised

- How labour is developed

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(a) External Environment( )

i Social changesi. Social changes- Aging population

- Drug/alcohol use

ii Economic changes- Deepening inequality and access to health care

iii Policy changesiii Policy changes- Entrenching of the ‘new’ public management

• Manage by results/outcomes

• Cost control defined independently of service quality as key concern

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(b) Immediate Context – elements of the problem( ) p

› Geographical contextR l d i l- Rural and regional

› Physical Design of the ED

› Integration of the ED within the hospitalAccess Block- Access Block

- NEAT/4 Hour Rule

› External facilities- aged care facilities

- mental health services

- social services

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(b) Immediate operational context - initiatives( ) p

› Rural clinical schoolsExposure to rural settings increased later willingness to work in such settings- Exposure to rural settings increased later willingness to work in such settings

› 4 Hour Rule Program (WA)- Recognised that solving Access Block could not be done solely in the ED- A whole-of-hospital approach- Incentives to reward successes not failuresIncentives to reward successes not failures- Examination of systems across the hospital that created bottlenecks.- Dramatic improvements to patient outcomes: eg patient treatment times- Not problem free: increased workload + stress, reduced teaching opportunities

- Pre-conditions: high performing organisational culture requires clear shared values, transparency and strong leadership

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(c) Labour management arrangements - elements( ) g g

(i) How labour requirements are defined + deployed(i) How labour requirements are defined + deployed

(ii) How labour is developed( ) p

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(c) Labour management - How are skills defined? ( ) g

- Technical Dimension

Three dimensions of skill (Mounier, 2001)

- Technical Dimension- Cognitive Dimension- Behavioural Dimension

Technical- Priority is on technical skillsy- Development of new roles to improve ED efficiency and flow

- Nursing roles with greater scope and responsibility e.g. Nurse PractitionerN di l t ff l t li li i l t ff f d i i t ti i ti- Non-medical staff roles to relieve clinical staff of administrative, communication and other non-medical tasks e.g. Technical Assistant role

- Physician’s AssistantU f Alli d H lth l t i ti t t d fl- Use of Allied Health roles to improve patient outcomes and flow

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(c) Labour management - How are skills defined? ( ) g

› Cognitive

The technical dimension is the only dimension of skill

› Cognitive- English language competency

- Contexts that facilitate or hinder cognitive function: busy environments, multitasking, noise, sleep and working hours

- Decision making skills and strategies

› Behavioural- Leadership

- Communication

- Teamwork

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(c) Labour management – Initiatives in redefining skill requirementsq

› Morey et al (2002)› Morey et al. (2002)- Nine teaching and community hospital EDs in US (experimental group = 684

physicians, nurses, and technicians). Formal teamwork training found to significantly improve team behaviours, reduced errors and improved staff g y p , pattitudes

› Kalisch et al. (2007)- Intervention to improve nursing staff teamwork and engagement foundIntervention to improve nursing staff teamwork and engagement found

significantly lower patient fall rate, staff ratings of improved teamwork on the unit, and lower staff turnover and vacancy rates.

› Yeung et al. (2012)- Teams led by leaders with the best leadership skills performed higher quality

cardiopulmonary resuscitation with better technical performance.- Prior training in team leader skills was independently associated with better

leadership behaviour.

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(c) Labour management arrangements –How are staffing levels defined and met?g

› Defined› Defined- Difficulties in establishing minimum numbers and ratios

- EDWAT: every site is different and recognition of similar contexts

- Models of care – implementation is not standardised

- Issues around FTE accuracy

› Meeting required staff levels- Lack of proactive initiatives for recruitment and retention

- Better information needed on preferences, motivations and career pathways onBetter information needed on preferences, motivations and career pathways on potential recruits and existing staff

- The problem of locum employment in Depts in NSW Public Hospitals

Reliance on overseas trained workforce without adequate support and- Reliance on overseas trained workforce without adequate support and recognition

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(c) Lab management – Staff levels – Initiatives to improvep

› Ramsay Health Care› Ramsay Health Care- Employee Wellness Initiatives- CEO led wellbeing initiatives embedded in HR- Staff wellbeing recognised as essential to quality patient outcomes- Reported improved retention and staff engagement and decreased recruiting and

on-boarding costs

› Queensland Health: - Dedicated website for recruiting emergency medicine physicians- Supervised Practice for Overseas Trained Specialists (SPOTS) program toSupervised Practice for Overseas Trained Specialists (SPOTS) program to

attract and train overseas trained specialists

› Alberta, CA –Nursing Retention and Recruitment Programs Evaluation7 programs post hoc evaluation found higher satisfaction increased morale- 7 programs, post-hoc evaluation found higher satisfaction, increased morale, decreased stress and perceived improved ability to provide high-quality care

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(c) Labour management - How is skill reproduced?( ) g p

› Inadequate time and supervision for training and development

Skills Development and Training

› Inadequate time and supervision for training and development- In one study, ED Directors (n=23) “identified a problem with reduced on-the-job

support, supervision and training as a result of high workloads and low FACEM numbers Out of hours working further reduced the time and energy available tonumbers. Out-of-hours working further reduced the time and energy available to Registrars for study in non-work time.” (Wise and Buchanan, 2007)

› Inadequate resources for intern influx

› Shortage of FACEMs limits training of new specialists

› Little research on what are the best ways to train emergency physicians

› Need for rural/regional specific training› Need for rural/regional specific training

› Need to develop clearer training and career development pathways that are co-ordinated with recruitment and retention planning – government, colleges, universities need to work cooperatively

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(c) Labour management – staff development - Initiatives

› Qld More Learning for Interns in Emergency (MoLIE) project› Qld More Learning for Interns in Emergency (MoLIE) project- hiring additional staff and organising schedules to ensure that the interns had 8

hours per week of “off the floor” structured learning time supervised by consultantsconsultants

- “Overall, the 90 interns surveyed were highly satisfied with their training. Most agreed or strongly agreed that the sessions were relevant and covered the right mix of clinical and professional issues Most of the 12 senior staff surveyed feltmix of clinical and professional issues. Most of the 12 senior staff surveyed felt that the participating interns performed slightly or much better than interns in previous years, and that their experience as supervisors and overall patient care were improved.” (Brazil et al, MJA, 2011)

› Rural specific short courses and postgraduate courses

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Conclusions

› Immediate problems literature documents many› Immediate problems – literature documents many => can generate a shopping list of ailments.- Stress and burnout in ED, turnover, under-investment in staff development

› Evidence on most successful interventions highlights importance of making the links

› Key finding of the project: need to understand underlying systemic problems not just individual EDs or isolated problemsproblems not just individual EDs or isolated problems => a systematic or skill eco-system approach

- Death spirals vs- Virtuous cycles (built around a strategic margin of reserve capacity).

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Implicationsp

› Systemic forces are strong but not totally overwhelming

› There are three spheres of influence

- what can be done within them?

( ) E l i l d li i(a) External, social and policy environment

(b) Immediate Operational context

(c) Labour management arrangements• Development of labourDevelopment of labour• Deployment of labour

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Preliminary Recommendationsy

› Acknowledging the systematic nature of problems agreeing to find

Short Term

› Acknowledging the systematic nature of problems – agreeing to find systematic solutions Explicit commitment by leaders, esp at hospital and higher levels

R iti f t ff llb i i t l t lit ti t t› Recognition of staff wellbeing as integral to quality patient outcomes Explicit commitment by leaders, esp at hospital and higher levels

› NEAT/4 hour rule targets to initiate review of whole-of-hospital issues that lead to access block – not expecting all problems to be solved in ED e.g. Royal Perth created process maps of systems across the hospital to identify

and classify issues relevant to patient flow. But processes not enough - Prof Frank Daly: “If I was to do it again I would start with an analysis of the hospital’sFrank Daly: If I was to do it again I would start with an analysis of the hospital’s organisational culture.”

› Prioritise behavioural skills when recruiting new staffF ilit t b h i l kill t i i f i ti t ff› Facilitate behavioural skills training for existing staff

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Preliminary Recommendationsy

› Develop proactive and systematic approaches to recruitment

Medium Term› Develop proactive and systematic approaches to recruitmentCreation of a centralised unit for workforce planning, situated in government with industry body

and training institution representationCreation of centralised recruitment initiatives e.g. ED staff recruitment portal Coordinate with universities to ensure training optimises opportunities for targeting identified

priorities (e.g. specialisation, rural exposure, behavioural skills) + collect and use data on student preferences and trends to inform workforce planning and recruitment initiatives

› Develop proactive and systematic approaches to retentionCentralised workforce planning unit to plan, coordinate and facilitate retention initiatives Collect better data to understand workforce trends and preferences e.g. More accurate FTE data,

tracking geographical and career pathwaysDevelop staff feedback channels (e.g. surveys) to measure engagement and identify potentialDevelop staff feedback channels (e.g. surveys) to measure engagement and identify potential

problemsCreation of staff wellbeing KPIs for management accountability (measures can include

engagement survey results, retention)Build embedded wellbeing initiatives in HR, with genuine executive buy-in. E.g. Creation of aBuild embedded wellbeing initiatives in HR, with genuine executive buy in. E.g. Creation of a

wellbeing officer located in HR.

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› Better planning of in hospital training

Medium Term cont.

› Better planning of in-hospital trainingQuarantined time for learning and development

Structured responses to intern training load e.g. MOLIE initiative

› Coordinated Training PathwaysCentralised workforce planning unit to improve coordination of training pathways

with recruitment and retention goalswith recruitment and retention goals

Use of training to support recruitment initiatives e.g. Rural Clinical Schools

Development of rural/regional specific qualifications

Development of postgraduate courses for career and skills development

› Better support Internationally Trained WorkforceP t t d t i lifi d l f NSW ttiPrograms to mentor and train overseas qualified personnel for NSW settings

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Preliminary Recommendationsy

› Develop better coordination between government professional bodies and training

Long Term

› Develop better coordination between government, professional bodies and training institutions

› Funding needs to support identified initiatives

› Structuring budgets to value and maintain a strategic margin of reserve capacity› Structuring budgets to value and maintain a strategic margin of reserve capacity

› Development of KPIs that assess systematic performance

› Development of high performing workplace cultures is a long term commitment

D l t f t t ti lit i t d t bilit› Development of systems to ensure continuous quality improvement and accountability

› Systematic approach to the development and evaluation of new ED roles and models of care

› Development of ongoing research to better understand career pathways and how ED› Development of ongoing research to better understand career pathways and how ED staff can be better supported across the pathway

› Further research on how to best teach and develop the skills of ED staff

› Further research on the cognitive contexts and how EDs can be designed to support› Further research on the cognitive contexts and how EDs can be designed to support and not diminish cognitive function

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Don’t forget importance of changing the trajectory of evolutionj y

› The importance of defining principles:› The importance of defining principles:- Cost minimisation/working to budget limits vs

- Maintaining a strategic margin of reserve capacity.

› Be realistic about what change can occur within ‘death spiral’ cycle/trajectory

Improvements are possible but are constrained- Improvements are possible, but are constrained

- Lasting change requires changing the cycle/trajectory, not just one or two elements of it.

- Such change requires a encompassing and widely supported change coalition

- Maintenance of ‘strategic margin of reserve capacity’ must be at the centre of such program.

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An example of our approach- skill eco-systems + understanding changing skill requirementsg g g q

Fuels new revitalised Scenario A:

U d S i l

“Farmers eating their seeds”

growth path

Breakdown Implications:

Upward Spiral•‘Turning the tide’•Building new capacity

Excess capacity

Intense competition

Skill impacts•Direct

seeds” in on + off job training

:(i) limited capacity to handle:•New skill requirements

capacity•Modernising existing capacity

capacity competition •Direct•indirect

New organisation

Changing role of large

q•Established skill requirements(ii) Victorian innovation

id f t

Scenario B: Downward

organisational forms

workplaces provide future pointers Spiral: steady

slide of manufacturing