BRINGING YOUR NURSE STAFFING COMMITTEE TO LIFE: Staffing, Scheduling & Budgeting for the Bedside Clinician Cathe Clapp, RN, MN Barbara Hyland-Hill, RN,

BRINGING YOUR NURSE BRINGING YOUR NURSE STAFFING COMMITTEE TO STAFFING COMMITTEE TO LIFE:LIFE:Staffing, Scheduling & Staffing, Scheduling & Budgeting for the Bedside Budgeting for the Bedside ClinicianClinician

Cathe Clapp, RN, MNCathe Clapp, RN, MN

Barbara Hyland-Hill, RN, MN, CNAA-Barbara Hyland-Hill, RN, MN, CNAA-BCBCJune 22, 2010 - WenatcheeJune 22, 2010 - Wenatchee

June 23, 2010 – SpokaneJune 23, 2010 – Spokane

June 24, 2010 – RentonJune 24, 2010 – Renton

July 14, 2010 - LynnwoodJuly 14, 2010 - Lynnwood

Ruckelshaus Nurse Staffing Steering CommitteeRuckelshaus Nurse Staffing Steering Committee

2Ruckelshaus Nurse Staffing Steering Committee

WA State Staffing Legislation – WA State Staffing Legislation – House Bill 3123House Bill 3123 (2008)(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


Our ObjectivesOur Objectives

Provide you with basic concepts about:Provide you with basic concepts about: Budgeting (Staffing/Labor Budget)Budgeting (Staffing/Labor Budget) Staffing and SchedulingStaffing and Scheduling Nurse Sensitive IndicatorsNurse Sensitive Indicators Staffing Committee EffectivenessStaffing Committee Effectiveness

Have you apply the conceptsHave you apply the concepts You leave with a toolkit (tools and resources)You leave with a toolkit (tools and resources) You will be able to share your learnings with You will be able to share your learnings with

your committee members (Train the Trainer) your committee members (Train the Trainer)


AgendaAgenda

Budgeting 101Budgeting 101 Staffing and Scheduling Made SimpleStaffing and Scheduling Made Simple Nurse Sensitive Indicators for Nurse Sensitive Indicators for

DummiesDummies Making the Staffing Committee WorkMaking the Staffing Committee Work Putting It All Together – Case Putting It All Together – Case

ApplicationApplication

Budgeting 101Budgeting 101


Personal BudgetPersonal Budget

IncomeIncome Salary – Pay checkSalary – Pay check Interest/investment Interest/investment

earningsearnings

ExpensesExpenses House payment or rentHouse payment or rent UtilitiesUtilities FoodFood InsuranceInsurance Car paymentCar payment GasGas EtcEtc


What is a budget?What is a budget?

A A PlanPlan Coordination of revenue and Coordination of revenue and

expensesexpenses

Specific period of time – usually Specific period of time – usually 1 1

yearyear

Formalized Formalized →→ written down written down

Forecast the futureForecast the futureAn Educated An Educated GuessGuess


Functions of the BudgetFunctions of the Budget Financially Financially

operationalize an operationalize an organization’s goals organization’s goals and objectivesand objectives

Keep management Keep management informedinformed

Evaluate performanceEvaluate performance Refine program Refine program

development and plandevelopment and plan EducateEducate Increase cost Increase cost

awarenessawareness


Budgeting ProcessBudgeting Process

Understand your organization’s Understand your organization’s process, forms, timeline, terminology, process, forms, timeline, terminology, fiscal yearfiscal year

Planning Planning Department Goals & ObjectivesDepartment Goals & Objectives Projected Units of Service (Volume and Projected Units of Service (Volume and

Acuity)Acuity) PreparingPreparing Monitoring and ControllingMonitoring and Controlling ReportingReporting

Staffing BudgetStaffing Budget(Labor, Personnel, Manpower)(Labor, Personnel, Manpower)


Basic Concepts – Basic Concepts – Units of Units of ServiceService Unit of Service (UOS) – measure of product or service Unit of Service (UOS) – measure of product or service

produced by the departmentproduced by the department For Nursing DepartmentsFor Nursing Departments

Inpatient UnitsInpatient Units Patient DaysPatient Days Outpatient UnitsOutpatient Units VisitsVisits Emergency DepartmentEmergency Department VisitsVisits Surgical UnitsSurgical Units Procedures Procedures (Major & Minor)(Major & Minor)

MinutesMinutes Labor & DeliveryLabor & Delivery DeliveriesDeliveries

Procedures Procedures (Ante partum)(Ante partum)

OP OncologyOP Oncology TreatmentsTreatments


The Story of The Story of Your UnitYour Unit

Who are your patients?Who are your patients? DRG, age, drugs/therapies/treatments usedDRG, age, drugs/therapies/treatments used

What are their needs?What are their needs? Acuity, severity of illnessAcuity, severity of illness

What are your hours of operation?What are your hours of operation? 24/724/7 Other: Mon-Fri, 8 am – 5 pmOther: Mon-Fri, 8 am – 5 pm

Collect information on:Collect information on: VolumesVolumes Length of stayLength of stay ADT ratio/churn factorADT ratio/churn factor Number of proceduresNumber of procedures Do you have outpatients or 23-hour stay patients?Do you have outpatients or 23-hour stay patients? Is the census done at midnight?Is the census done at midnight?


Basic Concepts – Basic Concepts – NursingNursing HoursHours

Total Paid Nursing Hours

Productive Hours

(Hours worked)

Non-Productive Hours

(Hours paid but not worked)

· Vacation time· Sick leave· Holiday time· Bereavement time· FMLA· Jury Duty· Education/Professional leave

· Regular scheduled hours· Overtime hours· Premium pay hours· Call back hours· Registry/Traveler hours

Direct Care Hours(Variable Staff)

Hours worked by nursing staff assigned to a unit who have direct

patient care responsibilities for greater than 50% of their shift** –

for the pt)

Indirect Care Hours(Hours worked on or off the unit/

department but for the unit/department)

Direct Care Hours are:“Patient centered nursing activities by unit-based staff in the presence of the pt or activities that occur away from the pt, but are pt related:· Med administration & nursing

treatments· Admit, Discharge, Transfer activities· Pt teaching· Pt communication· Coordination of pt care and nursing

rounds· Documentation time· Treatment planning”**

· Staff counted in staffing matrix or core staffing

· Replaced if calls in sick· Hours worked are charged to the

unit cost center

· Inservice education time· Orientation hours· Staff meeting time· Shared Governance meetings or

activities· Unit related project work – QI/ QA,

standards development, etc· Committee meeting time or work

Variable and Fixed Staff

Variable:Staff whose hours of work flex with patient census, volume, or acuity, i.e., RN, LPN, NA-C, Surgical Tech

Fixed:Staff whose hours of work are set without consideration of patient census, volume or acuity, i.e., Manager, HUC, unit-based Educator/CNS , Monitor Tech

**NDNQI Guidelines for Data Collection

Fixed Hours(Hours required to support

department operations regardless of department activity or volume)

· Director/Manager· CNS or unit-based Educator· HUC, Monitor Tech· Scheduler· Central Supply Tech


Required Required Care HoursCare Hours

Projected Projected UOSUOS volume volume Determination of workload hoursDetermination of workload hours

Direct nursing care hours per pt day Direct nursing care hours per pt day (or UOS) (or UOS) standardstandard

Patient Classification System – Case Patient Classification System – Case MixMix

Desired Fixed Staffing CoverageDesired Fixed Staffing Coverage


Basic Concepts - Basic Concepts - FTEsFTEs

FTE = FTE = Full Time EquivalentFull Time Equivalent Equivalent of 1 full-time employee Equivalent of 1 full-time employee

working for 1 yearworking for 1 year 1.0 FTE = 2080 hrs/yr 1.0 FTE = 2080 hrs/yr (8 hrs X 5 days X 52 (8 hrs X 5 days X 52

wks)wks)

= 40 hrs/wk= 40 hrs/wk (8 hrs X 5 days)(8 hrs X 5 days)

= 80 hrs/2 wks = 80 hrs/2 wks (8 hrs X 10 days)(8 hrs X 10 days) FTEs are converted to positions which FTEs are converted to positions which

are filled by employeesare filled by employees


Workload Hours - Workload Hours - DNCHDNCH

General Medical UnitGeneral Medical UnitBed CapacityBed Capacity 3636

Pt Days (UOS)Pt Days (UOS) 11,79011,790

ADCADC

% occupancy% occupancy32.332.3

89.7%89.7%

11,790 pt days/365 days11,790 pt days/365 days

32.3 ADC/36 beds X 10032.3 ADC/36 beds X 100

DNCH/UOSDNCH/UOS 8.148.14 StandardStandard

DNCH DNCH Required/YrRequired/Yr

FTESFTES

95,97195,971

46.146.1

11,790 pt days X 8.14 11,790 pt days X 8.14 DNCHDNCH

95,971 hrs/208095,971 hrs/2080

DNCH DNCH Required/DayRequired/Day

# Staff# Staff

262.93262.93

32.932.9

32.3 ADC X 8.14 DNCH32.3 ADC X 8.14 DNCH

262.93/8 hr shifts262.93/8 hr shifts


Workload Hours - Workload Hours - AcuityAcuity

Pt Acuity Pt Acuity LevelLevel DNCHPPDDNCHPPD Pt DaysPt Days

Workload Workload HoursHours

11 3.03.0 1,0611,061 3,1833,183

22 5.25.2 3,6753,675 19,11019,110

33 8.88.8 4,8764,876 42,90942,909

44 13.013.0 1,7041,704 22,15222,152

55 18.218.2 474474 8,6278,627

TotalTotal 11,79011,790 95,98195,981

DNCHDNCH46.1 FTEs46.1 FTEs

XX ==


Workload Hours - Workload Hours - FixedFixed

Department

UOS

Hours of Operation

M T W Th F S STotal Hrs

FTEsHrs40 M T W Th F S S

Total Hrs

FTEsHrs40

Manager 8 8 8 8 8 40 1.0 1.0

Charge RN 10 10 10 10 10 50 1.3 1.3

RN 16 16 16 16 16 16 96 2.4 16 16 16 16 16 80 2.0 4.4

LPN

NA-C 8 8 8 8 8 8 48 1.2 8 8 8 8 8 40 1.0 2.2

HUC/Receptionist 8 8 8 8 8 8 48 1.2 8 8 8 8 8 40 1.0 2.2

11.1

Oncology Infusion Center

### Treatments

M - F 7:30 am - 7:00 pm; Sat 7:30 - 4:00 pm

Shift Hrs: 7:30 am - 4:00 pm Shift Hrs: 10:30 am - 7:00 pm

Total FTEs



General Surgical UnitGeneral Surgical UnitBed CapacityBed Capacity 3232


ADCADC

% occupancy% occupancy

pt days/365 dayspt days/365 days

ADC/36 beds X 100ADC/36 beds X 100



FTESFTES

pt days X DNCHpt days X DNCH

DNC hrs/2080DNC hrs/2080


# Staff# Staff

ADC X DNCHADC X DNCH

DNC hrs/8 hr shiftsDNC hrs/8 hr shifts



General Surgical UnitGeneral Surgical UnitBed CapacityBed Capacity 3232


ADCADC


92%92%

pt days/365 dayspt days/365 days

ADC/36 beds X 100ADC/36 beds X 100



FTESFTES

84,14384,143

40.540.5

pt days X DNCHpt days X DNCH

Yearly DNC hrs/2080Yearly DNC hrs/2080


# Staff# Staff

230.69230.69

28.828.8

ADC X DNCHADC X DNCH

Daily DNC hrs/8 hr shiftsDaily DNC hrs/8 hr shifts


Workload Hours - Workload Hours - AllocationAllocation Staffing ModelStaffing Model

Total pt care, Team, Modular, Total pt care, Team, Modular, Primary Care, Partnership (Dyad)Primary Care, Partnership (Dyad)

% RN, % LPN, % NA-C% RN, % LPN, % NA-C Length of shifts – 8, 10, 12 hrLength of shifts – 8, 10, 12 hr % care allocated per shift% care allocated per shift


Required DNC Required DNC StaffStaff Per Per DayDayGeneral Medical UnitGeneral Medical UnitADC = 32.3 ADC = 32.3 DNCH 8.14DNCH 8.14

Required Hrs = 262.93 Required Hrs = 262.93 Required staff = 32.9Required staff = 32.9

(Hrs by shift)(Hrs by shift)

DaysDays40%40%

(105.17)(105.17)

EveEve30%30%(78.88)(78.88)

NightsNights30%30%(78.88)(78.88)

TotalTotal(by skill (by skill

mix)mix)

RN RN (71%)(71%) 9.39.3(105.17 (105.17 X .71/8)X .71/8)

7.07.0(78.88 X .71/8)(78.88 X .71/8)

7.07.0(78.88 X .71/8)(78.88 X .71/8)

23.323.3

LPNLPN

NA-C NA-C (29%)(29%) 3.83.8(105.17 (105.17 X .29/8)X .29/8)

2.92.9(78.88 X .29/8)(78.88 X .29/8)

2.92.9(78.88 X .29/8)(78.88 X .29/8)

9.69.6

TotalTotal(by shift mix)(by shift mix)

13.113.1 9.99.9 9.99.9 32.932.9


Required DNC Required DNC StaffStaff Per Per DayDayGeneral Surgical UnitGeneral Surgical UnitADC = 29.5 ADC = 29.5 DNCH 7.82DNCH 7.82

Required Hrs = Required Hrs = Required staff = Required staff =


DaysDays40%40%

EveEve35%35%

NightsNights25%25%


mix)mix)

RN RN (71%)(71%)

LPNLPN

NA-C NA-C (29%)(29%)



Required DNC Required DNC StaffStaff Per Per DayDayGeneral Surgical UnitGeneral Surgical UnitADC = 29.5 ADC = 29.5 DNCH 7.82DNCH 7.82

Required Hrs = 230.69 Required Hrs = 230.69 Required staff = 28.8Required staff = 28.8


DaysDays40%40%(92.28)(92.28)

EveEve35%35%(80.74)(80.74)

NightsNights25%25%(40.95)(40.95)


mix)mix)

RN RN (71%)(71%) 8.28.2(92.28 X .71/8)(92.28 X .71/8)

7.27.2(80.74 X .71/8)(80.74 X .71/8)

5.15.1(40.95 X .71/8)(40.95 X .71/8)

20.520.5

LPNLPN

NA-C NA-C (29%)(29%) 3.33.3(92.28 X .29/8)(92.28 X .29/8)

2.92.9(80.74 X .29/8)(80.74 X .29/8)

2.12.1(40.95 X .29/8)(40.95 X .29/8)

8.38.3


11.511.5 10.110.1 7.27.2 28.828.8

Required DNC Required DNC FTEsFTEs Per Per YearYearGeneral Medical UnitGeneral Medical UnitUOS = 11,790 UOS = 11,790 DNCH 8.14DNCH 8.14

Required Hrs = 95,971 Required Hrs = 95,971 Required FTEs = 46.1Required FTEs = 46.1

DaysDays40%40%

EveEve30%30%

NightsNights30%30%


mix)mix)

RN RN (71%)(71%) 13.113.1 9.89.8 9.89.8 32.732.7

LPNLPN

NA-C NA-C (29%)(29%) 5.45.4 4.04.0 4.04.0 13.413.4

TotalTotal 18.518.5 13.813.8 13.813.8 46.146.1

Required DNC Required DNC FTEsFTEs Per Per YearYearGeneral Surgical UnitGeneral Surgical UnitUOS = 10,760 UOS = 10,760 DNCH 7.82DNCH 7.82

Required Hrs = Required Hrs = Required FTEs = Required FTEs =

DaysDays40%40%

EveEve35%35%

NightsNights25%25%


mix)mix)

RN RN (71%)(71%)

LPNLPN

NA-C NA-C (29%)(29%)

TotalTotal

Required DNC Required DNC FTEsFTEs Per Per YearYearGeneral Surgical UnitGeneral Surgical UnitUOS = 10,760 UOS = 10,760 DNCH 7.82DNCH 7.82

Required Hrs = 84,143 Required Hrs = 84,143 Required FTEs = 40.5Required FTEs = 40.5

DaysDays40%40%

(33,658)(33,658)

EveEve35%35%

(29,450)(29,450)

NightsNights25%25%

(21,035)(21,035)


mix)mix)

RN RN (71%)(71%)

11.511.5(33,658 (33,658

X .71/2080)X .71/2080)

10.110.1(29,450 X .71/2080)(29,450 X .71/2080)

7.27.2(21,035 X .71/2080)(21,035 X .71/2080)

28.828.8

LPNLPN

NA-C NA-C (29%)(29%)

4.74.7(33,658 (33,658

X .29/2080)X .29/2080)

4.14.1(29,450 X .29/2080)(29,450 X .29/2080)

2.92.9(21,035 X .29/2080)(21,035 X .29/2080)

11.711.7

TotalTotal 16.216.2 14.214.2 10.110.1 40.540.5


Non-Productive HoursNon-Productive Hours

Coverage for anticipated time off Coverage for anticipated time off (backfill or replacement)(backfill or replacement)

How does your organization define How does your organization define Non-Productive HoursNon-Productive Hours?? PTO, Vacation, Sick Leave, Holiday, PTO, Vacation, Sick Leave, Holiday,

Bereavement, FMLA, Bereavement, FMLA, Education/Professional Education/Professional

What categories of staff must be What categories of staff must be replacedreplaced RN, LPN, NA-C, HUC, Monitor Tech, RN, LPN, NA-C, HUC, Monitor Tech,

Surgical Tech, etcSurgical Tech, etc



How does your organization budget for How does your organization budget for Non-Productive Non-Productive coverage?coverage? Ave % of non-productive time Ave % of non-productive time

VacationVacation 15 days15 daysHolidayHoliday 9 days 9 daysAverage sickAverage sick 6 days 6 daysEducationEducation 2 2 days days

32 days = 256 hrs (8 hr shift)32 days = 256 hrs (8 hr shift)2080 - 256 = 1824 prod DNCH2080 - 256 = 1824 prod DNCH256/1825 = 256/1825 = 14%14%46.1 DNC FTEs X 1.14 = 52.6 – 46.1 = 46.1 DNC FTEs X 1.14 = 52.6 – 46.1 = 6.56.5 NP NP

FTEsFTEs



How does your organization budget for How does your organization budget for Non-Productive Non-Productive coverage?coverage? Calculate by category of staff replaced and Calculate by category of staff replaced and

type of type of NPNP time time VacationVacation Sick leaveSick leave HolidayHoliday Education/Professional leaveEducation/Professional leave

# days by staff category X 8 hours X DNC FTE# days by staff category X 8 hours X DNC FTE

20802080


Productive – Productive – Fixed StaffFixed Staff

Positions whose hours are set and do Positions whose hours are set and do not adjust with pt census, volume or not adjust with pt census, volume or acuityacuity

Manager, CNS, Unit-based educatorManager, CNS, Unit-based educator Health Unit Coordinator, Monitor TechHealth Unit Coordinator, Monitor Tech Need to know:Need to know:

# of days/week and shift coverage# of days/week and shift coverage Are they replaced when off?Are they replaced when off?


Non-ProductiveNon-Productive ImpactImpact

FTEFTE NP %NP % NP FTENP FTE Total FTE Total FTE

ManageManagerr

1.01.0 -- -- 1.01.0

RNRN 32.732.7 14%14% 4.64.6 37.337.3

NA-CNA-C 13.413.4 14%14% 1.91.9 15.315.3

HUCHUC 2.82.8 14%14% .4.4 3.23.2

Total Total 49.949.9 6.96.9 56.856.8


Indirect Care HoursIndirect Care Hours

Paid, worked hours related to Paid, worked hours related to unit/dept functionunit/dept function

OrientationOrientation Inservice education – CPR, Inservice education – CPR,

mandatory educationmandatory education Staff meeting timeStaff meeting time Shared governance meetingsShared governance meetings Committee time/workCommittee time/work QA, Clinical Pathways, Standards, etcQA, Clinical Pathways, Standards, etc



Calculated by type of activity by skill mixCalculated by type of activity by skill mix

# staff X # hrs X # times = hrs# staff X # hrs X # times = hrs OrientationOrientation

Turnover by categoryTurnover by category Anticipated RetirementsAnticipated Retirements

Ave # days orientedAve # days oriented New graduatesNew graduates

Do you take?Do you take? Do you have a Residency Program? How long is it?Do you have a Residency Program? How long is it? Are the new graduates hours expensed centrally or to Are the new graduates hours expensed centrally or to

unit?unit?

Indirect Care Hours Indirect Care Hours Indirect Productive HoursIndirect Productive Hours

AnnualAnnual

HrsHrs# #

StaffStaffTotalTotal

HoursHours FTEFTE

Education and MeetingsEducation and Meetings

RN Education & Meetings RN Education & Meetings 4040 6464 2,5602,560 1.21.2

NA-C Education & Meetings NA-C Education & Meetings 2020 3232 640640 .3.3

HUC/MT Education & Meetings HUC/MT Education & Meetings 2020 77 140140 .1.1

SubtotalSubtotal 1.61.6

OrientationOrientation

RN (average # days – 15)RN (average # days – 15) 120120 55 600600 .3.3

NA-C (average # days – NA-C (average # days – 10)10) 8080 44 320320 .2.2

HUC (average # days – HUC (average # days – 15)15) 120120 11 120120 .1.1

SubtotalSubtotal .6.6

TotalTotal 2.22.2


Staff Per Day & FTE Staff Per Day & FTE BudgetBudget

Direct Care # Direct Care # Staff/DayStaff/Day

32.932.9

FTEsFTEs

Direct Nursing Care Direct Nursing Care 46.146.1

Fixed StaffFixed Staff 3.83.8

14% Non-14% Non-Productive Productive

6.96.9

Indirect TimeIndirect Time 2.22.2

Total Paid FTEsTotal Paid FTEs 59.059.0

++

++

++


Premium PayPremium Pay

Shift differentialShift differential Weekend differentialWeekend differential Charge nurse, certification, preceptor Charge nurse, certification, preceptor

differentialdifferential OvertimeOvertime Standby and call back payStandby and call back pay


Basic Concepts – Basic Concepts – Hours Per Hours Per UOSUOS UOS are compared in a ratio to paid or UOS are compared in a ratio to paid or

direct hours required to deliver the direct hours required to deliver the service or productservice or product

Common Productivity Standard in Common Productivity Standard in NursingNursing Nursing Hours Per Pt Day (HPPD)Nursing Hours Per Pt Day (HPPD)

Direct Care HoursDirect Care Hours Productive Hours Paid/UOSProductive Hours Paid/UOS Total Hours Paid/UOSTotal Hours Paid/UOS


Basic Concepts – Basic Concepts – FormulasFormulas Average Daily Census (ADC)Average Daily Census (ADC)

Total pt daysTotal pt days

# of days # of days (week, month, year)(week, month, year)

Average Length of Stay (ALOS)Average Length of Stay (ALOS)Total pt daysTotal pt days

# of discharges# of discharges

Percent OccupancyPercent OccupancyTotal pt daysTotal pt days Census or ADCCensus or ADC

Total # bed days availableTotal # bed days available Beds availableBeds availableoorr


Basic Concepts – Basic Concepts – FormulasFormulas

Total Direct or Total Productive Total Direct or Total Productive Hrs/UOSHrs/UOS

Total direct or productive hrsTotal direct or productive hrs

Patient days Patient days oror UOS UOS

Total Paid Hours/UOSTotal Paid Hours/UOSTotal paid hrsTotal paid hrs

Patient days Patient days oror UOS UOS


Basic Concepts – Basic Concepts – FormulasFormulas Average Hourly RateAverage Hourly Rate

Total salary $Total salary $

Total hours paidTotal hours paid

Total Productive Salary Expense/UOSTotal Productive Salary Expense/UOSTotal productive salary $Total productive salary $

Patient Days Patient Days oror UOS UOS

Total Salary Expense/UOSTotal Salary Expense/UOSTotal productive salary $Total productive salary $

Patient Days Patient Days oror UOS UOS


Sample Cost Center Sample Cost Center ReportReport

DescriptionActual Budet Variance Var% Prior Yr Actual Budet Variance Var% Prior Yr

Revenue1,400,000 1,040,000 360,000 135% 915,000 Inpatient Revenue 15,253,126 12,062,013 3,191,113 126% 13,748,936

- - - - Outpatient Revenue 500 - 500 100% 250 1,400,000 1,040,000 360,000 135% 915,000 Total revenue 15,253,626 12,062,013 3,191,613 126% 13,749,186

Expenses222,156 191,952 30,204 116% 198,554 Salaries and wages 2,469,073 2,229,607 239,466 111% 2,359,006 105,005 90,000 15,005 117% 101,775 Benefits 302,404 313,963 (11,559) 96% 307,449

85,000 60,000 25,000 142% 54,332 Professional fees 1,118,881 728,346 390,535 154% 663,951 150 200 (50) 75% 188 Purchased services 2,338 1,150 1,188 203% 1,872

13,222 12,654 568 104% 11,952 Supplies 155,409 162,654 (7,245) 96% 145,739 1,500 600 900 250% 720 Other 6,050 1,942 4,108 312% 2,378 8,263 8,152 111 101% 8,152 Depreciation 105,968 106,942 (974) 99% 106,942

435,296 363,558 71,738 120% 375,673 Total Expenses 4,160,123 3,544,604 615,519 117% 3,587,337

964,704 676,442 288,262 143% 539,327 Contribution Margin 11,093,503 8,517,409 2,576,094 130% 10,161,849

Actual Budet Variance Var% Prior Yr Statistic Actual Budet Variance Var% Prior Yr625 605 20 103% 645 UOS 8,224 7,362 862 112% 7,888

20.83 20.17 0.67 103% 21.50 ADC 22.53 20.17 2.36 112% 21.61 87% 84% 0.03 103% 90% % occupancy 94% 84%8362 7528 834 111% 8109 Productive hours 107,651 93,239 14,412 115% 95,386

998 1012 (14) 99% 975 Nonproductive hours 10,992 11,377 (385) 97% 11,445 9360 8540 820 110% 9084 Total paid hours 118,643 104,616 14,027 113% 110,398

13.38 12.44 0.94 108% 12.57 Productive hours/UOS 13.09 12.66 0.42 103% 12.0914.98 14.12 0.86 106% 14.08 Total paid hours/UOS 14.43 14.21 0.22 102% 14.00

FTEs48.24 43.43 4.81 111% 46.78 Productive FTEs 51.76 44.83 6.93 115% 45.86

5.76 5.84 (0.08) 99% 5.63 Nonproductive FTEs 5.28 5.47 (0.19) 97% 5.5054.00 49.27 4.73 110% 52.41 Total FTEs 57.04 50.30 6.74 113% 53.08

St Elsewhere Hospital

Department: TelemetryCost Center: 6150Period Ending: June 30, 2008

Manager: Sally Jones

Current Month Year to Date


Basic ConceptsBasic Concepts – – Variance Variance AnalysisAnalysis

A variance is the difference between the A variance is the difference between the BudgetedBudgeted amount and the amount and the ActualActual results results

FavorableFavorable versus versus Unfavorable Unfavorable variancevariance Variance analysis is a component of Variance analysis is a component of

budget monitoring to investigate and budget monitoring to investigate and explain explain whywhy differences occurreddifferences occurred

Individual manager accountability for Individual manager accountability for budget variancesbudget variances


Basic ConceptsBasic Concepts – – Variance Variance AnalysisAnalysis

Flexible Budget Variance AnalysisFlexible Budget Variance Analysis Variance is a function of:Variance is a function of:

Volume (output)Volume (output) (Patient Days or (Patient Days or UOS)UOS)

Price or RatePrice or Rate (Ave Hourly Rate)(Ave Hourly Rate) Quantity or UseQuantity or Use (Nursing Hours (Nursing Hours

Used)Used)

ff (Volume + Quantity + Price)(Volume + Quantity + Price)


Basic Concepts – Basic Concepts – StaffingStaffing CostsCosts What affects What affects Staffing CostsStaffing Costs??

Volume (UOS)Volume (UOS) Total Hours PaidTotal Hours Paid

Direct Care Hrs – Direct Care Hrs – Pt Acuity, ADT ratio, staffing to matrix Pt Acuity, ADT ratio, staffing to matrix Indirect Care Hrs – Indirect Care Hrs – Orientation of new staff, mandatory Orientation of new staff, mandatory

inservices or meetingsinservices or meetings Non-Productive Hrs – Non-Productive Hrs – Sick leave, vacation, FMLA, holidaySick leave, vacation, FMLA, holiday

Average Hourly Rate PaidAverage Hourly Rate Paid Overtime or premium pay situationsOvertime or premium pay situations Registry or Traveler useRegistry or Traveler use Skill mix usedSkill mix used


Staffing and Staffing and Scheduling Made Scheduling Made

SimpleSimple


CreatingCreating Position Control Position Control and and SchedulesSchedules DEMANDDEMAND

Patient TypePatient Type Patient Volume and AcuityPatient Volume and Acuity Demand Variations (churn, time of day, Demand Variations (churn, time of day,

days of week, months, seasons)days of week, months, seasons)

RESOURCESRESOURCES Roles (Fixed and Variable)Roles (Fixed and Variable) FTE MixFTE Mix Days of the weekDays of the week ShiftsShifts


48

Staffing ModelStaffing Model

Revisit, or build from the ground up, Revisit, or build from the ground up, so allows manager and staff to so allows manager and staff to understand all of the elements of understand all of the elements of staffing and resource usestaffing and resource use

Start with Start with budgeted average daily budgeted average daily census census (DEMAND) and the and the direct direct care staff FTE budget care staff FTE budget (RESOURCES)


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)



Paid hours related to unit/dept Paid hours related to unit/dept function not in DNCHsfunction not in DNCHs

OrientationOrientation Inservice education – CPR, mandatory Inservice education – CPR, mandatory

educationeducation Staff meeting timeStaff meeting time Shared governance meetingsShared governance meetings Committee time/workCommittee time/work QA, Clinical Pathways, Standards, etcQA, Clinical Pathways, Standards, etc


Staffing ModelStaffing ModelIndirect Productive HoursIndirect Productive Hours

AnnualAnnual

HrsHrs# #

StaffStaffTotalTotal

HoursHours FTEFTE

Education and MeetingsEducation and Meetings

RN Education & Meetings RN Education & Meetings 4040

CNA Education & Meetings CNA Education & Meetings 2020

USMT Education & Meetings USMT Education & Meetings 2020

Total Education and Total Education and MeetingsMeetings

EXAMPLE

RN EducationRN Education 4040 7373 29202920 1.41.4

Do same for any other identifiable indirect and/or Do same for any other identifiable indirect and/or non-productive hours i.e. vacationnon-productive hours i.e. vacation


Non-ProductiveNon-Productive ImpactImpact

FTEFTE NP %NP % NP FTENP FTE Total FTE Total FTE

ManagManagerer

1.01.0 -- -- 1.01.0

RNRN 32.732.7 14%14% 4.64.6 37.337.3

NA-CNA-C 13.413.4 14%14% 1.91.9 15.315.3

HUCHUC 2.82.8 14%14% .4.4 3.23.2

Total Total 49.949.9 6.96.9 56.856.8


Unit Budget OverviewUnit Budget Overview

General Medical UnitGeneral Medical UnitBed CapacityBed Capacity 3636 Pt Days (UOS)Pt Days (UOS) 11,79011,790

ADCADC


89.7%89.7%DNCH/UOSDNCH/UOS 8.148.14

DNCH Req/YrDNCH Req/Yr

FTESFTES46.146.1 DNCH Req/DayDNCH Req/Day

# Staff/ 8 # Staff/ 8 hourshours

32.932.9

Non-Productive FTEs (14%)

6.9 6.9 Total Unit FTEsTotal Unit FTEs 56.856.8


Consider Consider # of Days# of Days per weekper week to to StaffStaff

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


Aim of Improving Aim of Improving StaffingStaffing and and Scheduling SystemsScheduling Systems and and ProcessesProcesses

The Right The Right StaffStaff In the Right In the Right PlacePlace At the Right At the Right TimeTime At the Right At the Right CostCost Doing the Right Doing the Right

ThingThing


Why is it worth it?Why is it worth it?

High quality careHigh quality care

Eliminating a last minute crisis modeEliminating a last minute crisis mode

Decreases labor intensive re-workDecreases labor intensive re-work

Agreements between key players Agreements between key players

Reduce use of temporary agency and Reduce use of temporary agency and premium paypremium pay

Support staff satisfactionSupport staff satisfaction


Why is it worth it?Why is it worth it? To provide To provide high quality carehigh quality care to our patients by to our patients by

effectively managing our scheduling and staffing practices.effectively managing our scheduling and staffing practices. Move us to more proactive planning and problem solving Move us to more proactive planning and problem solving

with the goal of with the goal of eliminating a last minute crisis modeeliminating a last minute crisis mode of operation.of operation.

Standardize and streamline processes and increase Standardize and streamline processes and increase accuracy which in turnaccuracy which in turn decreases labor intensive re-decreases labor intensive re-workwork..

Create Create role role agreements between key playersagreements between key players that that help make working together more pleasant and effective.help make working together more pleasant and effective.

Reduce use of temporary agency and premium payReduce use of temporary agency and premium pay in a sustainable fashion.in a sustainable fashion.

Support staff satisfactionSupport staff satisfaction with equitable treatment as with equitable treatment as well as reasonable and transparent accommodations when well as reasonable and transparent accommodations when appropriate.appropriate.


Monthly schedules including vacations etc

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 PATIENTSTHE PATIENTS THE STAFFTHE STAFF

The Moment Of TruthThe Moment Of TruthWe GO LIVE 24/7


High Level Staffing and Scheduling Overview

ForecastingHiring Targets(# and timing)

Technology • Scheduling • Timekeeping

Recruitand Hire

Scheduling

UnitPosition Control

andCore Staffing

MiddleStaffing

Last24 Hours

StaffingMid-Shift

Float PoolAnd

On-Call

Census / Bed Management

Supplemental Staff• Agency• Travelers

Float PoolSizing

Forecasting Process – Planning activities that include determination of core staffing and hiring targetsScheduling Process – From when requests are due until final schedule is postedMiddle Process – Activity occurring after the schedule is posted and up to 24 hrs before (72 hrs on weekends)Staffing Process – From 24 hrs before (72 hrs on weekends) to day of staffing


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.”


Overview of Three Distinct Overview of Three Distinct Staffing and Scheduling Staffing and Scheduling

PhasesPhases

Scheduling Process - - from when requests are due until final schedule posted 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 activity after the schedule is posted -up to 24 hrs before (72 hrs on

weekends) weekends) Staffing Process --from 24 hrs before (72 hrs on weekends) to day of staffingfrom 24 hrs before (72 hrs on weekends) to day of staffing

Before the schedule is posted

Before the schedule is posted

Mid Process: Posted to 24-72 Hrs before

Mid Process: Posted to 24-72 Hrs before

Outcome

-Balanced schedule

-Cost effective plan for

filling vacancies

Outcome

-Balanced schedule

-Cost effective plan for

filling vacancies

Outcome

-Re-balancing of

schedule prn

Outcome

-Re-balancing of

schedule prn

Outcome

-Final staffing adjustments

-Float pool assignment

Outcome

-Final staffing adjustments

-Float pool assignment

24 Hrs before to day of staffing

SchedulingScheduling The MiddleThe Middle StaffingStaffing


SchedulingScheduling Philosophy 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

Patient

Staff Manager

Scheduler

Effective scheduling models minimize the ultimate last-minute staffing needs for a shift

Schedules are dynamic and flexible but changes are minimized


Capable of creating schedules that meet unit Capable of creating schedules that meet unit needsneeds

Recognizes importance of stakeholder Recognizes importance of stakeholder “relationship” and role agreements in scheduling “relationship” and role agreements in scheduling and staffing processesand staffing processes

Ability to flex schedules (up and down) based on Ability to flex schedules (up and down) based on patient and unit needspatient and unit needs

Recognizes unit volumes and workload patternsRecognizes unit volumes and workload patterns Recognizes special circumstancesRecognizes special circumstances Takes technology into considerationTakes technology into consideration Defines options for filling vacanciesDefines options for filling vacancies

What are the characteristics What are the characteristics of anof an effective unit scheduling effective unit scheduling process?process?


Scheduling Process Scheduling Process StepsStepsSchedulerScheduler ManagerManager StaffStaff

Core and patterns are establishedCore and patterns are established Staff submit requestsStaff submit requests Anticipated monthly variationsAnticipated monthly variations Schedule adjustment are identifiedSchedule adjustment are identified Temporary schedule reviewedTemporary schedule reviewed Temporary schedule postedTemporary schedule posted Gaps (to core) are filledGaps (to core) are filled Final schedule postedFinal schedule posted

Important to clarify the roles and Important to clarify the roles and responsibilities of key players in the responsibilities of key players in the

Scheduling processScheduling process


Staffing and Scheduling Staffing and Scheduling DefinitionsDefinitions

Balanced Balanced ScheduleSchedule

Nursing units have a pre-defined “core” number of staff for each day of the week 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 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 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 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 surgical unit that schedules seven nurses early in the week and two less on weekends because of surgeries occurring early in the week.weekends because of surgeries occurring early in the week.

RebalancingRebalancing The process of exploring and scheduling additional hours to compensate for The process of exploring and scheduling additional hours to compensate for unplanned uncontrollable changes in scheduled hours and/or volume after the 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 schedule is posted or any time up until the staffing process map begins at 24 hrs (72 hrs on weekends)(72 hrs on weekends)

Unbalanced Unbalanced ScheduleSchedule

OkayOkay-Multiple open positionsMultiple open positions

Not-Okay Not-Okay -Granting more than established capsGranting more than established caps-People not working to FTE statusPeople not working to FTE status-Guaranteed patterns that create imbalanceGuaranteed patterns that create imbalance-Per Diems not working required shiftsPer Diems not working required shifts

Non Productive Non Productive (NP) Caps(NP) Caps

Specified amount of NP shifts allowed per schedule. Non-productive hours Specified amount of NP shifts allowed per schedule. Non-productive hours include vacation and educational meetings.include vacation and educational meetings.


Handy and Very HelpfulHandy and Very Helpful DefinitionsDefinitions• 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


Source: Source: Perspective on Staffing & SchedulingPerspective on Staffing & Scheduling, , September 2000September 2000

ADT Factor – ADT Factor – AKA Workload Intensity AKA Workload Intensity DemandDemand

The decrease in patient length of stay and the drive to The decrease in patient length of stay and the drive to enhance unit throughput has increased work activityenhance unit throughput has increased work activity

The number of admissions, discharges, and transfers The number of admissions, discharges, and transfers are usually not reflected in patient classification are usually not reflected in patient classification systems and never in midnight censussystems and never in midnight census

This activity consumes nursing care hours and must be This activity consumes nursing care hours and must be considered when looking at daily staffing, particularly considered when looking at daily staffing, particularly in nursing units where there is high patient turnoverin nursing units where there is high patient turnover

The Hidden Patient Demand


Calculation Calculation of theof the ADT ADT FactorFactor

Divide the total number of Divide the total number of AdmissionsAdmissions, , DischargesDischarges, , Transfers In & OutTransfers In & Out, and , and

DeathsDeaths in a designated 24-hour in a designated 24-hour period period

by the by the Midnight CensusMidnight Census

to determine the to determine the ADT FactorADT FactorSource: Source: Perspective on Staffing & SchedulingPerspective on Staffing & Scheduling, , September 2000September 2000


ADT Factor - ADT Factor - ExampleExample

Nursing Nursing UnitUnit

Number Number of ADTof ADT

Midnight Midnight CensusCensus

Unit Unit Specific Specific ScoreScore

Unit AUnit A 1515 1212 125% 125% turnoverturnover

Unit BUnit B 55 2525 20% 20% turnoverturnover

Source: Source: Perspective on Staffing & SchedulingPerspective on Staffing & Scheduling, , September 2000September 2000


ADT Factor - ADT Factor - ImpactImpact

Has significant impact on Has significant impact on budgeting and staffing budgeting and staffing effectivenesseffectiveness

Works out to Works out to oneone hourhour of care of care required per patient turnover required per patient turnover (Admission, Discharge, Transfer (Admission, Discharge, Transfer In, Transfer Out)In, Transfer Out)


ADT Factor - ADT Factor - ExampleExample

2000 patient turnovers per year 2000 patient turnovers per year X 1 hour of care = X 1 hour of care = 2,0002,000 additional hours of care neededadditional hours of care needed

2000/2080 = 2000/2080 = .96.96 additional FTE’s additional FTE’s needed to manage patient needed to manage patient turnover requirementsturnover requirements


ADT FactorADT Factor – – TypicalTypical Unit Unit PercentsPercents

Medical/SurgicalMedical/Surgical 50 - 55%50 - 55% TelemetryTelemetry 70 - 75%70 - 75% Critical CareCritical Care 85 - 90%85 - 90% Post PartumPost Partum 85 - 90%85 - 90% Mental HealthMental Health 40%40% RehabRehab 25 - 30%25 - 30%

Source: Source: Perspective on Staffing & SchedulingPerspective on Staffing & Scheduling, September 2000, September 2000


UnscheduledUnscheduled Absences 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,* Shiftwork Practices 2005, Circadian Technologies, as cited in Bureau of National Affairs, Inc., Circadian Technologies, as cited in Bureau of National Affairs, Inc., “Absence Management: Making the Critical Shift from Transactional to Strategic,” 2006. “Absence Management: Making the Critical Shift from Transactional to Strategic,” 2006.


UnscheduledUnscheduled Absence Absence MonitoringMonitoring

What staffing response does each What staffing response does each unit have available to respond unit have available to respond effectively to unscheduled effectively to unscheduled absences?absences?

Overtime most commonly used as Overtime most commonly used as a response to deficit demandsa response to deficit demands

Evidence growing that overtime Evidence growing that overtime adversely impacts patient safety adversely impacts patient safety and quality of careand quality of care


Overtime Overtime MonitoringMonitoring

Guideline for overtime use is to Guideline for overtime use is to keep it less than keep it less than 5%5% of worked of worked hours hours

Overtime between Overtime between 5 – 8%5 – 8% is is symptomatic of financial distresssymptomatic of financial distress

Overtime greater than Overtime greater than 8%8% is is symptomatic of serious distresssymptomatic of serious distress


Overtime Overtime MonitoringMonitoring

IOM report recommended limiting IOM report recommended limiting work hours to not more than work hours to not more than 12 12 hours per dayhours per day and not more than and not more than 60 60 hours per weekhours per week as a safety measure as a safety measure

In the U.S., many states have In the U.S., many states have legislated “No Mandatory Overtime” legislated “No Mandatory Overtime” as a result of patient safety issuesas a result of patient safety issues


Staffing PlanStaffing Plan - Example - Example

Patient Care Link - http://www.patientsfirstma.orgPatient Care Link - http://www.patientsfirstma.org

Winchester Hospital, MA – Medical Winchester Hospital, MA – Medical UnitUnit


Staffing PlanStaffing Plan - Example - Example

Patient Care Link - Patient Care Link - http://www.patientsfirstma.orghttp://www.patientsfirstma.org

Winchester Hospital, MA – Medical Winchester Hospital, MA – Medical UnitUnit

Nurse Sensitive Nurse Sensitive IndicatorsIndicators

For DummiesFor Dummies


What we know…What we know…

Preventable medical errors cost US Preventable medical errors cost US

healthcare system healthcare system $17 billion/year$17 billion/year (IOM)(IOM)

Medication errors cost nearly Medication errors cost nearly $3.5 $3.5

billion/yearbillion/year (IOM)(IOM)

Medical errors cause ~ Medical errors cause ~ 195,000 195,000

deaths/ yeardeaths/ year in the US in the US (Health Grades)(Health Grades)


Nursing Impact on Nursing Impact on Pt Pt OutcomesOutcomes

There is a clear link between nurse There is a clear link between nurse staffing (ARNPs and RNs) and patient staffing (ARNPs and RNs) and patient outcomesoutcomes

RNs are the surveillance system for RNs are the surveillance system for early detection and intervention for early detection and intervention for adverse outcomesadverse outcomes

Institutional advocate for patient Institutional advocate for patient centerednesscenteredness

The environment of practice is critical The environment of practice is critical to safetyto safety


Nursing Impact on Nursing Impact on Pt Pt OutcomesOutcomes

A study of medication errors in 2 hospitals over 6 months A study of medication errors in 2 hospitals over 6 months showed nurses were responsible for intercepting 86% of showed nurses were responsible for intercepting 86% of all medication errors before error reached the patient all medication errors before error reached the patient (Leape et al., 1995)(Leape et al., 1995)

Leaner RN staffing/less RN hrs of care are associated with:Leaner RN staffing/less RN hrs of care are associated with:

↑ ↑ LLOSOS (AHRQ, 2001; Needleman et al., 2002, 2006)(AHRQ, 2001; Needleman et al., 2002, 2006)

Nosocomial infections (UTI, post-op infection, pneumonia)Nosocomial infections (UTI, post-op infection, pneumonia) (AHRQ, 2001; Needleman et al., 2002, 2006; Aiken et al., 2002)(AHRQ, 2001; Needleman et al., 2002, 2006; Aiken et al., 2002)

Pressure ulcersPressure ulcers (AHRQ, 2001)(AHRQ, 2001)

GI bleedingGI bleeding (Needleman et al., 2002, 2006)(Needleman et al., 2002, 2006)

Cardiac arrestsCardiac arrests (Needleman et al., 2002, 2006)(Needleman et al., 2002, 2006)

Patient deathsPatient deaths (Needleman et al., 2002, 2006; Aiken et al., 2002)(Needleman et al., 2002, 2006; Aiken et al., 2002)


Thus, what we know….Thus, what we know….

NursesNurses Patient SafetyPatient Safety

NursesNurses Quality OutcomesQuality Outcomes

Quality Quality Cost Effective CareCost Effective CareOutcomesOutcomes


StaffingStaffing Indicators Indicators NHPPDNHPPD**** On call/per diem On call/per diem

useuse OvertimeOvertime Sick timeSick time Skill mixSkill mix**** % Agency hours% Agency hours Sitter hoursSitter hours Meal breaksMeal breaks

Staff injuriesStaff injuries Staff satisfactionStaff satisfaction Staff turnover Staff turnover

raterate**** Staff vacancy rateStaff vacancy rate Understaffing Understaffing

compared to compared to staffing planstaffing plan

Practice Practice environment environment scalescale****

**** National Quality Forum endorsed Nursing Sensitive National Quality Forum endorsed Nursing Sensitive IndicatorsIndicators


ClinicalClinical Indicators Indicators Patient fallsPatient falls**** Patient falls with Patient falls with

injuryinjury**** Pressure ulcerPressure ulcer**** Infection ratesInfection rates

Urinary tractUrinary tract**** PostoperativePostoperative Central lineCentral line**** Ventilator Ventilator

relatedrelated**** PneumoniaPneumonia

Adverse drug eventsAdverse drug events Injuries to ptsInjuries to pts Upper GI bleedingUpper GI bleeding Shock/cardiac arrestShock/cardiac arrest Length of stayLength of stay Failure to rescueFailure to rescue**** Restraint Restraint

prevalenceprevalence**** Smoking cessationSmoking cessation

AMI, CHF, Pneumonia AMI, CHF, Pneumonia **** National Quality Forum endorsed Nursing Sensitive National Quality Forum endorsed Nursing Sensitive IndicatorsIndicators


ServiceService Outcomes Outcomes

Patient satisfaction scorePatient satisfaction score Patient complaintsPatient complaints Family complaintsFamily complaints Patient satisfaction with pain managementPatient satisfaction with pain management Patient satisfaction with ability to manage Patient satisfaction with ability to manage

care at home (patient teaching/education)care at home (patient teaching/education) Patient satisfaction with nursing and Patient satisfaction with nursing and

overall careoverall care


CoreCore Measures (JCAHO) Measures (JCAHO)

Surgical Care Improvement Project Surgical Care Improvement Project (SCIP)(SCIP)

Heart FailureHeart Failure AMIAMI PneumoniaPneumonia PregnancyPregnancy Children’s Asthma CareChildren’s Asthma Care Hospital Inpatient Psychiatric ServicesHospital Inpatient Psychiatric Services


CMS: CMS: Non-Reimbursed Non-Reimbursed ConditionsConditions

Preventable Hospital-Acquired Preventable Hospital-Acquired ConditionsConditions Object left in pt during surgeryObject left in pt during surgery Air embolismAir embolism Blood incompatibilityBlood incompatibility Catheter-associated urinary tract infectionCatheter-associated urinary tract infection Pressure ulcerPressure ulcer Vascular catheter-associated infectionVascular catheter-associated infection All surgical site infectionsAll surgical site infections


CMS: CMS: Non-Reimbursed Non-Reimbursed ConditionsConditions

Preventable Hospital-Acquired Preventable Hospital-Acquired ConditionsConditions Falls with injuriesFalls with injuries Ventilator associated pneumoniaVentilator associated pneumonia Staphyloccus aureus septicemiaStaphyloccus aureus septicemia Deep vein thrombosis and pulmonary Deep vein thrombosis and pulmonary

embolismembolism MRSAMRSA Clostridium difficile-associated diseaseClostridium difficile-associated disease Wrong surgery Wrong surgery


Benchmarking and ReportingBenchmarking and Reporting

National Database of Nursing National Database of Nursing Quality Indicators (NDNQI)Quality Indicators (NDNQI)

Collaborative Alliance of Nursing Collaborative Alliance of Nursing Outcomes (CALNOC)Outcomes (CALNOC)

Washington State Hospital Washington State Hospital AssociationAssociation


WA State - WA State - NSQINSQI

FallsFalls Falls with injuryFalls with injury Pressure ulcersPressure ulcers Nursing hours per patient Nursing hours per patient

dayday Skill mixSkill mix


Cost Factors Related to Cost Factors Related to Pt Pt SafetySafety

Occurrence of the medical errorOccurrence of the medical error Prevention of the medical errorPrevention of the medical error Treatment of the medical errorTreatment of the medical error

Pay Now or Pay Pay Now or Pay LaterLater


Where to Where to startstart….…. Collect the dataCollect the data

What data are being tracked now?What data are being tracked now? Unit/department levelUnit/department level Organization wideOrganization wide Frequency of data collectionFrequency of data collection Reports availableReports available

Analyze the dataAnalyze the data TrendsTrends Comparison to benchmark dataComparison to benchmark data Questions to askQuestions to ask

Make the data visual and availableMake the data visual and available Identify patterns or improvement Identify patterns or improvement

opportunitiesopportunities


Sample Sample Nursing Nursing ScorecardScorecard

Nosocomial Pressure Ulcer Prevalence

4.7%

1.0%

2.6%1.9%

5.6%

6.4%

1.4%

3.9%

5.3%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

Q1-06 Q2-06 Q3-06 Q4-06 Q1-07 Q2-07 Q3-07 Q4-07 Q1-08

Per

cen

tag

e

Nosocomial Pressure Ulcers by Hospital2007 and 2008 YTD

4.2%

3.0%

5.5%

4.0%

5.3%

0.0%

5.8%6.3%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

System Hosp A Hosp B Hosp C

Pe

rce

nta

ge

2007 2008 YTD

Patient Satisfaction with Pain Management

86.8 87.785.6 85.6 86.0

83.885.6 84.8

83.585.7 86.8

83.285.9 84.8 85.3

86.5

75.0

80.0

85.0

90.0

95.0

100.0

J F M A M J J A S O N D J F M A

Me

an R

ati

ng

2007 2008

Patient Satisfaction with Pain Management by Hospital

2007 and 2008 YTD

85.3 85.6 85.2 85.385.787.5

86.1 85.2

75.0

80.0

85.0

90.0

95.0

100.0


Me

an

Rat

ing

2007 2008 YTD

Acute Care Fall Rate

3.63.1

3.7 3.5

2.0 2.22.7 2.9

3.6

-

1.0

2.0

3.0

4.0

5.0

6.0

Q1-06 Q2-06 Q3-06 Q4-06 Q1-07 Q2-07 Q3-07 Q4-07 Q1-08

Ra

te P

er 1

000

Pa

tien

t D

ays

Acute Care Fall Rate by Hospital2007 and 2008 YTD

2.42.8

2.4 2.4

3.6 3.6

5.7

2.9

-

1.0

2.0

3.0

4.0

5.0

6.0


Ra

te P

er

100

0 P

ati

en

t D

ays

2007 2008 YTD

Quality


Performance MeasurePerformance Measure ExampleExample









Professional Nursing Organizations - Recommended Staffing Standards

WSNA, 2010 - www.wsna.org/Topics/Safe-Nurse-Staffing/Toolkit/Documents/Staffing-Ratio-Grid.pdfWSNA, 2010 - www.wsna.org/Topics/Safe-Nurse-Staffing/Toolkit/Documents/Staffing-Ratio-Grid.pdf

Professional OrganizationRecommended

Standards Ratio CommentsAssociation of Women's Health, Obstetrics & Neonatal Nursing - AWHONN

Yes

Intrapartum 1:1 - 1:21st Stage Labor 1:22nd Stage Labor 1:1With Complications 1:1Induction or Augmentation 1:2Initiation of Epidural Anesthesia 1:1Circulation for C-Section 1:1

Antepartum - Postpartum 1:2 for Post-Op Recovery/ 1:6 for care w/o complicationsAntepartum-Postpartum without complications 1:6Postoperative Recovery 1:2Antepartum-Postpartum with complications but stable 1:3Newborns and those requiring close observation 1:4

Newborns 1:1 - 1:6 1:1 for unstable infants/ 1:6 for routine care onlyNewborns requiring routine care 1:6-8Mother-Baby Couplets 1:3-4Newborn requiring continuing care 1:3-4Newborns requiring intermediate care 1:2-3Newborns requiring intensive care 1:1-2Newborns requiring multisystem support 1:1Unstable newborns requiring complex critical care 1:1 or greater


Professional Nursing Organizations - Recommended Staffing Standards

WSNA, 2010 - www.wsna.org/Topics/Safe-Nurse-Staffing/Toolkit/Documents/Staffing-Ratio-Grid.pdfWSNA, 2010 - www.wsna.org/Topics/Safe-Nurse-Staffing/Toolkit/Documents/Staffing-Ratio-Grid.pdf

Professional OrganizationRecommended

Standards Ratio Comments

American Association of Critical Care Nurses - AACN NoStaffing Blueprint - recommends using acuity, experience, system to determine staffing

National Association of Neonatal Nurses - NANN YesCore Staffing - at least two registered nurses with neonatal experience

Emergency Nurses Association - ENA YesCore staffing - minimum of two registered nurses with ER experience

Oncology Nursing Society - ONS No Endorses patient classification system

American Society of Perianesthesia Nurses - ASPAN Yes A minimum of 2 RNs in room at all times

American Society of Gastrointestinal Endoscopy - ASGESociety of Gastroenterology Nurses & Associates - SGNA

Yes If pt under deep sedation, 2 RNs necessary

Association of peri-Operative Registered Nurses - AORN Yes

Intraoperative 1:1Postoperative 1:1-2 A minimum of 2 RNs in room at all timesPost-Op Phase II level of care 1:1 - 2:1 1:1 for critically ill/2:1 critically ill, unstablePost-Op Phase III level of care 1:3-5

Radiologic Society of North America - RSNA No

Society of Pediatric Nurses - SPN No

Society of Urologic Nurses & Associates - SUNA No

Academy of Medical-Surgical Nurses - AMSN No


Making the Making the Staffing Staffing

Committee WorkCommittee Work


Too many meetings?Too many meetings?

Team building Team building and conflict and conflict resolutionresolution

Problem solveProblem solve

Set goals and Set goals and make plansmake plans

AccountabilitAccountability and y and

tracking tracking progressprogress

Share contentShare content


Meeting Meeting ToolsTools

Team CharterTeam Charter Ground Rules for TeamsGround Rules for Teams Meeting RolesMeeting Roles AgendaAgenda MinutesMinutes EvaluationsEvaluations


Type of Type of MeetingsMeetings

Hospital-wideHospital-wide Unit basedUnit based MultidisciplinaryMultidisciplinary

that can be….that can be…. Short term projectsShort term projects Ongoing standing committees Ongoing standing committees Focused sub-committeesFocused sub-committees

Tools work for all types of Tools work for all types of meetings…meetings…


Committee Committee CharterCharter ElementsElements

Purpose and GoalsPurpose and Goals Membership and Membership and SponsorshipSponsorship Boundaries Boundaries Decision Making and Decision Making and Levels of AuthorityLevels of Authority Roles and ResponsibilitiesRoles and Responsibilities Ground Rules / Team Agreements Ground Rules / Team Agreements Meetings and CommunicationsMeetings and Communications Measures of SuccessMeasures of Success

Go Slow to Go FastGo Slow to Go Fast


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

Consulted

Input on Decision Making

Full Decision Making Authority

Developers

1 1

2 2

3 3

4 4

55

LevelsLevels of Involvement of Involvement


Other Other Supporting Supporting StakeholdersStakeholders MedicineMedicine Ancillary and Support DepartmentsAncillary and Support Departments HRHR FinanceFinance QualityQuality Staffing OfficeStaffing Office Medical RecordsMedical Records Communication and MarketingCommunication and Marketing


AgendasAgendas

Published prior to Published prior to meeting to each meeting to each membermember

Established at previous Established at previous meetingmeeting

Includes members’ Includes members’ names next to assigned names next to assigned agenda itemagenda item

Includes time allotment Includes time allotment for each topicfor each topic


Effective Effective AgendasAgendas

Review objectivesReview objectives Review agenda itemsReview agenda items Work through agenda itemsWork through agenda items Review assignmentsReview assignments Plan for next meetingPlan for next meeting Rate effectiveness of meetingRate effectiveness of meeting


Minutes:Minutes: Official Record Official Record List who was present (and who was List who was present (and who was

absent if group membership is absent if group membership is defined)defined)

Summary of decisions made for each Summary of decisions made for each agenda itemagenda item

List assignmentsList assignments Next meeting time and locationNext meeting time and location Published within a weekPublished within a week

Tailor to Your Needs : Legal? Tailor to Your Needs : Legal? Functional? Communication Functional? Communication Tool?Tool?


Team Ground RulesTeam Ground Rules

- - KeyKey - -

Established by Committee!Established by Committee!


Ground Rules for Good Ground Rules for Good TeamsTeams Assumption that each person wants to be hereAssumption that each person wants to be here Team members speak freely and in turnTeam members speak freely and in turn All team members and opinions are equalAll team members and opinions are equal If you have something to say, say it in the room If you have something to say, say it in the room “No Meetings “No Meetings

After the Meeting”After the Meeting” No sidebar communicationsNo sidebar communications Each one must be heard - others listen attentivelyEach one must be heard - others listen attentively No one may dominate - no whiningNo one may dominate - no whining Problems are discussed, analyzed or critiqued, not peopleProblems are discussed, analyzed or critiqued, not people Honesty before cohesivenessHonesty before cohesiveness Consensus is the goal--finding solutions acceptable to everyone Consensus is the goal--finding solutions acceptable to everyone

“ “ I can support this even if it isn’t the ideal solution”I can support this even if it isn’t the ideal solution” Silence is not understood to equal agreement. Making a Silence is not understood to equal agreement. Making a

request for someone’s point of view is acceptable. request for someone’s point of view is acceptable. All agreements are kept unless renegotiatedAll agreements are kept unless renegotiated Once agreement occurs, speak with “ONE VOICE ”Once agreement occurs, speak with “ONE VOICE ”


Ground Rules for Good Ground Rules for Good MeetingsMeetings

Meeting frequency and length definedMeeting frequency and length defined Start and end on timeStart and end on time Come prepared; do homeworkCome prepared; do homework Members must attend regularly Members must attend regularly Stay on targetStay on target Leave rank at the doorLeave rank at the door At least one bright idea per sessionAt least one bright idea per session Identify problems and focus on solutions – input, discussion, Identify problems and focus on solutions – input, discussion,

decisiondecision Review the objectives before we leave – realistic in scopeReview the objectives before we leave – realistic in scope Leave with a sense of accomplishmentLeave with a sense of accomplishment – a purpose, making a – a purpose, making a

differencedifference Expect work outside of the meeting – subgroups and task forcesExpect work outside of the meeting – subgroups and task forces


Important Meeting Roles Important Meeting Roles

- - Co-ChairsCo-Chairs-- Opens the meetingOpens the meeting Reviews the agendaReviews the agenda Makes sure someone is taking notes & keeping track of Makes sure someone is taking notes & keeping track of

timetime Moves through the agenda one item at a timeMoves through the agenda one item at a time Keeps the team focusedKeeps the team focused Establishes an appropriate paceEstablishes an appropriate pace Facilitates discussion and manages participationFacilitates discussion and manages participation Helps the team use appropriate decision-making methodsHelps the team use appropriate decision-making methods Helps the team evaluate the meetingHelps the team evaluate the meeting Gathers ideas for the next meeting’s agendaGathers ideas for the next meeting’s agenda Closes the meetingCloses the meeting (from The Team

Handbook)


- NotetakerNotetaker – –

Records minutes which include key topics, Records minutes which include key topics, points made during discussion, decisions made, points made during discussion, decisions made, actions items (who will do what, and by when)actions items (who will do what, and by when)

Rotate turns taking minutes / seek secretarial Rotate turns taking minutes / seek secretarial supportsupport

Send minutes to Co-Chairs for review then Send minutes to Co-Chairs for review then distribute the minutes within one week of the distribute the minutes within one week of the meetingmeeting


(from The Team Handbook)


- - TimekeeperTimekeeper - -

Keeps track of time to help team Keeps track of time to help team move alongmove along

Alerts the team when the allotted Alerts the team when the allotted time is almost up so that the team time is almost up so that the team can decide whether to continue can decide whether to continue discussion or table itdiscussion or table it




- - Discussion ScribeDiscussion Scribe - -

Posts ideas on a flipchart or whiteboardPosts ideas on a flipchart or whiteboard Write legibly and large enough so that Write legibly and large enough so that

all can seeall can see Captures issues that do not directly Captures issues that do not directly

relate to the topic on a parking lot relate to the topic on a parking lot (separate flip chart page) (separate flip chart page)




Communications Communications

Between committees – vertical and Between committees – vertical and horizontalhorizontal

Between co-chairs and members of Between co-chairs and members of committeescommittees

Between stakeholders and committeesBetween stakeholders and committees Members at largeMembers at large Multiple modalitiesMultiple modalities Over communicate: Over communicate: You are You are

Educating a parade!Educating a parade!


Sources of Sources of Data Data and and ExamplesExamples

Your committee is ready for data?

Staffing/Staffing/SchedulingScheduling

Core staffing structureCore staffing structure Low Census daysLow Census days

Medical RecordsMedical Records Documentation Documentation compliancecompliance Length of stayLength of stay

Unit/DepartmentUnit/Department ER: Left without being ER: Left without being seenseen OR: Case start timesOR: Case start times Patient satisfactionPatient satisfaction


Sources of Sources of DataData and and ExamplesExamplesFinancial / BudgetFinancial / Budget Cost per patient dayCost per patient day

Volume Volume oror Units of service Units of service

PayrollPayroll AbsencesAbsences Overtime HoursOvertime Hours

Human ResourcesHuman Resources Vacancies and TurnoverVacancies and Turnover Full Time/ Part Time MixFull Time/ Part Time Mix

QualityQuality Medication errorsMedication errors Infection rateInfection rate Patient fallsPatient falls

Putting it All Putting it All Together:Together:

Case ApplicationCase Application


Budgeting ScenarioBudgeting Scenario Staffing and Scheduling ScenarioStaffing and Scheduling Scenario Creating a Council CharterCreating a Council Charter Workforce Planning AssessmentWorkforce Planning Assessment Staffing Committee SurveyStaffing Committee Survey Quality ScenarioQuality Scenario

Putting it All TogetherPutting it All Together Case ApplicationsCase Applications