1. Bantle, Anita RN, MS


Open shift management increases staff satisfaction by enhancing visibility.


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CHRISTUS Spohn Health System, Corpus Christi, Tex., opted for an open shift management program to give nurses more scheduling latitude and to better leverage its existing resource pool.


In January 2006, CHRISTUS Spohn went live to qualified staff across its three urban and three rural hospitals, each within 1 hour of Corpus Christi. The program lets nurse managers post vacant shifts online. Qualified nursing staff at all six hospitals use the technology to browse from work or home, 24/7, to identify available shifts, and to make online requests for shifts that match their skills and experience.


The health system decided to use regular pay with targeted incentives for the hardest-to-fill shifts to optimize deployment of nursing resources where they're needed most. As adoption of the program progressed during the first 3 months, we saw a steady increase in the amount of incentive dollars awarded for shifts. During the second quarter of program use, this dollar amount leveled off. When projected for 12 months, it showed a potential incentive expense decrease of over one million dollars when compared with the previous year without the program.


The savings occurred because we standardized the rules and process for offering incentives. First, the manager had to calculate the vacancy in the unit by full-time equivalent (FTE) for a shift, job title, or total budget. Then if the vacancy was greater than 20%, the manager completed a new standard form and submitted it to the nursing associate administrator for approval. Prior to designing this system, there were no controls or standard approaches for offering and awarding incentives.


Control of incentive management

In the first 6 months the managers awarded 139,967 hours, an equivalent of 11,663 12-hour shifts. Although the open shift management program helped set limits on incentives (incentives average to $2.05 per every hour awarded), we still needed a better way to manage incentives and last-minute staffing needs. So in late summer 2006 we created "just-in-time" (JIT) positions, "virtual units," and "virtual hospitals." (See "What's a[horizontal ellipsis]?".) The goal was to develop a process using our open shift management program that created better availability of qualified staff for last-minute staffing needs. To reach this goal, we developed a method to flex staff that would provide us the ability to:


[white diamond suit] manage a "flex/float" assignment based on a need that isn't known until the last minute.


[white diamond suit] maintain an incentive award program that recognizes qualified staff for their willingness to be reassigned within the hospital or across the three city hospitals to units requiring their clinical expertise.


[white diamond suit] offer incentives only to those staff that are willing to be reassigned at the last minute.


[white diamond suit] continue to decrease the cost of the incentive program.



Within the city, the existing 20% vacancy rule in the units was eliminated along with the ability to offer incentives in clinical units. The incentives became available only to those staff willing to be reassigned from their home unit to a virtual unit or virtual hospital. Staff members know they'll be working on a given day, but their specific unit assignment, and sometimes their hospital assignment, isn't made until immediately before the start of the shift. This approach to managing unexpected needs has relieved the manager of making last-minute phone calls on the days when "virtual staff" is available, as the staffing coordinator makes assignments.


What's a just-in-time position?

Virtual shifts for JIT positions exist for all shifts to gain flexibility covering patient care needs when an unexpected gap occurs due to call-ins or census spikes. We realized that the easiest and most efficient way to manage JIT positions was by gathering data on actual last-minute call-ins and staffing needs related to budgeted census data for each month and for seasonal changes. Rather than waiting to collect this data, we start with a best "guess" on needs and tracking utilization. We adjust our anticipated needs with every schedule. Such adjustments allow us the greatest flexibility to cover our seasonal vacation census fluctuations in this resort town.


What's a virtual unit?

A shift is created in a virtual unit to assist with JIT staffing. A staff member with the required skills for that clinical area is awarded the virtual unit shift, sometimes several days or weeks before the actual shift. (The unit in which they'll work is assigned no later than 1.5 hours before the shift.) The last-minute assignments allow the staffing office/house supervisor to accommodate late call-ins. The staff member may be assigned to his/her own unit, or float outside of his/her home unit, within the hospital, or across hospitals to areas that match his/her skill set.


What's a virtual hospital?

Virtual hospitals were created using the three city hospitals to allow for even greater flexibility in reassigning nurses to meet the last-minute needs across hospitals, not just across clinical units within one hospital. For example, one virtual hospital was created by merging two separate hospitals' labor and delivery units; one was created to merge five ICUs. The nurse assigned a virtual ICU shift knows that she's to report to a specific hospital when the shift is awarded, but reassignment by the staffing coordinator can occur 2 hours before the start of the shift.


Who manages these entities?

CHRISTUS Spohn's staffing coordinators are the only personnel given access to these units in the electronic open shift management program for scheduling purposes. These shifts are always posted every schedule to cover for sick calls, census fluctuations, vacations, holidays, or education time. Only the staffing coordinators may post these shifts, add incentives, and award shifts in the virtual units and hospitals.


The electronic technology controls the permissions for who has access to manage the virtual units. This process is used to make it easier to approve incentives and track/control where they're posted and awarded. The number of shifts posted and awarded is evaluated quarterly. With this new approach, the hospitals have experienced an increase in the number of nurses who are willing to work outside of their home units.


Why request a virtual shift?

Incentive bonuses are offered only to the JIT positions, which are assigned to the virtual units or hospitals. The incentive is posted by the scheduler who manages that particular virtual unit. This process is used to control when and where an incentive is offered, to encourage staff members to float outside of their home unit, and to reward them for their willingness to float.


The manager uses the program to manage open shifts in their specific units created by needs that are less than 20% of the total budgeted FTE. These shifts-posted by managers when they have a need or a small number of vacancies-carry no incentive. CHRISTUS Spohn hopes to control and decrease incentive expenditures even more than already documented using this new approach to incentive management.


In the first quarter of electronic technology use, staff members requested reassignment outside of their home hospitals for 505 shifts (31% of all awarded shifts). Since the creation of the JIT positions and virtual units, staff members have requested 1,072 shifts per month outside their home units (53% of all awarded shifts). These shifts occurred across the city hospitals, from the city to the rural locations, and from the rural hospitals into the city. When census falls, particularly in the rural area, some staff preferred to work in the city rather than not work at all.