1. Gibson, Shirley RN, MSHA
  2. Oldershaw, Karl RN
  3. Lockhart, Jim MEA
  4. Baker, Kathy RN, MS

Article Content

Suppose it's Labor Day: Do you know where your nursing staff is? At our hospital-Virginia Commonwealth University (VCU) Medical Center-that wasn't always an easy question to answer[horizontal ellipsis] on Labor Day, other holidays, or sometimes even just the overnight shift on Sundays. That's because our paper-based, decentralized scheduling system prevented our nursing executives from getting a clear and timely picture of staffing across our organization.


Now, thanks to a centralized, automated solution and systematized procedures, VCU Medical Center has saved millions of dollars by reducing supplemental labor costs by 13% and decreased overtime from 3.5% to 2.5% of total direct care costs, while improving patient care by ensuring an appropriate blend of nursing talent across every shift. What's more, generating a schedule can be done in just a few minutes, instead of several hours.


Runaway costs

The VCU Medical Center is one of the country's leading academic medical centers, offering state-of-the-art care in more than 200 specialties. The facility is a 779-bed regional referral center for the state, and the region's only Level I Trauma Center, with a critical-care tower, 52 nursing units/procedure areas, and 30 operating suites, as well as 80 clinics spread across multiple campuses. Not surprisingly that level of complexity led to inefficiencies in the way we managed the scheduling of our thousands of nurses. In the last decade, responding to an industry-wide emphasis on decentralization and local control, each VCU unit tended to operate within its own unique "silo." And that limited our hospital's ability to see across units and facilities and assess our short- and long-term staffing requirements and understand our true costs.


Two years ago, the situation finally reached an inflection point that everyone could plainly see and no longer tolerate: a personnel variance of $13 million. Most of that overrun came not from overtime but from the way we used our supplemental pool and traveling nurses. We're proud of the supplemental pool that we assembled-an internal team of nurses that gave us control over costs, quality, and scheduling-but it was overused because of inefficient base scheduling practices. Requests for travel nurses were also spiraling, which contributed to runaway costs.


In analyzing the situation, we could see that the challenge started with the simple fact that we were using paper and pen to create and manage our schedules-a scenario we liken to the idea of an accountant still using paper and pencil ledgers to track expenses. There was no simplified way to roll up the data, balance the schedule for skills and patient acuity perform short-term re-allocations of nurses to short-staffed units, or otherwise manage the scheduling process. In the longer term, we also lacked the ability to see how to permanently reassign and transfer nurses to other units to create greater scheduling stability and cost-certainty.


Previously, our use of travel nurses was unstructured. Units could individually request travelers but there wasn't a meaningful way for managers and executives to know what levels of functional staffing the requests were based on. Because our data were on paper, there also was no way to easily detect underlying trends, such as a need for additional permanent staff, or changes in how staff was being scheduled or used.


As a result, it wasn't unusual for us to have unexpected scheduling problems that we wouldn't see until a day or two before the shift-or sometimes not until the shift started. Instead of the three nurses we thought were scheduled, we might have only one. And instead of a blend of talents and skills, we might have a team of only less experienced nurses. The result: our Labor Day scenario[horizontal ellipsis] a shortage of skilled nurses to work on a day that most nurses traditionally prefer to take off, with no way to see it and take action until it's upon you.


No black boxes

Aiming to resolve these scheduling challenges and bring a greater level of consistency, quality, and cost-control to the process, we formed a cross-functional team to evaluate and deploy an automated solution. We recognized that we needed to partner with our information technology and finance departments because they would play a central role in the success of any system. We also brought in representatives from the VCU Medical Center patient-care team because their expertise is essential and their participation up front would help facilitate adoption by our thousands of nurses.


While many health systems seek an off-the-shelf solution for workforce scheduling-and that's an entirely valid choice-we took a different approach. We didn't want someone to build something and hand a "black box" to us. With so many diverse units in our health system, a one-size-fits-all approach simply wasn't going to be feasible. Instead, we treated our software vendor as a consulting partner and built a solution that's highly customized and flexible to meet our unique requirements at VCU Medical Center. The vendor gave us the help we needed-without getting in our way.


That's not a choice that every hospital would or could make but we had the talented team to enable us to take that approach. Yes, the development took a little longer than simply deploying a single packaged solution, but we now have a thorough understanding of the nuances and inner workings of our scheduling solution. That understanding gives us much more latitude in our deployment. We can also troubleshoot the system and solve problems ourselves in far less time.


Shifting culture

When the development was complete and we were ready to deploy, we took a cautious approach-implementing the solution among selected units. We worked with volunteer units that self-selected as early adopters. Not surprisingly, once the early units had success with the system, their peers in other departments were eager to begin their deployments as well.


Perhaps the most important step in our deployment was communication and education to initiate a change in the VCU nursing culture and the way we schedule our staff. To balance our staff more appropriately, we would ask our staff to make changes to scheduling protocols-certainly an issue that every nurse feels passionate about. We discussed the American Nurses Association principles on safe nurse staffing with our nursing leadership, and we all agreed that we needed to put those into practice at VCU. Without the transparency and accountability that the electronic scheduling system provided everyone, it would've been difficult to put these principles into action. To their credit, our senior nurses recognized the need to balance the talent and embraced our new processes by surrendering some of their shift-scheduling perks. Given the transparency of the new system, and once we demonstrated that we could accomplish this with equity, potential reservations or hesitancy faded.


The biggest change we saw concerned our supplemental pool. Rather than being used to fill gaps in poorly balanced unit schedules, which both uses up our flex labor force and increases costs at the unit level, they're now able to be used as envisioned, a pool of flexible labor to respond to changes in workload and staffing as needed. The new system reduced our need for supplemental staffing. Even better, since deploying the new scheduling application, our use of traveling nurses has dropped to zero.


Balanced in minutes

With our new system, VCU Medical Center has achieved a high level of transparency and visibility in nurse scheduling for nurse managers and executives across the organization. It's creating a culture of accountability, while still empowering individuals and departments to schedule according to their needs and requirements. With our new system, we have the reports and visibility that enable us to coach the staff and make them more accountable. The end result is much "better," that is, more balanced and fair, schedules. Today, our new system schedules the work shifts of more than 2,000 VCU Medical Center nurses. A department/unit can create a balanced and fair schedule in just a few minutes-instead of the many hours that our previous paper-bound process required.


With our new scheduling process, we've decreased our use of premium labor because our schedules are balanced far better and we're not scrambling to plug short-term holes. This is allowing us to use our supplemental pool more for the flex in nursing workload and call-ins, rather than filling the gaps in base schedules. As a result, we decreased the cost of that supplemental labor by 13%. Overtime hours decreased from 3.5% to 2.5% of total direct care hours. Collectively, for a facility of our size, these two moves represent a savings of millions of dollars, which is welcome news for any cost-constrained health system.


Finally, VCU Medical Center previously earned the Magnet(R) designation from the American Nurses Credentialing Center. Perceived staffing equity is a major criterion for achieving Magnet(R) status, of course, because staffing and clinical outcomes are intricately linked. When it's time for us to reapply for Magnet(R) designation, we believe our scheduling system will play a key role in our redesignation.


When Labor Day arrives this year, our new scheduling system and processes will help us run a simple series of reports for all of the units and confirm excellent staffing coverage. Scheduling for a difficult holiday will be a non-event-the best outcome for all.