It’s cheaper to hire them!

Sinai cuts agency use, concentrates resources on staff

In a time of shortage, there often doesn’t seem to be any choice but to use agency nurses. But cutting the use of premium labor became a stated goal at Sinai Hospital, a 398-bed hospital in Baltimore, says Linda LaHart, RN, its director of patient care services. "Everyone was involved in the effort," she says. "The CEO, every vice president, and all the rest of leadership."

There were several strategies involved in the program, which started in 2000. First, the hospital sent representatives to the Philippines to hire a large number of nurses. "We didn’t do 20," she says. "We hired 132. And we hired another 100-plus on the second trip."

The hospital justified the large number of hires based on projected nursing needs over the course of several years, the length of time to get the nurses from the Philippines to Baltimore, and the hope that if they did this right, the nurses would stay past the three-year contract they would sign upon hiring. More than 100 of the nurses already are on board, says LaHart.

The foreign nurses have their own orientation program, as well as an internship for each area of the hospital. "Domestic nurses know the health care system we have here," she says. "We have to teach [the foreign nurses] about accessing resources and about the modern equipment we have here that they may not be familiar with. We have to teach them how to reach a physician or order up physical therapy. They need to know about all the ancillary support we have here." The orientation takes three weeks and includes facts on issues such as banking, taxes, and social security, as well as clinical information. Then they do an internship that lasts three months for noncritical care and six months for the OR.

Keeping the home fires burning

A second part of the program was linking up with a university in Baltimore, providing money for scholarships, and creating a senior practicum at Sinai for that school’s nursing students. The seniors are paid for this practicum and then commit to working at least a year at the hospital after. There also is a special assistant program where students come in and work directly with an RN so that they get more of a sense of what it is to be a registered nurse, rather than a nursing assistant. In the recruitment area, Sinai’s human resources staff took on the task of calling all the alumni of the hospital to see if they could be reengaged. About four or five nurses came back from that effort, she notes.

The hospital also looked inside to see how the working environment could be improved for staff. Nurses on staff told LaHart that they wanted to make sure their patients had what they needed when they needed it, so Sinai worked on strengthening support services so that supplies, medications, and food all came to nurses and their patients in a more timely manner.

They also hired a manager assistant to do the clerical work that often takes nurse managers away from a unit. "If our managers were better supported, then they could be more supportive to the nursing staff," says LaHart. "The new assistant can do the payroll entry and the scheduling, and our RNs can do more clinical work."

Nurse managers also were given incentives for recruitment and retaining existing staff. "It wasn’t good enough any more for a single unit to be good at retaining nurses," she explains. "If one unit was in trouble, then goals for retention that a nurse manager had might not be met. They had to all work together to stop the bleeding."

That, along with the hiring of foreign nurses, seems to have the biggest impact, says LaHart. To help make sure the managers met their retention goals, the hospital developed training programs to ensure they "developed behaviors that were more supportive of staff," she says. "We made sure by hiring the manager assistant that they weren’t in the office doing paperwork. Instead, they were on the units listening and responding to nurses."

The managers were taught to ask, "What do you need help with now?" If a nurse approached a manager and said, "I don’t have the meds I need — again," a typical response might be for the manager to respond, "I’ll call the pharmacy and get it fixed." Now, LaHart explains, she gets the meds first, then she works on the systemic issues to ensure it doesn’t happen again.

Sinai also created a nurse advisory board that included a nurse from each department, the vice president of nursing, the director of nursing, a nurse manager, the vice president of human resources, and both the president and CEO of the hospital. That group looks at global nursing issues and makes recommendations for change. If a big issue comes up, the board can study it. If a nurse has an idea, he or she can run it by the board. "They are our panel of experts," explains LaHart.

What’s bugging you?

Staff also were surveyed on the things that bothered them most. One big issue, she says, was schedules. Units that had day/night rotations changed to have strictly day and strictly night staff. "That has really helped retention, although it was a painful process to implement it," she notes.

Compensation was another issue for staff. "We are one of the top paying hospitals in our area, so that was kind of a surprise." But not when administration looked at what the nurses were comparing their pay to: They were seeing that agency nurses were getting higher hourly rates. But the rates staff nurses get don’t include the benefits they also receive that travelers do not. Still, a change was made. Now, any nurse who works overtime gets $10 more per hour over the base rate. If a 36-hour nurse works an extra shift, they get the higher amount at the 37th hour.All of these changes have had a tremendous impact. The direct caregiver vacancy rate was 35% in February 2002, and the RN turnover rate was 23.6% in January 2002. Now, the vacancy rate is at 13.7% and the turnover rate 12%.

The hospital still is using some traveling nurses, but the amount spent for them over the course of 18 months has dropped by about $6 million. "It used to be that every day, every unit had at least one agency nurse on it," LaHart says. "Now, we only use them for unexpected situations. We have changed the norm."

The money saved getting rid of agency nurses was partially spent making staff nurses happier. That, says LaHart, has stopped some of the loss they were experiencing. "I think it was working together and incentivizing our staff for referrals and managers to keep staff that has made a difference," she says. "We had been losing some people during orientation. But now we have people who can help them through the newness. We get them here and keep them happy." That, too, has an impact on patients, she adds. "The thought is that happy nurses provide better patient care, and we are seeing elevated patient satisfaction scores, too."

Now that retention is up and recruitment is chugging along, the work environment only can get better, says LaHart. Next on the list is to look at workload issues and bettering the patient-to-nurse ratios in some departments. "We have the right staff members and the right numbers of nurses."


• Linda LaHart, RN, Director of Patient Care Services, Sinai Hospital, 2401 W. Belvedere Ave., Baltimore, MD 21215. Telephone: (401) 601-9000.