1. Forte, Joan BSN, MBA

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Use staffing systems to increase efficiency, improve patient care.


In any healthcare organization, the greatest costs of operation are those related to labor. In many cases, institutional survival hinges on effectively managing the workforce and maximizing efficiency. Over time, even a small difference in hours per patient day (HPPD) translates to a major budget variance. Technology provides numerous mechanisms for nurse leaders to increase staffing accuracy and monitor labor use, reducing financial burdens. These techno-solutions contribute to daily staffing, ongoing monitoring, and justification of used resources to third-party payers.



Nurse leaders can heighten daily staffing accuracy by using staffing tools that allow adjustments to mirror changes in acuity and census. At Stanford University Medical Center, day and evening shifts are the most liable, so the staffing program routinely assesses staffing needs in 4-hour increments instead of the traditional 8 hours. When an acuity tool interfaces with the staffing tool, it factors into the equation the changing needs of acutely ill patients, further ensuring that the right number of people are in the right place at the right time.


A staffing system can help identify staffing trends, such as higher needs on shifts where admissions most frequently occur or reduced needs in some areas on weekend shifts. In addition, it can help identify seasonal trends. Nurse leaders can use these patterns in the scheduling process by setting minimum numbers that vary according to true staffing needs. They can also use these trends to manage position control, placing higher numbers of staff on peak shifts or using registry staff during seasonal highs, instead of hiring additional core staff. With the soaring costs of providing employee benefits, the judicious use of temporary staff makes good fiscal sense.


To effectively manage the use of resources, in addition to staffing personnel, frontline nurse managers must have mechanisms for monitoring unit staffing. Fiscal accountability resides with the managers, and good financial outcomes rely on their effectiveness. Current technology offers tools and data in formats that make this monitoring process simple and quick. Some systems generate a daily report that includes the variable and the targeted HPPD, as well as other parameters.


The acuity system also creates a routine report that monitors acuity and its impact on staffing. At Stanford, nurse leaders use these reports, in addition to pay period staffing, acuity, and payroll reports, to ensure that unit decision makers make appropriate choices. Variance reports are required when HPPDs exceed targets; nurse managers use reports generated by these systems to explain deviations. In turn, nurse executives use this data in their reports to the organization as a whole. Staff members also perform periodic audits using data generated by the systems to guarantee appropriate staffing and compliance with California's mandated ratios.


Another area in which technology can impact solvency is in the relationship with third-party payers. Good data management allows crucial information collection and demonstration. These data may be needed to justify billing, which is based on acuity and the use of labor resources. The system allows for provision of information in real time to payers or summaries at the conclusion of the length of stay. During the contracting process, the data can be used to ensure that negotiated rates more closely reflect true costs, an outcome which heavily impacts net revenue.



The external environment isn't the only venue in which nurse managers strive to justify labor costs. The nursing budget is a significant portion of an organization's expenditures and, as such, is often challenged intensively. In the past, unsubstantiated claims, such as "our patients are sicker this year," have fallen on the deaf ears of CEOs and CFOs.


Nursing often struggles to maintain last year's dollars. With the incorporation of technology, hard data are retrievable and can be displayed in convincing arrays. These techno-solutions allow nurse managers to finally speak the same language as those making crucial financial decisions for the organization. At the beginning of the fiscal year, nurse leaders can determine what data will be important to collect to justify next year's budget.


Information such as acuity trends, average acuity, admission times, and staff productivity all provide a solid basis for budget requests. At Stanford, the census at midnight is used most often to compute HPPD and other essential ratios. Most units experience a high admission, discharge, and transfer rate, and the midnight census rarely reflects the true number of patients cared for that day.


A final component to effective staffing is using the right people. Technology can be used to record and monitor the various competencies and certifications required to care for a certain population, and then to ensure there's a match in daily staffing. Many organizations ensure competency and meet the Joint Commission on Accreditation of Healthcare Organizations standards by conducting annual skills fairs where nurses are required to master the competencies for the populations with which they work. Nurse leaders can record staff nurses' achievement of these skills in the staffing system. When matched with the competencies required to care for an individual patient or patient population, staffing personnel can make appropriate choices in floating staff. The ability to easily track and determine this match also contributes to financial management in that staff can be used appropriately throughout the facility. These systems can also track essential requirements, such as BLS and current licensure, reducing both legal and medical liability. Monitoring these requirements proactively also ensures that staff nurses don't become unavailable when it's "discovered" that a certification has lapsed. These factors also contribute to staff satisfaction, which links to retention, a key element in reducing staffing costs. Using technology in staffing, scheduling, and competency programs simply makes fiscal sense. Organizations can quickly justify the purchase of these systems in the savings of time and dollars, accompanied by increases in accuracy and efficiency.


CONTRIBUTORS TO THIS ISSUE [horizontal ellipsis]

Leslie H. Nicoll, PhD, MBA, RN, BC, is Editor-in-Chief of CIN: Computers, Informatics, Nursing.


Kathryn H. Bowles, PhD, RN, is an associate professor at the University of Pennsylvania School of Nursing, Philadelphia, PA.


Diana S. Contino, MBA, RN, CNE, CCRN, is president, Emergency Management Systems, Inc, Laguna Niguel, CA.


Cynthia T. Williams, MSN, MBA, RN, FACHE, is vice president of patient care services at St. Vincent's Hospital in Birmingham, AL, a 338-bed facility that's designated the Flagship Digital Hospital for its health system.


Joan Forte, BSN, MBA, is a financial analyst for patient care administration at Stanford University Medical Center, CA.


William Perry, MA, RN, is clinical information specialist at Kettering Medical Center, Kettering, OH.