Effective staffing requires more than counting heads

Evaluate productivity, hire the right people

(Editor’s note: This is the first of a two-part series on effective staffing for same-day surgery programs. This month, we look at how to determine how many people and what skills are needed for a successful program. Next month, we’ll look at accreditation standards on staffing effectiveness standards and how the standards will affect same-day surgery managers.)

You’ve read the headlines. You’ve attended the seminars. You know that there is a nursing shortage and that’s it’s hard to find people to staff your same-day surgery program. All of the attention to the shortage doesn’t change the fact that you still need to staff your program and you need to justify the numbers of staff members you need to your bosses. Add to these the Joint Commission on Accreditation of Healthcare Organizations’ staffing effectiveness standards implemented July 2002 for hospitals, and you have quite a task to accomplish.

Staffing effectiveness standards for same-day surgery programs that are accredited under ambulatory care standards are being tested and probably will be implemented in 2004, says Wilma Delaney, staffing effectiveness team leader for the Joint Commission. The new standard requires accredited organizations to look at the cause and effect of human resource indicators such as sick time, overtime, or staff vacancy rate on clinical outcomes such as medication errors, patient complaints, and delayed or postponed procedures, she says. "These studies will give management a useful tool that identifies human resource factors that affect clinical outcome," Delaney adds.

In addition to knowing how issues such as overtime and sick leave affect outcome, you need to make sure you have the right number of staff. As for how many employees you need to staff one operating room, the minimum number is two, says Judy Swanson, RN, director of perioperative services at Texas Children’s Hospital in Houston. If you rely on two per operating room, however, you leave yourself no room for sick time or vacations, she points out. "For four operating rooms running an eight-hour day in a same-day surgery program, I plan on 2½ people per operating room, or 10 people," she says. Within each operating room, there is a scrub nurse and a circulator, she says. The extra person floats between two rooms, she adds.

Just as important as making sure you have enough people is to make sure you have enough RNs, Swanson says. "To make sure you have a minimum of one RN per operating room, as recommended by the Association of periOperative Registered Nurses [AORN],1 my perioperative staff are no less than 60% registered nurses," she says. Swanson makes sure that any staff members who float from room to room are registered nurses to ensure that minimum of one RN is always met.

Of course, intraoperative time is not the only staff time you need to consider when staffing a same-day surgery program, Swanson explains. You need to account for staff time to process instruments, schedule and admit the patients, and perform any preadmission tests, she says. In fact, the extra staff time and the minimum of two caregivers in the operating room means that one hour of surgery time requires six to seven work hours of staff time, she says.

Be sure you have the data in hand when you approach your administrative team with a request for additional staff, says Jill Speedy, a health care consultant with Seay Management Consulting in Orlando, FL. "Use numbers and facts to justify the size of your staff," she says. Also, don’t use negative statements such as, "I need more people, or we can’t get the job done," to request additional staff, Speedy says. "Point out that if you add one more part-time or full-time person, you can increase turnover and schedule more procedures, or you can discharge patients more quickly, which will increase patient satisfaction," she suggests.

Evaluate staff productivity

Even before you ask for extra staff, be sure that your employees are as productive as they can be, Speedy says. "Perform an internal assessment to make sure that you are operating efficiently and identify any improvements you can make," she says. If you can accompany your request for staff with a description of how you make sure you are as productive as possible with existing staff, your request has more credibility, she adds.

One important way to increase productivity is to hold staff meetings at which employees can brainstorm ideas to improve efficiency, Speedy suggests. Often, it is the employee who does the job every day who sees ways to improve, she adds. Team meetings also improve communications between all staff members by giving everyone an outlet for concerns or suggestions, she says.

Hiring the right people also is important. "A same-day surgery program needs multifunctional, flexible, dependable staff who include people willing to cross-train to other areas," adds Swanson. "All of my nurses are trained to work in the post-anesthesia care unit [PACU] in addition to their primary areas of responsibility." This cross-training gives Swanson an opportunity to move employees to PACU as the day goes on; and fewer patients are in the operating room, and more are in recovery, she points out. It also helps Swanson plan vacation leave or cover areas when a nurse calls in sick.

In addition to hiring the right employees, be sure you promote the right employees as well, Speedy says. "Don’t base promotions on seniority alone," she says. "Not everyone is cut out to be a supervisor, so you need to make sure the person you’re promoting has the right skills to supervise." These skills include not only clinical skills, but also management skills such as record keeping and reporting, and communication skills with employees and patients, Speedy explains.

If you do promote someone who needs to work on certain skills, promote that person with a skill upgrade plan that spells out what skills you want developed or enhanced, and identify ways to accomplish the plan, she advises. "Depending on the skills needed, the plan can call for further clinical education through seminars or vendor training, or management training through outside sources," Speedy says. "Set a timeline for achievement of the plan objectives, and make it a condition of the promotion."


1. Association of periOperative Registered Nurses. Standards, Recommended Practices & Guidelines. Denver; 2002.


For more information on staffing issues, contact:

Judy Swanson, RN, Director of Perioperative Services, Texas Children’s Hospital, 6621 Fannin St., Mail Code 2-1450, Houston, TX 77030. Telephone: (832) 824-5699. E-mail: jxswanso@texaschildrenshospital.org.

Jill Speedy, Consultant, Seay Management Consultants, 1030 North Ave., Suite 101, Orlando, FL 32801. Telephone: (407) 426-9484. Fax: (407) 423-8891. E-mail: jspeedy@seaymanagement.com.

Wilma Delaney, Staffing Effectiveness Team Leader, Joint Commission on the Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5837. Fax: (630) 792-5005. E-mail: wdelaney@jcaho.org.