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  1. 1. Chapter 15 Effective Staffing
  2. 2. Objectives <ul><li>Upon completion of this chapter, the reader should be able to:  </li></ul><ul><ul><li>Calculate full-time equivalents (FTEs) needed to staff a typical inpatient nursing unit </li></ul></ul><ul><ul><li>Analyze the impact of patient volume and work intensity on the demand for nursing care </li></ul></ul><ul><ul><li>Discuss appropriate units of service used to measure nursing need by unit type </li></ul></ul>
  3. 3. Objectives <ul><ul><li>Critique organizational, regulatory, staff, and patient dynamics underlying development of a staffing plan </li></ul></ul><ul><ul><li>Analyze scheduling issues that impact the matching of nursing resources to patient needs </li></ul></ul><ul><ul><li>Compare and contrast models of care delivery and their impact on patient outcomes </li></ul></ul>
  4. 4. Determination of Staffing Needs <ul><li>Patient census was historically used to determine staffing needs </li></ul><ul><li>Has proven to be inaccurate, since patient care needs vary greatly </li></ul><ul><li>Better matching of patient needs to nursing resources is now an important financial quest in health care institutions </li></ul>
  5. 5. Core Concepts <ul><li>Full-time equivalent (FTE) is a measure of the work commitment of an employee who works 5 days a week or 40 hours per week for 52 weeks per year; some agencies consider 36 hours (three 12-hour shifts) full time </li></ul><ul><li>FTE hours are a total of all paid time </li></ul>
  6. 6. Core Concepts <ul><li>Productive hours </li></ul><ul><ul><li>Hours worked and available for patient care </li></ul></ul><ul><li>Nonproductive hours </li></ul><ul><ul><li>Benefit time such as vacation, sick time, and education time </li></ul></ul><ul><li>Direct care </li></ul><ul><ul><li>Time spent with hands-on care to patients </li></ul></ul><ul><li>Indirect care </li></ul><ul><ul><li>Time spent with activities that support patient care </li></ul></ul>
  7. 7. Units of Service <ul><li>A variety of volume measures used to reflect different types of patient encounters as indicators of nursing workload </li></ul><ul><li>Used in budget negotiations to project nursing needs of patients and to assure adequate resources for safe patient care </li></ul>
  8. 8. Nursing Hours per Patient Day (NHPPD) <ul><li>A standard measure that quantifies the nursing time available to each patient by available nursing staff </li></ul><ul><li>NHPPD reflects only productive nursing time available based on: </li></ul><ul><ul><li>Midnight census </li></ul></ul><ul><ul><li>Past unit needs </li></ul></ul><ul><ul><li>Expected practice trends </li></ul></ul><ul><ul><li>National benchmarks </li></ul></ul><ul><ul><li>Budget negotiations </li></ul></ul>
  9. 9. Patient Classification Systems <ul><li>Patient classification system (PCS) </li></ul><ul><ul><li>A measurement tool used to determine the nursing workload for a specific patient or group of patients over a specific period of time  </li></ul></ul><ul><li>Patient acuity </li></ul><ul><ul><li>The measure of nursing workload that is generated for each patient </li></ul></ul>
  10. 10. Patient Classification Systems <ul><li>Nurse intensity </li></ul><ul><ul><li>A measure of the amount and complexity of nursing care needed by a patient </li></ul></ul><ul><li>Patient turnover </li></ul><ul><ul><li>A measure reflecting patient admission, transfer, and discharge </li></ul></ul>
  11. 11. Factor Classification Systems <ul><li>Use units of measure that equate to nursing time </li></ul><ul><li>Attempt to capture assessment, planning, intervention, and evaluation of patient outcomes along with written documentation processes </li></ul><ul><li>Are the most popular type of classification system </li></ul>
  12. 12. Factor Classification Systems <ul><li>Advantages </li></ul><ul><ul><li>Data readily available for day-to-day operations </li></ul></ul><ul><ul><li>Provide information against which one can justify changes in staffing requirements </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Create an ongoing workload for the nurse in classifying patients every day </li></ul></ul><ul><ul><li>Problems with “classification creep” </li></ul></ul><ul><ul><li>Do not capture patient needs for psychosocial, environmental, and health management support </li></ul></ul><ul><ul><li>Calculate nursing time based on a “typical” nurse </li></ul></ul>
  13. 13. Prototype Systems <ul><li>Allocate nursing time to large patient groups based on an average of similar patients  </li></ul><ul><li>Advantage </li></ul><ul><ul><li>Reduction of work for the nurse by not classifying patients daily </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>No ongoing measure of the actual nursing work required by individual patients </li></ul></ul><ul><ul><li>No ongoing data to monitor the accuracy of the preassigned nursing care requirements </li></ul></ul>
  14. 14. Utilization of Classification System Data <ul><li>Can be utilized by staff and managers for planning nursing care over the next 24 hours </li></ul><ul><li>Essential for preparing month-end justification for variances in staff utilization </li></ul><ul><li>Used to cost out nursing services for specific patient populations and global patient types </li></ul><ul><li>Information useful in negotiating payment rates with third-party payers </li></ul><ul><li>Used in preparing the budget </li></ul>
  15. 15. Considerations in Developing a Staffing Plan <ul><li>Benchmarking </li></ul><ul><ul><li>A tool used to compare productivity across facilities to establish performance goals </li></ul></ul><ul><ul><li>Does not always reflect quality of care indicators that can link quality patient care outcomes to productivity measures </li></ul></ul><ul><ul><li>Can be helpful in establishing a starting point for a staffing pattern </li></ul></ul>
  16. 16. Considerations in Developing a Staffing Plan <ul><li>Regulatory requirements </li></ul><ul><ul><li>One controversial issue is nurse staffing levels </li></ul></ul><ul><ul><li>Mandated nurse staffing plans are enacted by law </li></ul></ul><ul><li>The Joint Commission does not regulate staffing levels </li></ul><ul><ul><li>Does assess staffing effectiveness </li></ul></ul><ul><ul><li>Requires organizations to monitor four of twenty-one specified indicators </li></ul></ul>
  17. 17. Considerations in Developing a Staffing Plan <ul><li>Skill mix </li></ul><ul><ul><li>The percentage of RN staff to other direct care staff </li></ul></ul><ul><ul><li>Should vary according to the care that is required and the care delivery model utilized </li></ul></ul><ul><li>Staff support </li></ul><ul><ul><li>The supports in place for the operation of the unit or department (a systematic process to deliver medications, patient transport services, secretarial services, etc.) </li></ul></ul>
  18. 18. Establishing a Staffing Plan <ul><li>Articulates how many and what kind of staff are needed by shift and day to staff a unit or department </li></ul><ul><li>Two ways of development </li></ul><ul><ul><li>Determine the ratio of staff to patients; nursing hours and total FTEs are then calculated </li></ul></ul><ul><ul><li>Determine the nursing care hours needed for a specific patient or patients and then generating the staff-to-patient ratio needed to provide the care </li></ul></ul>
  19. 19. Inpatient Unit <ul><li>An inpatient unit is a hospital unit that is able to provide care to patients 24 hours a day, 7 days a week </li></ul><ul><li>Using data from all your sources, you can build a staffing pattern that will meet the needs of the patients, the staff, and the organization </li></ul><ul><li>  Average daily census </li></ul><ul><ul><li>The total numbers of patients at census time, usually midnight, over a period of time, e.g., weekly, monthly or yearly, and dividing by the number of days in the time period </li></ul></ul>
  20. 20. Determining the FTEs Needed to Staff an Episodic Unit <ul><li>Episodic care units </li></ul><ul><ul><li>Units that see patients for defined episodes of care </li></ul></ul><ul><ul><li>Examples are dialysis and ambulatory care units </li></ul></ul><ul><li>Start with an assessment of the hours of care required by the patients </li></ul><ul><li>Add FTEs to cover days off and benefit time </li></ul>
  21. 21. Scheduling <ul><li>Scheduling of staff is the responsibility of the nurse manager </li></ul><ul><li>The manager must ensure that the schedule places the appropriate staff on each day and shift for safe, effective care </li></ul>
  22. 22. Considerations for Staffing <ul><li>The patient type and acuity </li></ul><ul><ul><li>The higher the patient acuity, the more consistent the staffing needs are across shifts </li></ul></ul><ul><li>The experience of the staff </li></ul><ul><ul><li>Novice nurses take longer to accomplish the same task than an experienced nurse </li></ul></ul><ul><ul><li>An experienced RN can handle more workload and higher acuity patients </li></ul></ul><ul><li>Good staffing requires putting the patient first </li></ul>
  23. 23. Scheduling <ul><li>Volume </li></ul><ul><ul><li>Patient volume numbers reviewed for peaks and valleys in the census and patient acuity </li></ul></ul><ul><ul><li>Scheduling adjustments are necessary </li></ul></ul><ul><li>Experience and capability of staff </li></ul><ul><ul><li>Different degrees of knowledge, experience, and critical thinking skills </li></ul></ul><ul><ul><li>Number of inexperienced staff (add hours) </li></ul></ul><ul><ul><li>Number of experienced staff </li></ul></ul><ul><ul><li>Need for staff with special skills </li></ul></ul>
  24. 24. Shift Variations <ul><li>Traditional staffing patterns </li></ul><ul><ul><li>Generally 8-hour shifts </li></ul></ul><ul><ul><li>Start times may vary by organization or nursing unit  </li></ul></ul><ul><li>Shift variations occur to meet the needs of patients and the staff </li></ul><ul><ul><li>12-hour shifts </li></ul></ul><ul><ul><li>Weekend programs  </li></ul></ul>
  25. 25. Concerns for Scheduling <ul><li>Impact on patient care </li></ul><ul><ul><li>Possible disruption of continuity of care </li></ul></ul><ul><ul><li>Weekend staff should be familiar with patients and recent care events  </li></ul></ul><ul><li>Financial implications </li></ul><ul><ul><li>Weekend programs are more expensive than traditional staffing patterns </li></ul></ul><ul><ul><li>They are a recruitment and retention tool for nursing leadership </li></ul></ul>
  26. 26. Self-Scheduling <ul><li>A process in which unit staff take leadership in creating and monitoring the work schedule while working within defined guidelines </li></ul><ul><li>Increasing staff control over their schedule is a major factor in nurse job satisfaction and retention </li></ul><ul><li>Has been associated with sick time usage </li></ul>
  27. 27. Implementing Self-Scheduling <ul><li>Form a committee made up of unit staff who report to the manager </li></ul><ul><li>Define the roles and responsibilities of each committee member </li></ul><ul><li>Establish generic boundaries regarding fairness, fiscal responsibility, evaluation of the self-scheduling process, and the approval process </li></ul><ul><li>Educate the staff </li></ul>
  28. 28. Evaluation of Staffing Effectiveness <ul><li>Patient outcomes and nurse staffing </li></ul><ul><ul><li>Studies have found consistent significant relationships between nurse staffing and some patient outcomes </li></ul></ul><ul><ul><li>Certain outcomes are affected negatively when nurse staffing or skill mix is inadequate </li></ul></ul>
  29. 29. Evaluation of Staffing Effectiveness <ul><li>Nurse staffing and nurse outcomes </li></ul><ul><ul><li>Effect of staffing on nurse performance should also be considered </li></ul></ul><ul><ul><li>Track staff’s perception of staffing adequacy </li></ul></ul><ul><ul><li>Provide ability for staff to communicate concerns in written and verbal form </li></ul></ul><ul><ul><li>Track recommended staffing versus actual staffing </li></ul></ul>
  30. 30. Models of Care Delivery <ul><li>Care delivery models </li></ul><ul><ul><li>Organize the work of caring for patients </li></ul></ul><ul><li>The decision for which care delivery model is used is based on the needs of the patients and availability of competent staff </li></ul><ul><li>Managers have the responsibility to implement models and evaluate the outcomes in their areas </li></ul>
  31. 31. Total Patient Care <ul><li>Total patient care </li></ul><ul><ul><li>The nurse is responsible for the total care for his or her patient assignment for the shift he or she is working </li></ul></ul>
  32. 32. Total Patient Care <ul><li>Advantages </li></ul><ul><ul><li>Consistency of one individual caring for patients an entire shift </li></ul></ul><ul><ul><li>Enables development of patient and family trust </li></ul></ul><ul><ul><li>Provides a higher number of RN hours of care than other models </li></ul></ul><ul><ul><li>The nurse has more opportunity to monitor progress of the patient </li></ul></ul>
  33. 33. Total Patient Care <ul><li>Disadvantages </li></ul><ul><ul><li>Utilizes a high number of RN staffing </li></ul></ul><ul><ul><li>More costly than other models </li></ul></ul>
  34. 34. Functional Nursing <ul><li>Divides nursing work into functional roles that are then assigned to one of the team members </li></ul><ul><li>In this model, each care provider is responsible for specific duties or tasks </li></ul><ul><li>Technical rather than professional nursing care often results </li></ul><ul><li>Decision making usually at the level of the charge nurse </li></ul>
  35. 35. Functional Nursing <ul><li>Advantages </li></ul><ul><ul><li>Care can be delivered to a large number of patients </li></ul></ul><ul><ul><li>Uses other types of health care workers when there is a shortage of RNs  </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Lack of continuity of care </li></ul></ul><ul><ul><li>Patient may feel that care is disjointed </li></ul></ul>
  36. 36. Team Nursing <ul><li>A care delivery model that assigns staff to teams that are then responsible for a group of patients </li></ul><ul><li>A unit is divided into two or more teams, each led by a registered nurse </li></ul><ul><li>The team leader supervises and coordinates all of the care provided by those on the team </li></ul><ul><li>Care is divided into the simplest components and then assigned to the care provider with the appropriate level of skills </li></ul>
  37. 37. Team Nursing <ul><li>Modular nursing delivery system </li></ul><ul><ul><li>A kind of team nursing that divides a geographic space into modules of patients, with each module having a team of staff led by an RN to care for them </li></ul></ul><ul><ul><li>Useful with decentralized nursing stations </li></ul></ul>
  38. 38. Team Nursing <ul><li>Advantages </li></ul><ul><ul><li>Maximizes the role of the registered nurse </li></ul></ul><ul><ul><li>Nurse is able to get work done through others  </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Patients often receive fragmented, depersonalized care </li></ul></ul><ul><ul><li>Communication is complex </li></ul></ul><ul><ul><li>Shared responsibility and accountability can cause confusion and lack of accountability </li></ul></ul>
  39. 39. Primary Nursing <ul><li>Clearly delineates the responsibility and accountability of the RN </li></ul><ul><li>Places the RN as the primary provider of care to patients </li></ul><ul><li>Patients are assigned a primary nurse </li></ul><ul><ul><li>The primary nurse is responsible for developing with the patient a plan of care </li></ul></ul><ul><ul><li>Other nurses caring for the patient follow this plan of care </li></ul></ul><ul><ul><li>Patients are assigned to their primary nurse regardless of geographic location </li></ul></ul>
  40. 40. Primary Nursing <ul><li>Advantages </li></ul><ul><ul><li>Patients and families are able to develop a trusting relationship with the nurse </li></ul></ul><ul><ul><li>Accountability and responsibility of the nurse developing a plan of care with the patient and family are defined </li></ul></ul><ul><ul><li>Facilitates continuity of care </li></ul></ul><ul><ul><li>Authority for decision making is given to the nurse at the bedside </li></ul></ul>
  41. 41. Primary Nursing <ul><li>Disadvantages </li></ul><ul><ul><li>Cost is high due to the higher RN skill mix </li></ul></ul><ul><ul><li>The person making assignments needs to be knowledgeable about all the patients and staff to ensure appropriate matching of nurse to patient </li></ul></ul><ul><ul><li>Lack of geographical boundaries within the unit may require nursing staff to travel long distances at the unit level to care for their primary patients </li></ul></ul><ul><ul><li>Nursing time is often used in functions that could be completed by other staff </li></ul></ul><ul><ul><li>Nurse-to-patient ratios must be realistic </li></ul></ul>
  42. 42. Patient-Centered or Patient-Focused Care <ul><li>Designed to focus on patient needs rather than staff needs </li></ul><ul><li>All patient services are decentralized to the patient area </li></ul><ul><li>Care teams are established for a group of patients </li></ul><ul><ul><li>The care team includes all disciplines </li></ul></ul><ul><ul><li>Disciplines collaborate to ensure that patients receive the care they need </li></ul></ul>
  43. 43. Patient-Centered or Patient-Focused Care <ul><li>Advantages </li></ul><ul><ul><li>Most convenient for patients </li></ul></ul><ul><ul><li>Expedites services to patients  </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Can be extremely costly to decentralize major services in an organization </li></ul></ul><ul><ul><li>Some perceive model as a way of reducing RNs and cutting costs in hospitals </li></ul></ul>
  44. 44. Patient Care Redesign <ul><li>Initiative that developed in the 1990s to redesign how patient care was delivered  </li></ul><ul><li>Motivated by need to reduce costs </li></ul><ul><li>Goals are to make care more patient-centered and not caregiver-centered </li></ul><ul><li>Reduces the number of caregivers a patient has to interface with, thus increasing patient satisfaction </li></ul>
  45. 45. Care Delivery Management Tools <ul><li>Work flow analysis </li></ul><ul><ul><li>A tool used to determine what activities are value- added  </li></ul></ul><ul><ul><li>Determines how to streamline or eliminate those activities that do not contribute to improved patient outcomes </li></ul></ul><ul><li>Value-added </li></ul><ul><ul><li>The customer is willing to pay for this activity </li></ul></ul><ul><ul><li>Activity must be done right the first time </li></ul></ul><ul><ul><li>Activity must somehow change the product or service in some desirable manner </li></ul></ul>
  46. 46. Care Delivery Management Tools <ul><li>In diagnosis-related groups (DRGs) the national average length of stay (LOS) for a specific patient type was used to determine payment for that grouping of patients </li></ul><ul><li>Hospitals looked to reduce LOS and reduce hospital costs </li></ul><ul><li>Clinical pathways and case management surfaced as significant strategies </li></ul>
  47. 47. Clinical Pathways <ul><li>Clinical pathways </li></ul><ul><ul><li>Care management tools that outline the expected clinical course and outcomes for a specific patient type </li></ul></ul><ul><ul><li>Should be evidence-based </li></ul></ul><ul><li>Pathways include expected outcomes specified for each day of care </li></ul><ul><li>Patient progress is measured against the expected outcomes </li></ul>
  48. 48. Clinical Pathways <ul><li>Advantages </li></ul><ul><ul><li>Very instructive to new staff </li></ul></ul><ul><ul><li>Save a significant amount of time in the process of care </li></ul></ul><ul><ul><li>In most cases, improved care and shortened lengths of stay for the population on the pathway are the results </li></ul></ul><ul><ul><li>Allow for data collection of variances to the pathway </li></ul></ul>
  49. 49. Clinical Pathways <ul><li>Disadvantages </li></ul><ul><ul><li>Some physicians perceive pathways to be cookbook medicine and are reluctant to participate in their development </li></ul></ul><ul><ul><li>Development requires a significant amount of work to gain consensus from the various disciplines on the expected plan of care </li></ul></ul><ul><ul><li>Pathways are less effective for patient populations that are nonstandard, since they are constantly being modified to reflect individual patient needs </li></ul></ul>
  50. 50. Case Management <ul><li>A strategy to improve patient care and reduce hospital costs through coordination of care </li></ul><ul><li>Typically a case manager: </li></ul><ul><ul><li>Is responsible for coordinating care and establishing goals from preadmission through discharge </li></ul></ul><ul><ul><li>Evaluates the patient’s outcomes daily and compares them to the predicted outcomes articulated in the clinical pathway </li></ul></ul><ul><ul><li>Works with all the disciplines to facilitate care </li></ul></ul>
  51. 51. Case Management <ul><li>In other models, the case management function is provided by the staff nurse at the bedside </li></ul><ul><li>The case manager also collects data on patient variances from the clinical pathway </li></ul><ul><ul><li>Shares this data with the responsible physicians and other disciplines that participate in the clinical pathway </li></ul></ul><ul><ul><li>This data is then used to explore opportunities for improvement in the pathway or in hospital systems </li></ul></ul>