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September 2011

Gloucestershire Hospitals NHS FT Case Study – Single Subject Reporting from ESR OLM

About the Trust Gloucestershire Hospitals NHS Foundation Trust is a large acute Trust that employs over 8,000 staff to provide a range of specialist services at Cheltenham General and Gloucestershire Royal Hospitals to a population of over 500,000 people. Introduction In 2009 the Trust’s system for recording training no longer met with their governance and assurance standards. Reporting by exception for independent assessment with the NHS Litigation Authority (NHSLA) for example was not possible. At the time there was low confidence amongst Managers in relation to the quality of the data, and overall compliance with statutory and mandatory training was static at around 60%, despite efforts to improve this. Understanding the benefits of the Oracle Learning Management (OLM) functionality within ESR, Julie Connell, Head of Induction and Mandatory Training and Diana Sheppard, Training Records Manager, established a project team to address the issues relating to data quality and improve compliance with statutory and mandatory training.

Their project, Single Subject Reporting using OLM would; • • • •

produce accurate and timely reports for Managers; streamline administrative processes; improve the overall compliance of statutory and mandatory training; provide assurance to the Trust Board and independent assessors around compliance with statutory and mandatory training.

Julie explains, “OLM within ESR provided us with an opportunity to change our reporting strategy. Our mandatory training portfolio comprised of over 30 mandatory training requirements encompassing annual, bi-annual and three year updates and up until now we hadn’t been able to report the status of individual employees or produce exception reports for managers”.

Gloucestershire Training Records Team Their approach “Once we had established a project team and developed a project plan there were a number of steps we were required to take. Firstly we had to scope what our reporting requirements were using OLM, set up local competencies and assure the quality of the data. Following this we designed a new report that could be easily used by Managers to proactively monitor and manage statutory and mandatory training. The reports provide Managers with a succinct summary that is RAG rated and enables them to very quickly take action with individuals who are not meeting their statutory and mandatory training requirements”.

The challenges The team had to deal with a range of challenges throughout the project:The culture change from face to face training to eLearning and the incorporation of training booklets was all part of the single subject reporting project. It was essential to have all the reporting streams in place from a data quality perspective before the first reports were produced. There were initial challenges from Managers about data quality. The challenges arose due to the new reporting system presenting them with a complete overview of the statutory and mandatory training compliance for their department. This amount of information had previously not been made available in such detail. Once the initial anomalies had been resolved managers acknowledged the accuracy of the new reporting system, the benefits of reporting of individual topics and the ease of use of the reports provided. The Benefits In March the Trust introduced Information Governance training and in May the topic was added to the reports to Managers identifying a need for all staff to complete this topic. The initial target nationally was to achieve 70%. Following the topic being included in the report our compliance dramatically increased to 59% which clearly demonstrated the reports effectiveness. Improved compliance with Safeguarding Children Level 1 has also been a success across the organisation. Paul Byrne, Director of Women’s and Children’s Division explains; “I have found the ESR OLM systems invaluable in monitoring levels of safeguarding compliance in the Trust in response to a recent OFSTED / CQC inspection which highlighted the need for a minimum of 80% of Trust staff to have basic safeguarding training. Reports were available upon request and noncompliant staff were then targeted on the basis of using the evidence in the reports. This had a significant impact on training numbers resulting in an improvement from 59% to a more recent figure of 91%. Single subject reports offered the operational framework to deliver this improvement in performance. From an operational management perspective the ability to have accurate timely reports on safeguarding and mandatory training areas greatly assists in ensuring that staff fulfil their professional training requirements and simplifies performance monitoring”. Julie adds; “Individual doctors who have not completed their safeguarding training are now being monitored using the reports and Paul has taken a very hands on approach to managing these individuals, which sends a very strong message to staff at all levels that non-compliance is not acceptable in our hospital”. The Trust’s corporate induction has also been streamlined. Julie explains; “Like many organisations we historically ran a full day for corporate induction

that included many statutory and mandatory training elements to it. By implementing OLM we have been able to strip out the statutory and mandatory training and have re-launched our corporate induction as a half day cultural induction with statutory and mandatory training for these staff being monitored through the new reporting system. This is first time we have really engaged clinicians to undertake their mandatory training. Through the Trust matrix and the new OLM reporting system clinicians have clear guidance on the topics they need to undertake and robust reporting that monitors their progress. Since these steps have been taken we have been encouraged by the steady increase in compliance for this staff group. The project enabled the Trust to provide robust evidence for their 2010 NHSLA assessment. “Where the assessor highlighted issues in relation to the Competent and Capable Workforce standards we were able to produce reports from within ESR OLM that provided the assessor with assurance that we had robust reporting and monitoring systems in place. These systems were supported by action plans to review our systems and processes and make improvements where necessary. We were delighted to achieve Level 2”. For Sharon Cornwell, Ward Sister, the benefits of the single subject reporting are clear. “When I first received the new style single subject reports I was impressed by the user friendliness and the impact they made visually. It was easy to use with the filters already set up so that I could choose to look at each member of staff, each topic or all outstanding topics. I used the summary report initially, printing it off and sticking it to the ward desk so that all the staff would be aware that I know who had topics outstanding and what those topics were. Subsequently I have filtered the report for each staff member and emailed them each a mini report. This allows staff to manage their own compliance, completing eLearning topics before they expire and booking face to face training events to ensure that they remain in date. In recent weeks the Trust has been prioritising completion of safeguarding and conflict resolution training and I have been able to target staff individually who were not compliant in these topics. I am really pleased that I have managed to increase compliance for my ward from 66% to 83% I plan to ensure that compliance is maintained by targeting staff with a status of ‘renew in next quarter’ for any topic and reminding them to book training”. Overall the Trust realised almost immediately a variety of benefits following their implementation OLM:

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The Trust now has a fully blended learning programme; The project has given some departments the incentive to encourage individual members of their team to develop new skills; for instance a Domestic Supervisor is now training other domestic staff in some topics of statutory and mandatory training in a drive to improve compliance; The project has engendered an element of healthy competition amongst Managers; As a result of the success of the project, they have stripped out inefficiencies where administrative staff were updating a variety of local databases to record training; All Managers now have confidence that the data is accurate and up to date allowing them to proactively manage non-compliance; The Trust can produce evidence from ESR for independent assessors such as the CQC within 30 minutes; The project has helped to significantly change the learning culture of the Trust, to one that is embracing and driven by both the benefits for staff and the business benefits; It has created centralised expertise and raised the profile of the Learning and Development Team; For the first time the Trust is taking Statutory and Mandatory training very seriously and there is a drive at all levels of the organisation to improve compliancy – even the CEO does it!

Advice to other Trusts “We have learnt a lot of valuable lessons along the way, but if I can give any tips to other organisations who are trying to tackle similar issue to ours they would be; Invest in a good skill set and make sure you have the right kind of IT knowledge and expertise so that you can use ESR to its full potential. We have a very talented team here and you cannot underestimate the value of having expertise and skills when working with complex relational databases. Take the time to carry out a detailed training needs analysis – this has to be done working very closely with subject matter specialists to ensure that they are very prescriptive about who needs to undertake the training and where relevant, what levels of training they need to complete. Make sure the competencies are assigned at the appropriate level in ESR. It may be quicker to assign competencies against organisations or roles, but we believe it is worth the extra time and effort to assign them against positions. Take the time to test the system to ensure the quality of the data at all stages. Demonstrate the benefits to your senior team and board colleagues, explain how it works and how it will benefit the organisation. This is crucial if you want to not only improve compliance, but also embed a blended learning programme and bring staff along on the journey with you. And finally staff will be more inclined to engage in their mandatory training if they know where to ask questions and where to get help. Managers will be

more inclined to use the reports to the maximum benefit if they can filter the reports to use them effectively and efficiently and easily understand them”.

The Future For Doctors and nurses particularly the current burden of statutory and mandatory training is quite onerous. The Trust is reviewing the full list of topics to identify where they can make possible changes to the frequency to ease this burden, but any changes will be made based on a full risk assessment. In terms of their next NHSLA assessment, one of the areas that requires further improvement relates to equipment competencies. This is something the team have offered to lead on and are currently preparing to run a pilot in two wards. They are currently developing a prototype report and will then roll this out across the Trust, starting with the Surgical Division followed by the other clinical areas in the Trust. Julie adds: “If we get the report right the project will run smoother, better and quicker. We anticipate the project to be completed in time for the NHSLA assessment in 2012. “Learning and Development and the single subject reporting system is now seen by all Trust Managers as a critical function within the Trust”. For more information If you would like to know more about the ESR OLM project within Gloucestershire Hospitals and the benefits they have realised please contact Diana Sheppard, Training Records Manager, on 08454 226873 or or Julie Connell, Head of Induction and Mandatory Training, on 08454 225115 or