EP8.    Describe and Demonstrate how Nurses Use Trended Data to Formulate the Staffing Plan and Acquire the Necessary Resources to Assure Consistent Application of the Care Delivery System.

Managers use budgeted nursing hours per patient day, determined through the annual budget process, as the foundation for developing staffing plans for each patient care unit. The staffing plan identifies the average daily census, number and skill mix of patient care personnel needed, as well as the number of registered nurses required to meet benchmark standards on a 24 hour a day basis. Patterns of daily, weekly, and seasonal volume variability are considered to most appropriately match scheduled nurses to the actual census and assure that necessary nursing hours per patient day are maintained. Reference materials available include the Nursing Section of the Plan for the Provision of Patient Care, (Reference Document CC); NAP 2.12: Assignments in the Provision of Nursing Care; and NAP 3.02: Guidelines for Scheduling Personnel. (See policies in Appendix EP8-A(1) and Appendix EP8-A(2).) All of these resources are accessible to nurses on NM Connect.

Based on the unit staffing plan, clinical coordinators, in collaboration with their managers, construct a schedule on each unit to provide a prospective plan to meet patient needs. Throughout the organization, a six week cycle is used for planning and posting unit schedules. The scheduling template, based on historical trended data, projects patient census and clinical activity, such as admissions, transfers, and discharges by day of week and time of day. The schedule is constructed to assure safe staffing levels at all times, in accordance with pre-established patient care ratios and acuity guidelines developed through benchmarking national data.

Patient acuity is assessed, documented, and trended to monitor and identify patient populations with changing care needs. On all inpatient units, staff nurses and clinical coordinators collaboratively assess the acuity of every patient at three points daily (0500, 1300, and 2100). Each patient is assigned an acuity score of 1, 2 or 3, based on specific unit guidelines. An average “unit acuity” score is determined and entered in the VasTech IntraGale 24/7 staff scheduling system. Trended increases or decreases in unit-based acuity scores provide data to guide decision-making for reallocating nursing resources among units. Examples of unit-based acuity tools from two units are displayed in Appendix EP8-B(1), Appendix EP8-B(2), Appendix EP8-B(3), Appendix EP8-B(4), and Appendix EP8-B(5).

Work is currently underway through our Nursing Professional Practice Committee (NPPC) to refine unit-based acuity measurement so that trended data more effectively support formulation of the staffing plan. (See sample NPPC minutes in Appendix EP8-C.) The NPPC is collaborating with the Departmental Shared Leadership Committees to evaluate the reliability and validity of our unit-based acuity tools. They are reviewing the literature to identify best practices and comparing data obtained from individual units using the specialty-specific acuity tools.

Managers regularly use tools to monitor staffing levels against budgeted resources and actual patient volume demands. The biweekly staffing assessment tool was developed internally to track statistics such as functional vacancy rates, and anticipated terminations. This tool assists managers in ensuring that they have the appropriate staff needed to care for patients and take the steps necessary to fill vacancies. Additionally, an optimal staffing model is updated on a monthly basis to determine if a unit requires additional resources as a result of a sustained higher than budgeted patient census or unseasonal surge in volume. A threshold is defined on a unit-specific basis and additional staff is allocated as appropriate. Examples of how the biweekly staffing assessment and optimal staffing model have been applied to ensure consistent application of our Patient Centered Care Model are shown in the examples 1 and 2 below.

Example 1:     Managing Unexpected Volume Fluctuations in the Renée Schine Crown Neonatal Intensive Care Unit (NICU)

In the Neonatal ICU at Prentice Women’s Hospital, managers and clinical coordinators monitor daily patient census and acuity and gauge their staffing needs against the unit’s ability to respond. The unit tracks additional shifts worked and shifts reduced for all staff, and continuously updates a log book with data on patient diagnosis and gestational age. This allows staff to analyze and monitor census trends.

In December of 2009, the NICU experienced significantly higher volumes than had occurred in December of the two previous years (39% higher than December of 2008 and 65% higher than December of 2007.) Through engagement of clinical coordinators in daily staffing assessments and timely responses to patient volume demands, our NICU nurses were able to quickly identify, in collaboration with the NICU Manager, Jodi Trotter, RN, BSN and Director of Women’s Health, Ann Schramm, RN, MSN, NEA-BC, that this was a situation of critical staffing need.

Ann and Jodi collaborated with Dina Pilipczuk, Business Manager, Patient Care Services and Kristin Ramsey, RN, MSN, MPPM, NE-BC, Director of Operations and Associate Chief Nurse Executive as well individuals from Human Resources and Elena Hill, RN, BSN, Manager of the Float Pool to establish a response plan. As part of the plan, an additional 4.5 FTEs were approved and hired. In the meantime, premium pay staffing was approved by Michelle Janney, our Wood-Prince Family Chief Nursing Executive. Premium pay was approved on a shift by shift basis in conjunction with pre-defined triggers based on census and acuity. The unit’s staffing and patient volumes were successfully stabilized by January. A copy of the NICU Master Staffing Assessment is shown in Appendix EP8-D.

NICU nurse leaders are continuing to use available tools to closely monitor staffing and volume and have already designed a plan in anticipation of a seasonal increase in volume during the summer months. NICU nurses’ use of trended data enabled them to identify a staffing need, escalate it appropriately and develop a plan to obtain the necessary resources to ensure consistent application of the care delivery system.

Example 2:     Responding to Higher Than Budgeted Census on the Urology Surgery Unit

During the first quarter of fiscal year 2009, our 12 West Urology Surgery Unit experienced a sustained average daily census that was approximately 58% higher than budgeted. Historical volume trends were evaluated and a thorough staffing needs assessment was performed by Ashley Currier, RN, BSN, Manager 12 West in collaboration with Carol Payson, RN, MSN, NE-BC, Director of Inpatient Surgical and Ortho-Neuro Nursing. Their analysis demonstrated that the unit needed an additional 8.3 FTEs to adequately care for its volume of patients.

Michelle Janney, our Wood-Prince Family Chief Nurse Executive approved the additional FTEs, and Ashley quickly moved forward with hiring. Leaders on the unit collaborated to successfully train new staff in an efficient manner to meet the volume growth. The unit’s staff educator, Tracy Haymon, RN, BSN, CMSRN, strategically organized orientation and preceptor time to ensure an effective experience for all staff.

The experience on 12 West served as the launching pad for the development of the optimal staffing model that is currently used to evaluate the need for additional resources on all units. The model enables managers of units experiencing higher or lower volumes than those budgeted to determine the percent to which they should be over or under hired. A copy of the Optimum Staffing Model is shown in Appendix EP8-E.

Example 3:     Increasing Nurse to Patient Ratios in the Cardiovascular and Transplant Intensive Care Unit as a Result of Patient Acuity

During fiscal year 2008, direct care nurses in the Cardiovascular and Transplant Intensive Care Unit (CTICU) recognized that an increasing number of patients with higher acuity and complex needs were requiring more hours of nursing care. Clinical coordinators were appropriately assessing and flexing staffing every four hours based on patient acuity, anticipated admissions and transfers and other clinical activities. They found, however, that assigning appropriate staff to meet patient acuity levels and care needs resulted in direct nursing hours per patient day (DHPPDs) that consistently exceeded budgeted hours. After the first six months of the fiscal year, year to date DHPPDs reflected a negative 0.74 variance compared to the budgeted hours (17.37). Kathy Hanson, RN, MS, NE-BC, and Paul Langlois, RN, PhD, CCRN, CCNS, CNRN, CTICU Managers, collaborated with unit nurses to reassess staffing requirements for patients in the CTICU. Their goals were to ensure safe and effective care for their patients as well as fiscal responsibility. They identified that Northwestern Memorial’s CTICU patient population is not typical of other intensive care units used for benchmarking staffing ratios. The CTICU houses both solid organ transplant and cardiac surgical patients. All of these patients require a 1:1 nurse to patient assignment for at least a portion of their ICU stay. Patients with a ventricular assist device, or who have undergone heart transplantation, sometimes require 2:1 nurse to patient assignments.

Kathy and Paul reviewed comparative staffing data from benchmarking sources. Solucient Action O-I data demonstrated that productive hours per patient day (HPPD) in the CTICU fell below the 50th percentile of comparison units for the previous three quarters. The Labor Management Institute Annual Survey of Hours Benchmark Report revealed average nurse to patient ratios of 1:1.4 on days and 1:1.5 on nights for database intensive care units as compared with 1:1.5 on all shifts in the CTICU. Assessment of the five intensive care units at Northwestern Memorial demonstrated that the CTICU had a higher case mix index (4.88) than any other of the other four units (range 2.68-3.64).

To better support unit staffing adjustments, CTICU direct care nurses were asked to participate in the development of criteria-based guidelines for 1:1 or 2:1 nurse to patient assignments. Using information from the nursing literature, critical care colleagues, and their own clinical expertise, guidelines were formulated and implemented to ensure that the same criteria would be used by each clinical coordinator in guiding staffing assignments. (See Appendix EP8-F for Criteria for 1:1 and 2:1 Assignments)

The criteria-based ratio guidelines and benchmarked staffing data provided Carol Payson, RN, MSN, NE-BC, Director, Inpatient Surgical and Ortho/Neuro Nursing, and Michelle Janney, RN, PhD, NEA-BC, our Wood-Prince Family Chief Nurse Executive, with evidence to advocate successfully for reallocating resources to increase the staffing on days from 1:1.5 to 1:1.4. A budget variance was approved for the remainder of the fiscal year and the increased nursing hours were incorporated into the fiscal year 2009 budget.