EP - Exemplary Professional Practice

EP8: Staffing and Scheduling Processes. Describe and demonstrate how nurses use trended data to formulate the staffing plan and acquire necessary resources to assure consistent application of the Care Delivery Model.

Rita Smith DNP, RN, NEA-BC, Chief Nursing Officer has provided the organization with the necessary resources and tools that assist nurses in formulating staffing plans. Examples of the provisions that Ms. Smith has made include: Nurse Directors/Managers Nursing Business Manager, and the Kronos and ResQ Scheduling System. These resources, along with Ms. Smith’s mentoring, has provided the valuable information needed to create optimal and efficient staffing plans that correlate with each patient care unit’s Care Delivery Model. Nursing Directors and Nurse Managers participate in the budgeting process, for their prospective units, by verifying the scope of services currently provided on their unit, and by monitoring nurse sensitive indicator outcomes, Case Mix Index, average daily census, and number and skill mix of nursing personnel needed on an ongoing basis.

Directors/Managers insure that resources are used consistently in accordance with the staffing plan. They monitor the actual hours-per-patient days (HPPD) to targeted HPPD on a daily basis. The nursing leadership monitors budgeted and targeted to actual staffing on every unit on every shift. The Nurse Staffing Office first verifies staffing every shift based on census, acuity, changes in patient mix and special variation, for example, 1:1 watches, or newly orienting staff. Secondly, the Nurse Staffing Office create a report after staffing is validated on each unit, the report compares the actual to target and what was budgeted. An example of this is as follows: 7 West is budgeted for 30 patients, with a staffing ratio of 6:1, there should be 5 nurses delegated for patient care. The staffing office determines what was actually used on each unit and then creates a variance report. The variance report is developed and sent to the Nurse Managers on a daily basis. This report is used to trend census and staffing requirements. Ms. Smith reviews this trending data on a quarterly basis and ascertains future budgetary adjustments.

On a biweekly basis, the Nursing Directors/Managers meet with Tom Fivek, Business Manager, to review established individualized unit goals using the Productivity Tool. The Productivity Tool consists of data from the previous two week pay period which measures hours-per-patient-day (HPPD) budgeted to actual. The data encompasses pertinent information that can be useful in identifying a change in staffing trends or allocation of needed resources (See sample of Productivity Report in Appendix EP8-A). An example of how the productivity tool is utilized occurred in the Emergency Department recently. The ED had an increase in overtime of nursing staff and staffing was at 100%. They also were using Per Diem staff. Ms. Smith in collaboration with the Mr. Fivek and Michele Lopez MSN, RN, CEN Nurse Manager of the Emergency Department determined that they would open more FTE positions and fill them instead of utilizing expensive overtime and per diem staff. The Nurse Managers also have monthly Clinical Leadership meetings that include Tom Fivek and Ms. Smith. During the course of these meetings data trends, such as census variations, position vacancies, overtime, and 1:1 patient watches as well as Patient Care Technician usage are monitored. In addition to the biweekly meetings, the Directors/Managers have monthly Clinical Leadership meetings that include the Business Manager and Ms. Smith. Any staffing problems and/or issues may be discussed at this meeting.

The Staffing Reporting Tool is sent electronically to all Nursing managers on a daily basis. The reporting tool portrays each unit’s bed capacity, average daily staffed census and the required number of staff needed for that census. For example, Manager, Charge Nurse, Direct Care Nurses, PCTs and Ward Clerks are delineated on the tool. Further breakdown includes a snapshot of the actual staffing for the previous day. Special circumstances are also noted on the tool, for example, Safety Watches, 1:1 Suicide Watches, number of staff on orientation, number of staff attending a conference or educational session. The tool then calculates a variance by unit, either over required HPPD or under HPPD. The tool reviews each unit and every shift on that unit. This tool allows the Nurse Managers to determine how effective their staffing plan is and also particular problems could be identified without allowing too much time to elapse. (See sample of Reporting Tool in Appendix EP8-B).

Tom Fivek, Business manager also prepares a variance report with justification which is sent monthly to the Chief Nursing Officer. This report delineates the Department, total salaries year-to-date, and the variance. Each month is compared with the previous month and cumulatively. Further delineation is made separating the RN staff salaries (total), Per Diem salaries, Technician salaries, overtime costs as well as the use of agency personnel and their costs. In this manner, Ms. Smith can review overall staffing expenditures and trend by job type what is being spent. Mr. Fivek also prepares an action plan monthly in collaboration with the Nurse Managers, what actions need to occur to reduce negative variances (Reference EP8-A). The goal of these reporting mechanisms is to insure that the Division of Nursing is using the right staff and delegating finances appropriately.

The unit staffing plan is also developed with the guidance of the optimal staffing model called the Matrix and the Nurse Staffing Plan Policy. (See Staffing Plan Policy in Reference EP8-B). Each unit has an individualized Matrix that was developed with the data obtained from the resources mentioned and nursing leadership input. (See sample of unit’s Matrix in Appendix EP8-C). The Matrix, along with assessment of patient acuity, and trended data assists in the construction of a safe staffing plan. The Nursing Directors/Managers monitor staff trending over a three to six month period in order to determine if the staffing plan needs to be modified because of increased volume or increased acuity. Staff personnel on all of the units have direct input into the unit schedule. They will take a blank schedule (with holidays and vacations already in place) and collaboratively, among their colleagues on the unit, determine what days they will work. Nurse Managers and Charge Nurses then verify and validate the schedule and make adjustments if necessary. The staffing plan is then entered into the ResQ system. Any changes that are made to the schedule prior to the day worked is entered into ResQ by the Nurse Manager/Charge Nurse. Daily staffing changes, for example, sick time, is entered into ResQ by the Staffing Office. Kronos is the payroll system, and data from ResQ downloads into Kronos for Payroll purposes. Throughout the organization, a four week cycle is used for planning and posting units’ schedules, which is fully discussed in EP9. In order to further ensure the optimal patient care is delivered according to the respective units’ Care Delivery Model, the Nursing Directors/Managers insure that the staff competencies are developed and implemented on an annual basis or more often if necessary.

At Jersey City Medical Center, the Medical/Surgical units with the exception of 6 East (Telemetry/Pulmonary) utilize a Care Coordination Model of Care. The benefit of using this model includes improved continuity of care, provides interdisciplinary care across the continuum and utilizes all healthcare providers.

The following are examples of nurses using trended data to formulate the staffing plan and assure necessary resources needed to remain consistent with their Care Delivery Model:

Responding to an Increase Need of 1:1 Patient Sitters: Development of Patient Sitter Positions

In order to assure consistency with the Care Coordination Model, Clare Cinelli BSN, RN Nurse Manager of the 7 East and West Medical/Surgical units, and the Charge Nurses communicate continuously to ensure that the daily staffing plan will provide optimum patient care. Ms. Cinelli provides knowledge of trended data to her Charge Nurses, while the Charge Nurses provide frontline knowledge of increased patient acuity and the need
for additional resources. Through this collaboration and use of trended data, the Patient Care Technicians (PCT) and Registered Nurses (RN) are assigned based on
his/her individual skills and competencies. As a result of using the Care Coordination Care Delivery Model, continuity of care and overall communication is improved.
During Ms. Cinelli’s assessment of trended data, she noticed an increase usage of PCTs throughout her Medical/Surgical department. Through further investigation of historical data, Ms. Cinelli discovered PCT usage for 1:1 watches had increased steadily by 12%, over a six month time period. (See 1:1 watch budget report found in Appendix EP8-D). This data promptly led Ms. Cinelli to collaborate with the Business Manager and develop a proposal of 10 full-time and part-time patient sitters. They additionally collaborated with human resource’s personnel to create a job description for patient sitters. This new position will assist various departments in the increase availability of PCTs and will support our number one priority of patient safety. (See Appendix EP8-E for more information on the Patient Sitter job description).

Development of the Medical Surgical/Telemetry Transition Nurses

In 2010, the need for Transition Nurses was assessed. This assessment was in collaboration between Franca DiBrita MSN, APN-C, CNL, CEN, Clinical Nurse Leader of 7 West Medical/Surgical unit and the Nurse Manager, Ms. Cinelli. In 2010, this nurse leadership team monitored data such as nurse satisfaction surveys, and Press Ganey Scores. This data revealed that improvement was needed on the discharge process, which was identified as an opportunity for improvement by patients and nurses. This information was used by Ms. DiBrita and Ms. Cinelli to conduct a Transition Nurse pilot study on 7 West in July 2010. The pilot study consisted of an English/Spanish bilingual nurse, without a patient assignment, to continue the process of collaboration with different disciplines to assure that patients had healthcare resources, knowledge on prescriptions, follow up appointments, and individualized education for the maintenance of an optimal healthy lifestyle. The Transition RN was also responsible for making discharge follow up phone calls, which were useful in identifying opportunities for improvement. (See sample of Discharge follow up log in Appendix EP8-F). After the pilot study, Ms. DiBrita and Ms. Cinelli proposed that a Transition RN position was needed. (See samples of Patient Comments during Discharge Phone Call survey in Appendix EP8-G). In 2010, Marilyn Alvarado BSN, RN became the Transition RN for the 7 East and 7 West Medical/Surgical units. Ms. Alvarado made herself available as a resource to staff in order to provide assistance for staff and patient discharge needs. Due to the benefits this role provided, an additional Transition RN was later added for the other Medical/Surgical and Telemetry/Pulmonary Units. The HCAPS Discharge Score for November 2010 increased (Appendix EP8-H). Anna Rivera BSN, RN is the Transition RN for the 7 East and West Medical/Surgical units and Ingrid Cardenas BSN, RN is the Transition Nurse for the 6 West and 6 East Medical/Surgical & Telemetry/Pulmonary units. These nurses are both bilingual which assists in effective communication with our patient population.

In the Critical Care Division, the Synergy Model is used to deliver optimal patient care. This model assists us in assessing and developing strategies that are driven by the needs of patients, families, and the healthcare team. The following are examples of nursing utilizing trended data, in the Critical Care Division, to formulate a staffing plan and acquire needed resources.

Increasing Cardiothoracic Intensive Care RNs

There was a tremendous surge in, 2011 and 2012, cardiothoracic surgical cases from January to April, 2012. (See open heart census in Appendix EP8-I). This trend in cardiothoracic patients triggered Cristina Simeone BSN, RN, Nurse Manager of the Critical Care Division to monitor the impact it would have on patient care. A total of 130 Cardiothoracic cases were performed from January to July. In order to manage the increasing volume, Ms. Simeone developed a staffing plan that would continue to promote optimal patient care delivery. Ms. Simeone also collaborated with Nicole Sardinas MSN, RN, CCRN, Critical Care Educator to plan for the Cardiothoracic Cross training of Cardiac Care Unit (CCU) nurse candidates. This planning consisted of partnering nurses with the right preceptor, as well the scheduling of Cardiothoracic Cross training education. Ms. Simeone proposed the hiring of six per diem experienced Cardiothoracic nurses, which allowed the continuation of care for the growing Cardiothoracic patient population while selected preceptors cross trained CCU nurses. This proposal was approved by Rita Smith DNP, RN, NEA-BC, CNO. Having a per diem pool of Cardiothoracic nurses allowed the flexibility of cross training more CCU nurses, continuation of Cardiothoracic patient care, and the stabilization of the CCU overtime budget. A two day Cardiothoracic training course was held in August. The availability of preceptors has allowed cross training of the following nurses into the Cardiothoracic Intensive Care:

Cardiacthoracic Coordinator:

Due to the tremendous growth in cardiothoracic patient volume, Ms. Simeone has proposed for an additional resource that will support the cardiothoracic patients, as well as a support to the interdisciplinary team caring for these patients. The increase in the Cardiothoracic census has prompted Ms. Simeone to propose an additional full-time position for a Cardiothoracic Coordinator. Ms. Simeone has seen a double increase in census with the Cardiothoracic population. She has assessed the need to further develop the Cardiothoracic Program, in collaboration with Dr. Krause, Chief of Cardiothoracic Surgical Services, to include Left Ventricular Assist Devices (LVAD), as well as Continuous Veno-Venous Hemofiltration (CVVH) in order to have the availability to

provide more treatment options. With the increase in Cardiothoracic patient population and possible expansion of the Cardiothoracic program, Ms. Simeone will have to further cross train more CCU nurses into Cardiothoracic nursing. The Cardiothoracic Coordinator position was proposed by Ms. Simeone and approved by Rita Smith DNP, RN, NEA-BC, CNO. In collaboration with Ms. Sardinas, Critical Care Educator and Dr. Krause, Chief of Cardiothoracic Surgical Services, Ms. Simeone developed the Cardiothoracic Coordinator job description (OO17-P). The coordinator will be a liaison between the Medical, Surgical/Trauma, Vascular, and Cardiology services and the cardiothoracic service. The Cardiothoracic Coordinator will assist in enhancing evidence-base patient management and patient education. Additionally, the coordinator will also assist with the professional development of the Cardiothoracic Nursing staff in collaboration with the Critical Care Educator. Furthermore, the coordinator will promote the continuum of care by following up on discharged Cardiothoracic patients. The coordinator will also be responsible for the development of the LVAD and CVVH program.