Common sense staff slash overtime

Nurses ebb and flow with patient volume

Which sounds better, staffing based on patient volume or traditional views of nurse scheduling? Parkview Memorial Hospital in Ft. Wayne, IN, took the common sense approach when it threw out a traditional staffing model and let patient numbers dictate when nurses would work.

Instead of the traditional eight nurses starting the day shift in the emergency department (ED) when patients are at their lowest with an average of six, four nurses arrive at 7 a.m. But later, when patients begin coming in, nurses also flow in to boost the number of nurses to nine during the peak periods.

"Our night shift was always saying they needed more help," says Dan Garman, division director for emergency services at Parkview. " They couldn’t handle the patient load, and we’d have to call people in on overtime. It was obvious what we needed to do."

By implementing the change, Parkview:

• cut its annual labor budget 9.3%, from $2.9 million to $2.6 million;

• slashed overtime from 300 hours per two-week pay period to 92 hours;

• increased staff, but reduced its nurse/full-time-equivalent ratio from 70% to 60% (44/63 to 47/78), only a few marks off the national average of 55% to 58%. The bulk of the increase in personnel are technicians (from three FTEs to 10). The department also boosted the number of unit secretaries from one on the day and evening shift to two to handle the extra duties when the department was split into two businesses: urgent care and emergent care. (See cover story, p. 61.) The night shift continues to staff one secretary.

Parkview decided to revamp its staffing model after comparing itself to other hospitals of similar size that performed more efficiently and posted higher staff and patient satisfaction scores.

Patient/nurse volume not in sync

To determine an appropriate staffing model, Garman used the ED/NET patient tracking system (from TENET Information Services, Salt Lake City), to determine patient load by the hour. Not surprisingly, patient volume dragged in the early morning and boomed in the evening. Meanwhile, staffing was the opposite, higher during the day, dropping off at night.

Garman showed the data to a team of staff who came up with the obvious solution of revamping shifts to handle the fluctuating patient volumes. (See charts, p. 65.)

The change immediately resulted in a drop in overtime.

"We’re not calling in people because we’re short like we used to," Garman explains. "Our staffing is aligned to the needs of the department."

In fact, if a rush occurs during the first morning shift, rather than calling in nurses to work overtime, nurses from management will pitch in until the second wave of clinicians arrive at 9:45 a.m.

In addition to looking at scheduling, the team analyzed the tasks of the various staff. They are now careful to adjust the level of expertise to the level of patient care needed. Nurses no longer wheel patients to X-ray when they should be tending to injuries.

This task analysis also prompted the decision to cross-train technicians on the night shift to draw blood. This change reduced lab turnaround time from 30 minutes to under 10 minutes. Based on this success, Parkview is considering cross-training techs on the other shifts.

Parkview further reduced overtime by condensing its six-month orientation program into two weeks, a tip received while conducting a benchmarking session at Community Hospital in Indianapolis.

"They told us these people are already trained," Garman says. "You don’t need to retrain them. Turn them loose. Just make sure you have a system in place to monitor them and make sure they have resources. . . . Our staff was spending more time in orientation than the ER."

All these changes did not go smoothly right away, but managers came away with a few lessons learned for the next time the hospital undergoes a change. These lessons include:

Communicate earlier.

Garman says the data he showed staff comparing Parkview to other hospitals of similar size and operation convinced staff of the need to change faster than any arguments he or others made. "Now I tell people to show this data from the start," Garman says.

Consider unintended ramifications of change.

When the new staffing schedules were announced, Garman admits he forgot to consider the staff’s day care needs. The hospital runs a day care facility, but it didn’t open early enough to accommodate the new schedule. He couldn’t change the day care’s hours of operation, but he says he will now make sure he warns people to consider such issues.

Think about effects of changes

"We tell people who are considering making changes to think through the effect it’s going to have on everyone’s lives," Garman says. "It can be really disruptive, and we need to be sensitive to that."

Garman says Parkview is reducing the need for future cataclysmic scheduling changes by continually monitoring patient volume trends. If a staff member resigns, an analysis is run to determine whether the position is still needed in its current time slot or if it needs to be changed. If it does, the position is advertised with the new time.

Create some consistency

"This way, we won’t come back after a year and say we need to change everything again and disrupt your lives because the trend has changed," Garman says. "We’re constantly looking at it now and making the adjustments as they come up."

Be patient and listen.

From a personal standpoint, Garman says he as a manager has had to learn to keep quiet. "I’m the facilitator," Garman says. "I don’t give my opinion. This is not an abdication of responsibility. It’s giving more to the staff. Empowering them and getting them to be accountable."