Looking backward gives hospital answers for the future

Philadelphia hospital moves staff around to safeguard jobs

When administrators at Albert Einstein Healthcare Network (AEHN) in Philadelphia began searching for ways to cut costs and improve patient care, they looked into their past.

There they found an age-old staffing model called flexing, a policy where staff move from one unit to another depending on patient volume and acuity. Redesign leaders dusted off the model, added a few changes to meet modern organizational needs, and returned it to the hospital floor.

After 11¼2 years in operation, the leaders are calling the new model a success. The network benefits because it enlarges its pool of resources enabling it to adapt quickly to changing needs. For example, fewer employees are called in or sent home due to variable patient volume. The employees benefit because they learn new skills that provide more job security. Patients benefit, too, because of their caregivers’ expanded skills.

"Flexing is not unique, but we’re doing more with it," says Suzanne Martin, MS, director of administrative services for nursing. "The guidelines are much more flexible. People now are working outside their speciality. We’re doing it wherever we can."

Here, Martin and other redesign leaders at AEHN share their flexing policy with the readers of Patient-Focused Care.

Breathing new life into an old policy

AEHN, which includes the flagship hospital Albert Einstein Medical Center, the Belmont Center for Comprehensive Treatment psychiatric hospital, the Moss Rehabilitation Hospital, and Willowcrest, a restorative care facility, began exploring restructuring initiatives more than 10 years ago.

Like most hospitals that decide to restructure, AEHN needed to cut costs while improving patient care to remain competitive. The goal was to become a flexible organization capable of adapting to the fickle industry.

The redesign leaders sorted through the variety of restructuring options, picking out those that would achieve their goal, among them the expanded flexing policy.

"We saw that some units, like OR, were busy in the morning, but in the afternoon they were sitting around. In recovery it was the opposite. We asked ourselves why can’t OR help them out. Then we began asking who is jammed and who needs more staff," says Wendy Leebov, EdD, associate vice president of organization and staff development.

To determine who should flex where, redesign leaders analyzed the skill sets of each position.

"We wanted to see which jobs were similar," Leebov explains. "We asked ourselves who has the core competencies? Who is capable of hitting the ground running?"

Staff looked at two areas for flexing:

across levels of care, such as from inpatient to outpatient, to the patient’s home;

across units, such as from maternity to pediatrics.

AEHN uses flexing in both the clinical and support setting. Within the hospital, a housekeeper may flex from unit to unit, while in a health care network a physical therapist may flex from the rehab hospital to the nursing home. In labs, technologists are trained to flex from hematology to the blood bank or chemistry.

"We’re doing it everywhere we can," Leebov says. "We’re always looking at new places to do it." (See lists of AEHN’s flexing roles, pp. 15-16.)

Once they identified who should flex where, the leaders sought volunteers to begin training.

"We had to have people with the right attitude," Martin says. "We wanted the people to come back and share their good experiences. We wanted to set the stage so people would see the change in a positive way."

These volunteers, and the subsequent flex staff, attend training sessions and work with a mentor until they feel comfortable in their new job. Upon completion of their training, they must pass a skill test.

"They’re probably not going to do everything that a full-time person does on the unit. They’re trained for what they need to do," Martin says. "We don’t ask them to do things they’re not comfortable with."

The cost of training and staffing the nurses, which amounts to the nurses’ wages and relevant training materials, is split among the flexing units, Martin says.

The trigger for flexing is patient census. Here, Martin offers an example of how a nurse in the oncology unit might flex:

Mary (a nurse) begins her shift at 7 a.m. in the inpatient oncology unit. She is told by the nurse manager or a member of the central staffing office, who has reviewed the unit’s needs for the day, that four of the 14 patients are scheduled for discharge at 10 a.m., so the four scheduled nurses are not needed for the full shift. Under the old system, Mary probably would have been sent home early. But under the new system, she has been cross-trained to work in other oncology areas.

Her manager tells her the outpatient cancer center has 10 patients scheduled for chemotherapy and needs extra help. Mary begins her shift in the inpatient unit and at 10 a.m., when the four patients are discharged, she reports to the outpatient center to help administer chemotherapy until her shift ends at 3:30 p.m.

Other redesign programs facilitate flexing

The success of AEHN’s new policy is related to its other redesign initiatives, which included altering the organizational structure and job roles of caregivers.

These and other changes, in some units, have begun to disintegrate department affiliations and the consequential turf wars, providing flexing staff with a smoother transition. Martin adds, though, that turf wars still exist and can pose a problem.

Martin says she does not yet have data reflecting the effect of the policy. She said this data is being collected by a recently formed in-house committee called Quality Watch that is assessing the effect of work redesign at AEHN. (See related story, p. 17.) She did say, however, she believes fewer staff are being sent home early when patient volume is low because they can be reassigned to busier units.

While she cannot provide data on the flexing policy itself, she says the networkwide redesign initiatives have resulted in positive changes.

She said AEMC nursing organization has cut its cost per day from $223 in 1996 to $216 in 1997 — a $7 reduction. The hospital has also adjusted its staffing ratios from 80% RNs and 20% other staff to 68% RNs to 32% other. It has also flattened its management structure, reducing the number of nurse managers from 21 to 16.

Staff reaction to flexing is mixed. Those that dislike it say it disrupts their routine. Others let their own lack of confidence interfere with their work.

Martin explains many employees feared they would lack the skills to perform the duties in a unit outside their speciality. To combat this fear, the redesign leaders reminded nurses they already have the knowledge necessary to succeed in their jobs.

"We told them they are licensed professionals," Martin says. "They already went through a broad training program, and they had to demonstrate their knowledge base to get where they are now. We told them we would be refreshing their knowledge, getting them to be confident and more competent in other skills."

Another key concern among nurses is maintaining competency in their newly acquired skills. Martin says staff should flex at least twice a month to prevent skills from going stale. But if for some reason they cannot flex, the solution is simple, she says. The nurses meet with their mentor on their flex unit to brush up on their skills.

"They don’t need to go through a whole new class," Martin explains. "At this point, it will only take a short while for them to get familiar with the procedures. It may take only 10 or 15 minutes. It depends on the person and what they’re doing."

Those who like flexing enjoy learning new skills and appreciate the job security the new training provides.

"They’re newly empowered," Janine Kilty, vice president of human resources at AEHN, explains. "They’re more responsible for their own careers. Their skill base is transferrable so if something happens they’re not out of a job. They can work elsewhere."

In fact, Martin adds, specialization could mean unemployment.

"The most valuable employee of the future is going to be the employee who is the most flexible," Martin says.

[Editor’s note: For more information about flexible staffing, contact Janine Kilty or Wendy Leebov, Albert Einstein Healthcare Network, 5501 Old York Road, Philadelphia, PA 19141. Telephone: (215) 456-7040.]