Exemplary Professional Practice: Staffing Scheduling and geting Processes EP10 Nurses use trended data in the budgeting process, with clinical nurse input, to redistribute existing nursing resources or obtain additional nursing resources. EP10b: Provide an example, with supporting evidence, where trended data was used during the budget process, with clinical nurse input, to assess actual-tobudget performance to redistribute existing nursing resources or to acquire additional nursing resources. Trended data must be presented. Introduction As described in EP10a, the annual operational budget process provides a structure to acquire nurse staffing resources for the Massachusetts General Hospital (MGH) inpatient nursing units. Development of inpatient staffing budgets involves the use of trended data and assessment of actual to budget performance for a variety of metrics. Input from clinical nurses is used by nurse leaders and managers to inform decisions made during the budget process as well as at other points during the fiscal year when adjustments may need to be made to redistribute or acquire additional nursing resources based on increased nursing workload. MGH Inpatient Staffing Model with Staff Nurse Input At MGH, staffing budgets are developed at the unit or cost center level during the annual operational budget development process that usually occurs from March through July of each year. The process involves quantifying the expected work of a nursing unit/department which, in turn, assists in determining the required personnel. The Quadramed Plus Productivity, Benchmarking, and Outcomes System - Inpatient Methodology (Quadramed) is used to quantify the nursing care needs for the MGH inpatient units. The Quadramed acuity system, sometimes to referred to as the patient classification system, assures that clinical nurses provide input, through their daily electronic data entry, that results in a measurement of patients needs for nursing care (i.e. acuity). The acuity values and volume that results from the clinical nurse input are used to provide a measurement of nursing workload, which is a function of both census and acuity. This daily input which reflects patient care needs based on nursing assessment is invaluable in the determination of required nursing resources. Each day clinical nurses complete the patient classification tool, a factor evaluation tool comprised of 24 indicators that are known to impact nursing workload. The resulting score aggregates patients into one of six categories with assigned values that are used to quantify the needs for nursing care in a 24-hour period. Additional information is added by the clinical nurses for an additional 11 categories of care that also impact
nursing workload, such as a patient who must travel off the unit for a procedure with an RN or the need of 1:1 observation for safety reasons. Additional information is added from the hospital s ecare system to capture nursing time related to admissions, discharges, and transfers. The resulting workload information then quantifies the staffing requirements, based on hours of care, for each patient and unit. Since the Quadramed data is key to decision making related to acquiring or redistributing valuable nursing resources, there is a strong focus on daily compliance with the data entry requirements and the reliable use of the tool. All clinical nurses receive education regarding patient classification during their central onboarding, which is reinforced during their unit-based orientation with an RN preceptor. The rate of completed classification events is monitored and consistently demonstrates a compliance rate of approximately 98%. In addition, inter-rater reliability is audited on an on-going basis to assure reliable application of the tool and the consistent interpretation of indicators. These efforts based on input from clinical nurses result in quantification of nursing workload that can be used in the budgeting for the nurse staffing resources required to meet the workload demands. Nursing & Patient Care Services Management Systems & Financial Performance (N&PCS MSFP) supports nursing leadership during this annual budget process, and throughout the year by monitoring actual-to-budget performance of workload and productivity. Utilization of Trended Data During the get Process The MGH get Office begins the process by providing trended data for volume statistics to be used in developing the next year s high-level budget assumptions. Data specific to admissions and discharges, length of stay, and patient days are provided for each service to demonstrate trends and patterns in patient volume. Together with information about internal and external factors affecting the organization, this data is used to forecast overall volume for the next fiscal year. Attachment EP10b.a contains the volume trends that were presented and used in the Fiscal Year 2018 (FY 18) budget development process, which shows that the proposed volume would have a 5.9 % decrease in discharges, a slight decrease in, and an overall decrease in patient days and projected Average Daily (ADC) of 4.1% over FY 17. A year-to-date (YTD) trend report of the actual census by clinical service by unit is then used to establish the expected ADC for each unit for the coming year. The N&PCS MSFP compiled YTD unit-level data from Quadramed for Adjusted, Average, Hours Per Workload Index, Direct Care used per 24 Hours, and actual RN versus Non-RN Skill Mix. YTD data was analyzed to determine the difference between the Midnight ADC and Adjusted for each unit. The trend for average acuity from October 2016 through February 2017 was also analyzed and then used with the census data to quantify the expected need for nursing care or the unit s workload. This workload or Workload Index, calculated as X
, is quantified for each unit. The established staffing targets for Hours Per Workload Index () were then applied to the workload to calculate the required direct care clinical nurse and patient care associate (i.e. unlicensed assistive personnel) Full Time Equivalents (FTEs). To complete the FTE calculations for each inpatient unit, N&PCS MSFP created a summary of actual benefit time utilization based on the previous 12 months, so as to account for seasonal variations and trends. This percentage is added to the calculated direct care FTEs to assure backfill staffing to cover paid time off for direct care staff. For FY 18, an average of 14.1% for clinical nurses and 10.6% for patient care associates was added to the FTE budgets to cover expected time off. A percentage of 4.4% was then added to cover the indirect time needed for orientation, education, professional development and administrative project time. Note that the indirect time addition was reduced from 4.5% as used in the FY 17 budget to 4.4% for the FY 18 budget to reflect a planned decrease in central onboarding time and a reduction of 2.3 FTEs in the indirect time budget for the inpatient units. The resulting data will provide the total FTEs for direct care staff to be included in the FY 18 budget for each unit. Trended acuity data from Quadramed and actual benefit time by role group that was compiled to form the basis for the FY 18 budget process are included as attachment EP10.b.b. During the process, the Associate Chief Nurses provide feedback about the trended data and initial staffing calculations, including explanations of actual or expected variances. They advise the N&PCS MSFP staff as to whether or not the trended data is appropriate to use for staffing calculations. They also critically review the budget targets for RN mix and provide recommendations for desired changes. The Associate Chief Nurses share the results of the calculations using the trended data with the Nursing Directors (NDs) during the process, to obtain their front-line insight about the proposed changes. For the FY 18 budget process, some of this planning and feedback occurred earlier in the year as a result of work with a consultant engaged by Partners Health Care who compared MGH actual staffing to national benchmarks for HPPD, as well as a review of internal staffing targets (s) for all Partners Hospitals. One proposal from this analysis was a decrease the internal staffing target (i.e. Hours Per Workload Index or ) target by 0.05 for all units. The impact of this change was calculated and shared with the associate chief nurses who in turn communicated the proposal to the NDs in their areas. An example of this is contained in an e-mail from Theresa Gallivan, RN, MSN, NEA-BC, Associate Chief Nurse for Cardiac, Medicine and Emergency Nursing Services, on January 09, 2017 where she shared this proposal and asked for feedback from the NDs. Gallivan asked Chris Annese, RN, MSN, AHN-BC, Staff Specialist, to compile the feedback. In response, Judy Silva, RN, MSN, NE-BC, Nursing Director for the Cardiac Access Unit (Ellison 11) shared some concerns regarding the proposed reduction and its impact on her unit (attachment EP10b.c).
Assessment of ual to get Performance N&PCS MSFP produces weekly Workload/ Productivity Reports that provide an ongoing tool for nursing leadership to monitor both workload and appropriate use of direct care staffing. The report provides an overview of actual to budget performance by unit, including weekly, month-to-date and year-to-date data. In her e-mail to Annese, Silva voiced her concerns and referenced her actual to budget performance in regards to nursing workload. She shared her concerns about the proposed reduction since Ellison 11 was performing significantly above budget in workload. Excerpt from Workload Productivity Report for the Week of January 7-14, 2017: Workload Hours Unit Ellison 11 29.6 29.7 1.79 1.93 53.0 57.4 5.50 5.26 36.5 37.7 Excerpt from Workload Productivity Report for January 14, 2017 YTD: Workload Hours Unit Ellison 11 29.6 29.7 1.79 1.86 53.0 55.2 5.50 5.10 36.5 35.2 Although the census for Ellison 11 was running very close to the FY 17 budget target, the acuity and workload were running beyond the budget. The result was that the nursing staffing used per unit of workload (i.e. Hours Per Workload Index of ) was falling short of the desired staffing target. Annese shared Silva s concern with Nancy Raye, RN, MSN, Staff Specialist in N&PCS MSFP. Raye took the opportunity to clarify with Silva that, although the proposed reduction in get for FY 18 would ultimately result in slightly less staffing, that the changes she was seeing in acuity and workload would most likely result in additional staffing for Ellison 11. Raye provided this information in an e-mail response to Silva on January 10, 2017 (attachment EP10b.c) and discussed it further with her by phone. The feedback helped to frame the concerns regarding the actual to budget performance and, in advance of the formal budget submission, highlighted Ellison 11 as a unit expected to receive additional staffing for FY 18.
Clinical Nurse Input Regarding Resource Distribution NDs have a variety of ways that they communicate with clinical nurses on an on-going basis both to inform and receive feedback regarding the staffing budget. In addition to daily conversations with scheduled nursing staff, Silva holds unit-based staff meetings with all three shifts and then summarizes the discussions in an e-mail that she sends to all Ellison 11 clinical and advanced practice nurses. For example, at the September 9, 2016 staff meeting the Ellison 11 clinical nurses shared their opinions that since the EPIC go-live in the Spring of 2016, their experience had been that admissions were occurring later in the day and that there was additional workload during the 3PM 7PM timeframe. This led to a discussion about how to staff the evening shift given the increasing workload. The staff provided open, honest feedback and proposed that they should minimize use of 12-hour evening shifts because the overlap from 11AM to 3PM was not necessary. They suggested using only 8-hour evening shifts, which would allow a move of the 11AM to 3PM hours to the evening (e.g. 3PM-11PM) timeframe where the increased workload was being experienced. Attachment EP10b.d contains the minutes distributed by Silva after the September 9, 2016 meeting where she thanks the nurses for their input regarding staffing. Acquiring Additional Nursing Resources To date, the initial submission for the FY 18 personnel budget has been completed and it is expected that due to the increased acuity and workload on Ellison 11, the unit s direct care personnel budget will be increased for clinical nurses, by at least 1.4 FTEs. There is also an expected 1.9 FTE increase for Unlicensed Assistive Personnel. Further, as previously mentioned, Nurse Directors obtain input from clinical nurses throughout the year. Attachment EP10b.e contains the annual get Sheet that will be provided to Silva containing the information that was used in the budget process and the resulting changes in FTEs by role group. In determining where to distribute these specific additional 3.3 FTEs of nursing resources, Silva will consider the input from the Ellison 11 clinical nurses that was provided at the September 2016 staff meeting. The translation of this clinical nurse input into the redistribution of resources is evidenced in the annual process MGH undergoes to report staffing plans through PatientCareLink. PatientCareLink, originally called Patients First, was created in 2005 and endorsed by the Massachusetts Hospital Association and the Massachusetts Organization of Nurse Executives (now the Organization of Nurse Leaders). As stated on the PatientCareLink website (www.patientcarelink.org), the initiative is a healthcare quality and transparency collaborative supporting a quality and safety initiative that is committed to the advancement of professional nursing, promoting the delivery of quality patient care and influencing the development of health policy. All acute care hospitals participate in PatientCareLink and are required to post budgeted staffing plans on the Massachusetts Hospital Association website, presented by role group, day of the week, and shift. Nursing Directors review and approve this information on an annual basis. The table
below indicates how Silva will change the information for FY 18 to include the additional 3.3 FTEs, incorporating the staff nurse input regarding additional resources needed on the evening shift. 2017 Patients Care Link Data - get Staffing FY'17 Staff Nurse Patient Care Associates FY'17 MN Calc. FY'17 RN FY'17 PCA TOT Unit/Dept HPPD SH SH SH D E N D E N D E N D E N Ellison 11 30.20 9.66 29.5 6.9 36.5 13.0 11.5 6.5 11.0 9.0 6.0 3.5 2.8 1.0 3.0 2.5 0.5 2018 Patients Care Link Data - Planned get Staffing FY'18 (as of 5/15/17) Staff Nurse Patient Care Associates FY'18 MN Calc. FY'18 RN FY'18 PCA TOT Unit/Dept HPPD SH SH SH D E N D E N D E N D E N Ellison 11 30.50 10.12 30.9 7.7 38.6 13.0 12.0 7.0 11.0 10.0 7.0 3.5 3.0 1.0 3.0 3.0 1.0 The FY 18 budgeting process used for Ellison 11 demonstrates how clinical nurse input and trended data of various types was used to budget direct care staffing FTEs. The monitoring of actual-to-budget performance for census, acuity, workload, and indicated an increased acuity and workload beyond budget targets. This trended information was used in planning for the FY 18 staffing budget, which will result in additional direct care FTEs for Ellison 11. Silva worked with clinical nurses to obtain their input into how the new nursing resources should be allocated, and incorporated their feedback into decisions regarding shift coverage changes for the Ellison 11 staffing schedule.