Page 345 EP 8 How nurses use trended data to formulate the staffing plan and acquire necessary resources to assure consistent application of the Care Delivery Model(s). The development of operational budgets for nursing units, departments and programs is the primary mechanism used to acquire resources that assure consistent application of the Patient Care Delivery Model. The MGH Patient Care Delivery Model is based on interdisciplinary, patient- and family-focused care, with the Staff Nurse assuming a number of roles in the delivery of patient care, such a coordination, accountability, autonomy, authority and cultural competency. Inherent in this model is the need for adequate levels of nursing staff to accomplish this work and provide quality care. Determining adequate operational budgets involves quantifying the primary work of the department which, in turn, assists in determining the required personnel, salary expenses and nonsalary resources required to accomplish that work. The budget is developed at the unit or cost center level and incorporates the components of the Patient Care Delivery Model that are both department wide standards (e.g., indirect time) and specific to a nursing unit/department (e.g., RN mix). Patient Care Services Financial Management Systems (PCS FMS) has the primary responsibility for supporting the development, implementation and management of systems to collect and analyze data, including trended data, for decision-making regarding resource allocation and utilization. Historical and trended data are essential to the process of developing the direct care staffing budget for the 38 MGH inpatient units. As determined by the MGH Office, the timeline for the budget process extends from planning and projecting in February/March, formal submission in April, negotiations and adjustments in May and June, final approval in July or August, and implementation in October, the start of the next fiscal year. As described further in EP 12, the MGH Office begins the process by projecting the next year s high-level budget assumptions. Trended and current data are integral to the projection of these volume statistics. The organization uses operational and fiscal data sources (e.g., admissions and discharges, length of stay, discharge diagnoses, etc.) to identify trends and patterns in volume of services. Together with information about internal and external factors affecting the organization, these data are used to forecast overall volume in terms of discharges (attachment EP 12.a) and expected length of stay by service. The Office volume projections for expected patient days by service are then converted to an expected average daily midnight census. A trended report of the actual census by clinical service distributed by unit is used to then establish the expected unit census for the coming year. A portion of the February 2012 YTD report used for FY 13 budget planning is included as (attachment EP 8.a). To further prepare for the unit-level budget preparation, the PCS FMS compiles trended unit level information for: Midnight Census Length-of-Stay Adjusted Census Average Acuity Hours Per Workload Index Direct Care Shifts per 24 Hours Benefit Time RN Mix Trended data indicating the difference between the the Midnight Census and Length of Stay (LOS) Adjusted Census is calcualted for each unit and is used to establish the expected census that will drive the staffing. The average acuity for the past several months is then used to quantify the
Page 346 Workload Index (i.e., LOS Census x Acuity) for each unit. The internal established target for Hours Per Workload Index is applied to the workload to calculate the required Staff Nurse and Patient Care Associate worked FTEs. During budget planning meetings, the Associate Chief Nurses provide feedback about the trended data, including explanations of variances. They advise the PCS FMS staff as to whether or not the trended information is appriopriate for staffing calculations. They also critically review the budget targets for RN mix and provide recommendations for desired changes. Examples of feedback received during the FY 12 budget planning process included: Lunder Building Moves Five oncology and neuroscience inpatient units would move to a new building with unit size differing from FY 11 units affecting the workload estimates Blake 12 Surgical ICU Proposal to create a new 18 bed ICU in vacated space that would include Transplant ICU patients previously cared for in the Blake 6 ICU as well as other surgical ICU patients, which required estimating expected workload Blake 6 Tansplant ICU Plan to eliminate ICU beds and remain with workload based on general care patients (i.e., lower HPWI target for general care versus ICU level care) Bigelow 6 (Pediatric ICU) Although the unit size had increased from 8 to 13 inpatient beds, the census estimates were maintained similar to FY 11 based on unsuccessful recruitment of a new pediatric cardiac surgeon In addition to adequate staffing levels, the Patient Care Delivery Models for various units impact the distribution of direct care staff FTEs and thus the breakdown of Staff Nurses and Patient Care Associates (PCAs) for each unit. For example, the models for the Pediatric ICU, Neonatal ICU, and Obstetrical Units are based on a 100% RN staff mix. In comparison, the RN mix is about 89% for adult ICUs and 82% for the general care units. In general, these established targets for RN % of total nursing care hours are higher than seen in in many Academic Medical Centers, however the model supports the known Staff Nurses workload specific to the Patient Care Delivery Model and patient care area. For example, nursing care provided in the PICU and NICU is primarily RN in nature, including frequent clinical assessments, procedural care and family education. Unlicensed assistive personnel (UAP) have a limited role in this environment and thus the 100% RN mix target is appropriate. In the adult ICUs, the nursing responsibilites are similar to the pediatric ICUs, however, there is more of a role for UAPs, Patient Care Assistants (PCAs) at MGH, in assisting Staff Nurses with positioning, supply management, and even with some procedural care such as large, complex dressings in the Burn ICU. On the general care units, where patient care needs are usually less than in the ICUs, there is more of a role for PCAs in supporting ADLs and assisting with safety interventions. Therefore the lower RN mix of approximately 82% supports that model. To complete the required FTE calculations for a unit, PCS FMS staff create a summary of actual benefit time utilization based on the previous 12 months to include seasonal variations and trends. This percentage is added to the worked FTEs to assure backfill staffing to cover direct care staff s paid time off. Attachment EP 8.b contains a portion of the report used in FY 12 budget planning. A percentage of 4.75% is then added to cover the indirect time needed for orientation, education, professional development and administrative project time. The resulting data represents the total FTEs for direct care staff that will be included in the budget. A sample section of the FY 12 direct care staffing calculations for the units is included as an attachment in EP 12.b. Trended data reflecting clinical volume is used for units that do not use a patient classification system. For example, the operating room and PACU budgets are impacted by the volume and type of cases anticipated for the coming year. The Vice Presidents overseeing the various clinical services provide these predictions as part of the budget process, allowing the nursing budgets to use this information in calculations for staff. The following trend data showing a
Page 347 significant increase in both case volume and case hours from FY 11 to FY 12 and predictions for continued increases for FY 13 serve as compelling justification for increases in direct care staffing for these areas. MGH Main Campus Operating Room Volume Avg. Case Length Change Case Hours Timeframe Case Volume Case Hours Change Volume FY06 Actual 34872 88199 152 FY07 Actual 33609 87132 156-3.6% -1.2% 2.5% FY08 Actual 33437 88111 158-0.5% 1.1% 1.6% FY09 Actual 33792 91009 162 1.1% 3.3% 2.2% FY10 Actual 33855 91573 162 0.2% 0.6% 0.4% FY11 Actual 33909 91009 161 0.2% -0.6% -0.8% FY12 35494 97907 166 4.7% 7.6% 2.8% FY12 Actual (Annualized) 35623 99948 168 0.4% 2.1% 1.7% FY13 36171 101650 169 1.9% 3.8% 1.9% Note: FY'12 Data as of April 3, 2012 Similar trend data is available for other clinical areas such as Dialysis and Endoscopy are used to formulate the staffing budgets for these areas (attachments EP 8.c-d). In the Labor and Delivery Unit (Blake 14), trended data for volume of births by month is used to predict direct care staffing for the subsequent fiscal year (attachment EP 8.e). The Emergency Department administrative staff also produce an on-going monthly report containing trend data for a number of metrics that impact care, staffing and outcomes (attachment EP 8.f), containing data such as number and hours of boarder patients that is necessary to include in the determination of appropriate staffing levels. Trend data are also available to assist with budgeting of non-salary resources. In this component of the budget process, each unit is asked to predict expenses in categories such as supplies, utilities, and services. Staff from Patient Care Services Financial Management Systems and Patient Care Services Clinical Support Service work with nurisng leadership to predict expenses for the upcoming fiscal year. In the process, they use a report that is generated to show actual utilization for the previous 13 months. This utilization data assists in projections that are based on trends of actual unit needs. A portion of the December 2011 13-Month Non Salary Trend Report used in the FY 13 budget process is included as attachment EP 8.g. The summary was instrumental in quantifying PCS cost centers account that required significant adjustment for FY 13. After budgets are developed and implemented, these trend reports also assist in decision making in regards to staffing. For example, in the FY 12 budget process, two new Lunder Building units, Hematology/Oncology/Bone Marrow Transplant Unit (Lunder 10 - formerly Ellison 14) and Hematology/Oncology Unit (Lunder 9 - formerly Phillips House 21), were budgeted at an expected occupancy of 85%. Within the first few months and continuing throughout FY 12, the units actually experienced occupancy rates of 91-93% (see attachment EP 8.a data for Lunder 9 and 10). Due to this on-going, trended data, these units were allowed to hire beyond budget during FY 12 and occupancy rates of 93% were used for the direct care staffing budgets for FY 13. Change Length
Attachment EP 8.a Page 348
Page 349 Attachment EP 8.b MGH Department of Nursing Direct Care RN Benefit Time March 11 - February 12 Unit/Dept Total FTE Staff Nurse (Agency) Worked FTE Staff Nurse (Agency) Benefit FTE % Benefit Worked ER Nursing 219.4 0.0 194.0 0.0 25.4 13.1% OR Nursing Adm 1.0 0.0 0.9 0.0 0.1 16.2% MOR 234.6 0.2 204.4 0.2 30.2 14.8% PACU 125.8 4.0 108.8 4.0 17.1 15.7% SDSU 27.8 2.9 24.3 2.9 3.5 14.6% PATA 13.4 0.0 11.5 0.0 1.9 16.2% Endoscopy 70.9 1.0 61.9 1.0 8.9 14.4% Perioperative 473.5 8.1 411.8 8.1 61.7 15.0% CA SICU 70.8 0.0 62.0 0.0 8.7 14.1% EL 8 62.9 0.0 55.1 0.0 7.8 14.1% EL 9 CCU 60.0 1.4 52.0 1.4 8.0 15.5% EL 10 62.7 2.6 55.8 2.6 6.9 12.3% EL 11 CAU 59.9 0.0 52.0 0.0 7.9 15.2% Cardiology 316.3 4.0 276.9 4.0 39.4 14.2% SICU 95.8 2.3 83.4 2.3 12.5 14.9% BL12 ICU 23.6 0.0 21.9 0.0 1.6 7.3% BG 13 49.6 0.3 44.0 0.3 5.5 12.6% BL 6 32.2 1.8 28.2 1.8 4.0 14.2% WH 7 49.7 1.2 44.3 1.2 5.4 12.2% EL 7 66.5 0.5 58.0 0.5 8.5 14.6% EL 19 51.8 0.3 45.9 0.3 5.9 12.9% PH 22 36.8 0.5 32.3 0.5 4.5 13.9% BG 14 47.5 0.0 42.2 0.0 5.4 12.7% Surgical 453.5 7.0 400.1 7.0 53.3 13.3% BL 7 MICU 68.5 3.5 61.3 3.5 7.2 11.8% EL 16 64.9 0.0 56.5 0.0 8.4 15.0% PH 20 33.6 1.7 29.8 1.7 3.8 12.7% BG 9 43.0 1.7 37.1 1.7 5.9 15.8% BG 11 53.2 0.0 46.0 0.0 7.1 15.5% WH 9 46.9 0.3 42.0 0.3 4.9 11.7% WH 8 48.4 0.9 42.9 0.9 5.5 12.8% WH 10 38.5 0.0 34.6 0.0 3.9 11.4% WH 11 43.9 0.4 39.2 0.4 4.7 12.0% WH 13 4.8 0.0 4.2 0.0 0.6 13.8% Dialysis 20.0 0.4 17.5 0.4 2.5 14.6% Anticoag service 12.2 0.0 10.6 0.0 1.6 14.9% Medical 477.8 9.1 421.6 9.1 56.2 13.3%
Page 350 Attachment EP 8.c Dialysis Volume Trends FY09 FY10 FY11 FY12 FY13 INPT HD ONE EVAL 4447 4451 4440 4193 4236 INPT HD ONE EVAL 52 51 53 48 36 INPT HD ONE EVAL 2 3 3 0 7 INPT HD ONE EVAL 0 0 0 0 0 INPT HD ONE EVAL 0 0 0 0 0 OPD CHRONIC HD 111 93 96 132 154 OPD CHRONIC HD 7 8 8 12 22 OPD CHRONIC HD 559 479 693 708 924 OPD CHRONIC HD 0 0 0 0 0 OPD ACUTE HD 2 3 3 2 5 OPD ACUTE HD 0 0 0 7 2 OPD ACUTE HD 77 92 95 31 43 APHERESIS PLASMA 45 38 65 APHERESIS PLASMA 0 0 0 APHERESIS PLASMA 41 26 2 Total Dialysis 5258 5180 5318 5134 5429 Total Pheresis 86 65 67 Total Procedures 5404 5199 5496 Change FY'12 to FY'13 297 % Change FY'12 to FY'13 5.7% RN FTEs 14.0 14.5 14.5 14.5 15.5 Change FY'12 to FY'13 6.9% % Change FY'12 to FY'13
Page 351 Attachment EP 8.d Endoscopy Procedure Volume Procedure # FY11 Mins RVUs Procedure # FY12 Mins RVUs Change Procedure # FY13 Mins RVUs Change COLON 14935 130 32359.2 COLON 14386 130 31169.7-1189.5 COLON 15476 130 33531.3 2361.7 EGD 8042 108 14475.6 EGD 8554 108 15397.2 921.6 EGD 9259 108 16666.2 1269.0 FLEX SIG 691 77 886.8 FLEX SIG 640 77 821.3-65.4 FLEX SIG 729 77 935.6 114.2 ERCP 1301 231 5008.9 ERCP 1072 231 4127.2-881.7 ERCP 1194 231 4596.9 469.7 EUS 281 185 866.4 EUS 866 185 2670.2 1803.8 EUS 1038 185 3200.5 530.3 LIV BX 73 134 163.0 LIV BX 2 134 4.5-158.6 LIV BX 5 134 11.2 6.7 OTHER 45 123 92.3 OTHER 96 123 196.8 104.6 OTHER 64 123 131.2-65.6 MOTILITY 8 56 7.5 MOTILITY 782 56 729.9 722.4 MOTILITY 866 56 808.3 78.4 INFUSION 1600 252 1493.3 INFUSION 1790 252 1670.7 177.3 INFUSION 1806 252 1685.6 14.9 CAPSULE 290 120 580.0 CAPSULE 210 120 420.0-160.0 CAPSULE 263 120 526.0 106.0 Total 27266 123 55932.9 Total 28398 123 57207.4 1274.5 Total 30700 123 62092.7 60818.3 Change Year to Year 1132 1274.5 2302 4885.4 % Change Year to Year 4.2% 2.3% 8.1% 8.5%
Page 352 Attachment EP 8.e Vincent Obstetrics Registrations and Deliveries FY 2012 MGH FY12 Actual FY12 Targeted FY11 New ed Projected FY12 Act FY12 Act FY12 Act FY11 Act New Patient New Patient Patient FY 2012 Deliveries Deliveries Deliveries Liveborn Stillborn Deliveries Registrations Registrations Registrations MONTHLY CUMULATIVEMONTHLYCUMULATIVE 1st 2nd Baby Baby Total Total Total October 294 316 316 316 316 324 2 276 160 191 351 331 323 November 273 300 616 289 605 296 2 287 181 189 370 331 332 December 283 279 895 289 894 298 2 299 164 197 361 332 327 January 292 274 1,169 265 1,159 277 0 285 160 178 338 332 367 February 269 281 1,449 261 1,420 268 0 271 150 173 323 304 333 March 293 304 1,754 287 1,707 297 1 303 187 193 380 337 373 April 282 300 2,054 307 2,014 320 1 332 152 158 310 326 342 May 280 333 2,387 0 2,014 0 0 292 0 0 0 337 312 June 300 318 2,705 0 2,014 0 0 295 0 0 0 326 323 July 293 296 3,001 0 2,014 0 0 313 0 0 0 338 329 August 307 0 3,001 0 2,014 0 0 305 0 0 0 337 342 September 284 0 3,001 0 2,014 0 0 306 0 0 0 326 358 Total 3,450 3,001 2,014 2,080 8 3,564 1,154 1,279 2,433 3,957 4,061
Attachment EP 8.f Page 353
Attachment EP 8.f continued Page 354
Page 355 Attachment EP 8.g Legend Top 5 expenses over budget. Expenses comprising 80% of spending or a former Tiger Team Account. Department of Nursing Controllable Non-Salary Expenses Thirteen Month Actual Trend v. Period Ending: December 31, 2011 Account Account Description Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 910400 Med/Surg - General 797,300 790,479 778,025 913,877 824,502 869,556 839,841 909,722 809,069 865,360 861,670 836,253 904,902 2,602,825 2,132,929 (469,895) 940202 Laundry Chargebacks 164,344 191,172 195,966 310,148 174,657 169,415 221,613 234,226 286,192 219,002 247,128 288,340 242,625 778,093 506,564 (271,529) 912700 I V Sets 123,494 112,086 108,313 122,088 116,209 112,487 112,788 123,739 125,776 121,400 124,078 115,797 125,676 365,552 356,254 (9,297) 910500 Med/Surg - Gloves 124,199 119,937 120,900 131,394 118,236 118,551 129,933 139,782 140,081 131,949 140,771 132,473 136,248 409,492 294,992 (114,499) 910100 Med/Surg - Catheters 113,016 91,025 92,856 124,690 75,777 138,359 144,102 118,957 98,288 126,458 109,417 116,743 103,517 329,676 295,545 (34,132) 910300 Med/Surg - Dressings 100,989 101,384 83,363 100,748 86,182 99,248 98,868 123,100 103,353 100,660 107,751 95,447 103,795 306,993 263,934 (43,059) 955300 Rentals or Leases - Equipment 42,692 33,572 59,539 37,284 42,132 70,544 91,607 67,897 88,293 89,394 63,093 37,178 50,460 150,731 136,910 (13,821) 970503 Telephone Chargebacks 93,459 76,975 73,478 75,453 71,781 67,465 77,986 76,554 71,812 77,244 78,262 82,227 86,120 246,609 241,211 (5,398) 930100 Printing & Forms 85,416 71,307 65,909 77,410 80,705 54,822 90,370 74,270 80,942 133,119 59,053 97,929 109,778 266,761 174,920 (91,841) 912800 I V Solutions 44,891 45,260 40,901 46,581 44,078 45,120 47,204 57,783 47,843 47,199 48,559 43,758 44,304 136,621 127,826 (8,794) 912300 General Lab Supplies 31,082 29,708 27,978 33,676 27,562 31,041 31,788 34,345 33,072 28,811 32,258 33,587 32,872 98,717 88,205 (10,512) 918200 Food 30,061 27,252 28,329 31,236 30,774 29,089 30,162 34,867 35,974 23,157 33,276 35,041 34,007 102,324 82,346 (19,979) 930200 Office Supplies 29,611 36,108 25,936 27,642 31,543 27,075 30,115 12,120 50,529 49,839 45,066 30,824 38,224 114,114 73,836 (40,278) 954200 Maint Contr-Equipment 50,328 19,597 16,602 26,415 21,359 19,888 24,612 26,406 20,522 25,006 19,356 36,975 37,600 93,931 148,093 54,162 930700 Non Capital Equipment 16,730 34,024 11,985 10,039 4,810 10,742 13,022 8,679 (3,927) 27,279 52,223 35,380 23,481 111,085 99,248 (11,836) 912200 Disposable Linen 32,582 32,883 30,818 34,656 30,775 31,023 31,836 32,538 35,150 31,026 34,728 29,990 35,361 100,078 88,206 (11,873) 910200 Med/Surg - Custom Packs 24,583 29,597 35,502 15,960 33,673 37,935 63,395 62,088 34,461 23,058 43,067 33,608 36,788 113,463 80,484 (32,979) 940100 Laboratory - Purchased Service 40,525 38,181 10,194 24,273 32,436 25,354 19,572 24,442 32,189 25,565 25,000 17,188 45,701 87,889 49,223 (38,666) 912100 CPD Expense 17,503 14,878 13,835 17,730 14,321 18,761 17,665 19,498 17,360 19,542 16,995 18,462 20,321 55,779 49,938 (5,841) 951700 Telephone - Pagers & Beepers 17,710 19,980 18,610 18,560 19,230 18,650 18,930 18,820 19,455 20,670 19,250 18,930 17,470 55,650 53,103 (2,547) 954700 Repairs - Equipment 11,313 12,933 12,707 14,662 (292) 9,190 9,752 4,709 8,915 10,567 11,257 12,578 8,629 32,464 20,106 (12,358) 919800 Miscellaneous Supplies 19,840 20,179 7,999 11,256 46,611 25,282 11,525 42,580 16,041 32,358 18,091 22,887 23,660 64,638 26,449 (38,189) 917800 Rehabilitative Supplies 9,825 8,971 8,568 9,937 9,262 10,610 10,853 13,783 10,951 10,122 10,910 10,434 9,951 31,294 33,094 1,799 MTD Dec-11 Actual YTD Dec-11 Actual YTD Dec-11r FYTD Variance