Articles from Cass Knowledge

Software that could save hospitals millions

Research shows that electronic rostering could make inroads into the £150 million a year lost through workforce inefficiencies. Two Cass academics may have the answer, says Liz Hall.

Academics at Cass have developed software that could be the Holy Grail in drawing up staff rotas for hospitals. The state-of-the-art electronic rostering program devised by Celia Glass, Professor of Operational Research, and Roger Knight, a research fellow, has the potential to save the health sector millions of pounds by improving use of resources, slashing reliance on costly agency staff and reducing the risk of fines for breaching legal requirements such as the European Working Time Directive. NHS trusts with efficient electronic rostering (e-rostering) systems could save £500,000 a year while the NHS loses £150 million a year through workforce inefficiencies, according to a study by the market research and strategic consultants Pierre Audoin for SMART - a company that specialises in complex staff rostering - published in September 2010. Yet 54 per cent of NHS trusts do not have such systems in place, the study found. NHS Direct and the Centre for Better Managed Health and Social Care at City University London have highlighted several ways in which Professor Glass and Dr Knight's software would make a positive contribution. These include more appropriate use of resources (saving time and money and improving patient care); more sensitivity to business and patient needs; enhanced staff morale; improved decision-making and better industrial relations.

Challenging scenarios
Professor Glass and Dr Knight have created a tool that allows rosters for nurses and junior doctors to be drawn up in just a few minutes. To test it they took four widely publicised benchmark problems involving different numbers of nurses and shifts over different time spans and produced optimal rosters with the minimum number of undesirable shifts per employee. The software ensures shifts are fairly distributed and accommodates individual off-duty requests without the time-consuming "tinkering" associated with many existing electronic rostering systems. "The first thing about all this is that we can do it at all, scheduling efficiently without the need for agency staff, which is a very difficult problem," says Professor Glass, who draws on 30 years of experience in mathematical optimisation techniques and applications. Dr Knight has 25 years of experience in workforce management. Additionally, the program takes account of flexible contracts and holiday requirements, says Professor Glass. She adds: "The second thing is being able to accommodate personal preferences and ergonomic factors such as work design to ensure maximum fairness. It even goes down to the number of weekends worked so it's really, really fair. Junior doctors are not usually even asked what work they want and there's a lot of interest at that level. "When we realised we could satisfy the ergonomic [human factors] criteria and cover the work requirements with no additional staff, we were over the moon and the best thing is that it doesn't cost the employer any more. We thought there would be a massive trade-off but there isn't."

Financial penalties
Dean Fathers, Director of the Centre for Better Managed Health and Social Care, says the system would help the NHS to avoid wasting resources and to avoid hefty fines for non-compliance with regulations such as the working time directive. Health sector employers are particularly vulnerable to litigation, given the long hours worked and the stressful conditions faced by many medical staff. "Avoiding fines for non-compliance would enhance the UK's status as a [European Union] member state," he says. Helen Young, Executive Clinical Director and Chief Nurse at NHS Direct, agrees that inefficient rostering systems - manual or electronic - can result in financial penalties and clinical safety issues, "leaving the organisation and its executive team vulnerable to criticism and, ultimately, prosecution. "Shortage of staff is the issue but if this is happening whilst we have periods of over-staffing on a large scale this position becomes indefensible." Witnessing stark inadequacies drains staff morale, too, affecting "their satisfaction with their role and their ability to fulfil their role in the way they wish to," she says.

Significant breakthrough
In a four-month trial of the software in the accident and emergency department at the Horton General Hospital in Banbury, Oxfordshire, the rosters were able to accommodate almost all holiday requests. Professor Glass says: "Being able to grant half of holiday requests is generally considered to be a good outcome for junior doctors, so being able to accommodate all or almost all is a significant breakthrough." The rosters complied fully with the New Deal (a 1991 package of measures to improve the conditions for doctors in training, including - since August 2003 - a 56-hour limit on the working week), WTD and Health and Safety Executive guidelines. In the trial, the software - which so far remains unnamed - distributed fairly the number of hours worked, days on leave, weekends off and bank holidays. The number of consecutive night duties worked by any member of staff was reduced from seven to four and consecutive days from seven to five. Nobody was forced to work a late shift followed by an early shift. Professor Glass says: "[Previously] junior doctors were rostered to work long, unsociable stints, exacerbated by duty swaps to accommodate annual leave. There is a lot of unrest at that level, and tired doctors are not the safest." E-rostering is widely recommended by bodies such as the NHS Employers Organisation as a way to improve workforce productivity and to reduce reliance on costly agency staff, but has been slow to take off. Manual rostering by stressed matrons on busy wards is still common and poor rostering practice is widespread.

Arithmetical errors
Research* by Rhian Silvestro, Associate Professor of Operations Management at Warwick Business School and her husband, Claudio Silvestro, a management consultant, mathematician and partner in Adept Software, highlighted poor monitoring of contracted hours and annual leave, inequity in the allocation of shifts, careless editing of rosters, and arithmetical inaccuracies in adding up the total number of shifts. Their paper highlighted a raft of negative outcomes from poor roster design. These included costly over-manning; under-manning, compromising patient care and increasing stress levels; failure to offer flexible working conditions; excessive and costly use of agency and bank staff; inability of staff to integrate their home and professional lives; low morale and poor relations between management and staff; absenteeism; high staff turnover and a poor employer reputation, making it difficult to attract new staff. Helen Young reports** that directors of nursing across NHS Direct say that manual rostering is very labour intensive (and therefore often expensive in labour terms) and that it can become unmanageable on a large scale. It is also inefficient and can be less sensitive to business and patient needs resulting, for example, in too many or too few staff being on duty. But the directors stress that some e-rostering systems can be inefficient, too, with "lots of post-build checks and interventions/changes to make the rota fit for purpose. Therefore any savings made would be lost again in providing staff to redraw the rota."

Staff retention
"One of the biggest savings is simply the time it takes somebody to do the roster - this is crucial. It takes one to four days a month," says Professor Glass. Giving employees more control over their working lives has the potential to increase staff retention. "It will bring benefits to lifestyle and patient care," says Professor Glass. "There is a lot of evidence that national strategies for improving [staff] retention, such as the Improving Working Lives initiative***, are frustrated by poor rostering at ward level." Fathers says: "One of the things that I perceive about this system is that it will allow people to operate in a way where they are making better decisions which will cost the organisation less."

*Towards a Model of Strategic Roster Planning and Control: An Empirical Study of Nurse Rostering Practices in the UK National Health Service (2008). Rhian Silvestro and Claudio Silvestro, Health Services Management Research 21, Royal
Society of Medicine Press.
**Helen Young surveyed NHS Direct directors of nursing in November 2010 on behalf of InBusiness.
***Department of Health, visit

Liz Hall is a freelance journalist.