using nursing resource teams to improve quality of care

REPRINT August 2013 Delphine Mendez de Leon Judy A. Klauzer Stroot healthcare financial management association hfma.org using nursing resource teams to improve quality of care Nursing resource teams can help hospitals deal with fluctuations in staffing without having to pay expensive overtime to exhausted staff nurses or rely on temporary help that is not integrated into their organizational cultures. AT A GLANCE The process of setting up and monitoring nursing resource teams for maximum effectiveness involves five key steps: > Set the resource team goals and approach. > Plan for development and oversight. > Gather and analyze the relevant information. > Deploy the team. > Reevaluate staffing levels and effectiveness. Nursing resource teams also known as flex pools can reduce workforce costs while improving quality of care. Hospitals that implement resource teams as part of an overall staffing management plan typically save 2 to 5 percent of total nursing labor costs, which, with benefits, are the largest component of hospital labor costs and, in turn, the largest component of hospital costs. Although resource teams may be feasible for small hospitals, including hospitals with fewer than 150 beds, in general, they are better suited to larger organizations. Resource teams may be used as needed on nearly any unit, including general medical-surgical units, intensive care units (ICUs), and emergency departments (EDs). Resource team nurses may require crosstraining and may command a higher rate of pay, but their contributions to the organization often outweigh these costs, given that the quality of a hospital s nursing care largely determines the hospital s overall quality of care and is a key factor in patient satisfaction. Recent research supports the effectiveness of the resource team model. The landmark 2004 Institute of Medicine report, Keeping Patients Safe: Transforming the Work Environment of Nurses recommends using internal resource teams. a Also, a study conducted by the Bloomington, Minn.-based a. Institute of Medicine, Keeping Patients Safe: Transforming the Work Environment for Nurses, Washington, D.C.: National Academies Press, 2004. hfma.org AUGUST 2013 1

Labor Management Institute showed that overtime and adverse patient outcomes, such as medication errors and patient falls, were lower when unit core staffing provided at least 85 percent of the care delivery hours, and that up to 15 percent of an organization s nursing staff needs could be safely met by a flexible source (e.g., per diem/ casual, staff from other units, float pool, or agency/travelers). b In our experience, only about 40 percent of hospitals use resource teams, and those that do frequently do not use them effectively. Effectiveness may be limited by an initial planning process that does not provide for optimal staffing levels, cross-training, and routine feedback; by failure to assess team performance on an ongoing basis; or by staffing and scheduling systems that are not designed to accommodate the layering of resource teams. In some instances, resource team coverage may even be more expensive than floor staff at overtime rates. How to Plan and Implement an Effective Nursing Resource Team To set up and monitor nursing resource teams for maximum effectiveness in improving care and controlling labor costs, a hospital will need to use a five-step process: > Set the resource team goals and approach. > Plan for development and oversight. > Gather and analyze the relevant information. > Deploy the team. > Reevaluate staffing levels and effectiveness. b. For more information about the study, please see Suby, C., LMI Workforce Management Findings Regarding Overtime and Position Control, Minimum, Good and Best Position Control Management, PSS Newsletter, Vol. XXVI, No. 6, 2007; Suby, C., Impact of Admissions, Discharges, Transfers (ADT) on Average Length of Stay (ALOS), Decreasing Length of Stay Impacts Admissions, ADT, ALOS, OT% Compared to Medication Errors and Patient Falls, 2-Year Comparison of Non-Unit Based Educator Ratios, PSS Newsletter, Vol. XXVII, No. 1, 2008; Suby, C., Schedulers, Worker Performance and Work Environment Scheduling Principles, Defining Employee Requests, Measuring Quality with Schedule Report Cards, 10 Indicators That Your Unit s Schedule is Not Working, Scheduling Best Practices, PSS Newsletter, Vol. XXVII, No. 3, 2008; Suby, C., Improving Workforce Efficiencies Conserving Resources, PSS Newsletter, Vol. XXVII, No. 6, 2008. Set Goals and Approach Resource teams should be able to cover 15 percent of the hospital s total nursing staff needs. The objective is to have the resource team fully deployed at all times to walk the fine line between being overstaffed and having to rely on temporary local agency nurses, expensive travelers, extra shift incentive pay, or excessive overtime to meet unexpected staffing needs. Each organization's resource team will reflect its unique needs. For example, an organization whose patients tend to have high-acuity conditions may find value in building a critical care resource team. Another may find it makes sense for the maternity unit and a women s health unit to share a resource team. An ICU might share a team with the ED. If an organization s primary challenge is volume variability, it may need a single resource team of registered nurses (RNs) who can float to any unit during volume spikes. (Resource teams typically are made up of RNs and licensed practical nurses, but some hospitals opt to create a separate team for nursing assistants or house unit coordinators.) In general, resource teams work best when managed by a central staffing office and deployed in concert with unit managers, both during initial schedule development and in daily shift-to-shift unit management. Design of the resource team should be consistent with optimal unit-based overall staffing patterns, including any mandated ratios or other recognized care and staffing models. In our experience, an optimal overall combination of unit-based staff includes: > Committed, unit-based full-time/part time staff : 80 to 90 percent > Committed resource team staff (part-time and per-diem) assigned in initial unit schedules to fill in for planned time off and family and medical leave: 3 to 6 percent > Uncommitted resource team staff assigned to cover daily and shift-to-shift schedule changes: 5 to 10 percent > Overtime: 2 to 4 percent Initial goal setting should also assess whether the resource team will be composed solely of RNs or 2 AUGUST 2013 healthcare financial management

include other positions, such as nursing assistants, cardiac monitor technicians, and house unit coordinators. A tool for determining the optimal scope and size of the resource team is shown in the exhibit below. Plan for Development and Oversight A task force should be built to develop the framework for resource team design, including how many staff are needed, what kind of training they should have, and how the resource team(s) will be managed. Task force members typically include nursing managers, directors, supervisors, educators, and the chief nursing officer (CNO). Members from outside the nursing department often include representatives from human resources (HR), finance, business-process engineering or quality assurance, and information systems. At one hospital, the task force comprised nurses (both from nursing units and from the resource team), a house supervisor, an HR representative, a staffing clerk, a unit director, a finance representative, and the assistant CNO. Gather and Analyze Information Detailed information is essential for creating the most effective resource team model. Metrics needed for each nursing unit include: > Type of patients and level of acuity > Caregiver ratios needed and associated direct and support staffing matrix > Defined target worked hours per unit of service c > Number of hours needed to make up for education, training, and orientation > Number of hours needed to make up for paid time off (PTO) and unpaid time off, including vacations, sick days, holidays, and family and medical leave c. Defined targeted hours per unit of service should be calculated based on a full year s frequency distribution of daily volume and appropriate staffing matrices for direct and indirect nursing staff. It should take into account patient flow issues that affect workload and variability, such as ED boarders, observation conversions, surgical schedule delays, and late discharge times. DETERMINING THE OPTIMAL SIZE AND SCOPE OF THE NURSING RESOURCE TEAM Full Staffing Component 85% of committed staff required to cover projected volume at target 15% of total predictable need Provides coverage for nonproductive time Committed Core Unit Full-Time/Part-Time Staff Committed PRN (as needed) Resource Staff Internal External Resource staff who have committed hours but not units Provides coverage for predictable nonproductive hours Noncommitted Resource Staff Internal External PRN staff with no committed hours or unit (may have a preferred unit) Provides coverage for unpredictable spikes in volume Travelers who have committed hours and units Provides coverage for predictable need, productive hours Agency staff or local area supplemental resources Provides coverage for unpredictable spikes in volume not covered by existing resources. Match staff competencies to what is required for unit of assignment Source: Huron Healthcare. Used with permission. hfma.org AUGUST 2013 3

> Current committed staffing FTEs by level and status (full time, part time, and per diem) > Average level of annualized family and medical leave worked/paid FTEs (added to resource team staffing to cover reduction in actual committed unit-based core staffing) > Pay scales for wage rates and premium pay by level and for contract staff Pay scales and related metrics are shown in the exhibit below, A daily, shift-by-shift graph of scheduled PTO, actual family and medical leave, and call-ins by unit can guide the staffing office in predicting how many resource staff are needed to fill in a planned new schedule and how many must be assigned to cover a unit on a shift-byshift basis. Each department represented on the task force has a role in contributing to the development of the resource team. Nurse managers/directors should determine the right skill mix to achieve best-practice quality outcomes and the competencies that are most important for fulfilling the unique needs of particular units. HR managers should make recommendations on benefits and pay scale, as well as whether these should vary among the workers in the resource team or between flex workers and regular staff. If the organization uses years of experience to set a base PAY SCALE AND RELATED METRICS FOR DETERMINING NURSE STAFFING POOL REQUIREMENTS Option I Benefited Part Time Option II Nonbenefited Full Time Minimum two years of experience 0.9 Option III PRN Option IV Nonbenefited 12 Week Assignment Minimum two years of experience 0.1 Requirements Eligibility Minimum two years of experience 0.4-0.8 Minimum two years of experience 0.1 0.2 FTE Minimum Requirement Off Shift/Weekend Coverage Holidays 36 weekend hours every six weeks > One major, two minor > Must be primary shift 36 weekend hours every six weeks > One major, one minor > Must be primary shift > One major, one minor > Must be primary shift > One major, two minor > Must be primary shift Evening & Night Shift 80 hours worked on evenings and/or nights every six weeks Pay rate based on YOE RN $5.00 LPN $2.50 NA $2.00 HUC $1.50 36 hours worked on evenings and/or nights every six weeks Pay rate based on YOE RN $5.50 LPN $3.00 NA $2.50 HUC $2.00 36 hours worked on evenings and/or nights every six weeks Pay rate based on YOE RN $3.00 LPN $1.50 NA $1.25 HUC $1.00 Rate Pay rate based on YOE and bonus upon completion of 12 weeks RN $1,200 LPN $750 NA $500 HUC $250 12-week assignments; submit schedule four weeks in advance, if possible Scheduling Must submit six-week schedule four weeks in advance Must submit six-week schedule four weeks in advance Must submit six-week schedule four weeks in advance Source: Huron Healthcare. Used with permission. PRN = as needed; YOE = years of experience; LPN = licensed practical nurse; NA = nursing assistant; HUC = house unit coodinator Additional incentives may apply for all options, per an organization s incentive policy. For all options, employee receives two hours of pay (excluding differentials) if given less than 1.5 hours notice of shift cancellation. 4 AUGUST 2013 healthcare financial management

pay rate, it makes sense to do the same for the resource team so that it will attract experienced nurses. Cross-trained nurses who can work in multiple areas may receive a higher hourly rate. However, the combined cost of pay, benefits, and taxes for a resource team member should be kept below what the organization would pay for an agency nurse or overtime for regular staff. Management engineers should analyze data on workload and activity for each unit, identify peaks and valleys, and, together with unit managers, validate the target worked hours per unit of service and determine what the core staffing should be by level of staff. They should compare core staffing requirements with the current complement of committed staff by type (full time, part time, and per diem) and determine which units need flex staff and at what level. Finance representatives should assist with the development of a business plan and budget. Finally, performance improvement representatives should provide support in the development of staffing effectiveness metrics, such as productivity monitoring; patient, staff, and physician satisfaction; infection rates; and falls. An example of a simple staffing plan model is shown in the exhibit on pages 6 and 7. The task force should use the data to make key decisions, as shown in the exhibit below. The process of building staffing plans often highlights the need for additional flexible staffing resources. KEY DECISIONS FOR THE RESOURCE TEAM TASK FORCE Key Question Should there be one resource team for the whole institution, or individual teams shared by related departments? What competencies are needed to staff the team, and how can those be acquired most efficiently? How will the resource team be used to cover holes as the original four- or six-week schedule is being developed, and how will nurse managers and the scheduling office coordinate this activity? What shifts are most in need of flexible coverage on a given day? How will the teams be managed for initial scheduling, and whose responsibility will it be day-to-day to match the competencies of the available nurses with the needs of the units? How large should the team or teams be to start, and how will their use be tracked and readjusted as needed? Additional Considerations If the decision is made to use a combination of individual and shared teams, consider which departments would most benefit from having access to a resource team and which departments can share one. For example, a hospital that wants to cross-train staff might start with a resource team of 10 nurses and set a goal to have all of them cross-trained to at least one additional competency within six months, continuing the process until all the flex nurses can be used in any department covered by the team. For example, should units look within their own per-diem and part-time staff to supply added hours for coverage prior to using the resource team? Resource team staff should expect staffing assignment changes every four hours. One approach is to have each nursing unit served by the team assess its needs about two hours before a given shift and communicate its needs, or the presence of extra nurses who can be used by other units, to the central managing office, which can reassign staff as needed. An organization with a large team or several different teams may assign a supervisor within the central staffing office. For a small team, a nursing supervisor on one of the units that will draw from the team often takes on accountability for day-to-day management. The goal is to have all flex staff assigned at all times. hfma.org AUGUST 2013 5

No matter how the resource team is designed, centralized staffing management is recommended to optimize resources. The manager with primary accountability for the resource team should work hand-in-hand with nursing unit management to ensure that the team works effectively. It is important to make clear designations of responsibility for managing the teams on a shift-to-shift basis. Deploy the Resource Team Planning and deploying a nursing resource team always raises issues both organizationally and with regard to the resource team nurses themselves. Effectiveness of the resource teams can be maximized by taking the following approach to team deployment. Evaluate productivity targets realistically. Validate the core level of staff required on each unit prior to defining resource team requirements. Avoid depleting the regular staff. Use a mix of existing staff and hired known agency nurses for the initial resource team composition to avoid excessive demands on regular staff. Identify units that are currently overstaffed. Consider moving nurses on overstaffed units to the resource team. Where staffing overages exist, work closely with HR to ascertain staff interest and competency for resource team deployment or reassignment. Be sure nurses from the resource team are assigned only to roles where they have proven competence. Cross-train as necessary. Look for top performers. Nurses who are comfortable with frequent changes in their work settings and are able to communicate easily will make ideal resource team members. The right attitude is just as important as the right training. Consider organizational knowledge. Nurses with at least a year (and, ideally, two years) of experience in the organization tend to adapt to resource teams more easily than new staff or agency nurses. Standardize nursing unit processes and logistics. For example, each unit s supply storage should be stocked in the same manner (with the exception of unit-specific items) to reduce time spent searching for supplies when floating from unit to SIMPLE STAFFING PLAN MODEL Medical or Surgical Unit Average RN NA RN NA HUC RN NA HUC Daily Ratio Ratio Worked Worked Worked Paid Paid Paid Census 1:X 1:X FTEs FTEs FTEs FTEs FTEs FTEs Days 24 5 10 6.7 3.4 1.0 7.5 3.8 1.6 Evenings 24 5 10 6.7 3.4 1.0 7.5 3.8 1.6 Nights 23 5 10 6.5 3.2 0.5 7.2 3.6 0.8 24 hours 23.7 TOTAL 19.9 10.0 2.5 22.3 11.2 3.9 Committed Unit Staff Percentage 85% 85% 85% 85% 85% 85% Budgeted Unit Dedicated Core Staffing* 16.9 8.5 2.1 19.0 9.5 3.3 Budgeted Overtime Use (3% worked FTEs) 0.6 0.3 0.1 0.7 0.3 0.1 Resource Team Staffing* 2.4 1.2 0.3 2.7 1.3 0.5 Total Position Control Staffing Requirements 19.9 10.0 2.5 22.3 11.2 3.9 * Shift Budgeted unit dedicated core staffing to Resource team staffing as needed based on actual experience with family and medical leave. RN = registered nurse; NA = nursing assistant; HUC = house unit coodinator; WHPUOS = worked hours per unit of service. Totals may not add as expected due to rounding. 6 AUGUST 2013 healthcare financial management

unit. Standardized admissions and discharge processes, medication management, and daily rounding by interdisciplinary teams will help ensure that patient care and discharge planning are consistent from unit to unit. Ask for feedback. Feedback from both units and resource team staff is important. One method is to have unit managers fill out an evaluation form for each floating nurse, describing strong points and areas where additional training is necessary or desirable. This approach gives regular staff a stake in the resource team and in steadily improving it as a resource. Resource team nurses should also be asked for feedback, which can highlight ways to make the unit more effective. Resource team nurses can offer useful perspectives on the differences among the units on which they work, as well as which practices are most effective and should be considered for organization-wide adoption. Metrics to gauge team performance could include the resource team request fill rate, worked hours per patient day productivity goals achieved, and staff satisfaction. Reevaluate Staffing Levels and Effectiveness Without careful monitoring and readjustment, a nursing resource team can end up out of synch with the needs of the organization. To keep the team responsive to the hospital s needs and to ensure its long-term success, a central staffing resource should be assigned to coordinate planned staffing and scheduling, manage the resource team, and assess deployment requirements every four hours. Also, feedback from unit managers and resource team nurses should be reviewed on a regular basis and changes should be made as needed. In addition, it is important to monitor and report request and fill rates by unit. If a unit is requesting resource team help routinely, this may signal the need to hire additional FTEs. Finally, the core program should be reviewed annually, rather than rubber-stamping each year s resource team based on the previous year s budget. One approach is to go through the same analysis that was used to set up the resource team initially. The number and types of nurses needed in the resource team, as well as the compensation Annual Annual Education Sitters PTO Turnover (days/year) (shift/day) 1.12 10% 5 1 Other Charge (Manager, RN Total Total Paid Specialist) Orientation RN NA Paid Worked Target FTE Paid FTE (3 months) Education Sitters FTEs FTEs WHPUOS 1.0 2.0 0.17 0.1 0.5 16.7 14.9 1.0 0.0 0.17 0.1 0.5 14.7 12.9 0.0 0.0 0.17 0.1 0.5 12.4 11.0 2.0 2.0 0.5 0.4 1.4 43.8 38.8 9.33 100% 100% 0% 0% 0% 2.0 2.0 0.0 0.0 0.0 35.8 81.8% 0.0 0.0 0.0 0.0 0.0 1.1 2.6% 0.0 0.0 0.5 0.4 1.4 6.8 15.6% 2.0 2.0 0.5 0.4 1.4 43.8 100% hfma.org AUGUST 2013 7

platform, may vary substantially from year to year depending on fluctuations in patient population, the hospital s strategic plan, and the local labor market. A Solid Investment Nursing resource teams are not a quick fix, but if planned and executed with care and monitored for ongoing effectiveness, they can reduce costs, improve productivity and quality, and increase satisfaction among both employees and patients. About the authors Delphine Mendez de Leon, BS, MBA, MPH, RN, is managing director, Huron Healthcare, Chicago, and a member of HFMA s Metropolitan New York Chapter (dmendezdeleon@huronconsulting group.com). Judy A. Klauzer Stroot, RN, BSN, MA, NEA-BC, is senior director, Huron Healthcare, Chicago and a member of HFMA s Sunflower (Kansas) Chapter (jstroot@huronconsultinggroup.com). Reprinted from the August 2013 issue of hfm magazine. Copyright 2013 by Healthcare Financial Management Association, Three Westbrook Corporate Center, Suite 600, Westchester, IL 60154-5732. For more information, call 800-252-HFMA or visit www.hfma.org. 8 AUGUST 2013 healthcare financial management