Flexibility, cross-training help managers solve the hiring game

Is your staff working too hard -- or hardly working?

It's 8 a.m., the turnover is brisk, and the OR is loaded with patients and cases. It's so busy, you wonder how you can continue to function without hiring more staff. Before you know it, it's early afternoon, and just as suddenly, the OR thins out. The once frenetic pace has slowed to a crawl. Staff members are standing around like they have nothing to do.

If fluctuation in same-day surgery volume is inevitable, so is the search for staffing solutions. Same-day surgery managers need the flexibility to accept cases at peak periods, but you can't afford to be overstaffed during the lulls.

Same-Day Surgery interviewed SDS managers and consultants who have solved that staffing dilemma. They offer advice on how to make sure you have quality staff -- when you need them.

At Southwest General Health Center in Middleburg Heights, OH, where case volume has increased steadily, a supplemental staff program has helped ease the burden of overworked full-timers. Judy Paukovits, RN, clinical manager of surgical services, created 20 positions and gave them each the status of one-tenth of a full-time equivalent (FTE) position.

Paukovits then advertised in the local paper for OR nurses and techs with three to five years experience and at least Basic Cardiac Life Support (BCLS) training. Post-anesthesia care unit (PACU) nurses must have Advanced Cardiac Life Support (ACLS) training. Many of the nurses come from a nearby community hospital and have 10 years of experience or more.

Supplemental staff works peak days

Some of these supplemental staff have committed to working peak days on a regular basis. At the beginning of each month, Paukovits reviews case bookings and schedules other supplemental employees. These staffers receive the high end of their salary scale but no benefits, she says.

"I don't know how we would have survived without this," says Paukovits, noting that her OR schedules cases during evening hours and weekends and never turns away physicians and their cases. "The staff just had to keep working harder and harder to keep up with the volume."

When supplemental staff are hired, they complete a skills inventory checklist, assessing their skill level in various specialties, from zero (no experience) to three (high proficiency). As many as 10 days are set aside for orientation, but few people need that much time, says Holly Klinger, RN, preceptor in surgical services.

After learning about general hospital information and policies, nurses and techs are paired with another scrub or circulating nurse in a "buddy" system. "Our supplemental staff people assimilated quite well," Klinger says.

The supplemental staff also receive the same education and training as regular staff, including inservice seminars and quarterly competency tests, Paukovits says.

The physicians readily accepted the supplemental staff, particularly since many of them had worked together in another hospital, Klinger says. Klinger and Paukovits are also sensitive to the feelings of their permanent staff when they make assignments.

"We have to make sure we utilize the supplemental staff to their fullest extent," says Klinger. "If the full-time people who are working gangbusters continue to work a heavy load and the supplemental staff come in and get the 'easy room' over and over, there's some resentment."

Instead, supplemental staff give the permanent personnel some relief, she says. The program has allowed Southwest General to cut down on overtime, maintain flexibility, and avoid hiring full-time personnel.

Block time allows for better planning

Block time for physicians and flextime for staff helps Grant Medical Center in Columbus, OH, manage staffing needs.

Physicians select blocks of 7:30 a.m. to noon or 12:30 p.m. to 5 p.m. Unscheduled time is released from the blocks two weeks before the surgery date and available for scheduling by other physicians. Cheryl Sangermano, RN, CNOR, CNA, manager of the surgery center, OR, and PACU, then can determine whether she will need to hire contingent personnel for a heavy load or offer voluntary time off to her staff because of a lighter schedule.

"I staff for the minimum of what the OR would need on a daily basis," she says. "Depending on what the caseload is, I would use contingent personnel to handle those particular days that are extremely heavy."

Sangermano has hired five experienced OR nurses who are interested in working on an as-needed basis. Several of them are former full-time workers who wanted to cut back their work but maintain enough hours to keep up their OR skills, Sangermano says. They are not guaranteed a minimum number of hours, but Sangermano tries to give them at least a week's notice of when they are needed.

Sangermano uses flextime and contingent personnel to help handle the busy morning and early afternoon hours. All regular nurses and techs begin their day at 7 a.m., but their workdays are staggered. Some leave at 3 p.m., some leave at 5 p.m., and one nurse works a 12-hour shift, leaving at 7 p.m. Contingent personnel are hired to assist from 10 a.m. to 2 p.m.

"That gives me some flexibility and helps me to be better able to manage staffing patterns and keep within budget," Sangermano says.

Every year, she analyzes the utilization of her ORs and determines whether her staffing level generally has matched her needs. Sangermano makes adjustments accordingly, either adding or cutting positions.

"Planning is a real important component [of proper staffing]," she says. "In this day of cost containment, you're looked down upon if you have an overabundance of staff."

Cross-training creates flexible staff

Cross-training has become a key aspect of flexible staffing for many same-day surgery managers. Sangermano is assessing the competencies of her RNs and providing inservice educational programs to expand their skills, such as in dealing with aseptic technique and opening sterile supplies.

At Grant Medical Center, PACU nurses help monitor patients in the OR. When necessary, OR techs help with room turnover.

Be careful with cross-training

While cross-training is vital to the OR, same-day surgery managers must be careful how they implement it, says Michael Ryan, RN, MBA, vice president of D.J. Sullivan & Associates, a surgical services management consulting firm based in Ann Arbor, MI.

"Too often we identify a lot of non-professional tasks, and we will delegate those to professional people," Ryan says. "We have to be careful of what we cross-train people to do and how many nurses we actually need in a surgery center doing that [work]."

"A lot of surgery centers take the position that 'if I have all RNs, I have more flexibility than with a mixture of staff,'" Ryan says. "That's not always the case. You may be causing frustration for nurses who are not doing patient care for a full eight hours, and you could have handled those tasks with a lower paid employee."

Same-day surgery managers should conduct at least annual evaluations of all per diem staff to make sure they have maintained their skill level, he says. Managers also should develop a system for communicating information and policy changes to this variable staff group. For example, same-day surgery managers may want to create a reference notebook that includes all memos. A newsletter or electronic mail on the center's computer system are other ways to provide information.

* Make permanent staffing adjustments as needed.

If you are overstaffed on occasion, you may give your staff time off without pay. But Ryan advises same-day surgery managers to do that judiciously.

"If you're going to have to send people home early, you're going to have to be fair and equitable, and everyone has to do their fair turn," he says.

Some people may become frustrated if they aren't getting enough hours, and they may look for another job, Ryan says. "You have to at least meet the minimum expectations of the individual for what they were hired to do," he says.

Same-day surgery managers may make better use of their staff by implementing flextime, with some employees starting earlier and others later. If someone leaves, managers often hold off before hiring a replacement to see if they can function with fewer full-time equivalent employees (FTEs), he says.

If you are consistently overstaffed, you may discover that some full-time staffers would prefer to work part time, Ryan says. "There needs to be open dialogue with the staff about some of the concerns and how we can manage," he says. *