EP10 Nurses use trended data in the budgeting process, with clinical nurse input, to redistribute existing nursing resources or obtain additional nursing resources.
Provide two examples with supporting evidence from different practice settings where trended data was used during the budget process, with clinical nurse input, to assess actual-to-budget performance to redistribute existing nursing resources or to acquire additional nursing resources. Trended data must be presented.
Example 1
NAME OF INITIATIVE
Seven-day OR Coverage
BACKGROUND AND PURPOSE
There have been many studies that indicate worker fatigue and adverse events are linked (Sentinel Event Alert #48, 2011). These studies further indicate that increased work hours lead to increase in adverse events and pose increased threats to patient safety. According to several studies, nurses who work longer than 12.5 hours per day, have a higher risk of making an error when delivering patient care (Lockley, et al., 2007). Impact of fatigue from lack of sleep over an extended period of time include but not limited to: inability to stay focused; memory lapses; compromised problem solving; confusion; reduced motivation; and loss of empathy (Lockley, et al., 2007).
The hours of operation for Homestead Hospital’s Surgical Services are Mondays through Fridays 7 a.m. to 7 p.m. The department is closed Monday through Friday after 7 p.m. to 7 a.m., along with weekends and holidays. The operating room (OR) and post-anesthesia care unit (PACU) are covered during the off hours by placing staff members on-call. These call hours are assigned to staff members for the entire weekend and rotated accordingly. If a surgical case needs to be performed during off hours, the surgeon calls the nursing supervisor. The nursing supervisor then notifies the on-call staff to come in. The on-call cases after hours and on weekends result in staff overtime (OT), usually an extra 8-12 hours for each staff member per day. The on-call staff members are also scheduled to work their regular hours Monday through Friday. The amount of extra hours worked per week could potentially increase worker fatigue. Additionally, there had been a steady increase in surgeries being performed on weekends from fiscal year 2011 to fiscal year 2013. This resulted in the on-call staff working more weekend hours and being assigned to a call weekend more frequently, that is, every 6-7 weeks. Many staff members split their weekends to reduce hours worked in one week. However, this increased the frequency of weekend call; hence, it did not provide a satisfactory solution.
Clinical Nurse Input
On March 13-14, 2013, the Surgical Services department held a team retreat. The purpose of the retreat was to increase engagement and teamwork. It was held from 7 a.m. to 11:30 a.m. on 2 consecutive days. The OR was closed for elective surgeries on those 2 days from 0700–1200. The employees were divided into 2 groups – the first half attended the first session and the other half participated in the second session. The attendance was mandatory for all Surgical Services staff members and anesthesiologists. Part of the agenda was to have a panel discussion with senior leaders, namely: Vice-President and Chief Nursing Officer Gail Gordon, RN, Surgical Services Director Carmen Bouchard, RN, Chief Executive Officer Bill Duquette, Board Member Chairman Reverend William Chambers, lll, and Anesthesia Chief Samir Kulkarni, MD. (EP10 01 Surgical Services Retreat Agenda and Notes March 13-14, 2013) During the question and answer session, several staff members including Clinical Nurse Janice Powell-Gates, RN and Surgical Technician Tiffanie Watson had questions and concerns regarding the amount of hours they were working in the evenings and weekends. Many were concerned about fatigue related to long hours and the amount of extra hours worked over their regular work schedule.
Purpose
The purpose of this initiative was to obtain adequate staff to expand the hours of operation to 7 days a week in Surgical Services which would result in decrease OT and worker fatigue, as well as improve patient safety and patient/staff satisfaction.
METHODS & APPROACH
After the retreat, the leadership team, Bouchard and Nurse Manager Wanda Vargas-Rosado, RN, approached several staff members in small informal groups to brainstorm possible solutions to the increased hours worked related to on-call coverage. Clinical Nurses Powell-Gates and Maritza Colon, RN voiced their concerns regarding the increase in the amount of hours worked while on call. The staff voiced concerns that many of the cases they were called in for did not meet the emergent or urgent criteria. Bouchard spoke with the surgeons and found out that in fact many cases could wait until Monday. However, surgeons opted to perform cases on the weekend so the patients could be discharged from the hospital sooner resulting in decreased length of stay and opening up of inpatient beds during the week.
Powell-Gates attended the 2013 AORN’s 60th Annual Congress and brought information to Bouchard and Vargas-Rosado regarding safe practices for on-call scheduling. She, along with Colon, brought to the leadership team the “AORN Guidance Statement: Safe On-Call Practices in the Perioperative Setting” (Association of Perioperative Nurses, 2013). This recommendation encouraged facilities to promote worker and patient safety with regards to the number of hours worked. It provided a review of the problems associated with staff members working long hours during scheduled and on-call hours. It offered recommendations for organizations to develop staffing plans that would minimize long work hours and allow staff members appropriate recuperation time between work hours.
During follow up discussions on the weekend staffing issue, many of the OR and PACU clinical staff articulated having a weekend staff as a solution to this problem. Bouchard felt the OR’s increased volume would justify staffing the weekends. CNO Gordon supported the need to staff the Surgical Services department on Saturdays and Sundays. In June 2013, Bouchard met with Assistant Controller Liliana Fong to evaluate the current FTE usage and plan for the additional full-time equivalent (FTE) budgeting for fiscal year 2014.
Use of Trended Data
Bouchard created a spreadsheet which included all scheduled FTE’s and OT by department and position classification. Fong compared this to current FTE usage. (EP10 02 Surgical Services Labor Worksheet) Bouchard used data available from the surgical scheduling system to recognize specific trends. She identified that majority of the weekend surgeries were between 7 a.m. and 5 p.m. Based on this information, she developed a proposal to staff the weekends during the aforementioned times. Fong presented the proposal to senior leadership in June 2013. Senior leaders reviewed the budget and approved the additional FTEs to be budgeted for FY 2014.
Exhibit EP10a: Trended Data for Weekend Surgical Volume and Room Time
Analysis: Above graph shows surgical case volumes have been consistently high during the weekend, with more cases done on Saturdays vs. Sundays, for the past 2.5 fiscal years.
Exhibit EP10b: Trended Data for Weekend Surgical Cases by Time of Day
Analysis: When drilled down to which shifts have the highest weekend surgical volumes, the above graph demonstrates that the majority of cases were performed from 7 a.m. to 7 p.m. for the past 2.5 fiscal years.
Additional Nursing Resources Acquired
Human Resources department posted the additional FTEs in August 2013. The additional FTE’s include 1 full time RN for the Preoperative area; 1 full time RN for PACU; 1 full time RN and 1 full time Surgical Technologist for the OR; 1 full time Surgical House Physician; 1 part time Anesthesia Technician; and converting a part time position in Central Sterile to a full time position. All but one of these positions was filled by December 1, 2013. The Patient Care Supervisors, Clinical Nurse Educator and staff preceptors on-boarded and oriented the new hires. Weekend staffing began in January 1, 2014. (EP10 03 DRR Budgeted FTE’s) The addition of these new FTEs and roles supported the Surgical Services’ care delivery system.
PARTICIPANTS
The team members involved in this initiative were:
Name/ |
Years RN / |
Title |
Department |
Role in the Team |
Janice Powell-Gates, RN, CNOR |
14 years RN/ |
Clinical Nurse |
Surgical Services |
Provided clinical staff input and brought information on the “AORN Guidance Statement: Safe On-Call Practices in the Perioperative Setting” |
Maritza Colon, RN, CNOR |
25 years RN/ |
Clinical Nurse |
Surgical Services |
Provided clinical staff input and brought information on the “AORN Guidance Statement: Safe On-Call Practices in the Perioperative Setting” |
Carmen Bouchard, MSN, RN, CNOR |
28 years RN / |
Director |
Surgical Services |
Project Lead |
Wanda Vargas-Rosado, BSN, RN, CNOR |
25 years RN / |
Patient Care Manager |
Surgical Services |
Team Member |
Gail Gordon, MSN, RN, NEA-BC |
45 years RN/ |
Chief Nursing Officer (CNO)/ Vice President |
Nursing Administration |
Executive Sponsor |
Liliana Fong, BA |
29 years / |
Assistant Controller |
Finance |
Assisted with the FTE budget proposal |
Bill Duquette, MPH, MT(ASCP) |
30 years / |
Chief Executive Officer |
Administration |
Approved additional FTEs |
OUTCOME(S)
In the old staffing plan, staff was pre-scheduled for on-call weekend shifts in addition to their regular work week. This often led to long work weeks and OT due to high surgical volume. As a result of the additional FTE’s, Surgical Services was able to implement 7-day OR coverage beginning the weekend of January 4 & 5, 2014. Vargas-Rosado updated the OR scheduling policy to reflect the hours and staffing for the department on the weekends. (EP10 04 HH-400-3600-600-006 Scheduling Operating Room)
Increasing the number of employees has ensured that the department is staffed appropriately 7 days a week. The new staffing model aligned Surgical Services with the intent of the “AORN Guidance Statement: Safe On-Call Practices in the Perioperative Setting”, by minimizing extended work weeks and long work hours as evidenced by decreasing OT hours.
Exhibit EP10c: Surgical Services Average Weekend Overtime Hours
Analysis: Above graph illustrates a reduction in weekend OT hours in various surgical cost centers with Ambulatory Surgery achieving the most dramatic reduction. Interestingly, OT hours increased in Endoscopy because instead of doing only emergency cases, gastroenterologists started performing more scheduled endoscopies on the weekends knowing that nurses were available.
Another purpose of this initiative was to improve staff satisfaction. The Employee Engagement survey conducted in May 2014 showed an improvement in the percentage of engaged employees from 61.5% to 74.6% compared to 2013 with corresponding drop in the percentage of actively disengaged from 8.7% to 3.2% (Avatar 2014 Executive Summary Report).
For FY 2016, the goal would be to expand the weekend coverage to include a scheduler on the weekend. This would allow the physicians to call the same number for add-on cases as they do Monday through Friday. This would also enable the scheduler to enter the charges on weekend decreasing the likelihood of late charges.
References
Lockley, S., Barger, L., Ayas, N., Rothschild, J., Czeisler, C., & Landrigan, C. (2007). Effects of health care provider work hours and sleep deprivation on safety and performance. Joint Commisssion Journal on Quality and Patient Safety, 33(11),7-18.
Sentinel Event Alert #48. (2011, December 14). Retrieved from The Joint Commission: www.jointcommission.org
Summary Attachments/Hyperlinks/Evidences
EP10 01 Surgical Services Retreat Agenda and Notes March 13-14, 2013
EP10 02Surgical Services Labor Worksheet
EP10 03 DRR Budgeted FTE’s
EP10 04 HH-400-3600-600-006 Scheduling Operating Room
Exhibit EP10a: Trended Data for Weekend Surgical Volume and Room Time
Exhibit EP10b: Trended Data for Weekend Surgical Cases by Time of Day
Exhibit EP10c: Surgical Services Average Weekend Overtime Hours
Example 2
NAME OF INITIATIVE
Decreasing Length of Stay (LOS) in the Emergency Department (ED) by Creating an Innovative Role
BACKGROUND AND PURPOSE
Homestead Hospital’s ED is the fourth busiest in Miami-Dade County with visits rapidly approaching 100,000 visits annually. The majority of these patients are seen in the low-acuity “treated and released” minor care area of the ED. The LOS in this area has often approached 5-6 hours for a number of reasons including extended wait times for radiology, ultrasound, and laboratory results, and waiting times for providers to disposition patients. The Center for Medicare and Medicaid (CMS), in data collected from 10/1/2012 to 9/30/2013, reported that the average national LOS in the ED from admission to being sent home was 134 minutes and the Florida average was 147 minutes. The average LOS at Homestead Hospital for the same time period was 174 minutes (Centers for Medicare and Medicaid, 2014). However, in a 1 week period from April 27, 2014 to May 3, 2014, average LOS was 225 minutes.
Clinical Nurse Lisa Smith, RN began to research methods used by performing a literature search of other EDs to improve patient flow through this area. One report described the methodologies utilized by Lakeland Regional Medical Center in Florida that implemented a bundle of strategies to improve ED throughput (Agency for Healthcare Research and Quality, 2013). Strategies used to facilitate this process included utilizing a previous flow method introduced in the ED 3 years ago. Door-to-Doc (D2D) improved patient flow by using a Split Patient Flow model. One strategy caught Smith’s attention which was the use of an RN to monitor and manage patient flow in the busiest area of the ED. The implementation of the Patient Flow Facilitator (PFF) included objectives focused on:
- Capacity Constraints
- Increased visits
- Holding inpatients
- Long waits for patients arriving
- Patients deteriorating in the waiting room
- Patient complaints, patient dissatisfaction
- Patients leaving without treatment
- Long waits to see an ED physician related to LWBS.
Smith brought the information to the attention of ED Nursing Director Sherine Craig, RN who also expressed an interest with the idea. Craig approved to have a group of nurses participate in a Lakeland Regional Medical Center ED site visit. The purpose of the trip was to observe first-hand the ED reorganization implemented there that focused on goals to improve throughput efficiency.
Use of Trended Data
Exhibit EP10d: Trended Data on Homestead Hospital’s LOS
Source: medicare.gov/hospitalcompare Retrieved 12/11/14
Analysis: Above graph indicates that Homestead Hospital’s ED average LOS before patients are sent home was above both the state and national average
Goal
To decrease ED LOS. LOS was defined as the total time from the patients’ arrival until the disposition.
METHODS & APPROACH
In October 2013, Craig and Smith, together with Clinical Nurses Letiana Severe, RN, Marc Celiz, RN, Benjamin Levy, RN, Physician Assistant Syad Ali, PA-C, and Administrative Assistant Dorothy Russo, traveled to Lakeland Regional Medical Center in Lakeland, Florida for a tour of their ED. The team met ED and Supportive Services Assistant Vice President Maureen Leckie, RN. She provided the Homestead Hospital team with a detailed description and showed them how the ED throughput operated prior to the innovation compared to the current throughput methods. Lakeland began their unit changes by reorganizing their space into pods. Their triage pod consisted of a nurse supervisor and 3 RNs. Each of the 6 adult and pediatric pods comprised of 12 rooms. One pod contained 2 beds for critical care patients, staffed by a physician, 4 RNs and nurse supervisor who monitored and managed patient flow for the assigned pod.
Lakeland reorganized their staffing pattern to provide, in addition to the nurse supervisor, a bed traffic controller for the triage pod; a throughput coordinator during off-hours and weekends; and an Assessment-Care-Treatment (ACT) team led by the triage supervisor when pods were full. The ACT team is described as a small group of RNs led by the triage supervisor that could initiate physician approved protocols to begin laboratory testing and other services. This was initiated prior to bed assignments, thereby reducing delays. The team was activated if a patient waited for bed assignment for more than 15 minutes after triage. The Homestead Hospital ED team was particularly impressed with the information and ideas they received from the facility tour.
Clinical Nurse Input
Upon returning, Craig endorsed the formation of an ED Throughput Committee. Its purpose was to address opportunity areas identified in ED patient flow and filtering these ideas through the shared governance structure. Craig wanted to ensure that direct care staff had participation in the decision-making and implementation of the change process. The committee would report to the ED Unit Practice Council (UPC) on a regular basis with updates and would also seek input to make changes. The committee members consisted of ED Clinical Nurses, a Patient Care Supervisor (PCS), ED Technicians, a Certified Nursing Assistant (CNA), and a Performance Improvement (PI) Nurse. Clinical Nurses Smith and Sheila DeBow, RN volunteered as co-chairs.
The committee first met in March 2014. During this meeting, Smith described her visit to Lakeland Regional Medical Center and the best practices she had learned while touring and meeting their ED staff. There were several innovative practices that Lakeland Regional Medical Center implemented which improved their patient throughput. This created a lot of excitement in the group and discussions on which best practices could be applied to Homestead Hospital ED ensued. After some deliberations, the team decided to initially pursue the Patient Flow Facilitator (PFF) model.
Lakeland utilized a PFF, an RN who monitored patient flow, identified and addressed any care delays. The PFF also followed-up on diagnostic tests that have not been performed or on results that have not been received. An important part of this role was communicating with providers when results were received and prompting physician and physician assistant decisions on patient disposition (whether admission or discharge). A research study at a large academic medical center showed that implementing a PFF resulted in the decrease of LWBS by 1.5% saving more than $5 million annually in lost potential charges (Murphy et.al, 2014). The implementation of the PFF could address capacity constraints, long waits and patients leaving without treatment.
Redistribution of Existing Resources
Since the initiative started in the middle of FY (Fiscal Year) 14, there were no extra FTEs budgeted that could accommodate a new PFF role. The committee decided that redistributing existing human resources would be a viable way to proceed while Craig submitted a request for additional FTEs for FY 15 budget.
The flow of the ED began with registering patients at the front desk; obtaining vital signs; and being triaged by the RN. Once the patient has been triaged, they were placed in the appropriate area based on their acuity. Based on the patients’ complaint and acuity level, appropriately assigned patients for minor care would either go to task for laboratory work or to the waiting room for radiology studies to be completed. If the patient had an IV in place, they would be placed in CDU (clinical decision unit). This area was staffed with 1 or 2 nurses who would check to ensure all patients’ results were reported the nurses would then notify the provider of the results and prompt them for a disposition decision. The nurses assigned to that area were also responsible for completing medication reassessments and following up on all patient concerns. In addition to these responsibilities, the nurses also ensured that orders were completed in a timely matter by communicating with ancillary departments for pending radiology, ultrasound and CT scans. Any abnormal results or delays were promptly reported to the provider.
Plan
Research has shown that an ED flow coordinator, when supported by departmental and hospital leadership can be a successful and a cost-saving measure (Murphy et al., 2014). The Throughput Committee first analyzed reasons for delay in the front end of the ED, which is also one of the busiest areas of the unit. This area consisted of triage bays, fast track (minor care), task room, and CDU, which was also referred to as the discharge area. ED delays were results of lengthy waits for radiology, ultrasound and laboratory results, which delayed providers dispositioning their patients. To identify all factors contributing to the delay, the committee requested a TRIM analysis of the front end. (EP10 05 Throughput Committee Minutes 4/2/14).This gave a visual depiction of the multiple steps involved in patient flow. Center for Performance Excellence Consultant Erik Rico from Corporate joined the Throughput Committee in May 2014 and facilitated a “Teams, Refocus, Imagine and Measure (TRIM) project (EP10 06 ED Throughput TRIM). The TRIM process assisted the group in identifying which areas were causing a delay in the front end.
Do
Committee members in-serviced ED RNs on the new position and responsibilities in March 2014 during shift huddles. The office in the front of the ED was changed from a discharge office to the PFF office. ED Throughput Committee members displayed instructions on the process along with ancillary department numbers on the wall in the PFF office and disseminated them to all staff members. The pilot began in the first week of April 2014.
One of the 2 discharge nurses in CDU was assigned as PFF to monitor the patients’ overall progress which entailed the time of arrival in triage to discharge. RNs that were proactive, with exceptional organizational and communication skills, were assigned to work as PFFs for the pilot program. The committee developed a list of responsibilities and posted them in the designated PFF room. The PFF checked patient orders to make sure all orders were carried out. The nurse assuming this role also communicated with CT, radiology, ultrasound and the laboratory to ensure orders were completed and resulted. During this process, the goal was also to keep the patient updated on their progress. When all results were received, the PFF notified the provider and requested disposition of the patient. During this transition, patient flow remained the same but the key change was in the PFF role who followed-up on the patient’s progress during their ED visit.
Check
Smith and DeBow collaborated with Quality Assurance Nurse Desi Wooten, RN to gather pre-and post-implementation data on average and median LOS for patients. They presented the pre-data during the first throughput meeting in March 2014, as a baseline measure for improvement. Smith evaluated the data approximately 4 weeks post-implementation to get an average LOS. Wooten gathered the data from T-systems (ED’s electronic medical record system). She calculated LOS using only patients seen through fast track (minor care) and excluded those seen in the main area of the ED. This allowed the committee members to accurately evaluate the impact of the PFF role.
Act
Initially, the Throughput Committee did not consistently meet their LOS goals due to several factors. For example, there was an increase in intravenous medication ordered instead of IM (intramuscular) or PO (by mouth), and the PFF who were assigned were not consistently following the guidelines of the role. At times, the PFF got pulled to provide patient care when volume was high. The committee invited ED Medical Director Otto Vega, MD to the May 2014 meeting and discussed the challenge of having too many IV medications on the front end. They also talked about enhancing the role of the PFF to that of a team leader. The PFF would communicate with all areas including intake, task, CDU and triage in order to expedite patient discharges.
PARTICIPANTS
Name/Credentials |
Years RN/ |
Title |
Role in the Team |
Sheila DeBow, BSN, RN, CEN |
11/9 |
Clinical Nurse |
Co-Chairperson |
Lisa Smith, RN, CPEN |
6/6 |
Clinical Nurse |
Co-Chairperson |
Jessica Gonzalez, BSN, RN, |
2/2 |
Clinical Nurse |
Member |
Karin Ameri, BSN, RN |
20/19 |
Clinical Nurse |
Member |
Christina Smith, RN |
8/8 |
Clinical Nurse |
Member |
Rene Bascoy, RN, CCRN, CPN |
10/8 |
Clinical Nurse |
Member |
Carlos Delgado, BSN, RN |
7/1 |
Clinical Nurse |
Member |
Liliana Zucki, BSN, RN |
16/6 |
Clinical Nurse |
Member |
Sherine Craig, BSN, RN, CNML |
17/12 |
Director |
Administrative Support |
Victor Garcia, ,BSN, RN |
17/17 |
Patient Care |
Administrative Support |
Silvia Hill, RN |
20/15 |
Patient Care |
Administrative Support |
Andrew Seaman, BSN, RN, CEN |
20/18 |
Patient Care |
Administrative Support |
Manny Claro, EMT-P |
5 |
Medic/Technician |
Member |
Jermaine Gray |
5 |
CNA |
Member |
Dorothy Russo |
|
Secretary |
Clerical Support |
OUTCOMES
As a result of the team’s findings, Craig requested additional FTE’s to support the staffing needs of the unit in conjunction with reducing LOS. In October 2014, she presented FTE justifications to senior leadership indicating the need for additional positions. (EP10 07 Approved FTE Request). The positions were granted and approved for use in FY 2015. With these new RN FTEs, Craig would be able to consistently allocate for PFF roles when rapid care is opened from 10 a.m. – 10 p.m. (EP10 08 Staffing Sheet)
Summary
Trended data are effective tools that clinical nurses can utilize to advocate for additional resources to their nurse leaders, which in turn nurse leaders can use for the budgeting process. Collaboration among the staff and the interprofessional team is key to successful implementation of an innovative PFF model. Ongoing measurement and monitoring of metrics coupled with organizational commitment will help sustain some of the initial outcomes.
References
Hospital Compare Timely & effective care: Emergency department care-details. Retrieved from Medicare.gov, November 13, 2014.
Leckie, M. (n.d.). Comprehensive bundle of strategies improves emergency department turnaround time, reduces boarding time and patients leaving without being treated. Retrieved September 27, 2014, from http://innovations.ahrq.gov.
Murphy, S., Barth, B., Carlton, E., Gleason, M.,& Cannon,C. (2014). Does an ED flow coordinator improve patient throughput?Journal of Emergency Nursing.
Summary of Attachments/Hyperlinks/Evidences
EP10 05 Throughput Committee Minutes 4/2/14
EP10 06 ED Throughput TRIM
EP10 07 Approved FTE Request
EP10 08 Staffing Sheet
Exhibit EP10d: Trended Data on Homestead Hospital’s LOS