Riverside s Vigilance Care Delivery Systems include several concepts, which are applicable to staffing and resource acquisition functions.

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1 1 EP8: Describe and demonstrate how nurses used trended data to formulate the staffing plan and acquire necessary resources to assure consistent application of the Care Delivery System(s). Riverside Medical Center nurses at all levels have used trended data to formulate and advise staffing plans. Riverside nurses continue to use internal and external data to assure staffing for our primary and team nursing Vigilance Care Delivery Systems are consistent and safe. Structures Riverside s Vigilance Care Delivery Systems include several concepts, which are applicable to staffing and resource acquisition functions. CONCEPT Patient/Family Care Vigilance DESCRIPTION In the care environment, the nurse s watchful, continual oversight of the patient s/family s changing needs and responses resulting in effective clinical judgments, nursing actions, and intended outcomes. EXPLANATION: Staffing plans are formulated to support our nursing mission of being vigilant in providing quality, caring services in a safe environment to our patients and families. Staffing ratios and acuity systems serve as guidelines for acquiring the necessary resources to support our nursing mission. CONCEPT Primary Care Vigilance DESCRIPTION In the patient care department or unit, a team of RNs who assume responsibility and accountability for 24-hour/7-days per week, direct care of patients and families. (All RNs work with interdisciplinary team members to support optimal outcomes.) EXPLANATION: Staffing plans address the type of personnel needed for care delivery to patient populations that are acutely ill. The ICUs, Special Procedures Lab, and PACU are examples of hospital units that employ only RNs. Occasionally, unlicensed assistive personnel (UAP) might assist with patient care, but almost all patient care is delivered by RNs. CONCEPT Team Care Vigilance DESCRIPTION In the patient care department or unit, a team of RNs and other caregivers who provide 24-hour/7-days per week, direct nursing care for patients and families. RNs lead the direct care team, delegating tasks and assignments that are appropriate to the skill and knowledge level of all nursing team members.

2 2 (All RNs and nursing team members work with interdisciplinary team members to support optimal outcomes.) EXPLANATION: Staffing plans address the type of personnel needed for care delivery to patient populations that allow for a team approach. In departments where team care is the staffing model, LPNs and UAPs can assist the RN in patient care delivery. The degree of watchful, continual oversight needed is less than in a primary care setting. Examples of units where team nursing is practiced are the medical-surgical units, rehabilitation unit, post partum/gyne area in obstetrics, telemetry units, and some parts of the ED. Delegation is also a related concept. According to the Illinois State Practice Act, RNs may delegate some patient care responsibilities to other RNs, LPNs, or UAPs. CONCEPT Consultation DESCRIPTION Consistently and appropriately identifies and uses available resources to define and implement the plan of care. EXPLANATION: The nurses involved in developing staffing plans use internal and external resources and consultants to formulate the plan based on trended data. External sources include data from the National Database of Nursing Quality Indicators (NDNQI), regulatory guidelines for staffing from state and federal agencies, and staffing standards from nursing specialty groups. Nurses also consult with internal experts in our finance department. Staffing costs from previous years are acquired from these internal resources, and these costs, coupled with expected staffing needs to support strategic initiatives, serve as trended data to support future staffing allocations. Hospital Plan for the Provision of Patient Care Another internal structure that supports formulation of staffing plans and acquisition of necessary resources is our policy titled Riverside s Hospital Plan for the Provision of Patient Care. This plan includes staffing guidelines for every patient care area. Following are excerpts from this policy, in which staffing plans are addressed. Staffing plans for patient care service departments will be developed based on the level and scope of care that needs to be provided, the frequency of the care to be provided, and a determination of the level of staff that can most appropriately (competently, comfortably, and confidently) provide the type of care needed. The hospital bases it's staffing levels and assignments on a variety of factors including staff qualifications, physical design of the environment, diagnoses treated, co-occurring conditions and age and developmental functioning of patients. Each department will have a formalized staffing plan, which will be reviewed at least annually based on the following: utilization review, employee turnover, performance assessment and improvement activities, changes in customer needs/expectations.

3 3 Measurement tools, such as Worked Hours per Patient Day, will be utilized to help assess the effectiveness of the staffing plans. The Hospital Plan defines the fundamental requirements for determining nurse staffing for every unit or area, the frequency with which plans are reviewed, and the factors used to formulate hospital staffing plans. Staffing plans for hospital services are formulated according to the level and scope of care that need to be provided, the frequency of the care to be provided, and a determination of the level of staff that can most appropriately (competently, comfortably, and confidently) provide the type of care needed. The hospital bases it's staffing levels on a variety of factors including staff qualifications, physical design of the environment, diagnoses, co-occurring conditions and age and developmental functioning of patients. In the Plan, every patient care department has defined populations served, hours of operation, services provided, staffing information, and the competencies RNs and other staff need to care for the specific populations in specific units or departments. The 2ICU staffing plan is provided below as an example.

4 4 Historical Staffing Data Additional structures used to formulate and/or revise staffing plans are historical data and national practices on staffing. The hospital s finance department provides historical data on staffing from previous years. The finance department also sends nursing leaders monthly reports such as the Stat Report which shows, by unit, length of stay (LOS), numbers of admissions and discharges, patient days, average daily census, and occupancy percentages. The Stat report shows the current year and last year to assist leaders in using trended data for staffing plan formulation. Another source for internal historical data is the National Database of Nursing Quality Indicator (NDNQI). Nurses at all levels use the indicator, Nursing Care Hours per Patient Day (HPPD) to formulate staffing plans. NDNQI data also provide national benchmarks, which leaders have used to support their requests for revising nurse:patient ratios. Process The process used by Riverside nurse leaders to formulate staffing plans occurs yearround. Staffing is assessed every day for every shift to determine if unit and patient needs are being met. On an ongoing basis, nurse managers and/or directors review staffing for upcoming shifts and share weekly reports at the Flex meeting, which was described in EP5. The Flex meeting occurs two to three times a week, or more often as the hospital patient census increases. The meetings are approximately 30 minutes long. The Flex meeting is designed as a forum for nurse executives (the CNO, Vice President of Nursing Services, and/or Vice President of Perioperative and Procedural Services), nursing directors, the patient placement coordinator, managers, and ancillary representatives to share information about patient census and ongoing staffing needs. Nurse managers share their weekly staffing sheets with the CNO and/or Vice Presidents of Nursing. During the meeting the CNO quickly reviews the reports and asks pertinent questions if variances from staffing plans are seen. This process allows Riverside nursing leaders to continually evaluate our financial performance pertaining to staffing. The Flex meeting provides a forum in which directors and managers can share ideas to increase efficiency. Staffing plans are a large component of the annual budget planning process. Budgets are done on a calendar year basis. As early as August, financial leaders start discussing the budget for the following year. Historical reports are available to nursing leaders via a secure portal on our intranet system. Budgets, including staffing data, are entered into an electronic system that calculates FTE usage and needs. Training on using this system are offered each year prior to the beginning of formal budget planning. Then, nursing leaders input data pertaining to labor and supply needs. (Capital equipment requests are made in a different electronic system.) NDNQI data has been useful in providing nurse leaders with a national benchmark of best performing hospitals. NCHHP is one element of NDNQI reporting. Nurse leaders

5 5 use this data as part of their planning for annual budgets. NDNQI provides us with data on Total NCHPPD as well as breaking this down into roles: RN, LPN, UAP, and contracted agencies. NDNQI also provides reporting capabilities to make comparisons against national data. Following are graphs showing Total NCHPPD and percentage of NCHPPD supplied by RNs for our NDNQI reporting units for 2008 and We also report the percentage of agency staff use. We have not included those graphs below because we very rarely use contracted staff in any hospital area. 2ICU and 5ICU Our total NCHPPD for both critical care units is within the national median range for 4 of the last 8 quarters, but we use a primary care delivery system, as shown in the graph at the right. We are above the median range for all but 2 of the last 8 quarters for percentage of hour supplied by RNs. We have considered using UAPs in these areas, but our patient acuity is high and nursing leaders believe it is safer for our patients to staff these units with mostly RNs only. 3 rd Med/Tele and 5 th Tele

6 6 The data for 3 rd Med/Tele and 5 th Tele tell somewhat the same story as in the ICUs. Our total nursing care hours are above the national median for all 8 quarters and we use a higher percentage of RNs to care for these patients. 3 rd Ortho/Neuro

7 7 On the 3 rd Ortho/Neuro unit, we are just below, on, or slightly above the national median range for total NCHPPD. Our percentage of RN use for staffing is below or in the lower median range for all 8 quarters. We have 1 full time LPN that works on this unit and UAPs. We have received national recognition for our orthopedic and neurosurgical outcomes. These graphs could show that our efficiencies in staffing reflect the expertise of RNs and non-rns in this unit, which is a specialized surgical unit. 2 nd Medical/Surgical These graphs demonstrate our staffing is much like the rest of reporting hospital medical-surgical units in terms of total NCHPPS and percentage of staff that are RNs. 4 th Rehab

8 8 Our 4 th Rehab unit graphs are similar to our 2 nd Medical/Surgical graphs, indicating our staffing patterns are similar to those of in the rest of the NDNQI reporting hospitals. 4 th Med/Peds The staffing information for 4 th Med/Peds shows our total NCHPPD are below the national median range for the 8-quarter reporting period, and we may use more UAPs than do other hospitals in the NDNQI database. This data does not reflect nor does our reporting data include the percentage of medical versus pediatric patients, which could make a difference in percentage of hours supplied by RNs if the pediatric nurse:patient ratios are lower. Nurse leaders have used the preceding date to make decisions when formulating staffing plans. An outcome has been staffing plans that are based on internal historical trends and external benchmarks. However, NDNQI does not, at this time, collect staffing measures for all departments. Therefore, nurses study trends in other ways to formulate staffing plans. The Emergency Department (E.D.) Staffing Plan Story Tanya Huston, RN, BSN, is the current E.D. Manager. She and a manager who preceded her have studied ED departmental trends and historical patient usage data to formulate a new staffing plan. Over the past five years, the E.D. staff has transitioned from their standardized 12-hour shift times (6:00 a.m. 6: p.m.; 6:00 p.m. 6:00 a.m.) to variable shift times to address changing E.D volumes throughout a 24-hour period. Because E.D. staffing needs can be very unpredictable, formulating a consistent staffing plan has been a challenge. At times, there seemed to be an adequate number of nurses

9 9 in the E.D.; at other times, staffing seemed short or there seemed to be too many staff in the unit. E.D. leaders decided to conduct a study to see if they could determine patient visit patterns over a 24-hour period. From studying their patient volume and flow patterns, E.D. leaders discovered that patient volumes increased at approximately 10:00 a.m., peaked at around 12:00 p.m., and remained relatively high until approximately 10:00 p.m. This pattern followed national E.D. volume trends, which the former E.D. director had researched. From studying volumes by week, the E.D. director also found the highest patient volumes were generally during day hours on Sunday and Monday, which was most likely attributed to patients trying to wait until Monday to see their physicians at office visits, and not being able to see the physician on Monday due to full schedules. The E.D. study was very useful. The director was able to plot predictions of high or low patient volumes on a staffing grid. Of course, there were would be times when the E.D. became very busy or slumped the trending was not 100% consistent which was expected. The E.D. director then worked with E.D. employees to establish a staffing plan that included a variety of shifts: 6-hour, 8-hour, 9-hour, and 12-hour shifts. The E.D. transition to variable shift times was implemented over approximately five years. Following is an example of the staffing grid that E.D. manager now uses. Tanya s Staffing Worksheet 6a RN, BSN, TEAM LEADER 6a RN, ADN 6a RN, MSN PENDING HIRES 6a 6a RN, BSN, TEAM LEADER 6a RN, ADN 6a RN, MSN OPEN RN, BSN, TEAM LEADER 6a RN, BSN 6a RN, MSN 6a RN, ADN 6a RN, BSN 6a RN, ADN 6a RN, ADN 6a RN, BSN 6a RN, ADN 6a RN, ADN 6a RN, ADN 6a RN, ADN 6a RN, ADN 6a RN, ADN 6a RN, ADN 1.0=80 6a-6p RN, ADN 7a-4p RN, ADN 9a-3p RN, ADN 0.9=72 6a-6p RN, ADN 7a-4p RN, ADN 9a-3p RN, ADN 0.8=64 6a-6p RN, ADN 7a-4p RN, ADN 9a-3p RN, ADN 0.75=60 6a-6p RN, AND, BHA 7a-4p RN, ADN 9a-3p RN, ADN 0.6=50 6a-6p RN, AND, BHA 7a-4p RN, ADN 9a-3p RN, ADN 0.5=40

10 10 6a-6p RN, ADN 7a-4p RN, ADN 9a-3p RN, ADN 0.4=32 6a-6p RN, ADN 7a-4p RN, ADN 9a-3p we 0.2=8 10a-10p RN, ADN 10a-10p RN, ADN 12p-12a RN, ADN 10a-10p RN, ADN 10a-10p RN, ADN 12p-12a RN, ADN 10a-10p RN, ADN 10a-10p RN, ADN 12p-12a RN, ADN 10a-10p RN, BSN 10a-10p RN, ADN 12p-12a RN, ADN 10a-10p RN, BSN 10a-10p RN, BSN 12p-12a RN, ADN 10a-10p RN, ADN 10a-10p RN, BSN 12p-12a RN, ADN 10a-10p RN, ADN 10a-10p RN, BSN 12p-12a 3p-3a 4p-1a 6p-6a RN, ADN TR RN 3p-3a RN, BSN 4p-1a 6p-6a RN, ADN RN, ADN 3p-3a RN, BSN 4p-1a 6p-6a STUDENT RN, ADN 3p-3a RN, BSN 4p-1a 6p-6a STUDENT RN, BSN 3p-3a RN 4p-1a 6p-6a RN, ADN RN, ADN 3p-3p RN 4p-1a 6p-6a RN, ADN 3p-3a RN 4p-1a 6p-6a RN, ADN 6p-6a RN, BSN 6p-6a RN, BSN 6p-6a RN, BSN 6p-6a RN, BSN 6p-6a RN, BSN 6p-6a RN, ADN 6p-6a RN, BSN 6p-6a RN, BSN 6p-6a RN, ADN 6p-6a RN, ADN 6p-6a RN, ADN 6p-6a RN, ADN 6p-6a RN, ADN 6p-6a RN, ADN 6p-6a RN, ADN 6p-6a RN, ADN 6p-6a RN, BSN 6p-6a RN, ADN 6p-6a RN, ADN 6p-6a RN, BSN 6p-6a RN, ADN This staffing worksheet includes a position control sheet, names, FTEs, and vacant positions. The RN Manager knows which staff (nurses and techs) prefer certain shifts. Some nurses and techs are attending school; therefore the RN Manager creates the staffing schedule around their school schedules, as much as possible. Since the

11 11 implementation of variable shifts, the E.D. has not had as large vacant nursing positions as before implementation. One outcome of the change is more satisfied staff. The perusal of trended date in the E.D. also resulted in another change in 2006: the opening of a new area, called the Low Acuity Patient Area. Originally designed for use with less acutely ill patients, this area can now house any patient and is especially useful if there is a large surge of patients with highly acute needs. This area s staffing is based on volumes throughout the entire E.D. This area is staffed from 10:00 a.m. to10:00 p.m. The addition of the Low Acuity Patient Area has afforded the E.D. with even more flexibility for staffing while meeting the needs of our patients. All E.D. nurses can work in either area, which allows for flexibility in staffing. The RN Manager found that expediting the care of patients with less acute or emergent needs has decreased throughput in the entire E.D., which is satisfying for patients and families. Another change in staffing plans in the E.D arose from the remodeling of the department and the 2009 opening of another patient care area in the E.D. The reason for the remodeling project was the department was seeing increasing volumes. In 2007 and 2008, the E.D. experiences a 7% growth. In addition, throughput time, even with the Low Acuity Patient Area, was increasing. The healthcare literature was supporting the benefits of private rooms in decreasing nosocomial infection rates and increasing patient satisfaction. The new area has five private rooms with doors and walls (no curtains!). In 2009, The RN Manager read in the literature about the growing population of elderly in the United States and the potential effects of this growing population on hospitals. Tanya decided to write a proposal to turn the new, 5-bay area into a designated area for the emergency treatment of the elderly population geriatric E.D. In 2010, work will be begin to make this area geriatric-friendly. Nursing proposed changing the lighting to include dimmer switches, painting the walls a different color, and ordering special mattresses. At the time she wrote the proposal, She had read of only two other hospitals that built a geriatric E.D. The new section can be closed if patient volumes do not support use of those rooms. This area will add another component to the staffing plan specialized training for RNs and other staff. Summary Riverside has a variety of structures and processes to support formulation of staffing plans. The concepts from the Vigilance Care Delivery System, our Hospital Plan for the Provision of Patient Care, and our use of NDNQI data and patient volume trends serve as foundations for staffing plans and acquisition of necessary resources. The Flex meeting provides a forum for open discussion on short-term and long-term staffing plans. Nurses at all levels have used trend data to make decisions about staffing in all hospital patient care areas. The specific example of the E.D. s introduction of variable shift times and changes in the physical layout of the department demonstrates Riverside nurses use of trend data to change staffing practices. These changes have allowed for

12 flexibility in staffing, which is based on trends and predictions in patient volumes and patient needs. 12