BRINGING YOUR NURSE STAFFING COMMITTEE TO LIFE: Staffing, Scheduling

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BRINGING YOUR NURSE STAFFING COMMITTEE TO
LIFEStaffing, Scheduling Budgeting for the
Bedside Clinician

• Cathe Clapp, RN, MN
• Barbara Hyland-Hill, RN, MN, CNAA-BC

June 22, 2010 - Wenatchee June 23, 2010
Spokane June 24, 2010 Renton July 14, 2010 -
Lynnwood
Ruckelshaus Nurse Staffing Steering Committee
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WA State Staffing Legislation House Bill 3123
(2008)

• All hospitals must establish a Nurse Staffing
  Committee
• Composition at least 50 direct care nurses
• Create staffing plans
• If the CEO does not adopt staffing plans, must
  provide written explanation
• Staffing plans must be posted in public area
• Collect data on 5 NSQI and submit to WSHA
• Report nurse staffing with adverse events
  reporting

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Our Objectives

• Provide you with basic concepts about
• Budgeting (Staffing/Labor Budget)
• Staffing and Scheduling
• Nurse Sensitive Indicators
• Staffing Committee Effectiveness
• Have you apply the concepts
• You leave with a toolkit (tools and resources)
• You will be able to share your learnings with
  your committee members (Train the Trainer)

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Agenda

• Budgeting 101
• Staffing and Scheduling Made Simple
• Nurse Sensitive Indicators for Dummies
• Making the Staffing Committee Work
• Putting It All Together Case Application

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Budgeting 101
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Personal Budget

• Income
• Salary Pay check
• Interest/investment earnings
• Expenses
• House payment or rent
• Utilities
• Food
• Insurance
• Car payment
• Gas
• Etc

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What is a budget?

• A Plan
• Coordination of revenue and expenses
• Specific period of time usually 1 year
• Formalized ? written down
• Forecast the future

An Educated Guess
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Functions of the Budget

• Financially operationalize an organizations
  goals and objectives
• Keep management informed
• Evaluate performance
• Refine program development and plan
• Educate
• Increase cost awareness

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Budgeting Process

• Understand your organizations process, forms,
  timeline, terminology, fiscal year
• Planning
• Department Goals Objectives
• Projected Units of Service (Volume and Acuity)
• Preparing
• Monitoring and Controlling
• Reporting

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Staffing Budget(Labor, Personnel, Manpower)
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Basic Concepts Units of Service

• Unit of Service (UOS) measure of product or
  service produced by the department
• For Nursing Departments
• Inpatient Units Patient Days
• Outpatient Units Visits
• Emergency Department Visits
• Surgical Units Procedures (Major Minor)
• Minutes
• Labor Delivery Deliveries
• Procedures (Ante partum)
• OP Oncology Treatments

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The Story of Your Unit

• Who are your patients?
• DRG, age, drugs/therapies/treatments used
• What are their needs?
• Acuity, severity of illness
• What are your hours of operation?
• 24/7
• Other Mon-Fri, 8 am 5 pm
• Collect information on
• Volumes
• Length of stay
• ADT ratio/churn factor
• Number of procedures
• Do you have outpatients or 23-hour stay patients?
• Is the census done at midnight?

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Basic Concepts Nursing Hours
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Required Care Hours

• Projected UOS volume
• Determination of workload hours
• Direct nursing care hours per pt day (or UOS)
  standard
• Patient Classification System Case Mix
• Desired Fixed Staffing Coverage

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Basic Concepts - FTEs

• FTE Full Time Equivalent
• Equivalent of 1 full-time employee working for 1
  year
• 1.0 FTE 2080 hrs/yr (8 hrs X 5 days X 52 wks)
• 40 hrs/wk (8 hrs X 5 days)
• 80 hrs/2 wks (8 hrs X 10 days)
• FTEs are converted to positions which are filled
  by employees

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Workload Hours - DNCH
General Medical Unit General Medical Unit General Medical Unit
Bed Capacity 36
Pt Days (UOS) 11,790
ADC occupancy 32.3 89.7 11,790 pt days/365 days 32.3 ADC/36 beds X 100
DNCH/UOS 8.14 Standard
DNCH Required/Yr FTES 95,971 46.1 11,790 pt days X 8.14 DNCH 95,971 hrs/2080
DNCH Required/Day Staff 262.93 32.9 32.3 ADC X 8.14 DNCH 262.93/8 hr shifts
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Workload Hours - Acuity
Pt Acuity Level DNCHPPD Pt Days Workload Hours
1 3.0 1,061 3,183
2 5.2 3,675 19,110
3 8.8 4,876 42,909
4 13.0 1,704 22,152
5 18.2 474 8,627
Total 11,790 95,981 DNCH 46.1 FTEs

X
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Workload Hours - Fixed
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Workload Hours - DNCH
General Surgical Unit General Surgical Unit General Surgical Unit
Bed Capacity 32
Pt Days (UOS) 10,760
ADC occupancy pt days/365 days ADC/36 beds X 100
DNCH/UOS 7.82 Standard
DNCH Required/Yr FTES pt days X DNCH DNC hrs/2080
DNCH Required/Day Staff ADC X DNCH DNC hrs/8 hr shifts
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Workload Hours - DNCH
General Surgical Unit General Surgical Unit General Surgical Unit
Bed Capacity 32
Pt Days (UOS) 10,760
ADC occupancy 29.5 92 pt days/365 days ADC/36 beds X 100
DNCH/UOS 7.82 Standard
DNCH Required/Yr FTES 84,143 40.5 pt days X DNCH Yearly DNC hrs/2080
DNCH Required/Day Staff 230.69 28.8 ADC X DNCH Daily DNC hrs/8 hr shifts
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Workload Hours - Allocation

• Staffing Model
• Total pt care, Team, Modular, Primary Care,
  Partnership (Dyad)
• RN, LPN, NA-C
• Length of shifts 8, 10, 12 hr
• care allocated per shift

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Required DNC Staff Per Day
General Medical Unit ADC 32.3 DNCH 8.14 Required Hrs 262.93 Required staff 32.9 General Medical Unit ADC 32.3 DNCH 8.14 Required Hrs 262.93 Required staff 32.9 General Medical Unit ADC 32.3 DNCH 8.14 Required Hrs 262.93 Required staff 32.9 General Medical Unit ADC 32.3 DNCH 8.14 Required Hrs 262.93 Required staff 32.9 General Medical Unit ADC 32.3 DNCH 8.14 Required Hrs 262.93 Required staff 32.9
(Hrs by shift) Days 40 (105.17) Eve 30 (78.88) Nights 30 (78.88) Total (by skill mix)
RN (71) 9.3 (105.17 X .71/8) 7.0 (78.88 X .71/8) 7.0 (78.88 X .71/8) 23.3
LPN
NA-C (29) 3.8 (105.17 X .29/8) 2.9 (78.88 X .29/8) 2.9 (78.88 X .29/8) 9.6
Total (by shift mix) 13.1 9.9 9.9 32.9
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Required DNC Staff Per Day
General Surgical Unit ADC 29.5 DNCH 7.82 Required Hrs Required staff General Surgical Unit ADC 29.5 DNCH 7.82 Required Hrs Required staff General Surgical Unit ADC 29.5 DNCH 7.82 Required Hrs Required staff General Surgical Unit ADC 29.5 DNCH 7.82 Required Hrs Required staff General Surgical Unit ADC 29.5 DNCH 7.82 Required Hrs Required staff
(Hrs by shift) Days 40 Eve 35 Nights 25 Total (by skill mix)
RN (71)
LPN
NA-C (29)
Total (by shift mix)
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Required DNC Staff Per Day
General Surgical Unit ADC 29.5 DNCH 7.82 Required Hrs 230.69 Required staff 28.8 General Surgical Unit ADC 29.5 DNCH 7.82 Required Hrs 230.69 Required staff 28.8 General Surgical Unit ADC 29.5 DNCH 7.82 Required Hrs 230.69 Required staff 28.8 General Surgical Unit ADC 29.5 DNCH 7.82 Required Hrs 230.69 Required staff 28.8 General Surgical Unit ADC 29.5 DNCH 7.82 Required Hrs 230.69 Required staff 28.8
(Hrs by shift) Days 40 (92.28) Eve 35 (80.74) Nights 25 (40.95) Total (by skill mix)
RN (71) 8.2 (92.28 X .71/8) 7.2 (80.74 X .71/8) 5.1 (40.95 X .71/8) 20.5
LPN
NA-C (29) 3.3 (92.28 X .29/8) 2.9 (80.74 X .29/8) 2.1 (40.95 X .29/8) 8.3
Total (by shift mix) 11.5 10.1 7.2 28.8
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Required DNC FTEs Per Year
General Medical Unit UOS 11,790 DNCH 8.14 Required Hrs 95,971 Required FTEs 46.1 General Medical Unit UOS 11,790 DNCH 8.14 Required Hrs 95,971 Required FTEs 46.1 General Medical Unit UOS 11,790 DNCH 8.14 Required Hrs 95,971 Required FTEs 46.1 General Medical Unit UOS 11,790 DNCH 8.14 Required Hrs 95,971 Required FTEs 46.1 General Medical Unit UOS 11,790 DNCH 8.14 Required Hrs 95,971 Required FTEs 46.1
Days 40 Eve 30 Nights 30 Total (by skill mix)
RN (71) 13.1 9.8 9.8 32.7
LPN
NA-C (29) 5.4 4.0 4.0 13.4
Total 18.5 13.8 13.8 46.1
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Required DNC FTEs Per Year
General Surgical Unit UOS 10,760 DNCH 7.82 Required Hrs Required FTEs General Surgical Unit UOS 10,760 DNCH 7.82 Required Hrs Required FTEs General Surgical Unit UOS 10,760 DNCH 7.82 Required Hrs Required FTEs General Surgical Unit UOS 10,760 DNCH 7.82 Required Hrs Required FTEs General Surgical Unit UOS 10,760 DNCH 7.82 Required Hrs Required FTEs
Days 40 Eve 35 Nights 25 Total (by skill mix)
RN (71)
LPN
NA-C (29)
Total
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Required DNC FTEs Per Year
General Surgical Unit UOS 10,760 DNCH 7.82 Required Hrs 84,143 Required FTEs 40.5 General Surgical Unit UOS 10,760 DNCH 7.82 Required Hrs 84,143 Required FTEs 40.5 General Surgical Unit UOS 10,760 DNCH 7.82 Required Hrs 84,143 Required FTEs 40.5 General Surgical Unit UOS 10,760 DNCH 7.82 Required Hrs 84,143 Required FTEs 40.5 General Surgical Unit UOS 10,760 DNCH 7.82 Required Hrs 84,143 Required FTEs 40.5
Days 40 (33,658) Eve 35 (29,450) Nights 25 (21,035) Total (by skill mix)
RN (71) 11.5 (33,658 X .71/2080) 10.1 (29,450 X .71/2080) 7.2 (21,035 X .71/2080) 28.8
LPN
NA-C (29) 4.7 (33,658 X .29/2080) 4.1 (29,450 X .29/2080) 2.9 (21,035 X .29/2080) 11.7
Total 16.2 14.2 10.1 40.5
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Non-Productive Hours

• Coverage for anticipated time off (backfill or
  replacement)
• How does your organization define Non-Productive
  Hours?
• PTO, Vacation, Sick Leave, Holiday, Bereavement,
  FMLA, Education/Professional
• What categories of staff must be replaced
• RN, LPN, NA-C, HUC, Monitor Tech, Surgical Tech,
  etc

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Non-Productive Hours

• How does your organization budget for
  Non-Productive coverage?
• Ave of non-productive time
• Vacation 15 days
• Holiday 9 days
• Average sick 6 days
• Education 2 days
• 32 days 256 hrs (8 hr shift)
• 2080 - 256 1824 prod DNCH
• 256/1825 14
• 46.1 DNC FTEs X 1.14 52.6 46.1 6.5 NP FTEs

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Non-Productive Hours

• How does your organization budget for
  Non-Productive coverage?
• Calculate by category of staff replaced and type
  of NP time
• Vacation
• Sick leave
• Holiday
• Education/Professional leave
• days by staff category X 8 hours X DNC FTE
• 2080

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Productive Fixed Staff

• Positions whose hours are set and do not adjust
  with pt census, volume or acuity
• Manager, CNS, Unit-based educator
• Health Unit Coordinator, Monitor Tech
• Need to know
• of days/week and shift coverage
• Are they replaced when off?

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Non-Productive Impact
FTE NP NP FTE Total FTE
Manager 1.0 - - 1.0
RN 32.7 14 4.6 37.3
NA-C 13.4 14 1.9 15.3
HUC 2.8 14 .4 3.2
Total 49.9 6.9 56.8
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Indirect Care Hours

• Paid, worked hours related to unit/dept function
• Orientation
• Inservice education CPR, mandatory education
• Staff meeting time
• Shared governance meetings
• Committee time/work
• QA, Clinical Pathways, Standards, etc

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Indirect Care Hours

• Calculated by type of activity by skill mix
• staff X hrs X times hrs
• Orientation
• Turnover by category
• Anticipated Retirements
• Ave days oriented
• New graduates
• Do you take?
• Do you have a Residency Program? How long is it?
• Are the new graduates hours expensed centrally or
  to unit?

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Indirect Care Hours
Indirect Productive Hours Indirect Productive Hours Indirect Productive Hours Indirect Productive Hours Indirect Productive Hours
   Annual Hrs Staff Total Hours  FTE
Education and Meetings      
RN Education Meetings 40 64 2,560 1.2
NA-C Education Meetings 20 32 640 .3
HUC/MT Education Meetings 20 7 140 .1
Subtotal 1.6
Orientation
RN (average days 15) 120 5 600 .3
NA-C (average days 10) 80 4 320 .2
HUC (average days 15) 120 1 120 .1
Subtotal .6
 Total      2.2
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Staff Per Day FTE Budget
Direct Care Staff/Day 32.9
FTEs
Direct Nursing Care 46.1
Fixed Staff 3.8
14 Non-Productive 6.9
Indirect Time 2.2
Total Paid FTEs 59.0



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Premium Pay

• Shift differential
• Weekend differential
• Charge nurse, certification, preceptor
  differential
• Overtime
• Standby and call back pay

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Basic Concepts Hours Per UOS

• UOS are compared in a ratio to paid or direct
  hours required to deliver the service or product
• Common Productivity Standard in Nursing
• Nursing Hours Per Pt Day (HPPD)
• Direct Care Hours
• Productive Hours Paid/UOS
• Total Hours Paid/UOS

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Basic Concepts Formulas

• Average Daily Census (ADC)
• Total pt days
• of days (week, month, year)
• Average Length of Stay (ALOS)
• Total pt days
• of discharges
• Percent Occupancy
• Total pt days Census or ADC
• Total bed days available Beds available

or
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Basic Concepts Formulas

• Total Direct or Total Productive Hrs/UOS
• Total direct or productive hrs
• Patient days or UOS
• Total Paid Hours/UOS
• Total paid hrs
• Patient days or UOS

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Basic Concepts Formulas

• Average Hourly Rate
• Total salary
• Total hours paid
• Total Productive Salary Expense/UOS
• Total productive salary
• Patient Days or UOS
• Total Salary Expense/UOS
• Total productive salary
• Patient Days or UOS

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Sample Cost Center Report
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Basic Concepts Variance Analysis

• A variance is the difference between the Budgeted
  amount and the Actual results
• Favorable versus Unfavorable variance
• Variance analysis is a component of budget
  monitoring to investigate and explain why
  differences occurred
• Individual manager accountability for budget
  variances

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Basic Concepts Variance Analysis

• Flexible Budget Variance Analysis
• Variance is a function of
• Volume (output) (Patient Days or UOS)
• Price or Rate (Ave Hourly Rate)
• Quantity or Use (Nursing Hours Used)
• f (Volume Quantity Price)

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Basic Concepts Staffing Costs

• What affects Staffing Costs?
• Volume (UOS)
• Total Hours Paid
• Direct Care Hrs Pt Acuity, ADT ratio, staffing
  to matrix
• Indirect Care Hrs Orientation of new staff,
  mandatory inservices or meetings
• Non-Productive Hrs Sick leave, vacation, FMLA,
  holiday
• Average Hourly Rate Paid
• Overtime or premium pay situations
• Registry or Traveler use
• Skill mix used

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Staffing and Scheduling Made Simple
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Creating Position Control and Schedules

• DEMAND
• Patient Type
• Patient Volume and Acuity
• Demand Variations (churn, time of day, days of
  week, months, seasons)
• RESOURCES
• Roles (Fixed and Variable)
• FTE Mix
• Days of the week
• Shifts

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Staffing Model

• Revisit, or build from the ground up, so allows
  manager and staff to understand all of the
  elements of staffing and resource use
• Start with budgeted average daily census
  (DEMAND) and the direct care staff FTE budget
  (RESOURCES)

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From Budget to a Balanced Schedule you need

• Unit Census and FTE Budget
• Staffing to Census (and Acuity) Matrix
• Core Daily Staffing Model (at census or occupancy
  target)
• Add in Non Productive FTEs
• Position Control (Personnel Budget)

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Indirect Care Hours

• Paid hours related to unit/dept function not in
  DNCHs
• Orientation
• Inservice education CPR, mandatory education
• Staff meeting time
• Shared governance meetings
• Committee time/work
• QA, Clinical Pathways, Standards, etc

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Staffing Model
Indirect Productive Hours Indirect Productive Hours Indirect Productive Hours Indirect Productive Hours Indirect Productive Hours
   Annual Hrs Staff Total Hours  FTE
Education and Meetings      
RN Education Meetings 40
CNA Education Meetings 20
USMT Education Meetings 20
Total Education and Meetings
EXAMPLE
RN Education 40 73 2920 1.4
       
Do same for any other identifiable indirect
and/or non-productive hours i.e. vacation
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Non-Productive Impact
FTE NP NP FTE Total FTE
Manager 1.0 - - 1.0
RN 32.7 14 4.6 37.3
NA-C 13.4 14 1.9 15.3
HUC 2.8 14 .4 3.2
Total 49.9 6.9 56.8
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Unit Budget Overview
General Medical Unit General Medical Unit General Medical Unit General Medical Unit
Bed Capacity 36 Pt Days (UOS) 11,790
ADC occupancy 32.3 89.7 DNCH/UOS 8.14
DNCH Req/Yr FTES 46.1 DNCH Req/Day Staff/ 8 hours 32.9
Non-Productive FTEs (14) 6.9 Total Unit FTEs 56.8
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Consider of Days per week to Staff

• 1 FTE needed x days to staff
• of days per week per FTE
• 12 hour shifts .9 FTE x 7 days of staff 2.1
  FTE
• 3 days per week
• 8 hour shifts 1.0 FTE x 7 days of staff 1.4
  FTE
• 5 days per week

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Aim of Improving Staffing and Scheduling Systems
and Processes

• The Right Staff
• In the Right Place
• At the Right Time
• At the Right Cost
• Doing the Right Thing

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Why is it worth it?

• High quality care
• Eliminating a last minute crisis mode
• Decreases labor intensive re-work
• Agreements between key players
• Reduce use of temporary agency and premium pay
• Support staff satisfaction

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Why is it worth it?

• To provide high quality care to our patients by
  effectively managing our scheduling and staffing
  practices.
• Move us to more proactive planning and problem
  solving with the goal of eliminating a last
  minute crisis mode of operation.
• Standardize and streamline processes and increase
  accuracy which in turn decreases labor intensive
  re-work.
• Create role agreements between key players that
  help make working together more pleasant and
  effective.
• Reduce use of temporary agency and premium pay in
  a sustainable fashion.
• Support staff satisfaction with equitable
  treatment as well as reasonable and transparent
  accommodations when appropriate.

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Monthly schedules including vacations etc
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High Level Staffing and Scheduling Overview
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Overuse of the Word STAFFING

• We are having a 2 hour surge in census every
  afternoon from 3 to 5 pm
• Our position control is unbalanced. The mix of 8
  and 12 hour shifts has weekly gaps in scheduled
  coverage from 3 to 7pm
• We are scheduling to our average census and are
  unable to meet peak patient census days which
  have been occurring 17 days per month in the last
  6 months.

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Overview of Three Distinct Staffing and
Scheduling Phases
Scheduling
The Middle
Staffing
Before the schedule is posted
Mid Process Posted to 24-72 Hrs before
24 Hrs before to day of staffing

• Outcome
• Final staffing adjustments
• Float pool assignment

• Outcome
• Re-balancing of
• schedule prn

• Outcome
• -Balanced schedule
• Cost effective plan for
• filling vacancies

• Scheduling Process - from when requests are due
  until final schedule posted
• Middle Flow - activity after the schedule is
  posted -up to 24 hrs before (72 hrs on weekends)
• Staffing Process -from 24 hrs before (72 hrs on
  weekends) to day of staffing

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Scheduling Philosophy

• Schedules ensure enough staff with the right
  skills to provide safe, quality patient care 24/7
  
• Schedules are proactive and account for all
  direct and non-productive staffing needs

• Effective scheduling models minimize the ultimate
  last-minute staffing needs for a shift
• Schedules are dynamic and flexible but changes
  are minimized

Patient
Scheduler
Manager
Staff
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What are the characteristics of an effective unit
scheduling process?

• Capable of creating schedules that meet unit
  needs
• Recognizes importance of stakeholder
  relationship and role agreements in scheduling
  and staffing processes
• Ability to flex schedules (up and down) based on
  patient and unit needs
• Recognizes unit volumes and workload patterns
• Recognizes special circumstances
• Takes technology into consideration
• Defines options for filling vacancies

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Scheduling Process Steps
Scheduler Manager Staff
Core and patterns are established Staff submit requests Anticipated monthly variations Schedule adjustment are identified Temporary schedule reviewed Temporary schedule posted Gaps (to core) are filled Final schedule posted Core and patterns are established Staff submit requests Anticipated monthly variations Schedule adjustment are identified Temporary schedule reviewed Temporary schedule posted Gaps (to core) are filled Final schedule posted Core and patterns are established Staff submit requests Anticipated monthly variations Schedule adjustment are identified Temporary schedule reviewed Temporary schedule posted Gaps (to core) are filled Final schedule posted
Important to clarify the roles and
responsibilities of key players in the Scheduling
process
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Staffing and Scheduling Definitions
Balanced Schedule Nursing units have a pre-defined core number of staff for each day of the week and each shift. This core is based on budgeted HPPD/HPUOS along with expected patient volumes and acuity by day of the week and shift. A balanced schedule meets core staffing levels in the most consistent manner possible i.e. a surgical unit that schedules seven nurses early in the week and two less on weekends because of surgeries occurring early in the week.
Rebalancing The process of exploring and scheduling additional hours to compensate for unplanned uncontrollable changes in scheduled hours and/or volume after the schedule is posted or any time up until the staffing process map begins at 24 hrs (72 hrs on weekends)
Unbalanced Schedule Okay Multiple open positions Not-Okay Granting more than established caps People not working to FTE status Guaranteed patterns that create imbalance Per Diems not working required shifts
Non Productive (NP) Caps Specified amount of NP shifts allowed per schedule. Non-productive hours include vacation and educational meetings.
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Handy and Very Helpful Definitions

• Scheduling Changes / Trades
• Floating guidelines
• Contracted Agency (local and travelers) and
  Extension Contracted
• Agency (local and travelers)
• Premium Pay Approval including use of
  prescheduled OT / On Call
• Posting and offering vacant shifts at straight
  time on the unit, division,
• system-wide (monthly, weekly and daily)
• Approving vacation requests
• Trades
• Holiday schedules
• Personal Leave
• Expectations for hours worked by per diem staff
  
• Approving and scheduling non-productive time at
  the time of schedule
• creation
• Scheduling all FT and PT staff to assigned FTE
• Soliciting voluntary increased hours by PT
  staff at FSLA rates of pay

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ADT Factor AKA Workload Intensity Demand

• The decrease in patient length of stay and the
  drive to enhance unit throughput has increased
  work activity
• The number of admissions, discharges, and
  transfers are usually not reflected in patient
  classification systems and never in midnight
  census
• This activity consumes nursing care hours and
  must be considered when looking at daily
  staffing, particularly in nursing units where
  there is high patient turnover

The Hidden Patient Demand
Source Perspective on Staffing Scheduling,
September 2000
68
Calculation of the ADT Factor

• Divide the total number of Admissions,
  Discharges, Transfers In Out, and Deaths in a
  designated 24-hour period
• by the Midnight Census
• to determine the ADT Factor

Source Perspective on Staffing Scheduling,
September 2000
69
ADT Factor - Example
Nursing Unit Number of ADT Midnight Census Unit Specific Score
Unit A 15 12 125 turnover
Unit B 5 25 20 turnover
Source Perspective on Staffing Scheduling,
September 2000
70
ADT Factor - Impact

• Has significant impact on budgeting and staffing
  effectiveness
• Works out to one hour of care required per
  patient turnover (Admission, Discharge, Transfer
  In, Transfer Out)

71
ADT Factor - Example

• 2000 patient turnovers per year X 1 hour of care
  2,000 additional hours of care needed
• 2000/2080 .96 additional FTEs needed to manage
  patient turnover requirements

72
ADT Factor Typical Unit Percents

• Medical/Surgical 50 - 55
• Telemetry 70 - 75
• Critical Care 85 - 90
• Post Partum 85 - 90
• Mental Health 40
• Rehab 25 - 30
• Source Perspective on Staffing Scheduling,
  September 2000

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Unscheduled Absences

• Most common staffing problem
• Utilization of unscheduled time is increasing
• Very costly Every year, unscheduled absences
  costs 2,650 per salaried worker and 3,600 per
  hourly worker
• Essential to monitor each pay period

Shiftwork Practices 2005, Circadian
Technologies, as cited in Bureau of National
Affairs, Inc., Absence Management Making the
Critical Shift from Transactional to Strategic,
2006.
74
Unscheduled Absence Monitoring

• What staffing response does each unit have
  available to respond effectively to unscheduled
  absences?
• Overtime most commonly used as a response to
  deficit demands
• Evidence growing that overtime adversely impacts
  patient safety and quality of care

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Overtime Monitoring

• Guideline for overtime use is to keep it less
  than 5 of worked hours
• Overtime between 5 8 is symptomatic of
  financial distress
• Overtime greater than 8 is symptomatic of
  serious distress

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Overtime Monitoring

• IOM report recommended limiting work hours to not
  more than 12 hours per day and not more than 60
  hours per week as a safety measure
• In the U.S., many states have legislated No
  Mandatory Overtime as a result of patient safety
  issues

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Staffing Plan - Example
Winchester Hospital, MA Medical Unit
Patient Care Link - http//www.patientsfirstma.org

78
Staffing Plan - Example
Winchester Hospital, MA Medical Unit
Patient Care Link - http//www.patientsfirstma.org

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Nurse Sensitive IndicatorsFor Dummies
80
What we know

• Preventable medical errors cost US healthcare
  system 17 billion/year (IOM)
• Medication errors cost nearly 3.5 billion/year
  (IOM)
• Medical errors cause 195,000 deaths/ year in
  the US (Health Grades)

81
Nursing Impact on Pt Outcomes

• There is a clear link between nurse staffing
  (ARNPs and RNs) and patient outcomes
• RNs are the surveillance system for early
  detection and intervention for adverse outcomes
• Institutional advocate for patient centeredness
• The environment of practice is critical to safety

82
Nursing Impact on Pt Outcomes

• A study of medication errors in 2 hospitals over
  6 months showed nurses were responsible for
  intercepting 86 of all medication errors before
  error reached the patient (Leape et al., 1995)
• Leaner RN staffing/less RN hrs of care are
  associated with
• ? LOS (AHRQ, 2001 Needleman et al., 2002, 2006)
• Nosocomial infections (UTI, post-op infection,
  pneumonia) (AHRQ, 2001 Needleman et al., 2002,
  2006 Aiken et al., 2002)
• Pressure ulcers (AHRQ, 2001)
• GI bleeding (Needleman et al., 2002, 2006)
• Cardiac arrests (Needleman et al., 2002, 2006)
• Patient deaths (Needleman et al., 2002, 2006
  Aiken et al., 2002)

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Thus, what we know.

• Nurses Patient Safety
• Nurses Quality Outcomes
• Quality Cost Effective Care
• Outcomes

84
Staffing Indicators

• NHPPD
• On call/per diem use
• Overtime
• Sick time
• Skill mix
• Agency hours
• Sitter hours
• Meal breaks

• Staff injuries
• Staff satisfaction
• Staff turnover rate
• Staff vacancy rate
• Understaffing compared to staffing plan
• Practice environment scale

National Quality Forum endorsed Nursing
Sensitive Indicators
85
Clinical Indicators

• Patient falls
• Patient falls with injury
• Pressure ulcer
• Infection rates
• Urinary tract
• Postoperative
• Central line
• Ventilator related
• Pneumonia

• Adverse drug events
• Injuries to pts
• Upper GI bleeding
• Shock/cardiac arrest
• Length of stay
• Failure to rescue
• Restraint prevalence
• Smoking cessation
• AMI, CHF, Pneumonia

National Quality Forum endorsed Nursing
Sensitive Indicators
86
Service Outcomes

• Patient satisfaction score
• Patient complaints
• Family complaints
• Patient satisfaction with pain management
• Patient satisfaction with ability to manage care
  at home (patient teaching/education)
• Patient satisfaction with nursing and overall care

87
Core Measures (JCAHO)

• Surgical Care Improvement Project (SCIP)
• Heart Failure
• AMI
• Pneumonia
• Pregnancy
• Childrens Asthma Care
• Hospital Inpatient Psychiatric Services

88
CMS Non-Reimbursed Conditions

• Preventable Hospital-Acquired Conditions
• Object left in pt during surgery
• Air embolism
• Blood incompatibility
• Catheter-associated urinary tract infection
• Pressure ulcer
• Vascular catheter-associated infection
• All surgical site infections

89
CMS Non-Reimbursed Conditions

• Preventable Hospital-Acquired Conditions
• Falls with injuries
• Ventilator associated pneumonia
• Staphyloccus aureus septicemia
• Deep vein thrombosis and pulmonary embolism
• MRSA
• Clostridium difficile-associated disease
• Wrong surgery

90
Benchmarking and Reporting

• National Database of Nursing Quality Indicators
  (NDNQI)
• Collaborative Alliance of Nursing Outcomes
  (CALNOC)
• Washington State Hospital Association

91
WA State - NSQI

• Falls
• Falls with injury
• Pressure ulcers
• Nursing hours per patient day
• Skill mix

92
Cost Factors Related to Pt Safety

• Occurrence of the medical error
• Prevention of the medical error
• Treatment of the medical error

Pay Now or Pay Later
93
Where to start.

• Collect the data
• What data are being tracked now?
• Unit/department level
• Organization wide
• Frequency of data collection
• Reports available
• Analyze the data
• Trends
• Comparison to benchmark data
• Questions to ask
• Make the data visual and available
• Identify patterns or improvement opportunities

94
Sample Nursing Scorecard
95
Performance Measure Example
Patient Care Link - http//www.patientsfirstma.org

96
Performance Measure Example
Patient Care Link - http//www.patientsfirstma.org

97
Performance Measure Example
Patient Care Link - http//www.patientsfirstma.org

98
Professional Nursing Organizations - Recommended
Staffing Standards
WSNA, 2010 - www.wsna.org/Topics/Safe-Nurse-Staffi
ng/Toolkit/Documents/Staffing-Ratio-Grid.pdf
99
Professional Nursing Organizations - Recommended
Staffing Standards
WSNA, 2010 - www.wsna.org/Topics/Safe-Nurse-Staffi
ng/Toolkit/Documents/Staffing-Ratio-Grid.pdf
100
Making the Staffing Committee Work
101
Too many meetings?
Team building and conflict resolution Problem solve
Set goals and make plans Accountability and tracking progress
Share content Share content
102
Meeting Tools

• Team Charter
• Ground Rules for Teams
• Meeting Roles
• Agenda
• Minutes
• Evaluations

103
Type of Meetings

• Hospital-wide
• Unit based
• Multidisciplinary
• that can be.
• Short term projects
• Ongoing standing committees
• Focused sub-committees

Tools work for all types of meetings
104
Committee Charter Elements

• Purpose and Goals
• Membership and Sponsorship
• Boundaries
• Decision Making and Levels of Authority
• Roles and Responsibilities
• Ground Rules / Team Agreements
• Meetings and Communications
• Measures of Success

Go Slow to Go Fast
105
Levels of Involvement

Communication Participate in developing
solutions, changes and proposals. Opportunity to
influence through giving feedback on what is
already designed. Opportunity to influence final
decision participate in monitoring and taking
corrective action. Full partners in reaching
final decisions, formulation plans, monitoring
and taking corrective action.
Informed
1 2 3 4 5
Consulted
Developers
Input on Decision Making
Full Decision Making Authority
106
Other Supporting Stakeholders

• Medicine
• Ancillary and Support Departments
• HR
• Finance
• Quality
• Staffing Office
• Medical Records
• Communication and Marketing

107
Agendas

• Published prior to meeting to each member
• Established at previous meeting
• Includes members names next to assigned agenda
  item
• Includes time allotment for each topic

108
Effective Agendas

• Review objectives
• Review agenda items
• Work through agenda items
• Review assignments
• Plan for next meeting
• Rate effectiveness of meeting

109
Minutes Official Record

• List who was present (and who was absent if group
  membership is defined)
• Summary of decisions made for each agenda item
• List assignments
• Next meeting time and location
• Published within a week

Tailor to Your Needs Legal? Functional?
Communication Tool?
110
Team Ground Rules

• - Key -
• Established by Committee!

111
Ground Rules for Good Teams

• Assumption that each person wants to be here
• Team members speak freely and in turn
• All team members and opinions are equal
• If you have something to say, say it in the room
  No Meetings After the Meeting
• No sidebar communications
• Each one must be heard - others listen
  attentively
• No one may dominate - no whining
• Problems are discussed, analyzed or critiqued,
  not people
• Honesty before cohesiveness
• Consensus is the goal--finding solutions
  acceptable to everyone I can support this even
  if it isnt the ideal solution
• Silence is not understood to equal agreement.
  Making a request for someones point of view is
  acceptable.
• All agreements are kept unless renegotiated
• Once agreement occurs, speak with ONE VOICE

112
Ground Rules for Good Meetings

• Meeting frequency and length defined
• Start and end on time
• Come prepared do homework
• Members must attend regularly
• Stay on target
• Leave rank at the door
• At least one bright idea per session
• Identify problems and focus on solutions input,
  discussion, decision
• Review the objectives before we leave realistic
  in scope
• Leave with a sense of accomplishment a purpose,
  making a difference
• Expect work outside of the meeting subgroups
  and task forces

113
Important Meeting Roles

• - Co-Chairs-
• Opens the meeting
• Reviews the agenda
• Makes sure someone is taking notes keeping
  track of time
• Moves through the agenda one item at a time
• Keeps the team focused
• Establishes an appropriate pace
• Facilitates discussion and manages participation
• Helps the team use appropriate decision-making
  methods
• Helps the team evaluate the meeting
• Gathers ideas for the next meetings agenda
• Closes the meeting

(from The Team Handbook)
114
Important Meeting Roles

• Notetaker
• Records minutes which include key topics, points
  made during discussion, decisions made, actions
  items (who will do what, and by when)
• Rotate turns taking minutes / seek secretarial
  support
• Send minutes to Co-Chairs for review then
  distribute the minutes within one week of the
  meeting

(from The Team Handbook)
115
Important Meeting Roles

• - Timekeeper -
• Keeps track of time to help team move along
• Alerts the team when the allotted time is almost
  up so that the team can decide whether to
  continue discussion or table it

(from The Team Handbook)
116
Important Meeting Roles

• - Discussion Scribe -
• Posts ideas on a flipchart or whiteboard
• Write legibly and large enough so that all can
  see
• Captures issues that do not directly relate to
  the topic on a parking lot (separate flip chart
  page)

(from The Team Handbook)
117
Communications

• Between committees vertical and horizontal
• Between co-chairs and members of committees
• Between stakeholders and committees
• Members at large
• Multiple modalities
• Over communicate You are Educating a parade!

118
Sources of Data and Examples
Your committee is ready for data?
Staffing/Scheduling Core staffing structure Low Census days
Medical Records Documentation compliance Length of stay
Unit/Department ER Left without being seen OR Case start times Patient satisfaction
119
Sources of Data and Examples
Financial / Budget Cost per patient day Volume or Units of service
Payroll Absences Overtime Hours
Human Resources Vacancies and Turnover Full Time/ Part Time Mix
Quality Medication errors Infection rate Patient falls
120
Putting it All TogetherCase Application
121
Putting it All Together Case Applications

• Budgeting Scenario
• Staffing and Scheduling Scenario
• Creating a Council Charter
• Workforce Planning Assessment
• Staffing Committee Survey
• Quality Scenario