• October 2008 FEATURE ARTICLES •
Scheduling: Case History
The Needs of the Many
A Phoenix-based medical center implements an automated patient acuity staffing and scheduling solution.
By Dave Kempson
Getting the right nurses in the right place at
the right time goes a long way toward optimizing the efficiency
and effectiveness of hospital care. That is why chronic over-
and under-staffing is a vexing problem. Is it reasonable for one
unit to have a surplus of nurses who possess the skills and
credentials to work in another unit that is struggling along
with too few? If two nurses on the same shift each have three
patients, should one be assigned their unit’s three patients
with the most intense care needs while the other cares for three
average patients?
Maricopa Medical Center (MMC) implemented
specialized software in its staffing and scheduling system (a
set of system interfaces) as well as management processes to
match staffing to the needs of patients and thereby schedule
nurses appropriately across units and balance workloads within
them. We wanted to ensure that every unit has the appropriate
number of nurses with the skill sets required to provide quality
care given the complexity of patients’ conditions and the
intensity of services they are likely to require during the next
shift. Moreover, Arizona law requires hospitals to account for
severity. Our charge nurses in five of our 22 units had been
documenting patient acuity for more than three years. However,
the process of calculating the level of acuity for each patient
was not automated, nor was it directly linked to staffing and
scheduling. Consequently, it was not possible to use the
definitions and measurements of patient acuity in real time to
assign staff based on patients’ clinical needs. Our primary
objective was to automate the process and then extend it across
the hospital so that we could start using patient acuity to
guide staffing and scheduling.
Staffing and Scheduling System
MMC is a full-service acute care teaching
hospital with 450 inpatient beds. It has approximately 20,000
inpatient admissions annually and some 50,000 patients count on
MMC for urgent and emergency care each year. MMC is the flagship
of Maricopa Integrated Health System (MIHS), a publicly-funded
health system in Phoenix. MIHS functions as the healthcare
safety net for many citizens of Maricopa County, Ariz., many of
whom face major challenges such as lack of health insurance,
complex medical problems and difficult socioeconomic situations.
Maricopa uses the RES-Q Labor Resource
Management (LRM) solution from RES-Q Healthcare Systems for
staffing and scheduling. It produces clinically sound,
skill-matched, financially optimized and productive staffing in
schedules that account for staff preferences. We have 475 active
users of the system and use it to manage staffing and scheduling
for 1,300 clinical employees. The system includes personnel
management with profiles for each employee. Certifications,
license renewal dates and special skill sets are among the
information maintained. The software translates hospital-defined
workload standards into specific staffing patterns by employee
skill level. It then uses the calculated staffing model and
schedules properly credentialed and licensed employees.
In August 2007, Maricopa added the RES-Q
Patient Acuity module to automate the calculation of each
inpatient’s acuity level and to integrate the results with
staffing and scheduling. The module provides an interactive
acuity tool that enables nurses to document nursing
interventions and other patient attributes by selecting items
from department-specific lists. Each attribute has an assigned
relative workload value, defined in units of time such as an
hour or a specific fraction of an hour. As attributes are
selected, the module automatically calculates the acuity level
(from one to seven) for each patient by shift. The system then
utilizes the resulting patient classifications to automatically
calculate optimal staffing for every unit by shift. Thus, we use
the software to determine the correct number and skill mix of
nurses that should be scheduled to provide appropriate patient
care and to balance workload — based on the intensity of
patients’ medical needs and the amount of nursing time required
to care for them. A total of 22 units are currently utilizing
RES-Q LRM with the Patient Acuity module.
Matching Resources To Patients’ Care Needs
To implement the process of matching staffing
and workloads to patients’ levels of acuity, each unit defined
its baseline patient and identified their attributes, hours of
care and staffing requirements. They then summarized the basic
services required for their typical patient across four
categories: Patient Care; Medication and Line Management;
Procedures, and Other (e.g., communication with physicians and
patients’ families). Attributes were then identified that are
associated with higher-acuity patients along with the additional
time each attribute adds to patient care. The sum of attributes
and associated workload values establishes each patient’s acuity
level and as the numbers of attributes and workload totals
increase from the baseline, the acuity level increases
appropriately.
Our vendor customized the Patient Acuity
module’s screens for each unit to establish department-specific
attribute lists. The Surgical, Medical and Coronary ICUs use the
same basic definitions of baseline patients. Interventions for
higher-acuity patients in our ICUs include, among others:
nursing services (such as two or more chest tube insertions at
bedside and changing medication dosages every hour or more
frequently); continuous renal replacement therapy (CRRT); and,
behavioral restraint monitoring and documentation. These
attributes increase the amount of necessary nursing time. For
example, Acuity Level 5 patients in the ICUs require up to six
hours of nursing care per 12-hour shift, and the nurse to
patient ratio is 1-to-2.
Agency nurses, float nurses and new nurse
employees use laminated copies of their unit’s patient attribute
lists as a tool to specify attributes for their assigned
patients. Charge nurses, assistant nurse managers and nurse
managers function as authorized users of the system and use the
module screens to enter patient attributes into the system.
Every shift, the charge nurse is responsible for completing
acuity determination by four hours prior to the next shift. The
system then calculates the number of nurses required and
compares the optimal staffing to the baseline staffing scheduled
for the next shift. That gives our staffing offices an overall
view of staffing needs and variances by skill level across all
units based on patient acuity. In coordination with the charge
nurses, the staffing offices can assess "whole house" nurse
staffing needs and quickly determine which units are under- or
over-staffed for the next shift. Schedules are then adjusted
accordingly to balance staffing among and within all units by
two hours before the start of the next shift.
System Interfaces
Five automated interfaces, which were
designed with vendor assistance, have already been developed and
implemented with two more scheduled to be in place by the end of
2008.
Employee Demographics Interface: Sends employee demographics from the Human Resources module of
Maricopa’s hospital information system (HIS) to RES-Q LRM and to
the time and attendance system once daily, populating the LRM
employee database.
Agency Staff Interface: Sends
demographics for both short- and long-term contract agency staff
from the LRM to the time and attendance system twice daily.
Patient Admissions, Discharges and Transfers
(ADT) Interface: A real-time, 24/7 interface using HL-7
messaging, the ADT interface sends admissions, discharges and
patient transfers information from the HIS to the Patient Acuity
module. This supports the entry of patient attributes, resulting
in acuity level calculations and staffing to patient acuity
every shift.
Actual Time Worked Interface: Once
daily, the actual time worked interface sends thousands of
transactions from the time and attendance system to the LRM
system, modifying schedules within the system to reflect actual
employee and agency clock in/out time, ensuring accurate
productivity reporting.
Schedules Interface: Sends schedules
from the LRM to the time and attendance system twice daily,
enabling staff to see their future schedules when they badge-in
for work and enabled Maricopa to implement cost-saving HR rules.
For instance, we are able to restrict staff from badging-in for
work more than 15 minutes before they are scheduled, thereby
reducing incidental overtime costs. Managers also use data from
this interface to produce reports on tardiness and other issues
for employee counseling.
We wanted to ensure that every unit has the appropriate number of nurses with the skill sets required to provide quality care, given the complexity of patients’ conditions and the intensity of services they are likely to require during the next shift.
Agency Hours Worked Interface: A
planned interface to link the LRM system to a third-party
vendor-managed application that logs the assigned shifts of
agency staff. The actual agency hours worked will be sent from
the time and attendance system to the LRM and to the third-party
application, helping to ensure the accuracy of billing and
auditing of this critical staffing expense.
Agency Costs for General Ledger: This
final interface will send the actual dollars expended monthly
for agency staff to the general ledger. Once implemented, this
will provide accurate reporting of this critical, closely
monitored expense and create an accurate
accrual entry.
Results
MMC sought to automate the process of patient
acuity calculation, extend it across all units of the hospital
and link the results to staffing and scheduling. Before the
process was automated, only five of the hospital’s 22 units were
using a manual process. Furthermore, our ICUs and behavioral
health units had not been able to calculate patient acuity and
instead used industry standards for staffing and assigning
nurses to patients which are based only on census numbers and do
not account for differences in acuity and care requirements
among patients. Today, all 22 units utilize the automated
process, making the extension of patient acuity determination
across the hospital a success.
The units previously using the paper acuity
system had been able to complete the process in a timely manner
for about 60 percent to 70 percent of their shifts. Today, the
inpatient units have this number at greater than 95 percent. The
behavioral health units have achieved a 75 percent on-time
completion rate.
Automating the process has improved our
ability to use patient acuity in real time to assign staff based
on patients’ care needs. We have attained significant process
improvements, and the automated patient acuity process is
yielding results in terms of moderating under- and
over-staffing. Our best-performing units now consistently staff
their shifts at 95 percent to 105 percent of optimal staffing
levels. Admittedly, others still have a ways to go. One of the
most significant results is improved workload balancing among
nurses. Decisions on patient assignments to nurses on each shift
are now made on the basis of patients’ documented acuity levels
and the intensity of care they will need during the shift.
Going forward, we are continuing the work to
complete the interfaces. We believe their implementation will
help us better control the use and costs of agency nurses. In
addition, we are exploring ways to improve the process,
especially with the behavioral health units, and we are using
the experience of the best-performing units for continuing
education of our charge nurses.
With the shortage of registered nurses in the
U.S. forecast at approximately 340,000 by 2020, every hospital
will be increasingly challenged to optimize the productivity of
its nurses and balance their workloads. Our experience matching
staffing to patient acuity at MMC suggests this is a sound
strategy for addressing this challenge and a practical one for
other hospitals to pursue. Most healthcare organizations will
already have the basic information required to implement our
approach to acuity measurement within their ADT systems, making
interfacing to staffing and scheduling systems a viable
solution.
Dave Kempson is chief information officer at
Marcopia Integrated Health System. Contact him at
David.Kempson@hcs.maricopa.gov .
