Rising Above the Bottom Line...In health care, rising costs over time hav e outpaced any gains made...

InternationalGlobal Centre for Nursing Executives

research consultingtechnology

Rising Above the Bottom Line

Nurse-led opportunities to achieve sustainable cost savings

Look inside for 11 proven strategies for labour savings, including:

• Creating accurate targets

• Precisely matching staffing to predicted demand

• Embedding flexibility to respond to unpredictable mismatches

• Leveraging the skills and training of every member of the care team

TOPIC

LEARN HOW TO

• Identify top opportunities for labour savings without cutting personnel

• Set targets that match staffing to predicted demand

• Reduce premium labour use

• Ensure maximum value in care team hours

Nursing productivity

READING TIME

2 hr.

BEST FOR

Nurse executives and other members of the executive team

research technology consulting


Nurse-led opportunities to achieve sustainable cost savings

InternationalGlobal Centre for Nursing Executives

©2016 Advisory Board • All Rights Reserved • 34059 advisory.com2

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Global Centre for Nursing Executives

Project DirectorsMarguerite Baty Lucea, PhD, MPH, RNVanessa Orco-Zerpa, MPP

Contributing ConsultantsSara Teixeira MoerhleAriel ShahKarl Frederick Meyer Whitemarsh

Managing DirectorKatherine Virkstis, ND

Executive DirectorAndrew Rosen, MBA

Design ConsultantJoy Drakes


Table of Contents

Advisors to Our Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Move from Insight to Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Introduction: Health Care’s “Cost Disease” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Section 1: Establish Safe, Cost-Effective Staffing Targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Opportunity: Accurately Project Patient Demand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Opportunity: Set Goals Based on Unit-Level Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Section 2: More Precisely Match Staffing to Predicted Demand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Opportunity: Equip Managers to Schedule Appropriate Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Practice 1: Tiered Scheduling Responsibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Practice 2: Skill Mix Tagging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Opportunity: Avoid Preventable Scheduling Overlap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Practice 3: Flexible Shift Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Practice 4: Patient Placement Algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Section 3: Embed Flexibility to Respond to Unexpected Mismatches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Opportunity: Calibrate Daily Staffing Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Practice 5: Real-Time Staff Target Tracking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58Opportunity: Improve In-House Alternatives to Premium Labour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63Practice 6: Cross-Subsidised Float Pool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65Practice 7: “Floater” Support System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Section 4: Fully Leverage the Skills and Training of Each Care Team Member . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71Opportunity: Optimise Skill Mix Based on Unit-Level Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76Practice 8: Unit-Level Modelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Opportunity: Better Utilise Support Staff to Fully Leverage RNs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79Practice 9: Evidence-Based Sitter Algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80Practice 10: Specialised PCA Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Opportunity: Reinforce Top-of-License Prioritisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Practice 11: Customised Care Teams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90


Advisors to Our Work

With Sincere AppreciationThe Global Centre for Nursing Executives’ research team is sincerely grateful to those who shared their insights, analyses, and time with us. We would especially like to recognisethe following organisations for being particularly generous with their time and expertise, helping to shape our research.

AUSTRALIABarwon HealthLucy Cuddihy

Darling Downs Hospital and Health ServiceRobyn Henderson

Monash HealthCheyne Chalmers

Princess Alexandra HospitalSean BirganVeronica Casey

Sir Charles Gairdner and Osborne Park Health Care GroupAnthony Dolan

BELGIUMUniversitair ZiekenhuisAntwerpenPaul Van Aken

CANADAAdvisory BoardRhonda Seidman-Carlson

Centre Hospitalier Universitaire de QuébecJosée GuillemetteLucie LévesqueBrigitte Martel

Children's Hospital of Eastern OntarioMorgan Cunningham-FetchMegan WrightHelen Yoxon

Health Sciences NorthDavid McNeil

Michael Garron HospitalIrene AndressSarah Coppinger

Southlake Regional Health CentreAnnette Jones

St. Joseph's Healthcare (Hamilton)Winnie Doyle

St. Joseph's Health Centre (Toronto)Jenni Glad Timmons

ENGLANDEast Sussex Healthcare NHS TrustAngela Colosi

The Royal WolverhamptonHospitals NHS TrustCheryl Etches

IRELANDMayo General HospitalCatherine Donohoe

JERSEYStates of Jersey Health and Social ServicesJulie GarbuttGary KynmanRose NaylorJason Turner

NETHERLANDSZGT AlmeloOlga BoutensAgnes Maas

NORWAYSykehuset ØstfoldAnne-Karine Østbye Roos

SAUDI ARABIA Johns Hopkins Aramco Health CareZeina Khouri-Stevens

King Faisal Specialist Hospital and Research CentreSandy Lovering

UNITED STATESCleveland Clinic HospitalMeg DuffyJeffrey KnoppAngie Walden

Inova Health SystemTheresa DryeMaureen Swick


Executive Summary

Health Care’s “Cost Disease”In health care, rising costs over time have outpaced any gains made in productivity. This concept, called a “cost disease” has led to unprecedented cost pressure. Rising salaries, increasing patient volumes and complexity, and demand for new technologies contribute to a steady growth in health care costs—and budgets are not keeping pace.

The Danger in Cutting Nursing PersonnelIt is no surprise that when health system boards examine their expenditures to find short- to medium-term savings, the nursing labour budget is a common target. Yet, nursing leaders understand the risks that cutting nursing positions has on quality and safety. Evidence shows that hospitals cutting costs through layoffs or by eliminating nursing positions are more likely to see increased mortality rates. Therefore, nursing leaders must find quality-conscious answers to the cost-cutting mandate.

Reducing Labour Costs Without Eliminating Nursing PersonnelResearch from the Global Centre for Nursing Executives indicates there is a path to cutting labour costs without cutting personnel. This study provides nurse leaders with a manual for reducing costs while safeguarding full-time staff. It includes 11 best practices that can help leaders overcome the following challenges:

• Failing to Use Accurate Targets• Missing Predictable Targets on a Daily Basis• Relying on Premium Labour to Meet Unpredictable Demand• Deploying “Expensive Hands” to Do Inexpensive Work


Adapt and Implement Proven Practices with Help from Global Centre Tool Suites Move from Insight to Action

This study contains global best practices for nurse-led cost savings. Leaders at the profiled organisationshave successfully found cost savings through improving staffing productivity.

In addition, the Global Centre for Nursing Executives has a suite of tools designed to help nursing leaders implement the practices profiled in this study.

Understand Innovative,

Proven Approaches

Pinpoint Improvement Opportunities

Enfranchise and

Equip Key Stakeholders

Accelerate Implementation

Evaluateand Revise Action Plan

Introducing Our Rising Above the Bottom Line Virtual Tool Suite

TRANSFORMING INSIGHTS INTO ACTION

Nurse Executive Guidance To provide recommendations and formulas for determining appropriate staffing metrics

Example Job Descriptions To assist leaders in introducing new or revising preexisting roles to tailor skill mix to unit needs

Customisable TemplatesTo adapt tools when implementing practices that meet unique organisation needs

Recommended Literature GuidesTo utilise related research and resources available

Cost Savings Calculators To help managers and executives measure potential and actual labourcost savings

Customisable DashboardsTo help managers track unit-level staffing data in real time

2More Precisely Match Staffing to Predicted Demand

3Embed Flexibility to Respond to Unexpected Mismatches

4Fully Leverage the Skills and Training of Each Care Team Member

Establish Safe, Cost-Effective Staffing Targets

1

Access the Rising Above the Bottom Line Virtual Tool Suite at advisory.com/gcne/ costsavingstoolkit


►Health Care’s “Cost Disease”

Introduction


Health Care’s “Cost Disease”

Ironically, the health care industry suffers from a “cost disease,” and it is one of the biggest challenges health care executives are facing today.

The “cost disease” is a concept developed by economist William Baumol. It states that in labour-intensive industries that rely on human interaction and activities, costs rise over time and widely outpace any gains in productivity.

This is in contrast to other industries, in which both productivity gains and cost reductions occur through innovation and automation. For example, by allowing workers to stay in one place, assembly lines in car manufacturing have cut the time required to build a car from 12 hours to less than two.

But, in service-oriented, labour-intensive industries such as education, performing arts, and health care, it is much more difficult to achieve these gains. While some things have been automated (i.e., electronic health records), the majority of health care delivery activities cannot be automated or sped up. As the wages of health care workers rise over time, so does the cost of providing care.

Source: Baumol WJ, The Cost Disease: Why Computers Get Cheaper and Health Care Doesn't, New Haven: Yale University Press, 2012; “An Incurable Disease.” The Economist. 29 September 2012, http://www.economist.com/node/21563714; Advisory Board interviews and analysis.

In the personal services industries [like health care] …automation is not always possible, and labor-saving productivity improvements occur at a rate well below average for the economy…

Employers in [these] sectors face a problem: they need to increase their wages so workers don’t defect. The result is that, although output per worker rises only slowly or not at all, wages go up as fast as they do in the rest of the economy.”

Baumol WJ, The Cost Disease: Why Computers Get Cheaper and Health Care Doesn’t


Multiple Factors Increase the Pressure from “Cost Disease”

Organisations Face Growing Pressure to Find SavingsIn addition to rising salaries, other forces contribute to the rise in health care costs.

As shown here, patient volume is increasing, and those patients are also older, sicker, and more complex. At the same time, new technologies create demand for more expensive services.

These trends show no signs of abating. Health care executives are faced with a “new normal” that must eventually be addressed through a full transformation of their care delivery model. However, such a universal transformation will take years. In the meantime, leaders must find savings to sustain hospital operations.

The question is: where can organisations look for savings?

Source: Advisory Board interviews and analysis.

Static or Decreasing Budgets, Ballooning Costs “We say we will reinvest sometimes, but the reality is [we are] just surviving because the pressure of the budget cuts is so high that we struggle to make it at the end of the year. Last year nothing came back for example, and that is just the reality.”

Director of Nursing, Canadian public hospital

Mon

ey

Time

Cost Versus Payer Budget Over Time

Example payer spending on health care

Cost required to deliver safe care

Budgetary gap and margin pressures increasing2015

2020

2025

Pressures Increasing Health Care Costs

Wages

Patient volume

Patient complexity

Technology


Nursing Labour Seen as Easy Target in Cost Cutting

When health system boards examine their expenditures to find short- to medium-term savings, the nursing budget is a common starting point.

This is not surprising, since nursing costs account for approximately 40% of all hospital costs. Of those, an average of 70% are typically comprised of labour costs.

As a result, nurse executives face increasing pressure to cut costs from the nursing budget. To avoid making personnel cuts, many nurse leaders begin by pursuing opportunities for non-labour savings, such as reducing supply waste and revising outdated care protocols.

The Global Centre for Nursing Executives’ briefing Untapped Opportunities for Saving Millions outlines these near-term, non-labourcost savings opportunities.

Source: Simoens S, et al., “Tackling Nurse Shortages in OECD Countries,” OECD Health Working Papers, 2005; Advisory Board interviews and analysis.

1) Organisation for Economic Co-operation and Development.2) Average proportion of budget, based on Advisory Board interviews; range from 50-90; n=20.

Non-labourLabour

Estimated Total Hospital Expenditure in OECD1 Countries

Labour as a Percentage of Nursing Budgets2

40% Nursing Costs

Other Costs

70%

“The challenge is that with nursing being the largest workforce, whenever you are sitting in a room with your operations or financial executives, they always look straight to that workforce.” Nursing executive, Australian public hospital

FOR MORE RESOURCES Consult the Global Centre’s research brief Untapped Opportunities for Savings Millions to learn about the four ripest operational cost-cutting strategies.

• Premium Labour

• Unfavourable Contract Terms

• Outdated Care Protocols

• SupplyWaste


The Danger in Cutting Nursing Personnel

Cutting Costs Through Layoffs Impacts Patient OutcomesThe reason nurse executives typically aim to exhaust all non-labour cost savings opportunities before cutting personnel from the nursing budget is shown here.

Research has shown that cutting costs through layoffs or by eliminating nursing positions has a negative impact on care quality and safety. Hospitals making large cuts to nursing labour are twice as likely to see a significant increase in patient mortality. Moreover, each additional patient a nurse is assigned increases the likelihood of that patient dying within 30 days of admission by 7%.

Many nurse leaders are now finding themselves with no clear path forward. They must prioritise patient safety, while receiving pressure to cut costs from the nursing labour budget.

Source: Aiken LH, et al., “Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States,” BMJ (2012); Ford S, “More than seven patients per nurse risks missing vital care,” Nursing Times, 29 July 2013; Aiken LH, et al., “Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study,” The Lancet, (February 2014); Murphy M, et al., “Cutting healthcare costs through work force reductions,” Healthcare Financial Management, 1996, 50(7): 64-9; Advisory Board interviews and analysis.

1) Based on survey of 26,516 nurses in nine European countries.

The Need to Think Differently“People are living longer, growing older, with more comorbidities—basically more demand. And we can’t meet that demand in terms of RN workforce...It’s impossible to think we can carry on the status quo in these times of change.”

Nursing executive, NHS Trust

Impact of Insufficient Staffing on Patient Outcomes

Impact of Nurse-to-Patient Ratio on Mortality

7%Percentage by which each additional patient per nurse increased the likelihood of patient dying within 30 days of admission1

Mortality Before and After RN Layoffs

2xLikelihood that hospitals cutting ≥4% of RN workforce see a statistically significant increase in mortality


Using a “Scalpel” Instead of an “Axe” to Cut Labour Costs

Finding Savings in Nursing Labour Without Cutting PeopleResearch from the Global Centre for Nursing Executives indicates there is a path to cutting costs from the nursing labour budget without cutting personnel or eliminating nursing positions.

Rather than “using an axe” to cut personnel or whole nursing positions, the Global Centre recommends examining the underlying drivers of productivity for opportunities to “use a scalpel” instead. Put another way, nurse executives can make more precise, proactive staffing adjustments by addressing key inefficiencies. The primary drivers of labour costs are the total number of nursing care hours delivered per day and the cost of each worked hour. Several costly inefficiencies exist within each of those drivers, some of which are highlighted here.

By using a “scalpel” rather than an “axe,” nurse executives can ensure that deployed care hours match actual patient demand as closely as possible.

Source: Advisory Board interviews and analysis. 1) Hours per patient day.

× =

Primary Drivers of Labour Expense

Hours per Patient Day

Cost per Worked Hour

Sample Inefficiencies

Inappropriate skill mix distribution

Overreliance on agency staff

Non-adjustable RNto patient ratios

No daily monitoring of HPPD1 targets

Unexpected alterations in patient census

Excess use of overtime

Hours per Patient Day

Costs per Worked Hour

Total Costs per Patient Day


Mismatches Between Staffing and Patient Demand Result in Avoidable Waste

In order to make more precise, proactive staffing adjustments, nurse leaders should begin by examining the typical census fluctuations on a given day. Although patient demand changes frequently throughout the day, many health care organisations do not adequately account for this fluctuation when setting their staffing patterns.

The typical approach to unit staffing is to use the average daily census (ADC) to determine staffing needs. This approach fails to account for even predictable census peaks and valleys. As a result, leaders often encounter the costly mismatches shown here.

First, if units have too few staff, managers must resort to expensive premium labour to meet patient needs—often agency and overtime.

Second, if units have too many staff for the current census, they are paying for more hours of staff than needed.

Finally, if units have the wrong staff mix, they may be overpaying for each worked hour, or “using expensive hands to do inexpensive work.”

Source: Advisory Board interviews and analysis. 1) Average daily census.

Pat

ient

Cen

sus

Time

Too Few StaffPatient levels above average daily census require calling in expensive labour or running understaffed

ADC

Actual Census Fluctuations Across Time

Too Many StaffPatient levels below average daily census require flexing down or paying staff not needed to meet care demands

Wrong Staff Failure to match level of staff to patient acuity creates unnecessary costs, employing expensive hands to do inexpensive work

Results of Staffing to Annual Average Daily Census

Many organisationscurrently staff to ADC1


Quantifying the Savings Opportunity in Matching Supply to Demand

By more closely matching staffing to demand, nurse leaders can achieve meaningful labour cost savings.

An Advisory Board study analyseddaily productivity volumes on all units in a 55-hospital cohort. Findings showed that the average 300-bed hospital could save $US 2.4 million by better matching staffing hours to patient demand. The total savings were from three key areas: agency use, overtime use, and being over target.

Source: Carter P, “Operational Productivity and Performance in English NHS Acute Hospitals: Unwarranted Variations,” 2016, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499229/Operational_productivity_A.pdf; Nursing Compass, 2008-2009 Cohort Data, The Advisory Board Company; Advisory Board interviews and analysis.1) US dollars.

Small Changes Can Mean Big Savings

“When you consider just 1% improvement in workforce productivity could represent around £400M in savings, it is easy to see why a stronger grip on workforce management can make a significant difference to costs.”

Carter P, Operational Productivity and Performance

in English NHS Acute Hospitals: Unwarranted Variations

2.4M

517K

637K

1.25M

Total Agency Overtime Over Target

Average Annual Savings Opportunity by Area of Spend1

Scaled to Typical 300-Bed Hospital

Too Many or Wrong StaffOver target, spending more than necessary

Too Few Staff:Calling in expensive labour through overtime and agency

Too Few StaffCalling in expensive labour through agency and overtime

Study in Brief: Advisory Board’s Productivity Savings Model Methodology

• Advisory Board’s Nursing Compass: Proprietary Advisory Board analytic platform that monitors workforce productivity; availability limited to US-based organisations

• Study Time Frame: Data pulled from April 2008 to December 2009• Data Selection: 55 hospitals evaluated in six-month period • RN Only: Due to wide variety in existence of nursing assistants and other care providers on units, model

reflects only RN labour costs• HPPD Targets: Over target cost calculated using institution-specific HPPD targets; calculation made on day-

by-day basis, so any target adjustments reflected accurately• Census Metrics: Model tracked census as determined by each institution, with some using midnight census

and some using more frequent census measures• Premium Costs: Overtime, contract hours tracked directly by Compass; cost above non-premium staff

determined using hospital’s mean RN hourly wage• Scaling: Total savings opportunity for hospitals calculated as percentage of internal RN labour costs; also

scaled to typical 300-bed facility, assuming 85% average occupancy rate


Precisely Matching Staffing to Demand Is No Simple Feat

There are four common pitfalls which result in overspending on care hours.

The first is using inaccurate staffing targets that do not reflect unit needs, or failing to use staffing targets at all.

The second pitfall is over- or under-shooting predicted staffing targets on a daily basis, which can add up to sizeable waste.

The third is relying on premium labourto manage unpredictable demand fluctuations.

The fourth pitfall is deploying licensed personnel to carry out work that can be accomplished by support staff in a more cost-effective, but equally safe manner.


Four Common Pitfalls

Overspending on each care hour when using licensed personnel to perform support-level activities (e.g., searching for supplies, cleaning a spill)

Deploying “Expensive Hands” to Do Inexpensive Work

Costly to use overtime and agency to manage unpredictable demand fluctuations

Relying on Premium Labour to Meet Unpredictable Demand

Over-shooting or under-shooting staffing levels on a daily basis adds up to sizeable waste

Missing Predictable Targets on a Daily Basis

Current targets not granular enough, do not account for variations in volumes and acuity

Failing to Use Accurate Targets



To help nurse leaders avoid the four pitfalls shown on the previous page and take a more proactive role in budgetary decisions, the Global Centre for Nursing Executives has developed the strategic framework shown here.

First, nursing leaders must develop accurate, cost-effective staffing targets that reflect patient demand and unit needs.

Second, leaders must equip managers to more precisely match staffing to predicted demand by addressing both scheduling overlap and scheduling complexity.

Third, leaders must reduce reliance on premium labour by embedding flexibility into their organisation’sworkforce.

Fourth, leaders must ensure every caregiver is working at the highest level of his or her training or preparation.

The remainder of this report provides best practices for achieving these aims.


2More Precisely Match Staffing to Predicted Demand

Equip Managers to Schedule Appropriate Staff

Avoid Preventable Scheduling Overlap

3. Flexible Shift Patterns

4. Patient Placement Algorithm

1. Tiered Scheduling Responsibility

2. Skill Mix Tagging

3Embed Flexibility to Respond to Unexpected Mismatches

Calibrate Daily Staffing Levels

Improve In-House Alternatives to Premium Labour

5. Real-Time Staff Target Tracking

6. Cross-SubsidisedFloat Pool

7. “Floater” Support System

Optimise Skill Mix Based on Unit-Level Needs

4Fully Leverage the Skills and Training of Each Care Team Member

Better Utilise Support Staff to Fully Leverage RNs

Reinforce Top-of-License Prioritisation

11. Customised Care Teams

8. Unit-Level Modelling

9. Evidence-Based Sitter Algorithm

10. Specialised PCA Roles

Establish Safe, Cost-Effective Staffing Targets

1

Accurately Project Patient Demand

Set Goals Based on Unit-Level Needs

Best Practices for Achieving Sustainable Cost Savings


1

►Establish Safe, Cost-Effective Staffing Targets

Section

• Accurately Project Patient Demand

• Set Goals Based on Unit-Level Needs


Setting Safe Targets Requires Striking a Balance

Weighing the Benefits and Costs of Adding Additional NursesDeveloping staffing targets in health care’s current financial reality is essential, but it requires a careful balance to enable delivery of quality care at lower costs.

While richer nurse to patient ratios may support high-quality care, each additional nurse added to the roster has an associated cost.

By setting staffing targets that accurately reflect unit realities, managers can predict how much nursing care will be required to meet the needs of patients safely and effectively. The best targets effectively balance quality and cost by accurately matching staffing to demand.

Source: Sochalski J, “Is More Better: The Relationship Between Nurse Staffing and Quality Care in Hospitals,” Med Care, 42, no. 2 (2004): ii67- ii73; “Nurses in the United States Earn 8 Times More than in Russia,” Pay Wizard, http://www.paywizard.org/main/salary/global-wage-comparison; “Overview of Key Nursing Contract Provisions,” Canadian Federation of Nurses Union, 31 October 2015; "What Do Nurses Earn?" Health Times, http://healthtimes.com.au/hub/nursing-careers/6/guidance/nc1/what-do-nurses-earn/605/; Advisory Board interviews and analysis.

1) Quality of nursing care measured by the item “In general, how would you describe the quality of nursing care delivered to patients on your unit on your last shift?” with a 4-category response (poor, fair, good, excellent). Mean quality scores were derived from summing the responses of nurses with similar patient ratios and dividing by number of nurses with that patient ratio. Mean quality scores ranged form a low of 2.7 for 1:10 to a high of 3.9 for a 1:1 ratio.

2) Salaries listed in US dollars and adjusted by purchasing power parity. 3) In US dollars.

Mean Quality Scores1 Based on RN-to-Patient Ratios

2.7 2.8

2.9 3.0

3.1 3.2

1:10 1:9 1:8 1:7 1:6 1:5

Average RN Hourly Salaries in Select European Countries2

$22.08NETHERLANDS

$19.17GERMANY

$13.64FINLAND

$16.79BELGIUM

Increased Quality with Lower Ratios Increased Cost with More RNs

If money was no object, I could pick all RNs to provide care because their scope is all-encompassing…but unfortunately none of us live in an environment where we have an endless supply of resources. You do have to make some choices.”

Chief Nursing and Health Professions Officer, Canadian public hospital

RN-to-Patient Ratios $27.76BRITISH COLUMBIA

$24.60QUEBEC

$28.42ONTARIO

$30.40SASKATCHEWAN

Average RN Hourly Salaries in Select Canadian Provinces3

Average RN Hourly Salaries in Select Australian States3

$22.78VICTORIA

$26.01NEW SOUTH WALES

$26.13QUEENSLAND

$26.92WESTERN AUSTRALIA


No Gold Standard for Targets

Variation in Target RN-to-Patient Ratios Signals Lack of Clear DirectionThere is no global consensus on optimal staffing targets. International research examining medical and surgical units shows wide variability in average staffing levels.

In an effort to create consistency across health care systems, some regions have legislated nurse-to-patient ratios. Ratios are helpful guidelines, but they are not sufficient for developing the most accurate workforce projections.

There is no one-size-fits-all solution for staffing projections. Targets must be specific to each organisation and represent the patient demand of the units.

Source: Aiken L, et al., “Nurse Staffing and Education and Hospital Mortality in Nine European Countries: A Retrospective Observational Study,” The Lancet, 383, (2014) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4035380/; Douglas K, “What Every Nurse Executive Should Know About Staffing And Scheduling Technology Initiatives,” Nursing Economics, 29, no. 5 (2011): 273-275; Advisory Board interviews and analysis.

1) According to surveys conducted in nine European countries as a part of the RN4CAST international study.

10.8

7.6 6.9 7.0 5.2

7.8

Belgium Finland Ireland Netherlands Norway Switzerland

Mean Number of Patients per Nurse in Med/Surg Units in Select European Countries1

Based on Opinion, Not Evidence“Staffing in hospitals has a history of being based in opinion and tradition, not evidence.”

Douglas K, What Every Nurse Executive Should Know About Staffing and Scheduling Technology Initiatives

1 to 5 Mandated daytime nurse to patient ratio in medical/surgical units in California, United States

:1 to 4 Mandated daytime nurse to patient ratio in medical/surgical units in Victoria and Queensland, Australia

:

Examples of Legislated Nurse-to-Patient Ratios


Using Inaccurate Workforce Projections

The Global Centre identified two key challenges that result in managers using inaccurate workforce projections.

The first is using imprecise estimations of patient demand. Many organisationsuse vague metrics to predict their patient census.

The second is using blunt staffing metrics. These limit managers’ ability to proactively make adjustments to match staffing to demand.

The first step in creating more precise staffing targets is to accurately project unit-level patient demand. Then, leaders must set staffing goals based on unit-level needs.

This section presents guidelines to help nursing leaders act on these two opportunities.


Accurately Project Patient Demand

Opportunity

Challenges Imprecise Census EstimationsPatient demand forecasts do not adequately account for predictable fluctuations; foundational metrics for measuring demand fall short

Set Goals Based onUnit-Level Needs

Blunt Metrics and Staffing TargetsBroad staffing metrics prevent granular management of staffing goals; limit ability to precisely match staff to patient demand

Two Key Opportunities to Establish Safe, Cost-Effective Staffing Targets


Blunt Averages Hide Census Peaks and Valleys

Common Metric for Budgeting and Staffing Misses the MarkTo determine how many staff they need, many organisations rely on an annual average daily census (ADC). But this blunt measure does not capture fluctuations in patient demand.

The graphic on the right represents a unit budget that remains static from month to month. The unit almost certainly will not see exactly 20 patients every day, but the budgeted daily or monthly workforce does not reflect census variation. As a result, units will have too many or too few staff as the census fluctuates.


Annual Average Daily Census (ADC)

2016 Nursing Salary BudgetMedical/Surgical Unit

Manager: Alice O’Reilly

Aug Sep Oct Nov Dec

ADC 20 20 20 20 20

Annual number of patients cared for in hospital

Number of days hospital was open

ADC =

Example Nurse Budget Using ADC


Harnessing the Predictable Elements of Patient DemandOpportunity: Accurately Project Patient Demand

Despite variance in patient demand, leaders can identify predictable trends to create more accurate targets. These trends fall into three categories. The first is seasonal fluctuation—times of the year with heavier or lighter patient volumes. Second, there are variations associated with the day of the week. Finally, there are variations by time of day, with peaks and valleys occurring depending on the types of patients seen on the units.

By accounting for predictable variation, nurse leaders can more precisely understand the “demand” side of the supply/demand equation. As shown here, historical, trended data more accurately informs managers’ predicted patient volumes. The adjusted ADC more accurately reflects actual volumes on the unit.


Seasonal Fluctuations

Integrates historical trends of natural peaks and valleys

Day of Week

Incorporates predictable trends in patient volume on a weekly basis

Time of Day

Includes assessment of normal fluctuations throughout the day

Three Kinds of Predictable Variation in Patient Demand

Exemplar Portion of Nursing Unit Budget Using Adjusted Average Daily Census



Aug Sep Oct Nov Dec

Total Volume 180 200 210 195 250

Adjusted ADC 17 20 20 20 28

WintertimeFlu Season

SummertimeLow Volumes

Seasonal Fluctuations to Consider Day of Week Fluctuations to ConsiderSurgeries typically scheduled on Mondays

Higher number of dischargeson Thursdays



Mon Tue Wed Thu Fri

Total Volume 32 28 26 22 25

Adjusted ADC 30 28 24 20 20

Sample Monthly Budgetary Projections Sample Day of Week Budgetary Projections


Completing the Equation to Develop Accurate Targets

Determining Staffing Number and Skill Level Necessary to Meet Demand

Opportunity: Set Goals Based on Unit-Level Needs

The next step in developing accurate targets is determining how many staff will be needed to meet predicted demand.

To do this, leaders should start by determining the right metrics to track. After selecting the right metric, leaders can set specific targets based on unit-level staffing needs.

The following page provides guidance on selecting the right metric.


Matching Nurse Supply to Projected Demand Considerations for Setting Targets

Determine Right Metric to Track

Set Accurate Targets Based on Unit Needs


Manage to Smallest Unit of Measurement

There are a variety of metrics available for projecting staffing needs. As shown here, common nurse staffing metrics include nurse-to-bed ratios and nurse-to-patient ratios. The Global Centre recommends using the most precise staffing metric available. For most organisations, that metric is hours per patient day (HPPD), defined as the total number of direct care hours worked in a day divided by the total number of patients seen that day. HPPD provides the most granular level of data that can assist leaders in determining where to find costs savings.

Source: Advisory Board interviews and analysis.1) Hours per patient day.2) Inclusive of all caregivers, but able to cut by provider type (RN, HCA, etc.).

Common Nurse Staffing Metrics

HPPD1

Nurse-to-Patient Ratio

Hours per Patient Day Formula

HPPD =TOTAL DIRECT CARE HOURS WORKED2

TOTAL PATIENTS PER DAY

Nurse-to-Bed Ratio

More precise metric for measuringstaffing requirements based on demand

Enables leaders to easily assign a costto hours and monitor productivity

Easy to benchmark against like unitsand sites of care

Advantages of Using HPPD Metric

Incr

easi

ngly

Pre

cise


Examine Limitations of HPPD

Although HPPD is the most precise staffing unit of measurement available to most organisations, it has limitations. In order to develop safe, cost-effective targets, leaders must understand these limitations.

Traditional HPPD measures treat all nursing hours equally. Yet, the care provided by an RN is not the same as the care provided by a health care assistant—and neither is the cost.

To address this, the Global Centre recommends examining the types of care providers, their experience, and their skills when using HPPD as a staffing target.

For example, some organisations track RN HPPD separately from HPPD of other nursing staff. The following pages provide further detail about why this additional consideration is important.

Source: Advisory Board interviews and analysis.1) Health care assistant.

RN RN

RN RN

RN RN

HCA1

HCA

Other

Exemplar Limitation of HPPD

Treats All Labour Hours Equally

Representative Differences in Caregiver Preparation

Education RN DiplomaRPN/AN/EN HCA

Experience 2 Years 10 Years 25 Years

Certification PaediatricNursing None None


Understanding the Cost of Each Hour

By understanding the cost of each hour of care delivered, leaders can more accurately predict staffing targets to provide the most appropriate care at the lowest cost.

An example of two units with similar patient demographics is shown here. Both units deliver 7.8 hours of care per patient day, but one unit is delivering that care at a lower cost.


Total Labour Cost per Patient Day

40-Bed Unit A 40-Bed Unit B

Representative Discrepancies Between HPPDand Total Labour Cost per Patient Day

7.8 7.8

HPPD

€195

€214

LABOURCOST PERPATIENT DAY

=TOTAL COST PER HOUR

TOTAL PATIENTS PER DAY

xTOTAL HOURS

Assumptions

• RN pay = €34 per hour

• HCA pay = €13 per hour

• 40-bed unit fully filled

• Total number of staff per 24 hours on unit (13 for Scenario 1; 14 for Scenario 2)

To learn more about calculating labour costs per patient day access the Rising Above the Bottom Line Virtual Tool Suite at advisory.com/gcne/costsavingstoolkit


Best Targets Combine Labour Costs and HPPD

Using Both HPPD and TLCPPD1 Allows Creativity in Care Team DesignWhen possible, the Global Centre recommends analysing labour cost per patient day in conjunction with setting staffing targets.

For illustrative purposes, two scenarios of a medical/surgical unit with a daily volume of 40 patients are shown here.

In scenario 1, the unit has nine RNs and four health care assistants. Collectively, they are delivering 7.8 hours of care per patient. Delivering that care costs €214 per patient day.

In scenario 2, the unit has changed the skill mix. Analysing historical demand, the manager sees the need for additional health care assistants (HCAs). When an RN retires, the manager hires two HCAs and the unit staff can now offer 8.4 hours of care—at a reduced cost of €210.

Although these savings may seem small, they can add up when multiplied over years and across units.


1) Total labour cost per patient day.2) Both scenarios represent a 40-bed Med/Surg unit.

Expected Shift in Total HPPD

7.8

8.4

€214

€210

Scenario 1 Scenario 2

RNs 9 8

HCAs 4 6

Representative Comparison of HPPD and Labour Cost per Patient Day Under Two Staffing Scenarios2

Unit Staffing Scenarios

In scenario 2, the unit added 2 HCAs when an RN retired

Scenario 1 Scenario 2Scenario 1 Scenario 2

Expected Shift in Labour Cost per Patient Day


Questions to Consider

Unit-Specific Characteristics Must Be Considered for HPPD TargetsThe Global Centre recognises that more hours do not universally mean better hours and therefore recommends considering unit characteristics when developing HPPD targets.

Several considerations for customisingHPPD to unit characteristics are shown here. By developing targets that reflect unit-specific needs, leaders can more accurately match staffing to patient demand.


Considerations for Customising HPPD to Unique Unit Characteristics

Staff Skill Mix, Characteristics

• What percentage of RNs, HCAs, and other personnel does the unit have?

• What tasks do RNs perform?

• What is the average age and experience level of unit staff?

Ancillary/Support Services

• Which ancillary and support services are centralised to the unit?

• How many non-nursing clinical services do direct caregivers perform?

• How many non-clinical servicesdo direct caregivers perform?

Patient Population

• What is the average acuity of patients on the unit?

• What is the range of diagnoses on the unit?

• What is the intensity of the work required by the patient population?

Accounting and Operations

• Are managerial, clerical support staff included in HPPD?

• What percentage of time do managers and charge nursesspend in direct patient care?

• What percentage of hours are budgeted for non-productive time (e.g., sick time, vacation time)?

Unit Design

• What percentage of single rooms and semiprivate rooms are on the unit?

• What is the total amount of walking involved for a direct caregiver?

• Does the unit have a central nursing station, a station at one end of the unit, or at both ends?

Length of Stay and Activity

• What is the average length of stay on the unit?

• What is the average number of daily admissions/discharges/transfers?

For more resources on this topic, see our full Towards Evidence-Based Staffing Toolkit at advisory.com/gcne


Combining Metrics for More Accurate Projections

Nursing units can further improve accuracy of staffing targets by examining multiple metrics together, rather than relying on a single metric.

A representative unit-level budget is shown here. The graphic shows adjustments for predictable variation in demand projections, reflected in the adjusted ADC1. These inform variations in unit-level staffing goals, using HPPD as the key metric. As a result, projected FTE requirements match projected patient demand more closely.

Because managers can allocate their FTE allotment more precisely throughout the year, they can avoid unnecessary overages or shortages.


1) Average daily census.2) Based on US calculations.


Volumes

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Total Volume 260 241 377 409 320 369 298 323 303 314 299 319

AdjustedADC1 8.4 8.7 12.2 13.2 11.4 11.9 9.9 10.4 10.1 9.6 10.6 10.6

Direct Care Hours

HPPD 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8

Direct Hours Required

2028 2036 2941 3190 2496 2878 2326 2519 2363 2449 2332 2488

Direct FTEs Required

11.5 11.9 16.6 18.1 15.6 16.3 13.6 14.3 13.8 13.9 13.2 14.6

Direct hours and direct FTEs required varies depending on patient volume

Example Nursing Salary Budget Using HPPD Targets2

Different ADC used for each month based on volume; projections adjusted each month as needed


2

►More Precisely Match Staffing to Predicted Demand

Section

• Practice 1: Tiered Scheduling Responsibility

• Practice 2: Skill Mix Tagging

• Practice 3: Flexible Shift Patterns

• Practice 4: Patient Placement Algorithm


Targets Necessary but Not Sufficient

Majority of Organisations Routinely Missing Specified Staffing TargetsWhile setting targets is an important first step, it is equally important to match targets with the right number of staffed hours. Yet, the majority of leaders report missing staffing targets on a daily basis.

The graphics here show how frequently leaders report missing staffing targets. As shown on the left, managers in the United States report missing daily targets by more than 5% nearly three quarters of the time, and by more than 10% almost half the time. On the right, nearly 80% of leaders in English hospitals report missing their staffing targets, during both day and night shifts.

These small discrepancies on each unit, each day, represent sizeable savings opportunities when tallied up over the entire organisation for a whole year.

Source: Lintern S, “Four Out of Five Hospitals Miss Own Nurse Staffing Targets”, Nursing Times, 21 April 2015, http://www.nursingtimes.net/roles/nurse-managers/four-out-of-five-hospitals-miss-own-nurse-staffing-targets/5084342.fullarticle; Advisory Board interviews and analysis.

Percentage of Days Within Specified Range of Worked HPPD Targetn=10,062

19%

7%

8%

5%

11%

14%

36%

Over Target > 10%

Over Target 5%-10%

Within 1% of Target

Under Target 5%-10%

Under Target > 10%

Over Target 1%-5%

Under Target 1%-5%

Percentage of English Hospitals Missing Safe Staffing Targets

85%For nurses working in the daytime

67%For nurses working at night

Percentage of English Hospitals Missing Day or Night Shift Targets

0%

100%

80%


Missing Predictable Targets on a Daily Basis

The Global Centre identified two key challenges that result in managers missing predictable targets on a daily basis.

First, unit schedules and rosters are extremely complex. Managers must rely on their knowledge of the team to create unit rosters—often without much input from staff themselves.

Secondly, the rigidity of traditional scheduling methods hinders managers’ ability to anticipate and match typical variations in patient demand.

To address these challenges, leaders must first equip managers to schedule appropriate staff. Then, they must avoid preventable scheduling overlap.

The first two practices in this section help leaders advance on the first opportunity: equip managers to schedule appropriate staff.

The last two practices in this section help leaders improve on the second opportunity: avoid preventable scheduling overlap.


Two Key Opportunities to More Precisely Match Staffing to Predictable Demand

Rigid Scheduling StructuresTraditional shift length and start times misaligned with real-time fluctuations in patient volumes, resulting in costly excess staffing

Inherent Scheduling ComplexitySchedules created with limited staff input and without sufficient accommodation of tenure and skill mix lead to unnecessary spending

Avoid Preventable Scheduling Overlap

Equip Managers to Schedule Appropriate Staff

Opportunity

Challenges


A Burden for Managers, a Frustration for Staff

Complex Schedules Fail to Account for Staff Preferences

Opportunity: Equip Managers to Schedule Appropriate Staff

Most commonly, unit managers shoulder the responsibility of developing their units’ schedules. Building these schedules is highly complex, accounting for factors such as patient flow, skill mix, leave schedules, and staffing targets. The managers must often rely heavily on their knowledge of the teams to accommodate their units’ needs.

Yet, these schedules often fail to account for staff preferences. The perception of unfair schedules can lead to nurse dissatisfaction and staff disengagement. In turn, lagging engagement can lead to unexpected vacancies. As shown here, scheduling is one of the top reasons for voluntary resignations of frontline nurses.

Source: “The Evidence is Clear: Analytics Key to Controlling Labor Costs,” Healthcare Insights, 2014, http://www.hcillc.com/files/HCI%20Labor%20Prod%20whitepaper_Ri.pdf; Advisory Board interviews and analysis.

Scheduling’s Costly Impact

The Evidence is Clear: Analytics Key to Controlling Labor Costs

“The cost of nurse turnover can have a profound impact on already diminishing hospital margins. Schedulingwas listed among the top five reasons most nursing employees voluntarily resign.”

Position Tour Type FTE Mon Tues Wed

RN (8 hours, 5 days/week) 1.0 7-15h 7-15h 7-15h

HCA (8, 5) 1.0 9-17h 9-17h O

RN (8, 3) 0.6 O O 9-17h

RN (8, 5) 1.0 8-18h 11-19h 11-19h

HCA (8, 3) 0.6 11-19h O 11-19h

Sample Schedule in a Postpartum Unit

Complicating Factors for Scheduling

Budget TargetsSkill Mix

Staff Needs

Patient Flow Absenteeism


Rigid Scheduling Results in Excessive OvertimePractice 1:Tiered Scheduling Responsibility

At Johns Hopkins Aramco Healthcare (JHA) in Dhahran, Saudi Arabia, leaders recognised that nurses were working dangerous levels of overtime—an average of 40 hours of overtime per nurse per month.

Leaders at JHA revisited their rostering practices and identified pervasive unplanned absences as a key root cause of overtime use. Managers struggled to find cost effective coverage, using overtime to cover the high levels of absenteeism.

Source: Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; Advisory Board interviews and analysis.

April 2012

Su Mo Tu We Th Fr Sa

1 2

3 4 5 6 7 8 9

10 11 12 13 14 15 16

17 18 19 20 21 22 23

24 25 26 27 28 29 30

31

Nurses scheduled based on inflexible, recurring shift patterns

Average 40 hours overtime per nurse per month

Inflexible System Leads to Unsustainable Costs“We had the same shifts no matter what the census was. Staff were placed in groups and on a fixed pattern. Changes to the schedule could only be made in emergencies. You couldn’t even remove overtime you didn’t need.”

Zeina Khouri-Stevens, CNOJohns Hopkins Aramco Healthcare

Expected and unexpected leave covered by overtime

Elements of Previous Staffing System

Case in Brief: Johns Hopkins Aramco Healthcare • 263-bed hospital in Saudi Arabia, a joint venture between Saudi Aramco and Johns Hopkins Medicine

• Organisation realised old rigid scheduling model with its excessive use of overtime needed to change

• Piloted self-scheduling with limitations on two units

• After initial success of pilot, tiered self-scheduling strategy rolled out across organisation

• Organisation experienced savings in terms of significant decrease in overtime spend


Tiered Approach to Unit Scheduling

Each Level in Scheduling Process Maximises Its ScopeTo address the challenge of excessive overtime, leaders at JHA introduced a tiered self-scheduling process that includes checks and balances.

There are four steps to this tiered approach, shown here. First, staff members enter their shifts into a master schedule using unit-based guidelines. Second, a unit-based committee reviews the schedule with organisational targets in mind. The committee makes adjustments as needed to ensure that the unit has the right complement of staff on each shift. Third, the manager reviews and approves the schedule and sends to the central staffing office. Finally, the central office tracks daily variations and fills any unforeseen gaps.


Scheduling Committee ReviewsUnit-based scheduling committee, composed of two to three senior staff, adjusts schedules to meet organisational targets and leave coverage before sending schedule to manager for approval

Manager ApprovesManager reviews schedule to ensure scheduling committee did not make any errors; sends schedule to central staffing office

Central Office Fills Unforeseen Gaps Central office ensures staff show up to work, helps coordinate filling gaps that occur on day-to-day basis, such as sick leave

Top-

of-L

icen

se T

iers

Bui

ld E

ffici

ency

Staff Self-SchedulesStaff select shifts for the upcoming schedule eight weeks in advance, using guidelines

Schedule Creation at Johns Hopkins Aramco Healthcare


Setting Parameters for Scheduling Success

To ensure staff members select appropriate shifts, leaders at JHA set clear guidelines for self-scheduling. Any necessary adjustments to the schedules are based on these parameters, which eliminates potential contention of the changes.


Ensure you sign up for one or two weekend shifts

monthly, depending on unit needs

Make sure you assign yourself five to seven

night shifts every month

Double check leave requests with leave allotment for the unit

Confirm everyone has appropriate distribution of nights and weekends

Ensure good mixture of senior and junior nurses per shift

UNIT-SPECIFIC GUIDELINES

STAFF NURSE GUIDELINES

Scheduling Guidelines at Johns Hopkins Aramco Healthcare

Verify your proposed leave time with your

manager before inputting into schedule


Addressing Common Fears About Self-Scheduling

Leaders at JHA recognised that the implementation of self-scheduling would generate questions and concerns from managers and staff. How JHA’s leaders proactively addressed the organisation-wide apprehensions are shown here.

Leaders adopted a two-pronged approach to create a groundswell of support. They first piloted self-scheduling on progressive units to demonstrate success. Next, leaders shared the pilot’s success with the rest of the organisation. Finally, they implemented the process across JHA.

Nursing leaders also addressed managers’ fears of losing control and added work. They developed a series of trainings and sessions to educate managers on the benefits of this practice. They emphasised how the tiered responsibility alleviates manager burden.


Leaders fear free-for-all will ensue if staff are given power to self-schedule

Staff nurses given specific guidelines to follow; transition period eased staff and managers into self-scheduling

Leaders fear gaps in care will occur when staff avoid signing up for unwanted shifts

Unit level guidelines for staff nurses, combined with higher level review ensure appropriate coverage

Employees fear culture shift required to transition to self-scheduling is unachievable

Pilot on two units demonstrates benefits and ease of implementation for both staff and leaders

Nurse unit managers fear less control of schedule and added work filling gaps that staff leave

Manager training highlights proven benefits of self-scheduling for unit leaders

Organisation’s Response Apprehensions

Sample of Apprehensions and Responses to Self-Scheduling


Overtime Decreases with Increased Staff Ownership

Through tiered self-scheduling, staff at JHA feel more ownership of the schedules that reflect staff needs and preferences. Staff report feeling more engaged and having improved work-life balance.

Leaders report saving 16 to 24 hours of overtime per full time employee per month. Additionally, this practice has improved retention and saved on costs associated with turnover.


Saving Money with the New System“We can confirm that what we saved is directly a result of moving to flexible and self-scheduling, which is 16 to 24 hours per month per FTE.”

Zeina Khouri-Stevens, CNOJohns Hopkins Aramco Healthcare

Better Work-Life Balance for Staff“The flexible schedule allows us to adapt our staffing needs for the unit and the individual. We have a greater work-life balance and it has enabled us to get to know all the staff on the unit not just your scheduled group.”

Staff nurse, Johns Hopkins Aramco Healthcare

16-24overtime hours saved per FTE per month in the new tiered self-scheduling model


Unclear Roster Composition Drives High CostsPractice 2: Skill Mix Tagging

Managers inadvertently overspend when scheduling an inappropriate staff mix. Many managers still struggle to find the most cost-effective, safe roster composition for their units

This was apparent to leaders at Ziekenhuisgroep Twente (ZGT) Almelo in the Netherlands. They employ a mix of staff on their units: RNs, health care assistants (HCAs), and hospitality workers. Yet they found that managers did not have a scientific way of determining the right care team composition during each shift.

When nursing leaders closely examined their existing model, they uncovered redundancies in work and confusion about staff responsibilities. Managers were creating flawed schedules with insufficient support for the RNs, using “expensive hands to do inexpensive work.”

Source: Ziekenhuisgroep Twente Almelo, Almelo, Netherlands; Advisory Board interviews and analysis.

Wasted time doing others’ tasks

Redundanciesin work

Confusion about responsibilities

RN

HCA

Hospitality

Unnecessarily highlabour costs

Observed Challenges at Ziekenhuisgroep Twente (ZGT) Almelo

Concern that patients were not getting best care possible

Disconnect Between Nursing Care Team

Observed Challengesin Daily Work

Impact on Patientsand Hospital

Case in Brief: Ziekenhuisgroep Twente (ZGT) Almelo

• Part of the two-hospital Ziekenhuisgroep Twente health system, with a total of 754 beds and 3,200+ employees; ZGT Almelo is located in Almelo, Netherlands

• Leaders at ZGT Almelo redesigned their nursing care team of RNs, HCAs, and hospitality staff to ensure everyone was doing the right work to care for patients

• Goal was to have highly qualified nurses coordinating the care of their patients rather than spending time on tasks that other care team members could safely accomplish

• Using Patricia Benner’s Novice to Expert Framework as inspiration, leaders assessed differentiated roles based on levels of expertise, tagging each person within e-rostering system based on their score


Achieving Clear Role Delineation

Tagging System Ensures the Right People Do the Right WorkFollowing a workplace assessment to understand the current workforce and workload, leaders designed a system to optimise each individual’s contribution to the care team. They developed clear “levels” for staff, with specific criteria and transparent expectations for each level. Examples of specific responsibilities for each level are illustrated here.


RN HCA HospitalityLevel 4:

Level 5:

Level 2 or 31: Level 1:

Examples of Responsibilities Based on Expertise Level

Cleaning rooms and other facilities

Cleaningwounds

Curing/repairingwounds

Washing and dressing patients

Restocking supplies

Transferring patients from one room to another

Updating documentation

Toileting patients

Managingcomplex patients

Managing less complex patients

1) In the Netherlands, Level 3 Health Care Assistants typically work in home care rather than hospitals.


Tagging Ensures Accurate Deployment of Staff

Expertise Level, Unit Needs Are Used to Create SchedulesTeam members receive a “tag” with their level, based on their discipline and expertise. These tags are part of the electronic rostering system. When managers create the unit schedules, they can easily match the unit’s targets with the appropriate “tagged” staff. Additionally, if staff members need to alter shift assignments for personal reasons, they can trade with someone at the same level.

By tagging staff, managers create schedules that more accurately deploy staff to meet patient demand.


Expertise Level Assigned to StaffUnit managers assign each RN, HCA, hospitality staff an expertise level (1-5) during annual performance evaluations

Staff “Tagged” inE-rostering SystemEach individual is tagged within the e-rostering system; information visible to all unit staff

Schedules Created Based on Unit NeedsUnit managers use tags to create schedules, taking unit needs and “scores” into account to ensure accurate skill mix for each shift

Tagging System Used to Fill Gaps as NeededStaff utilise tagging system to find replacement with same expertise level to cover shift as needed

Process for Utilising Tagging System at ZGT Almelo


Positive Impact of Deploying the Right Staff

Leaders at ZGT Almelo report positive outcomes as a result of skill mix tagging. In the two pilot wards, leaders observed a 15% to 20% reduction in labour costs—while maintaining or improving quality metrics, shown here.


Right People Doing Right Work

“The cost savings were achieved through redesigning around patient care needs and letting people do what they are qualified for, not having overqualified people doing simple tasks.”

Olga Boutens, Clinical Programme Director, ZGT Almelo

Improving Staff Satisfaction

“Giving people the responsibilities they deserve makes them feel more satisfied.”

Agnes Maas,Clinical Programme Director, ZGT Almelo

Key Organisation-Wide Results Since 2013

15%-20%Reduction in labourcosts across pilot units

3%Decrease in sick leave among care team

Key quality metrics remained stable throughout pilot


Traditional Scheduling Practices Limit PrecisionOpportunity: Avoid Preventable Scheduling Overlap

The second opportunity in this section is avoiding preventable scheduling overlap. As shown here, well-established staffing patterns in hospitals offer little room for adjustment. Shifts are often either eight or 12 hours in length, with uniform starting times.


Key Limitations of Traditional Scheduling Methods

Shift Length Shift Timing Nurse-to-Patient Adjustments

Day

700-1500

700 1500 2300 700

Evening

1500-2300

Night

2300-700

8-hours

700 1500 2300 700

8-hours 8-hours

12-hours 12-hours

1:5 ratio

1:5 ratio

Traditional shift lengths leave little room to make adjustments for shorter periods of time when more staff is needed

Traditional shift start and end times do not always align with actual times of patient fluctuation

Traditional approach to adjusting number of nurses to patient census results in wasted nursing hours


Scheduling Rigidity Creates Waste Practice 3: Flexible Shift Patterns

Legacy staffing practices can yield incremental waste.

Leaders at Pearson Health1 in the United States found that managers staffed the entire day shift with the number of nurses needed to cover peak census, even though the census fluctuated during predictable times.

The graph here shows the difference between a unit’s actual and ideal staffing patterns.

Source: Sinreich D, Jabali O; “Staggered Work Shifts: a Way to Downsize and Restructure an Emergency Department Workforce Yet Maintain Current Operational Performance,” Health Care Management Science, 10, no.3 (2007): 293-308; Hegwer LR, “Using Predictive modelling to Trim Nurse Staffing Costs,” Healthcare Cost Containment, Healthcare Financial Management Association, (August 2013), https://www.hfma.org/uploadedFiles/Publications/Newsletters/Healthcare_Cost_Containment/ HCC_August.pdf; Advisory Board interviews and analysis.

1) Pseudonym.2) Calculation of nurses needed based upon a 1:6 goal

ratio during the day and a 1:19 goal ratio at night.

1

2

3

4

5

Actual Nurse Numbers Ideal Nurse Numbers

Ideal Versus Actual Nurse Staffing on Inpatient Unit2

Shaded areas represent time when there are more nurses than needed because of inflexible shifts

Time

Nur

sing

Sta

ff on

Uni

tNumber of staff needed to hit target nurse-to-patient ratio

Daily spike in admissions at 11:00

Overstaffed pre-admission

Case in Brief: Pearson Hospital1

• 300-bed hospital located in the United States

• Devised new hospital-wide staffing strategy with staggered shift start times

• In the ED, implemented shorter shifts and flexible staff in addition to staggered start times after forecasting day-of-week and time-of-day volumes

• Strategy saved $110,409 in the Emergency Department and $1.7 million hospital-wide


Inpatient Admission Shift Maximises Staff Resources

Starting Shift at Prime Admission Time Eliminates Traditional WasteTo match admission swells and late afternoon discharges, nursing leaders implemented staggered shift start times on their inpatient units.

The graphic here shows an example of this change. Instead of four nurses scheduled per eight-hour shift, one nurse comes for an eight-hour shift midday to cover the typical surge of admissions. The boxes on the top bar illustrate the resulting time savings.

The midday nurse starts at 11 a.m. and finishes at 7 p.m. This nurse cares for patients admitted during this time, eliminating unnecessary handovers. By 7 p.m., the evening nurses have capacity from afternoon discharges, and the midday nurse hands over her patients to them.


600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 0000

Day Nurse 1

Day Nurse 2

Day Nurse 3

Revised Schedule at Wilson 7 West Medical Surgical

Midday Nurse 4

Evening Nurse 1

Evening Nurse 2

Evening Nurse 3

Night Nurse 1

Night Nurse 2 Night Nurse 2

Night Nurse 1

Day shift handover Evening shift handoverAdmissions

Previously Filled (Wasted Time)

Mid-day shift handover

Previously Filled (Wasted Time)


Staggered Start Times, Differing Shift Lengths Match ED Churn

Additional Flexibility Creates Efficiency in Areas of Patient FluctuationIn the Emergency Department, leaders adapted the model, applying both staggered start times and shorter shift lengths to match fluctuating patient demand.

Their analysis found a steady increase in patient census throughout the day—reaching a predictable peak in the evening, shown in the graphic here. They staggered shift start times for several nurses, with increasing overlap throughout the day. Leaders in the Emergency Department also added a short shift, timed to meet the highest peak in patient census.


RN 1

RN 2

RN 3

RN 4

RN 5

RN 6

RN 7

Time of DayE

D P

atie

nts

1100 1700 23000500 0900 1300 1500 1900 2100

Emergency Department Patient Census

Emergency Department Staff Nurses

Period of maximum patient levels matches period of maximum staff levels

For maximum flexibility, the hospital added shorter shifts; this can build additional savings if permitted by industrial agreement

Staggered shifts set to match frequent and ongoing admissions throughout the day

0700


Non Traditional Shifts Create Significant Savings

These adjustments to the traditional shift structures allowed managers to match predictable patient demand more closely, thereby saving the Emergency Department more than $US 100,000 and the organisation$US 1.7 million in one year.

Source: Advisory Board interviews and analysis.1) US dollars.

Savings Achieved in the Emergency Department at Pearson Hospital1

Saved hospital-wide1

from shift adjustments

$1.7M

Shortening Shift

Lengths

Adjusting Start

Times

Flexing to Projected Census

Total Cost Savings

$46,000

$36,000

$28,000 $110,409


Creating Structural Flexibility Requires Careful Consideration

The Global Centre recognises that adjusting shift structures to build flexibility requires special considerations.

For staggered start times, nursing leaders must closely analyse trends in patient demand. Surges in admissions and discharges that trend over time will dictate the most appropriate approach.

For shortened shifts, union and government requirements and employee constraints may influence implementation. In addition, certain employees and roles may have more flexibility for shortened shifts.


Definition Considerations

Key Considerations for Staggered Start Times and Shorter Shifts

Shifts are staggered throughout the dayto match available staff to patient demand

Stag

gere

d St

art T

ime

For the Emergency Department, evaluate when admissions rates are particularly high

Consider when admissions occur on inpatient units to match staff and patient flow

Short shifts match periods of extreme fluctuation in patient need

Shor

ter S

hifts

Consider which staff roles have more flexibility for shortening shifts

Think through union and government requirements to evaluate if shorter shifts are appropriate for the environment


The Harsh Reality of RN-to-Patient Ratios

Ratios Difficult to Translate into Reality, Lead to Wasted Nurse Capacity

Practice 4: Patient Placement Algorithm

Utilising nurse-to-patient ratios presents the challenge of “partial people math.” Although unit managers try to match their staff to census projections, patient volumes do not always correspond to ratios.

Leaders at Lee Memorial Health in Florida, United States, had a goal ratio of one nurse to six patients, but they rarely had the exact match. Their result was wasted capacity of nurses, as shown here.

Source: Lee Memorial Health System, Fort Myers, Florida, US; Advisory Board interviews and analysis.

14

13

12

11

Sample Nurse-to-Patient Ratios

Patient Census

Nurses Needed for RatioAssumes unit with 1:6 ratio

12 patients ideal for optimal staffing

Case in Brief: Lee Memorial Health System • 1,384-bed health system based out of Fort Myers, Florida, US

• Built demand forecast identifying volume patterns by month, day of week, and shift; numbers adjusted for preceding five months, accounting for recent trends

• Target numbers rounded to nearest ideal census point relative to staffing matrix; grid provided to managers for scheduling four weeks before next schedule begins

13 patients require “partial” nurse called in

11 patients result in “wasted” capacity of RNs


Using Whole Nurse Numbers to Inform Goals

Avoiding “Partial People” MathLee Memorial set ideal patient “census points” that corresponded to whole numbers of nursing staff, based on their RN-to-patient ratio targets. The graph on the bottom of the page is an example of the grid.

Managers use this grid when scheduling staff. They round historical volumes up to the nearest census point and staff accordingly.

House-wide patient flow coordinators also use the grid as they allocate patient admissions throughout the hospital. Admitted patients go to the units that best align with the required specialty as well as the predetermined census points.


Developing Unit Goals for Patient Census

Grid represents series of ideal patient census numbers that match to whole numbers of staff and meet required ratio

Manager uses census projections (historical of month of year/day of week) and rounds to nearest number on grid

Patient census “goal” is used as managers create staffing plans

Develop Grid as Organisational Guideline

Create Unit-Level Specificity

Use Adjusted Goals for Staffing Plans

Patient Census Targets

Monday Tuesday

Unit Name Day Night Day Night

4 East 18 12 24 18

Targets rounded to nearest ideal census point; for example, target of 17 becomes 18

Representative Staffing Grid


Rationalising More Precise Ratios

Precisely Matching Patients to Staff Eliminates Wasted Staff Time By using the census point strategy to assign patients, Lee Memorial reduced RN overtime by 33% and achieved $US 11 million. They also eliminated the need for temporary staff hired to cover seasonal surges.


1) In previous years, Lee Memorial contracted premium labour for short periods during high census months in the summer.

2) US dollars.

350

175

0

Year 1 Year 2 Year 3

Annual Seasonal Contracts1

0%

100%

33%Reduction in RN overtime labour

Overall labour savings in the first year2

$11M

Impact of Patient Census Grid on Select Indicators


3

►Embed Flexibility to Respond to Unexpected Mismatches

Section

• Practice 5: Real-Time Staff Target Tracking

• Practice 6: Cross-Subsidised Float Pool

• Practice 7: “Floater” Support System


Need to Prepare for the Unexpected

Regardless of how prepared leaders are to address predictable variation, health care is an unpredictable industry. For example, units may need to respond to unplanned absences or unexpected admissions. Managers’ responses to this unpredictable variation greatly influences the bottom line of labour costs.

Source: Advisory Board interviews and analysis.1) Average daily census.

Time

ADC1

Cen

sus

Core Staff Too Few Too Many

Census Fluctuations Across Time

We Never Know What’s Coming Through the Door

“[Predicting demand] is never a true science in places like ICU or ED. You just don’t know what’s going to come through the door, so you do it to the best of your ability.”

Director of nursing, Australian public hospital


Costly, Risky to Use Premium Labour as Default

For last minute adjustments, unit managers often have no other choice than to use expensive staffing alternatives—such as agency and overtime.

These expensive alternatives put quality at risk, as shown here. Nurses working overtime are up to 67% more likely to have a patient safety event. Additionally, the likelihood for 30-day mortality in a unit with a higher proportion of agency nurses is 26% higher than in a similar unit with no agency use.

Source: Estabrooks CA, et al., “The Impact of Hospital Nursing Characteristics on 30-Day Mortality,” Nursing Research, 54, no. 2 (2005): 74-84; Griffiths P, et al., “Nurses’ Shift Length and Overtime Working in 12 European Countries,” Med Care, 52, no. 11 (2014), http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419 6798/#R16; Advisory Board interviews and analysis.

1) Based on Advisory Board interviews.2) Percentage of total hours effective April 2017 (currently 2%). Penalty specific to hospitals in Ontario.3) Data from a cross sectional study of 31,627 nurses in med/surg units within 488 hospitals across 12 European countries.4) Data from a cross sectional analysis of 18,142 patients discharged from 42 acute care facilities in Alberta, Canada.

Cost Limitations Care Impact

67%More likely to have a failure of patient safety when working overtime3

26%Higher likelihood for 30-day mortality with a higher proportion of [agency] positions4

Increased staff burnout

Decreased staff engagement

No accountability for performance

Limited personal connection to organisation

Wide variability of skills

1.5x Overtime costs 1.5 timesthe rate of standard staff payment on average1

1.5-2.0xAgency costs 1.5-2.0 times the rate of standard staff pay on average1

$0.62/hrAdditional financial penalty if agency hours exceed 1.5% total RN hours2

Age

ncy

Ove

rtim

e

Implications of Overtime and Agency Use


Using Premium Labour to Meet Unpredictable Demand

The Global Centre identified two key challenges that typically result in the use of premium labour to meet unpredictable demand.

The first is the dearth of real-time staffing data. Many managers lack the ability to assess and address staffing variances in the moment.

The second is that many organisationslack the flexibility needed to fill staffing gaps internally.

There are two key opportunities for overcoming these challenges. First, nursing leaders must provide managers the tools to identify variances in the moment and calibrate daily staffing levels. Second, they must improve in-house alternatives to premium labour.

The practices in this section help leaders act on each of these opportunities in turn.


Limited Daily Staffing Data Managers struggle to recogniseand address incremental variances in the moment without daily access to data

Insufficient Flexible Labour Options Organisations fill gaps with agency and overtime rather than building internal flexible labour options

Calibrate Daily Staffing Levels

Improve In-House Alternatives to Premium Labour

Opportunity

Challenge

Two Key Opportunities to Embed Flexibility to Respond to Unexpected Mismatches


Operating in the Dark on a Daily BasisOpportunity: Calibrate Daily Staffing Levels

Unit managers need real-time, actionable data, but according to a Global Centre survey of CNOs, only 14% reported tracking staffing data on a daily basis. Most managers only have access to retrospective weekly, biweekly, or monthly staffing reports.

These reports do not always include essential information managers need. They rarely include budgetary data to track when variances occur. This means that managers are unable to make informed, in-the-moment adjustments to meet staffing targets.

Source: Global Centre’s 2016 CNO Survey on Cost Savings and Workforce Optimisation; Advisory Board interviews and analysis.

1) Responses to the question: “Does your organisation carefully track use of supplemental staffing data, including overtime hours, sitter use, and agency staff hours?” Potential responses included: Yes, I can see a daily report; Yes, I can see a weekly report; Yes, I can see a monthly report; Yes, I can see a quarterly report; No. N=14.

14%

Percentage of CNOs Reporting Organisation Tracking Data on Use of Supplemental Staff1 Lacking Access and Support

“[Our data is] retrospective and [we] are not looking at planned activity or what patient groups [we] have, what is changing...We also have a lot of information that is not used enough.

For one head nurse to get access to all the data she has to go into different systems. She has to be quite good in knowing: ‘what data do I need, how can I use it, where can I find it?’ There’s too little support. We need a better technical system, but we also need better support to know how to use the data.”

Nurse executive, Norwegian public hospital

Yes, a Daily Report

No Report

Yes, a Weekly Report

Yes, a Monthly Report

n=14


Missed Targets Result in Costly Incremental VariancePractice 5: Real-Time Staff Target Tracking

The CNE of Children’s Hospital of Eastern Ontario (CHEO) recognisedthe costs of regularly missing targets. She saw that the unit-based care facilitators at CHEO, who are in charge of the unit budgets, were consistently missing their HPPD targets. An example of this is shown here.

Care facilitators and managers were not held accountable for incremental expenses, since the organisation could not track daily performance and identify where and when variances occurred.

Source: Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Advisory Board interviews and analysis.

1) Costs shown are in Canadian dollars.

Representative Monthly Staffing Challenges at Unit 4 East1

Day 1HPPD target for Unit 4 East is 7.32 hours per patient

Day 5Unexpected uptick in patient census requires manager to call in extra staff; manager misses daily target by 11.97 hours

Day 15Nurses absent, manager calls in overtime; in reality, drop in census accommodates for absence, unit over target by 14.32 hours

Day 20Patient census low; manager does not adjust targets for the day, results in excess of 13.53 hours

Day 25Patient on unit requires more intense nursing care, ratio changes in excess of 10.22 hours

$15,000Total avoidable labourcosts shown by monthly manager report

Cost: $599 Cost: $716

Cost: $677

Case in Brief: Children’s Hospital of Eastern Ontario (CHEO)• 167-bed public children’s hospital in Ottawa, Ontario, Canada

• Chief Nurse Executive worked with Information Technology (IT) Department to develop a daily dashboard in Microsoft Excel

• Dashboard allows managers, care facilitators, and off-hours charge nurses to make real-time adjustments to their schedules and helps the unit avoid going over budget

• Daily bed flow meeting across units allows for reassignment of nurses as needed

Cost: $511


Automated Tool Enables Real-Time Assessments and Tracking

A task force composed of the CNE and representatives from quality improvement, organisationaldevelopment, and IT determined which data points needed tracking. They developed an Excel tool to facilitate in-the-moment analysis of the various inputs.

The now-automated dashboard, shown here, first calculates targets for the 24-hour day based on census data. Then, at the start of each shift, care facilitators enter their units’ actual numbers. The tool populates to show if the unit met its HPPD targets.

Managers can provide a rationale for missed targets in a section for “contextual factors.” Leaders also use this feature to identify systemic issues that need higher-level attention.


Excerpt of CHEO’s HPPD Dashboard

Metrics

17 August

Monday

Expected Census 5

Nursing Hours 112.50

Nursing Hours per Expected Census 22.50

Patient Days 13

Scheduled Nursing Hours 198.75

Nursing Hours per Patient Day 15.29

Budgeted Nursing Hours per Patient Day 14.79

Maximum Census Target 13

Budget to Planning (6.31)

Budget to Actual (0.54)

PLA

NN

EDA

CTU

AL

VAR

IAN

CE

Tool automatically populates planned data

Manager inputs actual data for the day

Tool automatically calculates overages, underages and colour-codes the day

Daily Process for Calculating Real-Time HPPD Performance

1

2

3


Managers Able to Quickly Address Mismatches

Care facilitators and managers can now intervene immediately when mismatches occur—with data to support their actions.

If the dashboard turns red, the unit is over budget. The care facilitator can ask nurses to take time off, float them to other units, or the unit can admit more patients.

If the dashboard turns green, the unit may be hitting its target exactly. While nothing needs to be done, managers reassess staffing throughout the day. The dashboard will also be green if there are too few staff. Managers must assess whether more support is needed and in which roles.

Care facilitators and managers are expected to ask staff to work overtime only if they have exhausted every other alternative.


1) Registered practical nurses.2) Health care assistants.

Enter actual information at start of shift

Current Staffing Algorithm at CHEO

IF IN THE GREENIF IN THE RED

Update tool after rounds; act on any changes

Too many nurses

Too few nurses

Offer nurses leave of absence

Admit more patients on unit

Float staff out of unit

Float external staff

onto unit

Bring in additional staff as needed (RNs, RPN1s, HCA2s)

Ask staff to work overtime or call staff at home

Look for internal

resources

If still missing target, care facilitator or charge nurse can explain mismatch in “contextual factors” section of tool; discuss with manager or director if systemic issue


Bed Flow Meeting Facilitates Action on Tool Results

Care Facilitators Share Data and React to Mismatches at MeetingThe decision to float nurses from one unit to another requires strong collaboration among units, and these conversations occur during daily bed flow meetings.

Representatives from all units attend and discuss staffing, bed allocation, and patient flow. Care facilitators present their reports and decide the actions needed. They strategisedischarges and triage admissions.

These meetings give managers and facilitators a global view of staff allocation for the whole organisation.


Meetings Occur Four Times a DayCare facilitators and charge nurses meet four times a day to discuss patient fluctuations; meetings take 15-30 minutes

Planners Help Each Other Hit TargetsCare facilitators and charge nurses discuss which units need nurses and decide whether to float staff

Units Evaluate Patient Flow and StaffingCare facilitators recommend which patients can be transferred or discharged to meet HPPD targets

Conversations Allow Real-Time AdjustmentsFour daily bed flow meetings provide opportunities for units to adjust to mid-day discharges and admissions

1 2 3 4

Key Components of Bed Flow Meeting

Bed Flow Meetings Allow for Hospital-Wide Perspective“Having this hospital-wide [meeting] has really been helpful...All managers know whether the unit is over or under [in staffing]. [We] have this hospital-wide conversation about where we sit for patient flow and HPPD for the day.”

Megan Wright, Chief Nurse Executive, CHEO


Managing to the Hour Results in Efficiency, Savings

Across the organisation, wasted hours at CHEO have decreased while quality measures remain high. Since the implementation of the tool, the nursing department has avoided $CAN 2.1 million in costs.

Additionally, frontline nurses feel more accountable for financial indicators and understand how their work impacts the budget.


1) In Canadian dollars.

Nursing Hours Worked on All UnitsSince August 2014

Gaining Financial Savvy on the Frontline

Pai

d H

PP

D

9.00

10.00

11.00

12.00

13.00

Aug '14 Dec '14 Apr '15 Aug '15 Dec '15 Apr '16 Aug '16

Actual Hours Worked Average Hours Worked

Implementation of HPPD Tool

“[Someone in my staff said that] as a frontline nurse, [she] never knew what the budget was and never questioned what the budget was. Now, [she] thinks it’s something that needs to be at the forefront for frontline staff.” Helen Yoxon, Manager of Palliative Care, CHEO

$2.1MCost avoided since the implementation of the tool in August 20151

Low patient census


Understanding the Amount of Flexibility Needed

Census Analysis Reveals Opportunities to Avoid Premium Labour

Opportunity: Improve In-House Alternatives to Premium Labour

To build sufficient internal responses to unpredictable variation, leaders must examine the amount of flexibility needed.

In the graph shown here, the solid line is the average daily census (ADC). The shaded area above the line represents one standard deviation above the mean. It encompasses nearly all of the unpredictable variation that a unit experiences that would require a flexible staffing response to meet increased demand. Although managers cannot predict when variation in the census will occur, they can anticipate the amount of fluctuation based on this calculation.

Leaders must also consider two critical factors calculating flexibility needs, shown here. Both target staff ratios and daily volume fluctuations will influence a unit’s flexibility needs.

Source: Advisory Board interviews and analysis.1) Average daily census, adjusted to reflect fluctuations as outlined in section 1 of this book.

Two Critical Factors to Determine Number of Flexible Hours Needed

Target Staff Ratios• Units with greater HPPD or lower RN-to-patient

ratios require more flexibility; even small volume changes require staffing adjustment

• Units with lower HPPD or higher RN-to-patient ratios do not need as much flexibility; only significant volume changes require staffing adjustments

Daily Volume Fluctuations• Units with highly variable volumes

require more flexibility to adjust to unexpected census changes

• Units with more stable daily volumes require less flexibility and can often rely on core staff

Cen

sus

Determining Size of Flexible Workforce Needs

Time

ADC1

One standard deviation above mean


The Challenges in Building an Internal Answer

To respond to unpredictable census fluctuations and avoid the use of costly premium labour, the Global Centre recommends building or expanding an internal float pool or nursing resource team

Many leaders struggle to grow and sustain their float pools. Nurses and managers often view flexible pools as unstable and unpredictable, with limited professional development opportunities. Float nurses often feel unsupported on their designated units. As a consequence, most nurses do not like to float and retaining float staff is a challenge.

Source: Bates KJ, "Floating as a Reality: Helping Nursing Staff Keep Their Heads Above Water," MEDSURG Nursing, 22, no. 3, (2013): 197-199; Dziuba-Ellis J, “Float Pools and Resource Teams: a Review of the Literature,” Journal of Nursing Care Quality, 21, no.4 (2005): 352-359; Advisory Board interviews and analysis.

0%

100%

73%Of nurses report disliking, resenting, or even “hating” floating

Like a Fish Out of Water“Experienced nurses...express feeling alone, anxious, and even incompetent when floated to other units. This in turn can affect their patients, as the anxiety they feel may be translated through verbal and nonverbal communication.”

Bates K, Floating as a Reality: Helping Nursing Staff Keep Their Heads Above Water

Frequent Obstacles to Building Internal Flexible Staffing Options

• Float pools seen as unstable and unpredictable• Float pool nurses viewed as generalists;

most nurses prefer to specialise• Float pools perceived as having limited

professional development opportunities

Recruitment Difficulties

• Float pool nurses feel alone, disengaged, and unsupported

• Float nurses receive limited orientation to unit; spend excess time finding supplies

• Float nurses frequently assigned most difficult patients

On-the-Job Challenges


Float Pool Enhances Graduate Nurse Programme

Approach Addresses Graduate Recruitment and Transition to RNs

Practice 6: Cross-Subsidised Float Pool

The first challenge in building a robust flexible staffing team is recruitment.

Structures to support the development and growth of a float pool are essential to strengthen the appeal of float pool participation. For instance, when nursing leaders at Princess Alexandra Hospital (PAH), in Australia, created their first permanent pool in 2008, new graduates were enthusiastic to join the pool.

Leaders developed a programmewithin the pool specifically for new graduates. They trained the nurses using a portion of government incentive monies earmarked for hiring newly graduated nurses. They also used the money to train experienced nurses as Graduate Clinical Facilitators—positions designed to provide 24/7 support for nurses in the float pool.

Agency costs at PAH decreased by almost 110,000 hours, resulting in nearly $AUD 4 million in savings. Engagement and retention of new grads increased, and the flexible workforce response stabilised.

Source: Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Advisory Board interviews and analysis. 1) In Australian dollars.

Benefits of Involving New Grads in Princess Alexandra’s Float Pool

For New Grads For Experienced Nurses• Opportunity to be employed at a

major health centre

• Exposure to different clinical areas

• Part-time hours assist in assimilating to role and work environment

• Funding received from hiring new graduates used towards graduate clinical facilitators

• Once educated, the facilitators have wider knowledge of hospital and specialist competencies

For Princess Alexandra Hospital

107,120 Hours of reduced agency use

$3,986,178 Savings achieved1

by avoiding agency useIncreased retention of new graduates

Increased frontline staff engagement

Case in Brief: Princess Alexandra Hospital • 1,059-bed, Magnet® accredited hospital located in Woolloongabba, Queensland, Australia • Purpose to utilise government graduate funding to hire new graduates and support upskilling

of graduate nurse facilitators towards specialised training for tenured and permanent staff• Programme designed to increase the number of graduate positions and assist in decreasing

agency shifts used • Provide a broad range graduate programme supporting the consolidation of skills before

progressing to specialised areas


An Integrated Flexible Staffing Solution Practice 7: “Floater” Support System

The second challenge is retaining the nurses who are “floating” and integrating them into the fabric of the organisation.

Leaders at the Cleveland Clinic, in the United States, wanted their flexible staff to have all the training and certifications necessary to operate as full staff members and share the Clinic’s culture.

Their two major flexible staffing teams are shown here. The Cleveland Clinic Staffing Resources is a highly specialised pool composed of specialty RNs who fill vacancies as needed across all sites. They are not considered full-time staff, required to work only one shift every 60 days.

The Main Campus Float Pool are nurses who fill last minute staffing needs for the main hospital only. They are on staff as “expert generalists” and are paid only slightly more than a regular staff nurse.

A dedicated manager oversees the float pool. The “unit” of floats has a unit council that shapes their practice environment.

Source: Cleveland Clinic, Cleveland, Ohio, US; Advisory Board interviews and analysis.

1) Pro re nata or per diem nurses work on an on-call, temporary basis, filling in for nurses on leave or providing additional help when patient intake rises.

2) Cleveland Clinic Staffing Resources: official name of the Cleveland Clinic’s enterprise-wide PRN pool. 3) As of April 2016. 4) As of April 2016. PCNA stands for Patient Care Nursing Assistant.

Enterprise PRN1

Staffing Pool (CCSR2)Main Campus Permanent Float Pool

Work across all units on Main Campus

Work across eight different campuses

31 PCNAs482119 RNs3

Scope

Specialties

Benefits

Scheduling

Specialty RNs hired into M/S telemetry, ED or Critical Care

Expert generalists hired into M/S telemetry or Critical Care

Partial benefits (access to pension); paid at a premium

Full/part-time benefits; paid same hourly rate as staff with hourly premium float differential

Selected Available Flexible Staffing Options at the Cleveland Clinic

Self-scheduled, offset staffing needs based on anticipated leave and volume spikes; required to work one shift every 60 days

Assigned by staffing office, cover last-minute staffing needs; PRN required to work 48 hours every six weeks

RNs3Size

Case in Brief: Cleveland Clinic• Health system headquartered in Cleveland, Ohio, US

• In 2014, developed support structure for unit-to-unit floats through a shared governance project

• Support system includes float ally, float packet, and caregiver celebration


Common Flexible Staffing Challenges Addressed

Shared Governance Project Becomes Foundational Support StructureEven with the robust float pool options outlined on the previous page, the Cleveland Clinic float nurses still faced challenges.

Float nurses frequently felt disengaged and struggled to adapt to their assigned units. As part of the float pool’s shared governance work, they developed a strategy to integrate float nurses immediately upon arrival to their assigned units. Leaders piloted this support programme on a unit with high utilisation of float nurses.

Source: Cleveland Clinic, Cleveland, Ohio, US; Advisory Board interviews and analysis.

Process to Develop Structured Support for Float Staff

Floats Struggle to AdaptAssistant nurse manager of float pool notices staff often struggleto integrate themselves into units

Shared Governance Day Provides Improvement OpportunityAssistant nurse manager and team develop project to integrate structured support for float staff

Literature Review Informs ProcessFloat management team conducts literature review on engagementof float nurses

Pilot Project Implemented in Organ Transplant UnitProject pilots in unit with high volumeof cross unit floats; pre-implementation survey conducted

For more resources on shared governance, access www.advisory.com/international/gcne/sharedgovernance

Second Pilot Supports More UnitsOrganisation expands pilot to six additional units; project to be expanded to entire institution


Embedding Unit Support for Floats

Three key elements make up the support model. First, each unit has a Float Ally on a shift—a nurse designated by the unit’s manager. The Ally serves as the point person for the float nurse. The Float Ally greets the float nurse upon arrival, provides a tour of the unit, and stays connected throughout the shift.

The second element is the float packet. At the beginning of the shift, the ally gives the float nurse a packet with all the information needed to function on the unit.

The third element is a float nurse celebration. At the end of the shift, the float nurse receives a note of appreciation from the unit manager or Float Ally. The float pool manager also receives notice of the recognition.

Source: "Nurses Create a Model to Enhance the Float Experience," Cleveland Clinic, https://consultqd.clevelandclinic.org/2015/02/nurses-create-a-model-to-enhance-the-float-experience/; Cleveland Clinic, Cleveland, Ohio, US; Advisory Board interviews and analysis.

Caregiver Celebration

Float Packet

• Floats receive a guide to the unit at the start of their shift

• Guide contains name and number of Float Ally and unit-specific checklist

Float Ally

• Units assign a Float Ally for both RNs and PCNAs on each shift

• Ally serves as the point person for float nurses

• Ally greets floats and stays in touch with them throughout shift

• At the end of shift, float receives a note of appreciation from unit manager or Float Ally

• Note thanks float for helping the unit during a time of need

Available Support Structures for Unit Floats at the Cleveland Clinic

A Model to Impact Engagement and Safety “The model is designed to provide unit-to-unit floats the support they need... Ultimately, not only will it enhance caregiver engagement, but it will benefit patients as well.”

Angie Walden, Assistant Nurse Manager, Nursing Floats, Cleveland Clinic


Integrated Approach Optimises Engagement and Savings

Leaders at Cleveland Clinic have grown and stabilised their float pools.

As a result of embedding unit support for float staff, average staff satisfaction increased 50%.

The pools have covered thousands of temporary relief hours in one year, shown here. These hours would have otherwise been covered by agency or overtime.

Source: "Nurses Create a Model to Enhance the Float Experience," Cleveland Clinic, https://consultqd.clevelandclinic.org/2015/02/nurses-create-a-model-to-enhance-the-float-experience/; Cleveland Clinic, Cleveland, Ohio, US; Advisory Board interviews and analysis.

1) Cleveland Clinic Staffing Resources: official nameof the Cleveland Clinic’s enterprise-wide PRN pool.

Productive Hours Filled by Flexible Staff in 2015

87,321Hours filled by CCSR1 RNs

172,478Hours filled by Main Campus float pool

Average Percentage of Staff Satisfied with Float Experience on Pilot Units

The Float as an Expert Generalist“Our units are specialised and our floats become expert generalists. When a specialty unit has an identified need they say, ‘where’s the float?’ because of the float’s familiarity and vast experience with a wide variety of patient care settings and needs.”

Angie Walden, Assistant Nurse Manager, Nursing Floats, Cleveland Clinic

35%

85%

Before After


4

►Fully Leverage the Skills and Training of Each Care Team Member

Section

• Practice 8: Unit-Level Modelling

• Practice 9: Evidence-Based Sitter Algorithm

• Practice 10: Specialised PCA Roles

• Practice 11: Customised Care Teams


Quantifying the Financial Impact of Not Working at “Top of License”

The final opportunity for achieving sustainable cost savings is to fully leverage the skills and training of every member of the care team. If leaders do not deploy their nurses at “top of license,” they overspend on care hours unnecessarily.

An analysis of nursing activities on several general medical/surgical units published in the Journal of Nursing Administration quantified this overspending. The researchers divided work into “value-added” work, which required a nurse’s training and skills to accomplish, and “non-value-added” work, which could be effectively accomplished by someone with less training. On average, each unit spent more than $750,000 in nurse wages on “non-value-added” work, which included searching for equipment and locating support staff.

Source: Storfjell J, Omoike O, and Ohlson S, “The Balancing Act: Patient Care Time Versus Cost,” JONA, 38 (2008): 244-249; Storfjell J, et al., “Non-Value-Added Time: The Million Dollar Nursing Opportunity,” JONA, 39 (2009): 38-45; Advisory Board interviews and analysis.

1) Assessing, teaching, providing hands-on care, providing psychosocial support, coordinating care, and documenting care.

2) In US dollars.

Nurses’ Time Not Spent on “Value-Added” Work1

0%

100%

36%

Percentage of nurse time spent doing “non-value added” work

$756,724RN wages2 spent on “non-value-added”

time per med/surg unit

Nurse executive, Australian public hospital

“Nurses should be doing the critical thinking about the clinical condition of the patient. They should be doing the assessment and the treatment plan.”

The Right Type of Work for Nurses


“We need a different mix. But I’m not sure what that is. I want to look at the work first, not the staffing. We have built up what we have over time and have never looked at [whether it is] valuable.”


Far More Complicated Than Task Reallocation

RN Top-of-License Practice Not Defined by TasksAlthough the majority of nursing leaders support the concept of top-of-license practice, many struggle to achieve this aim.

A seemingly logical approach to defining top-of-license practice is to list the activities that must be accomplished and reallocate them according to the training and skills for each discipline.

But there are four challenges to defining top-of-license by specific activities. First, the most appropriate care team member for a given activity depends on the patient’s acuity level. Second, one care team member may provide more efficient care by combining activities. Third, varying regulatory requirements make identifying a consistent set of activities for each care team member unrealistic. Finally, all caregivers must ensure patient safety, even if doing so requires completing an activity that is formally another team member’s responsibility.


Challenges Associated with Task-Based Approach to Role Redesign

Dependent on Patient Acuity Level Identifying the most appropriate caregiver requires professional judgment in the moment

Regulatory Requirements VariableRegulations vary and change over time as they are updated

One Activity Can Serve Multiple AimsOften more efficient to combine more than one care activity into a single event

Patient SafetyTrumps RoleCaregivers must “pitch in” to ensure patient safety, even if the activity is the primary responsibility of another caregiver


Defining Top-of-License Practice by Patient Needs

Establishing Consensus on Core ResponsibilitiesInstead of assigning specific activities to each care team member, nurse leaders should identify the key functions nurses must fill to meet the needs of increasingly complex patients across settings.

Based on input from a cross-section of nursing leaders in a variety of care settings, the Global Centre for Nursing Executives proposes defining top-of-license nursing practice as the eight core nursing responsibilities shown here.

The Global Centre encourages nurse leaders to use this list as the starting point for clarifying their organisation’sdefinition of top-of-license nursing practice. By establishing consensus on core nursing responsibilities, nurse leaders can transform top-of-license practice from an abstract concept to concrete guidance on how nurses should spend their time.


Assess Clinical and Psychosocial Patient Needs

1

Establish Patient Goals and Track Progress

2

Provide Patient-Centred, Outcomes-Focused Care

3

Educate and Engage Patients and Their Families

4

Manage Key Components of the Clinical Record

5

Coordinate Care with Interprofessional Caregivers

6

Facilitate Safe Patient Transitions

to the Next Care Setting

7

Assess and Incorporate New Technologies and

Evidence-Based Practice

8

Core Nursing Responsibilities Across Settings


Common Barriers to Implementing Top-of-License Nursing Practice

In addition to defining top-of-license nursing practice, nurse leaders must address three common barriers that prevent nurses from focusing on the core responsibilities, shown here.

The first barrier is that leaders have trouble identifying the optimal skill mix. Organisations often use outdated skill mix proportions that do not match unit realities.

The second barrier is underutilisation of supplementary help.

The final barrier is that staff can easily slip back into old habits, reverting to their previous roles and activities.

To overcome these barriers, leaders must first optimise skill mix based on unit-level needs. Second, they must better utilise support staff to fully leverage RNs. Third, they must continuously reinforce top-of-license nursing practice.

This section contains four practices to help nursing leaders address these challenges.


Opp

ortu

nity

Bar

rier

Three Barriers to Better Leverage the Skills of Each Care Team Member

Slipping Back into Old HabitsPoor structures lead to slippage away from top-of-license team nursing

Reinforce Top-of-License Prioritisation

Optimise Skill Mix Based on Unit-Level Needs

Ideal Skill Mix Unknown

Organisations struggle to determine ideal skill mix proportions

Inefficient Use of Supplementary HelpUnderutilising or overutilisingsupport staff leads to excessive spending

Better Utilise Support Staff to Fully Leverage RNs

Implementing top-of-license practice will also require a considerable shift in culture. To access practices, lessons, and case studies on culture change, visit advisory.com/gcne


RN-Heavy Skill Mix Inhibiting Top-of-License Practice

Time and Motion Analysis of RN Activities Reveals Inefficiencies

Opportunity: Optimise Skill Mix Based on Unit-Level Needs

Some leaders find their RN-heavy workforce does not have enough support staff to enable nurses to delegate activities that could be accomplished by someone with less training.

As a first step to leverage all members of the care team fully, the Global Centre recommends right-sizing the proportion of RNs in the skill mix.

Nurse leaders at Inova Health System in the United States examined unit work and skill mix. Their RNs were spending 18% of their time on care activities that unlicensed personnel could safely provide, including assessment of vital signs, blood sugar checks, and simple dressing changes. These data were foundational to making improvements.

Source: Swick M and Doulaveris P, “Application of Simulation Technology to Enhance the Role of the Professional Nurse,” JONA 42 (2012): 95-102; Advisory Board interviews and analysis.

1) Other services include: care coordination, shift assessments, walking, rounds/huddles/handoffs, breaks, outliers, admission assessments, information review and planning, discharge, blood draws, IV starts, and wound care.

2) Unlicensed assistive personnel.3) Licensed practical nurse. 4) In US dollars.

18%

18%

64%

Sample Observed Activities Performed by RNs That UAP Can Provide

• Vital signs

• Blood sugar checks

• Simple dressing changes

Other1 Activities UAP1

Can Provide

Medication Administration

Distribution of Observed RN Time by Activity at Inova

Data CollectedObservers collected data on time, service, location, and other notes on care activities

Staff Observed18 RNs and 7 UAPs were observed during 25 individual 4-hour sessions in time and motion study

Time and Motion Study Inputs

Case in Brief: Inova Health System• Five-hospital system based in Falls Church, Virginia, US

• In 2010, began planning to change nursing care model across system

• Leaders used Lean techniques and simulation technology to determine optimum nursing skill mix; team members include RNs, clinical tech 1s, and clinical tech 2s; clinical tech 1s are unlicensed while clinical tech 2s are LPNs3

• In 2011, individual nursing units implemented new nursing care model; proportion of RNs in skill mix decreased from system-wide average of 82% in 2010 to 73% in 2011

• Labour savings of approximately $10 million4 per year across the system with new nursing model


Using Simulation to Find the Right MixPractice 8: Unit-Level Modelling

The nursing leaders at Inova used the unit observation data in simulation modelling to test the effects of altering skill mix, patient volume, and other inputs on the unit’s outputs, such as nursing labour cost and value-added time.

After testing 129 scenarios, leaders at Inova determined unit-specific skill mixes that yielded the most favourable outcomes.

Source: Inova Health System, Falls Church, Virginia, US; Swick M and Doulaveris P, “Application of Simulation Technology to Enhance the Role of the Professional Nurse,” JONA 42 (2012): 95-102; Swick M, Doulaveris P, and Christensen P, “Model of Care Transformation: A System CNE’s Journey,” Nursing Administration Quarterly 36 (2012): 314-319; Advisory Board interviews and analysis.

1) Whether RNs focused only on RN-specific activities or also focused on nursing activities that do not require an RN license.

2) Proportion of services provided by RNs that require an RN-specific skill set.3) RN time spent performing services that require an RN-specific skill set.4) RN time spent performing unnecessary activities or services that could be performed by others.

Average patient time on unit

Required care for patient

Staffing mix and level

Professional practice technique1

Number of patients presenting to unit

Inova’s Simulation Model

OutputsInputs

Patient time waiting for care

RN professional service proportion2

Nursing labour cost

Value-added time3

Waste time4

Study in Brief: Application of Simulation Technology to Enhance the Role of the Professional Nurse• Computer simulation study of nursing care delivery models with varying staffing levels, skill mixes, and

professional practice techniques

• Goal to test impact of different models on patient wait times, RN service proportion2, percentage of RN time spent on value-added and wasteful care activities, and cost

• 52-bed adult medical unit at Inova Alexandria Hospital used as basis for simulation design; baseline staffing mix of 77% RN and 23% unlicensed assistive personnel (UAP)

• 18 nurses on unit in baseline care delivery model spent 18% of their time on services that could have been provided by UAP and an additional 18% of their time administering medications

• Authors tested 129 two-week simulated nursing care delivery models with varied levels of RNs, LPNs, and UAP; simulations run through Micro Saint software; scenarios based on mean patient census of 45

• Authors report most favourable impact on combination of mean patient wait times, RN service proportion, percentage of RN time spent on value-added activities, and cost when skill mix included RNs, LPNs, and UAP


Optimising Skill Mix While Improving Care Quality

Informed by the results of their simulation modelling, leaders reduced the system-wide average nursing skill mix from 82% RNs to 70% RNs. Inova’s new skill mix adjustment yielded system-wide improvements in quality and safety—as well as in patient and staff satisfaction.

Source: Swick M and Doulaveris P, “Application of Simulation Technology to Enhance the Role of the Professional Nurse,” JONA 42 (2012): 95-102; Advisory Board interviews and analysis.

1) Unlicensed assistive personnel.

UAP1 82%18% RNs 70%27%

3%

Clinical Tech 1s

Clinical Tech 2s

RNs

2030

62

6

19

37

4 16

36

Pressure Ulcers Falls and Trauma Central Line Infections

2010 2011 2012

Number of Occurrences of Nurse-Sensitive Patient Safety Events Across System

2010 System-Wide Nursing Skill Mix at Inova

2013 System-Wide Nursing Skill Mix at Inova


Excess Use of One-to-One Observation Raises Cost, but Not QualityOpportunity: Better Utilise Support Staff to Fully Leverage RNs

To ensure top-of-license work for RNs, leaders must effectively leverage support staff.

One support role often misused is the one-to-one observer, frequently referred to as a “sitter” or “special.”

A typical 300-bed hospital spends between $US 1.5 and 2 million on this resource annually. Some patients require one-to-one observation, but sitters are often overused and costly with no significant impact on quality. As shown on the right, one study from the Journal of Nursing Administration (JONA) found no evidence that constant observation reduces the risk of patient harm.

Source: Storfjell J, et al., “The Balancing Act: Patient Care Time Versus Cost,” JONA 38 (2008): 244-249; Advisory Board interviews and analysis.

1) Sitters are also referred to as specials, patient minders or watchers, and constant care aides. 2) Enrolled nurse.s3) Assistants in nursing.

Estimated amount a 300-bed hospital spends

on sitters per year1

$1.5M-$2MIneffective and Expensive“Direct observation remains an ineffective and expensive means of providing for patients’ safety requiring rapid human intervention...currently, there is no research to suggest the use of constant observation reduces the risk of patient harm related to their risk for falling or harming themselves.”

Harding A, Observation Assistants: Sitter

Effectiveness and Industry Measures

Staff Regularly Used as Sitters

RNs or ENs2

AINs3 and Orderlies

Security Guards


Inappropriate Sitter Use Results in Exponential Expense at CHU Quebec

Acute Increase in Sitter Use, Unit Costs Following Ban of Physical Restraints

Practice 9: Evidence-Based Sitter Algorithm

Leaders at Centre HospitalierUniversitaire (CHU) de Québec, in Canada, saw that their attempts to curtail use of physical restraints had resulted in inappropriate sitter use. In three years, their sitter costs had increased to $CAN 4 million annually across the five-hospital system.

The root causes for overuse are shown here, including poor guidance and no accountability for sitter use.

Source: Centre Hospitalier Universitaire de Québec, Québec City, Québec, Canada; Advisory Board interviews and analysis.1) In Canadian dollars.

2008

Excessive use of physical restraints led to new regulation on restraint use

2009–2010

Increase in sitter use due to doctors, nurses using them as substitute for restraints

2011

Regulation modified to include sitters asa form of restraint; usage remained high

$4M1ANNUAL SITTER COSTS AT CHU QUEBEC

Guidelines did not indicate when sitter use was appropriate

No accountability for sitter use among frontline staff and unit managers

Insufficient number of orderlies for sitter need led to using expensive security guards to fill the role

Nurses requested and doctors prescribed sitters without full evaluation or exhausting other options

Case in Brief: Centre Hospitalier Universitaire (CHU) de Québec• Five-hospital system with total of 1,767 beds located Québec City, Québec, Canada

• Mandate restricting physical restraint use put in place in 2008 after leaders noticed excessive use

• Experienced increase in sitter, as caregivers used sitters in place of physical restraints; resulted in annual sitter costs of over $4 million1

• Sitter Improvement Team created to identify underlying problems leading to overuse of sitters

• Clear protocols and easy-to-use algorithm have taught staff how and when to use alternative surveillance methods; training and additional resources encourage sitters to have meaningful interactions with patients

• Achieved close to $3 million1 in savings after 12 financial periods

Events Leading to Increased Sitter Use

Key Factors Leading to Excessive Sitter Costs


Task Force Develops Guidelines to Address Common Problems

Leaders at CHU de Québec developed tighter guidelines and evidence-based alternatives to sitters after a task force found no proven benefit to patient safety or quality for most patients with sitters.

They first authorised a set of safe alternatives to sitters, including intermitted surveillance.

Second, leaders developed clear guidelines for appropriate sitter use. They developed manuals, standardised protocols, and surveillance forms for staff and sitters.

Finally, they developed an in-the-moment decision-making tool, designed to help staff assess the need for one-to-one observation.

Source: Centre Hospitalier Universitaire de Québec, Québec City, Québec, Canada; Advisory Board interviews and analysis.

Checklist of alternative measures based on patient needs

Introduction of enhanced, tight surveillance (15-minute and 30-minute check-in)

Standardised routine established for staff and sitters to follow

Instruction manual and enhanced surveillance forms for managers

Safe Alternativesto 1:1 Sitters

Clear Instructions, Protocols for Sitter Use

In-the-Moment Decision-Making Tool

Colour-coded algorithm for frontline staff to use for patient evaluation

Guidelines and Resources Developed by Sitter Improvement Team


Easy-to-Use Algorithm Guides Staff Through Evaluation of Sitter Need

Unit staff use a decision-making algorithm, illustrated here, to determine if a patient requires constant observation.

If the staff determine that a sitter is required, the request must have unit manager approval as well as documentation of protocol adherence. Additionally, if a sitter is medically prescribed, the order is checked after 24 hours to assess the level of care needed.


Representative Evaluation of Patient at Risk of Aggressive, Violent Behaviour

Constant 1:1 Surveillance Needed

Good response to occupational activities (YES or NO)?

If utilise these activitiesto calm patient.

Is family presentor available (YES or NO)?If then ask family to be present, request possible solutions to calm patient.

Is it possible to use specialised equipment (YES or NO)?If then introduce necessary equipment(i.e., bed alarm, hand mitts, soft splint, chest vest).

Positive response to temporary, somewhat restrictive controls put in place for less than 24 hours (YES or NO)?If continue temporary controls with patient consent.

Assigning 1:1 Sitter Requires:• Approval from unit manager• Application of new sitter protocol• Validity check after 24 hours if

medically prescribed

NO

NO

NO

NO

YES YES

YESYES


Advancing Care Quality by Enhancing Therapeutic Alternatives

Leaders Arm Sitters with Resources to Improve Patient Experience, CareCHU de Québec’s leaders revised their sitter protocols intending to improve care quality and patient experience. In addition to protocols, leaders knew their staff needed training in and access to alternative therapeutic approaches. They invested in three areas.

First, they provided enhanced staff and sitter training on proactive, therapeutic measures to mitigate patient agitation.

Second, staff and sitters have access to the IMCEP1 cart, which contains therapeutic activities that sitters and staff can use to refocus and calm patients.

Third, sitters complete surveillance logs conveying their observations to the nurses.


1) l'intervention multisensorielle de confort émotionnel et physique (multisensory intervention for emotional and physical comfort).

IMCEP Sitter Cart

Sitters have access to an IMCEP cart; cart filled with supplies that appeal to five senses, helping calm patients and enabling meaningful interactions between sitters and patients

Sitter Training for Orderlies, Nurses

Orderlies and frontline nurses received training focused on appropriate sitter use and interactions with patients

Sitter Surveillance Log

Sitters required to fill out surveillance log; information provides nurse with important patient details that sitter has observed, therefore improving understanding of patient needs

Sitter Resources, Training, and Documentation at CHU Québec


Less Use of Sitters, Restraints Improves Quality, Lowers Costs

Sitter Costs, Restraint Use Cut While Decreasing Patient FallsCHU de Québec’s revised approach to sitter use has resulted in widespread improvements. Both sitter and restraint use have decreased. Care quality and safety have increased, shown here.

The work also yielded significant financial savings. CHU de Québec reduced its sitter costs by almost $CAN 3 million across the system in two years.

Moreover, leaders at CHU de Québec have seen a significant cultural shift in ownership and accountability among staff, managers, and doctors.


1) Based on CHU Québec internal analysis; Canadian dollars. 2) Based on CHU Québec internal analysis. 3) Soins aux aînés et vieillissement (Care for Ageing and Elderly Patients).

2013 2015

Annual Sitter Costs at CHU de Québec1

$4M

$1.2M

2013 2015

Restraint Use at CHU de Québec2

6.1%

4%

Department-Specific Total Patient Falls2013/14 – 2014/15

SAVIE3

61%Medicine

59%Surgery

76%

Ownership Among Staff“[Staff] are more aware of the sitter use and are asking more questions of their team…Now they quickly identify that there is a problem if they see the numbers rising.”

Nurse Unit Manager, CHU Québec


Advisory Board Resources on Sitter Use

Many organisations across the world struggle to manage sitter costs. The Global Centre has a suite of practices and resources shown here to support leaders to make improvements in this area.


Sitter Use Unit Accountability

Rewriting sitter policy to hold staff accountable for sitter use; building partnerships with volunteers and families

Observation Cross-Training

Offering cross-training on patient observationto support service employees

Partnering with nursing schoolsto deploy students as sitters

Developing concentrated monitoring area for patients requiring close supervision on geriatric psych unit

Investing in video system on units with high fall rate, combined with dedicated observer who alerts staff of imminent falls

Student Pipeline

Multiple Room Monitors

Video Surveillance

Strategies for Safely Reducing Sitter Usage

For more information on these practices visit advisory.com/gcne

On-Demand Webconferences• Reducing Falls and Sitter Costs

with Targeted Video Surveillance

• Tips to Reduce Patient Falls, from Expert Patricia Quigley


Creating Two PCA1 Roles to Cover “Reliable” and “Variable” WorkPractice 10: Specialised PCA1 Roles

To fully support RNs, managers must also ensure support staff can complete all activities delegated to them.

Leaders at University of Pittsburgh Medical Center (UPMC), located in the United States, found gaps in basic care were occurring. Patient care assistants (PCAs) were routinely interrupted to address time-sensitive, unpredictable patient needs which interrupted their workflow.

To address this, nursing leaders added two “specialised” PCAs per unit to ensure both predictable and unpredictable patient care activities were consistently completed. One PCA on each unit is dedicated to reliable work—performing routine patient care activities, including turning, rounding, and bathing. The other PCA is dedicated to variable work, focusing exclusively on unpredictable patient needs, such as call lights and lab draws.

Source: University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, US; Advisory Board interviews and analysis.1) Patient care assistant.

Reliable Work

• Rounding• Taking vital signs• Feeding patients• Turning patients• Bathing patients• Ambulating patients

Variable Work

Answers call light

Packs patient items for discharge

Answers call light

PCA tasked with responding to variable work

Representative Excerpt of “Variable Rounder” PCA Shift

Patient requests and care activities addressed quickly

Bathes Mrs. Smith

Bathes Mr. Jones

Bathes Ms. Scott

PCA tasked with bathing Mrs. Smith,Mr. Jones, Ms. Scott

Representative Excerpt of “Reliable Rounder” PCA Shift

Work completed with minimal interruptions

Case in Brief: University of Pittsburgh Medical Center (UPMC)• 20-hospital, 4,500+ bed system based in Pittsburgh, Pennsylvania, US

• In January 2011, piloted “Reliable and Variable Rounder,” now spreading system-wide

• PCAs formerly responsible for both predictable and unpredictable work, which competed for their attention

• Goal of “Reliable and Variable Rounder” model is to ensure routine care for patients (e.g., rounding, turning, ambulating, feeding, etc.) is delivered reliably and that time-sensitive work is handled quickly

• On pilot unit, increased patient satisfaction scores from the 82nd to 89th percentile for patient satisfaction with response to call light; percentage of patients responding “Always” to “Helped toileting as soon as wanted” increased by nine percentage points

• Call lights• Assisting RNs with

unexpected needs• New admissions• Lab draws• Preparing patients for

testing or discharge


Improving PCA Reliability and Care Quality at UPMC

After introducing specialised PCA roles on units, the pilot UPMC facility reported an improvement in patients’ satisfaction with response to time-sensitive requests, as shown here. UPMC leaders spread the cost-neutral initiative across the system, distributing the work between existing PCAs.

Source: University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, US; Advisory Board interviews and analysis.

1) Based on organisation’s results on Press Ganey survey.2) From the Hospital Consumer Assessment of Healthcare Providers and Systems

(HCAHPS) survey.

82nd89th

2010 2011 2010 2011

61%70%

Percentage of Patients Answering “Always” to “Helped Toileting as Soon as Wanted”2

Patient Satisfaction with Response to Call Light by Percentile1


Top Opportunities to Create Specialised Support Roles

There are many approaches to effectively utilising support staff. The Global Centre has identified several strategies for defining these support roles, shown here.


1) Medical assistant. 2) Boulder added one FTE per two providers in pilot clinics. 3) Pilot clinic A daily net revenue increased by $234 per two providers; pilot

clinic B daily net revenue increased by $478 per two providers.

Organisation Type of SpecialisedSupport Staff Role Capsule Description Results

UPMC Reliable and Variable Rounder PCAs

Delineated cohorts of PCAs to either reliablework on a unit (e.g., routine care) or variable work(e.g., answering call lights)

Patient satisfaction scores increased from the 82nd to 89th percentile for patient satisfaction with response to call light

Baptist Memorial Hospital-Memphis

Patient Centred Bath Techs (“Spa Team”)

Converted two PCAs on each unit into the “SpaTeam” to ensure patients reliably receive baths with a patient-centred focus

Facility-acquired pressure ulcer prevalence decreased by 2.2 percentage points

Boulder Community Health Specialised MAs1

Delineated MA responsibilities into three distinct roles2: Rooming MA, Resource MA, and Administrative MA

Average daily net revenue in pilot clinics increased by $3563

Comparison of Specialised Support Staff Roles

For more information on these practices see the study Achieving Top-of-License Nursing Practice


An All-Hands-on-Deck Approach to Care

Complexity of Care Complicates Role Definition

Opportunity: Reinforce Top-of-License Prioritisation

In today’s complex health care environment, nursing responsibilities are more numerous and demanding. Consequently, frontline staff often adopt an all-hands-on-deck approach to care delivery rather than maintaining top-of-license practice.

Source: Advisory Board interviews and analysis.1) Enrolled nurse.2) Assistant in nursing.


“I think there’s a blurring of lines of responsibilities between the RNs and ENs in terms of what they can and can’t do. And I honestly do think both RNs and ENs are not really clear about their scope and what they can and can’t delegate. [RNs] just delegate and ask an EN to do something and they don’t realise the implications.”

Sample Care Team Responsibilities

Bathe and Toilet Patient

Activate Discharge Process

Turn Patient Every Hour

Develop Care Plan

Educate Patients on Post-Discharge Instructions

Feed Patient

Fill Out Documentation

Remove Catheter

Coordinate Care with Other Disciplines

Administer Medications

RN EN1 AIN2

Risking safety when support staff do work that is beyond their scope

Overspending on RNs doing work that could be safely done by AINs


A Structured Approach to Care Team Redesign

Leaders and Unit Teams Work Together to Define Revised Model

Practice 11: Customised Care Teams

Nursing leaders at Michael GarronHospital in Toronto, Canada, addressed inefficiencies on their units through a team-based staffing model.

The steps are shown here. First, leaders set clear goals. Next, they delineated each role, providing a template for general guidance for unit managers to use when delineating roles. Third, unit managers customisedthe roles to fit their practice environments. Finally, two pilot units implemented the model before leaders introduced it across the organisation.

Source: Michael Garron Hospital, Toronto, Ontario, Canada; Advisory Board interviews and analysis.

1) Registered practical nurse.2) Unregulated care providers.

Set Goals

• Hospital leaders defined their organisation-wide aims with redesigning the staffing model

• Goal was to create a collaborative, interprofessional team-based model

Define Roles

• Examined RN, RPN1

and UCP2 roles, creating task lists for each care provider based on different patient needs

• Resulting template provided general guidance for unitsto work with

Customise Model

• Leaders worked with unit staff, using patient simulations and template to determine appropriate roles and responsibilities

• Each unit was armed with plan for implementing team-based model based on unit-specific needs

Implement Model

• Starting with two pilot units, staff shifted to new team-based staffing model using unit-specific plan

• General model across all units includes an RN team leader, RPNs providing care, and UCPs providing coordinated support

“The polarity within this transformation is implementing necessary standards of care while honouring the ability for teams to create a care environment that reflects the unique needs ofthe individuals they serve.” Irene Andress, Chief Nursing Executive,

Michael Garron Hospital, Canada

Structured Customisation

Michael Garron’s Process for Changing the Staffing Model

Case in Brief: Michael Garron Hospital• Community teaching hospital located in Toronto, Ontario, Canada

• The challenges and inefficiencies in their traditional care model prompted a transition to a collaborative, interprofessional team-based model

• Patients on each unit are divided between two teams; each team includes an RN team lead, RPNs, and unregulated care providers; the number of each role within teams differs across units based on patient needs

• An intentional co-creation strategy involving staff informed the design, education, implementation and evaluation for sustainability of revised staffing model

• Hospital has achieved quality improvements, cost stability, and increased nurse satisfaction since implementation of this dynamic staffing model


New Staffing Model Leverages All Skills

In this team-based staffing model, all team members work at the top of their training.

The model is structured, yet flexible. Unit managers can adjust it based on their unit and patient needs.

The composition and roles of the core teams are shown here. An RN is the team leader, overseeing the care provided to patients on that team’s roster, maintaining a global perspective on all the patients. The RN will provide direct care when a patient’s acuity is particularly high. Under normal circumstances, the RPNs provide the majority of direct patient care, with the RN available for consultation. The unlicensed care providers (UCPs) provide basic support work.


1) Canadian Triage and Acuity Scale. Scale for patients entering the Emergency Department to help define patients needs for more timely and appropriate care.

• Responsible for daily living activities such as toileting, bathing, feeding, and ambulation

UCPs

• Responsible for providing global perspective and coordination of care for all patients under team purview

• Serves as team liaison with interdisciplinary groups

• Acts as consultant for RPNs and UCPs

• Provides direct care for high acuity patients, if needed

RN Team Leader

• Responsible for providing direct patient care for most of team’s patients

• Partner with RN team leader to provide necessary patient education, care planning, and to develop patient discharge plans

• May consult RN if patient acuity exceeds RPN scope of practice

RPNs

Role Responsibilities Within Team-Based Staffing Model

Example Unit Variations to the New Model

Surgery: Additional RN that doesnot play team lead role provides direct care for high acuity patients

Emergency Department: Heavy RN/RPN mix with UCPs matched to patient CTAS1 level to provide support within designated zones


Bundled Practices Further Embed Team-Based Care Delivery

Core Practices Implemented in All Units Key to Sustaining Team ApproachNursing leaders at Michael GarronHospital created daily practices to embed and sustain top-of-license work, shown here.

Each member of the care team has assigned responsibilities enabling them to consistently focus on work they are uniquely suited to do.

Leaders and staff believe these guidelines and practices are essential to daily care delivery.


Bundled Practices to Support Care Team Model Care Team Members Involved

RN Team Leader

RN Team Leader

RPNs UCPs

RN Team Leader

RPNs UCPs

DedicatedNurse

Interdisciplinary Team

Minute RoundsQuick rounds attended by the RN team lead and interdisciplinary team; review patient care plan including special needs and discharge plan

Post-Discharge Phone CallsDedicated nurse conducts post-discharge call within 48 hours to bridge transition plans including medication regimens, home care support, follow-up appointments, and service recovery as appropriate

Hourly Rounding (Care Rounds)Hourly rounds assigned to individual teammembers to check on patient needs

Bedside Shift ReportEntire team will do a round together prior to shift change to ensure right patients are assigned toright care provider


Improving Patient Care, Re-engaging Nursing Staff

Since redesigning their staffing model, leaders at Michael Garron report improvements in fall rates, staff satisfaction, and time spent at the bedside, as shown here.


Improving Quality and Maintaining Costs, Despite Increased Demand

Irene Andress, Chief Nursing Executive, Michael Garron Hosiptal, Canada

“When you consider the predominant focus in health care today is on cost, the challenge is really about balancing fiscal responsibility and achieving quality outcomes, both for the patients we serve and for those who serve them.”

Results Achieved Between 2009 and 2016 at Michael Garron Hospital

Increase in staff satisfaction scores

35.5%Increase in Patient Care Hours per Patient Day1

4.5%Decrease in number of falls per 1,000 patient days

48%

This study is a publication of the Global Centre for Nursing Executives, a division of Advisory Board. As a member of the Global Centre for Nursing Executives, you have access to a wide variety of resources, including webconferences, studies, toolkits, our blog, and more. Check out some of our other studies on cost savings.

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Rising Above the Bottom Line...In health care, rising costs over time hav e outpaced any gains made...

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