EP - Exemplary Professional Practice

EP12: Staffing and Scheduling Processes-Describe and demonstrate how nurses analyze data to guide decisions regarding unit and department budget formulation, implementation, monitoring, and evaluation.

The annual budget development process includes input and verification of budget recommendations from various sources such as the Chief Nursing Officer, Clinical Directors, Managers, Coordinators, Direct Care Nurses, and the Finance Department. Issues which are reviewed and necessary for budget formulation include: volume data, patient days for each patient care unit, case mix index, changes in scope or intensity of service, trending over the most recent three-month period and a projection of new business due to program development, recruitment of new physicians and other external influences.

The Nurse Managers are a key component to this review process. The budget development process begins in August with the Clinical Directors, Clinical Managers and Clinical Coordinators assessing their units and programs for inclusion of budgetary needs for the following year. Nurse Managers and Coordinators, in collaboration with Senior Leadership and Physician Leadership have the responsibility of projecting the future growth of their units and providing a cost/benefit analysis on new program costs. In the event that a new program is to be initiated, the Nurse Manager of that particular unit will have to project staffing costs as well as supplies and equipment. In order to project staffing costs, Nurse Managers utilize standards from their professional organizations, national benchmarking organizations and current staffing ratios to project costs. All staffing budgets are done with the guidance and support of the Nursing Business Manager who works with the individual managers continuously throughout the year to review volume, patient days, adherence to productivity standards and to create plans for new programs or to adjust mid-year to changes in volume.

Rita Smith DNP, RN, NEA-BC, Chief Nursing Officer mentors the nurse leaders and provides guidance over the entire process. Ms. Smith conducts ongoing monthly Clinical Leadership Meetings, that includes each unit’s manager and the Business Manager, in which budget formulation is assessed and evaluated. Review sample of Clinical Leader Meeting Minutes in Reference EP12-A. For instance, changes that need to be addressed to meet on-going variances in planned services or volume is analyzed using productivity reports that are provided by the Business Manager. The same analysis takes place when we are projecting the next year’s budget. The average daily census over the past year is used as the basis for budgeting and then adjustments are made as indicated for growth or reduction in volume or changes in scope of service. For more information on productivity reports please refer to Reference EP8A-1.

The operating budget that Directors, Managers, and Coordinators are accountable for include line items such as FTE’s, education, certifications, tuition reimbursement, sick time, vacation time, supplies etc.

Jersey City Medical Center also compares the staffing of each unit in the division of nursing with nationally benchmarked data through the Solucient database. This benchmarked data compares hospitals across the country as to unit type, scope of service, and acuity of patients. Through outside consultants Jersey City analyzed staffing in 2010 and 2011 comparing our units to like units nationwide to insure that we were staffing effectively and efficiently. This benchmarking helped determine our hours-per-patient-day which is the measure for our productivity system. All units are expected to function between 95% and 102% of productivity. Variances above or below that range are addressed. Nursing is consistently compliant with productivity measures because staff, managers, directors and the CNO determines the targets.

Ms. Smith constantly involves and encourages nurses at all levels, such as direct care nurses, to provide their input in the development of the organization’s budget. Ms. Smith strongly feels that nurses’ input is vital to the effective and efficient management of budgets because they are aware of professional standards and the needs of the department. Staff nurses communicate their budgetary needs to the managers and to the CNO through Town Hall Meetings, Chief Nursing Officer Rounding with the staff and Unit Practice Councils. For example, in the operating room, the staff nurses provide valuable input to the capital budget process, as they have front line knowledge of the equipment needs of the OR. See sample of Town Hall Meetings in Reference EP12-B. Additional opportunities to discuss staffing and equipment needs related to patient care are provided during Vice President Rounds. The purpose of these rounds is to identify and reduces issues that impact on patient care. These issues may be related to budgetary needs. Vice President Rounds are conducted by:

In addition to providing nurses a forum to discuss and propose their recommendations, Jersey City Medical Center also provides nurses education on budget development. This educational session is made available for nurses currently responsible for a budget or for those that would like to broaden their knowledge on budget development. Tom Crowley Director of Finance initiated these educational sessions in 2011 for all those interested in the budget process. For further information see (Reference EP12-C). Due to the success of the sessions, the budget review will be made available on an annual basis. See Appendix EP12-A for further information on the budget sessions.

Each Manager receives a staffing reporting tool on a daily basis. This reporting tool incorporates the staffing matrix for that particular unit. The Staffing Matrix is reflective of the hours-per-patient-day or ratios that were agreed upon during the budget development process. This matrix ensures that adequate staffing will be provided regardless of census.

The Staffing matrix ensures census based staffing, but additional staff may be required shift to shift depending on the demands for 1:1 watches, orientation or education. Occasional variances are simply noted; sustained variances are discussed to determine the reason and likelihood for reoccurrence. Nurse Managers and the Business Manager are often able to make decisions that will allow a more cost effective solution to the issue or, in the case of sustained increased education requirements, plan for increased budgeting in the next budget cycle. Nurse Managers review this tool daily to detect trends, overages, and other staffing issues. This tool assists the Nurse Managers in justifying their budgetary needs on a monthly basis. Changes to the budget are not made on a short term basis; overall staffing is trended for a three month time period to establish consistent demand.

The budget formulation is a collaborative process that includes Nursing, Finance, and Senior Management. Once nursing assess volume and planned services, the Business Manager calculates labor and non-labor projections and it is then submitted to the Finance Department. The Finance Department considers nursing’s recommendations as essential input in developing a fiscally responsible clinical operating budget. Nursing and the Finance Department collaborate with one another in balancing the budget taking into consideration direct nursing hours required per patient day, patient volume, case mix index, and national benchmark data. By the end of the year, Ms. Smith and the Finance Department reach a mutually agreeable budget. Once finalized, Ms. Smith presents the budget to Senior Management, which includes Joe Scott, Chief Executive Officer, and Paul Goldberg, Chief Finance Officer. Once agreed upon between Nursing and Finance, the budget is then presented to the LibertyHealth Board of Trustees. The Board of Trustees’ provides feedback which is then reported back to the Directors, Managers, and Coordinators.

Additional Support for the Stroke Program

Michele Lopez MSN, RN, CEN, Stroke Manger has developed the Stroke Program at Jersey City Medical Center, since 2009. Due to Ms. Lopez’s efforts and collaboration with the Primary Stroke Program Medical Director, Dr. Gerrard Ferrer, she accomplished Jersey City Medical Center’s goal of becoming a designated Primary Stroke Center, on April 27, 2010. Ms. Lopez’s responsibilities include education of staff and physicians in early detection and treatment of stroke. Furthermore, Ms. Lopez provided education to the Jersey City Community in recognizing the signs and symptoms of stroke. In 2009, she started community stroke education by participating in two health fairs and one Dinner with the Doctor Program. In addition, Ms. Lopez develops and updates standardized stroke protocols representing evidence-based practice. Improvement plans for the maintenance of our stroke core measures is also part of her responsibilities. Providing quality care is Ms. Lopez’s number one priority. Therefore she monitors all data that impact the delivery of quality care. Since 2009, Ms. Lopez has been analyzing the expansion of the Stroke Program at Jersey City Medical Center. Jersey City Medical Center’s goals of increasing patient volume, staff education and competency, and increased community education programs have been realized as depicted in the following graphs. (Refer to Reference SE13-A2 Nurses Caring for the Community 2011 for stroke community education).

In order to continue to sustain the growing Jersey City Medical Center’s Stroke Program and its goals, Ms. Lopez in 2011 proposed the need for additional Stroke Program support. One FTE was granted to Ms. Lopez to assist her in education of staff and the community, abstraction of stroke data, and coordination of stroke patient care. Kelly Sietsma BSN, RN Stroke Coordinator has taken over the responsibility of supporting community education and adherence to Stroke quality measures. Ms. Lopez and Ms. Sietsma have sustained quality stroke patient care, which is seen in 100% stroke core measure compliance in 2011 and as seen in the first two quarters of 2012. (See Reference EP12-D Stroke Proposal for further information).

Additional Support for Staff

In 2011, Charge Nurses on the Medical/Surgical unit used Vice President Rounds as an opportunity to discuss their concern on the need for a Charge Nurse without a patient assignment. At the current time, the Charge Nurse’s role was rotated among staff, included having a patient assignment, while managing the patient flow. The Medical/Surgical nurses’, on 7 West met with Ms. Smith during these rounds and expressed their concerns about spending sufficient time caring for their patients while trying to manage the activity of the unit. The nurses stated that they spent much of their time dealing with various important departments, such as Pharmacy, Laboratory, Radiology, Admissions, Nursing Staffing Office, and other departments relaying or requesting information from them. Ms. Smith acknowledged the nurses’ concern and approved a Charge Nurse pilot to be conducted on 7 West. During this time period, Ms. Smith and Clare Cinelli BSN, RN, Nurse Manager of 7 West assessed the impact of h having a Charge Nurse without a patient assignment on the Medical/Surgical budget. It became evident, during the pilot, 7 West nurses’ satisfaction had increased. Nurses’ stated, during follow-up Vice President Rounds, they noticed they were spending more time with their patients because the Charge Nurses were able to manage patient flow and department requests The Charge Nurse pilot would consist of a permanent charge without a patient assignment. The Charge Nurse pilot continued through February 2010. During the time period, Ms. Smith and Clare Cinelli, 7 west’s Medical/Surgical Nurse Manager, assessed the impact of having a Charge Nurse without a patient assignment on the Medical/Surgical budget. It became evident, during the pilot, 7 west nurses’ satisfaction had increased. Nurses’ stated, during follow up Vice President Rounds, they noticed they were spending more time with their patients because the Charge Nurses were able to manage patient flow and department requests, as well as receive patient handoff of transferred or admitted patients. Also, the Charge Nurses served as an available resource for nurses, patients and family’s questions or concerns. Another crucial element to this pilot was budgetary compliance. In order to conform to the budget, the staff worked on reducing sick time and subsequently overtime. Over this period of time, the unit was able to show that they could sustain this additional charge nurse on a reduction in overtime. After the Charge Nurse Pilot was completed, permanent Charge Nurses were established on all shifts in the Medical/Surgical Division. See following table for the Medical/Surgical Permanent Charge RN’s.

As a result of having permanent Charge Nurses without a patient assignment, bedside handoff were established, fall rates decreased, and rapid response calls increased. The success of the pilot benefited other units, as well. The pilot set a precedent for the Neonatal Intensive Care Unit and the Critical Care Division to have permanent Charge Nurses as well. (Refer to Critical Care Charge Nurse Table in SE1E0).