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

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1 Cathe Clapp, RN, MN Barbara Hyland-Hill, RN, MN, CNAA-BC
BRINGING YOUR NURSE STAFFING COMMITTEE TO LIFE: Staffing, Scheduling & Budgeting for the Bedside Clinician Cathe Clapp, RN, MN Barbara Hyland-Hill, RN, MN, CNAA-BC June 22, Wenatchee June 23, 2010 – Spokane June 24, 2010 – Renton July 14, Lynnwood Ruckelshaus Nurse Staffing Steering Committee

2 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 Ruckelshaus Nurse Staffing Steering Committee

3 Ruckelshaus Nurse Staffing Steering Committee
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) Ruckelshaus Nurse Staffing Steering Committee

4 Ruckelshaus Nurse Staffing Steering Committee
Agenda Budgeting 101 Staffing and Scheduling Made Simple Nurse Sensitive Indicators for Dummies Making the Staffing Committee Work Putting It All Together – Case Application Ruckelshaus Nurse Staffing Steering Committee

5 Budgeting 101

6 Ruckelshaus Nurse Staffing Steering Committee
Personal Budget Income Salary – Pay check Interest/investment earnings Expenses House payment or rent Utilities Food Insurance Car payment Gas Etc Ruckelshaus Nurse Staffing Steering Committee

7 Ruckelshaus Nurse Staffing Steering Committee
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 Ruckelshaus Nurse Staffing Steering Committee

8 Functions of the Budget
Financially operationalize an organization’s goals and objectives Keep management informed Evaluate performance Refine program development and plan Educate Increase cost awareness Ruckelshaus Nurse Staffing Steering Committee

9 Ruckelshaus Nurse Staffing Steering Committee
Budgeting Process Understand your organization’s process, forms, timeline, terminology, fiscal year Planning Department Goals & Objectives Projected Units of Service (Volume and Acuity) Preparing Monitoring and Controlling Reporting Ruckelshaus Nurse Staffing Steering Committee

10 Staffing Budget (Labor, Personnel, Manpower)

11 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 Ruckelshaus Nurse Staffing Steering Committee

12 Ruckelshaus Nurse Staffing Steering Committee
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? Ruckelshaus Nurse Staffing Steering Committee

13 Basic Concepts – Nursing Hours
Ruckelshaus Nurse Staffing Steering Committee

14 Ruckelshaus Nurse Staffing Steering Committee
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 Ruckelshaus Nurse Staffing Steering Committee

15 Ruckelshaus Nurse Staffing Steering Committee
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 Ruckelshaus Nurse Staffing Steering Committee

16 Ruckelshaus Nurse Staffing Steering Committee
Workload Hours - DNCH 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 Ruckelshaus Nurse Staffing Steering Committee

17 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 Ruckelshaus Nurse Staffing Steering Committee

18 Ruckelshaus Nurse Staffing Steering Committee
Workload Hours - Fixed Ruckelshaus Nurse Staffing Steering Committee

19 Ruckelshaus Nurse Staffing Steering Committee
Workload Hours - DNCH 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 Ruckelshaus Nurse Staffing Steering Committee

20 Workload Hours - DNCH 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 Ruckelshaus Nurse Staffing Steering Committee

21 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 Ruckelshaus Nurse Staffing Steering Committee

22 Required DNC Staff Per Day
General Medical Unit ADC = DNCH 8.14 Required Hrs = Required staff = 32.9 (Hrs by shift) Days 40% (105.17) Eve 30% (78.88) Nights Total (by skill mix) RN (71%) 9.3 ( X .71/8) 7.0 (78.88 X .71/8) 23.3 LPN NA-C (29%) 3.8 ( X .29/8) 2.9 (78.88 X .29/8) 9.6 (by shift mix) 13.1 9.9 32.9 Ruckelshaus Nurse Staffing Steering Committee

23 Required DNC Staff Per Day
General Surgical Unit ADC = 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%) (by shift mix) Ruckelshaus Nurse Staffing Steering Committee

24 Required DNC Staff Per Day
General Surgical Unit ADC = DNCH 7.82 Required Hrs = 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 ( 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 ( X .29/8) 2.1 (40.95 X .29/8) 8.3 (by shift mix) 11.5 10.1 28.8 Ruckelshaus Nurse Staffing Steering Committee

25 Required DNC FTEs Per Year
General Medical Unit UOS = 11, DNCH 8.14 Required Hrs = 95,971 Required FTEs = 46.1 Days 40% Eve 30% Nights Total (by skill mix) RN (71%) 13.1 9.8 32.7 LPN NA-C (29%) 5.4 4.0 13.4 18.5 13.8 46.1

26 Required DNC FTEs Per Year
General Surgical Unit UOS = 10, DNCH 7.82 Required Hrs = Required FTEs = Days 40% Eve 35% Nights 25% Total (by skill mix) RN (71%) LPN NA-C (29%)

27 Required DNC FTEs Per Year
General Surgical Unit UOS = 10, 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 16.2 14.2 40.5

28 Ruckelshaus Nurse Staffing Steering Committee
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 Average is typically between 14 – 20% Ruckelshaus Nurse Staffing Steering Committee

29 Ruckelshaus Nurse Staffing Steering Committee
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 days Education days 32 days = 256 hrs (8 hr shift) = 1824 prod DNCH 256/1825 = 14% 46.1 DNC FTEs X 1.14 = 52.6 – 46.1 = 6.5 NP FTEs Ruckelshaus Nurse Staffing Steering Committee

30 Ruckelshaus Nurse Staffing Steering Committee
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 Ruckelshaus Nurse Staffing Steering Committee

31 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? Ruckelshaus Nurse Staffing Steering Committee

32 Non-Productive Impact
FTE NP % NP FTE Total FTE Manager 1.0 - RN 32.7 14% 4.6 37.3 NA-C 13.4 1.9 15.3 HUC 2.8 .4 3.2 Total 49.9 6.9 56.8 Ruckelshaus Nurse Staffing Steering Committee

33 Ruckelshaus Nurse Staffing Steering Committee
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 Ruckelshaus Nurse Staffing Steering Committee

34 Ruckelshaus Nurse Staffing Steering Committee
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? Ruckelshaus Nurse Staffing Steering Committee

35 Indirect Productive Hours
Indirect Care 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 7 140 .1 Subtotal 1.6 Orientation RN (average # days – 15) 120 5 600 NA-C (average # days – 10) 80 4 320 .2 HUC (average # days – 15) 1 .6  Total  2.2

36 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 + + + Ruckelshaus Nurse Staffing Steering Committee

37 Ruckelshaus Nurse Staffing Steering Committee
Premium Pay Shift differential Weekend differential Charge nurse, certification, preceptor differential Overtime Standby and call back pay Ruckelshaus Nurse Staffing Steering Committee

38 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 Ruckelshaus Nurse Staffing Steering Committee

39 Basic Concepts – Formulas
Average Daily Census (ADC) Total pt days # of days (week, month, year) Average Length of Stay (ALOS) # of discharges Percent Occupancy Total pt days Census or ADC Total # bed days available Beds available or Ruckelshaus Nurse Staffing Steering Committee

40 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 Ruckelshaus Nurse Staffing Steering Committee

41 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 Ruckelshaus Nurse Staffing Steering Committee

42 Sample Cost Center Report
Ruckelshaus Nurse Staffing Steering Committee

43 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 Ruckelshaus Nurse Staffing Steering Committee

44 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) Ruckelshaus Nurse Staffing Steering Committee

45 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 Ruckelshaus Nurse Staffing Steering Committee

46 Staffing and Scheduling Made Simple
Ruckelshaus Nurse Staffing Steering Committee 46

47 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 Ruckelshaus Nurse Staffing Steering Committee 47

48 Ruckelshaus Nurse Staffing Steering Committee
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) 48 Ruckelshaus Nurse Staffing Steering Committee 48

49 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) Ruckelshaus Nurse Staffing Steering Committee 49

50 Ruckelshaus Nurse Staffing Steering Committee
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 Ruckelshaus Nurse Staffing Steering Committee 50

51 Indirect Productive Hours
Staffing Model Indirect Productive Hours  Annual Hrs # Staff Total Hours  FTE Education and Meetings RN Education & Meetings 40 CNA Education & Meetings 20 USMT Education & Meetings Total Education and Meetings EXAMPLE RN Education 73 2920 1.4 Do same for any other identifiable indirect and/or non-productive hours i.e. vacation Ruckelshaus Nurse Staffing Steering Committee 51

52 Non-Productive Impact
FTE NP % NP FTE Total FTE Manager 1.0 - RN 32.7 14% 4.6 37.3 NA-C 13.4 1.9 15.3 HUC 2.8 .4 3.2 Total 49.9 6.9 56.8 Ruckelshaus Nurse Staffing Steering Committee 52

53 Ruckelshaus Nurse Staffing Steering Committee
Unit Budget Overview 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 Ruckelshaus Nurse Staffing Steering Committee 53

54 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 Ruckelshaus Nurse Staffing Steering Committee 54

55 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 Ruckelshaus Nurse Staffing Steering Committee 55

56 Ruckelshaus Nurse Staffing Steering Committee
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 Ruckelshaus Nurse Staffing Steering Committee 56

57 Ruckelshaus Nurse Staffing Steering Committee
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. Ruckelshaus Nurse Staffing Steering Committee 57

58 Long range clinical program development forecasts
Hiring projections Annual budget and census projection Seasonal volume projections Weekly forecast Daily shift census and acuity Annual FTE budget: direct, indirect etc Staffing plan: position control Weekly and 24 hour staffing plans THE PATIENTS THE STAFF The Moment Of Truth We GO LIVE 24/7 Monthly schedules including vacations etc Ruckelshaus Nurse Staffing Steering Committee 58

59 High Level Staffing and Scheduling Overview
Ruckelshaus Nurse Staffing Steering Committee

60 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.” Ruckelshaus Nurse Staffing Steering Committee

61 Overview of Three Distinct Staffing and Scheduling Phases
The Middle Staffing Before the schedule is posted Mid Process: Posted to 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 Ruckelshaus Nurse Staffing Steering Committee 61 61

62 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 Ruckelshaus Nurse Staffing Steering Committee 62

63 Ruckelshaus Nurse Staffing Steering Committee
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 Ruckelshaus Nurse Staffing Steering Committee 63

64 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 Important to clarify the roles and responsibilities of key players in the Scheduling process Ruckelshaus Nurse Staffing Steering Committee 64

65 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. Ruckelshaus Nurse Staffing Steering Committee 65

66 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 Ruckelshaus Nurse Staffing Steering Committee 66

67 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 Ruckelshaus Nurse Staffing Steering Committee 67

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 Ruckelshaus Nurse Staffing Steering Committee 68

69 Ruckelshaus Nurse Staffing Steering Committee
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 Ruckelshaus Nurse Staffing Steering Committee 69

70 Ruckelshaus Nurse Staffing Steering Committee
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) Ruckelshaus Nurse Staffing Steering Committee 70

71 Ruckelshaus Nurse Staffing Steering Committee
ADT Factor - Example 2000 patient turnovers per year X 1 hour of care = 2,000 additional hours of care needed 2000/2080 = .96 additional FTE’s needed to manage patient turnover requirements Ruckelshaus Nurse Staffing Steering Committee 71

72 ADT Factor – Typical Unit Percents
Medical/Surgical % Telemetry % Critical Care % Post Partum % Mental Health 40% Rehab % Source: Perspective on Staffing & Scheduling, September 2000 Ruckelshaus Nurse Staffing Steering Committee 72

73 Ruckelshaus Nurse Staffing Steering Committee
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. Ruckelshaus Nurse Staffing Steering Committee 73

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 Ruckelshaus Nurse Staffing Steering Committee 74

75 Ruckelshaus Nurse Staffing Steering Committee
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 Ruckelshaus Nurse Staffing Steering Committee 75

76 Ruckelshaus Nurse Staffing Steering Committee
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 Ruckelshaus Nurse Staffing Steering Committee 76

77 Staffing Plan - Example
Winchester Hospital, MA – Medical Unit Patient Care Link - Ruckelshaus Nurse Staffing Steering Committee 77

78 Staffing Plan - Example
Winchester Hospital, MA – Medical Unit Patient Care Link - Ruckelshaus Nurse Staffing Steering Committee 78

79 Nurse Sensitive Indicators For Dummies
Nurse Sensitive Indicators – Are those outcomes/indicators that have been studied and found to be reliably linked to the presence of nursing care Evidence Based

80 Ruckelshaus Nurse Staffing Steering Committee
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) Ruckelshaus Nurse Staffing Steering Committee

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 Ruckelshaus Nurse Staffing Steering Committee

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) Ruckelshaus Nurse Staffing Steering Committee

83 Ruckelshaus Nurse Staffing Steering Committee
Thus, what we know…. Nurses Patient Safety Nurses Quality Outcomes Quality Cost Effective Care Outcomes Ruckelshaus Nurse Staffing Steering Committee

84 Ruckelshaus Nurse Staffing Steering Committee
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 Ruckelshaus Nurse Staffing Steering Committee

85 Ruckelshaus Nurse Staffing Steering Committee
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 Ruckelshaus Nurse Staffing Steering Committee

86 Ruckelshaus Nurse Staffing Steering Committee
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 Ruckelshaus Nurse Staffing Steering Committee

87 Ruckelshaus Nurse Staffing Steering Committee
Core Measures (JCAHO) Surgical Care Improvement Project (SCIP) Heart Failure AMI Pneumonia Pregnancy Children’s Asthma Care Hospital Inpatient Psychiatric Services Ruckelshaus Nurse Staffing Steering Committee

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 Ruckelshaus Nurse Staffing Steering Committee

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 Ruckelshaus Nurse Staffing Steering Committee

90 Benchmarking and Reporting
National Database of Nursing Quality Indicators (NDNQI) Collaborative Alliance of Nursing Outcomes (CALNOC) Washington State Hospital Association Ruckelshaus Nurse Staffing Steering Committee

91 Ruckelshaus Nurse Staffing Steering Committee
WA State - NSQI Falls Falls with injury Pressure ulcers Nursing hours per patient day Skill mix Ruckelshaus Nurse Staffing Steering Committee

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 Ruckelshaus Nurse Staffing Steering Committee

93 Ruckelshaus Nurse Staffing Steering Committee
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 Ruckelshaus Nurse Staffing Steering Committee

94 Sample Nursing Scorecard
Ruckelshaus Nurse Staffing Steering Committee

95 Performance Measure Example
Patient Care Link - Ruckelshaus Nurse Staffing Steering Committee

96 Performance Measure Example
Patient Care Link - Ruckelshaus Nurse Staffing Steering Committee

97 Performance Measure Example
Patient Care Link - Ruckelshaus Nurse Staffing Steering Committee

98 Professional Nursing Organizations - Recommended Staffing Standards
WSNA, Ruckelshaus Nurse Staffing Steering Committee

99 Professional Nursing Organizations - Recommended Staffing Standards
WSNA, Ruckelshaus Nurse Staffing Steering Committee

100 Making the Staffing Committee Work
Ruckelshaus Nurse Staffing Steering Committee 100

101 Too many meetings? Team building and conflict resolution Problem solve
Set goals and make plans Accountability and tracking progress Share content Ruckelshaus Nurse Staffing Steering Committee 101

102 Ruckelshaus Nurse Staffing Steering Committee
Meeting Tools Team Charter Ground Rules for Teams Meeting Roles Agenda Minutes Evaluations Ruckelshaus Nurse Staffing Steering Committee 102

103 Ruckelshaus Nurse Staffing Steering Committee
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… Ruckelshaus Nurse Staffing Steering Committee 103

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 Ruckelshaus Nurse Staffing Steering Committee 104

105 Ruckelshaus Nurse Staffing Steering Committee
Levels of Involvement Informed 1 2 3 4 5 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. Consulted Developers Input on Decision Making Full Decision Making Authority Ruckelshaus Nurse Staffing Steering Committee 105

106 Other Supporting Stakeholders
Medicine Ancillary and Support Departments HR Finance Quality Staffing Office Medical Records Communication and Marketing Ruckelshaus Nurse Staffing Steering Committee 106

107 Ruckelshaus Nurse Staffing Steering Committee
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 Ruckelshaus Nurse Staffing Steering Committee 107

108 Ruckelshaus Nurse Staffing Steering Committee
Effective Agendas Review objectives Review agenda items Work through agenda items Review assignments Plan for next meeting Rate effectiveness of meeting Ruckelshaus Nurse Staffing Steering Committee 108

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? Ruckelshaus Nurse Staffing Steering Committee 109

110 Established by Committee!
Team Ground Rules - Key - Established by Committee! Ruckelshaus Nurse Staffing Steering Committee 110

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 isn’t the ideal solution” Silence is not understood to equal agreement. Making a request for someone’s point of view is acceptable. All agreements are kept unless renegotiated Once agreement occurs, speak with “ONE VOICE ” Ruckelshaus Nurse Staffing Steering Committee 111

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 Ruckelshaus Nurse Staffing Steering Committee 112

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 meeting’s agenda Closes the meeting (from The Team Handbook) Ruckelshaus Nurse Staffing Steering Committee 113

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) Ruckelshaus Nurse Staffing Steering Committee 114

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) Ruckelshaus Nurse Staffing Steering Committee 115

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) Ruckelshaus Nurse Staffing Steering Committee 116

117 Ruckelshaus Nurse Staffing Steering Committee
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! Ruckelshaus Nurse Staffing Steering Committee 117

118 Sources of Data and Examples
Your committee is ready for data? Sources of Data and Examples 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 Ruckelshaus Nurse Staffing Steering Committee 118

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 Ruckelshaus Nurse Staffing Steering Committee 119

120 Putting it All Together: Case 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 Ruckelshaus Nurse Staffing Steering Committee


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