Do You Drive a 4- or 6-Cylinder Engine? By Dr. Sandra Shelley Sandra Shelley Associates The engine of any nursing unit is the staffing infrastructure that provides the right caregivers, in the right numbers, at the right time to achieve the right patient care outcomes. Nurse leaders, management engineers, financial experts and others have traditionally focused on a "4-cylinder" engine to drive staffing effectiveness. Their emphasis has been on formulating more precise (1) staffing plans and budgets; (2) position control rosters (which list the approved positions); (3) master schedules; and (4) pools of flexible staffing resources. However, obtaining more "horsepower" from the staffing enterprise will also require attention to two often forgotten factors of staffing infrastructure: (5) care assignments and (6) shift reporting. Staffing plans, budgets, and position control rosters all focus on managing the supply of patient caregivers. Accurate allocation of staff is most often the result of a precise master schedule and a well-developed pool of flexible staff. Conventional wisdom implies that mastery over the supply and allocation of nursing personnel intrinsically leads to effective staff utilization. Contemporary thinking is that effective staff utilization must also include care assignments and shift reporting to create a more powerful "6-cylinder" engine to drive staffing effectiveness. Developing shift leader competency in the following areas of care assignments greases the fifth cylinder of the staffing engine.   Shift leadership: The priorities of those in charge of a given shift must be clearly aligned with the performance outcomes expected from their work unit. In particular, shift leaders must be cognizant of productivity targets, staff development goals and clinical benchmarks when making assignments.   Caregiver configurations: Shift leaders must have insight into the best options for combining the various types of caregivers on their shift into integrated teams of registered nurses and assistive personnel. This integrated approach attains optimal patient and operational outcomes.   Care team case loads: The arithmetic approach to patient assignments (wherein every staff nurse on the shift is assigned the same number of patients) is insensitive to both patient acuity and staff development. The number of patients assigned to a team should vary based upon the unique circumstances of the patients and the caregivers.   Care coordination: In many settings, the staff nurse and shift leader, focused on completion of tasks, make care assignments at the beginning of the shift. In a high-performance work environment, making assignments is a dynamic process of care coordination that requires critical thinking throughout the shift. To "fire" on all six cylinders of staffing, shift reporting must focus caregivers on the progress being made toward expected patient outcomes. The following tools and techniques foster outcome-focused shift reporting:   Integrated, evidence-based care plan: Staff utilization is optimized by focusing caregivers on the same set of patient outcomes, with a clear delineation of each caregiver's responsibilities. Integrated care plans are most effective when they are based on recognized best practices, rather than the preferences of an individual caregiver.   Face-to-face, exception-based reporting: All too often, patient information is shared through recorded reports that replay demographic data, routine interventions and other information that could be retrieved from other sources. Utilization is enhanced when the staff gets streamlined face-to-face reports of exceptions and focus on outcomes in the integrated plan of care. This enables staff to immediately clarify issues and eliminate any missing information — minimizing downtime, redundancy and errors.   Walking rounds: Caregiver utilization takes on new meaning when shift reporting is moved out of the lounge and closer to the patient's room. Not only can the outgoing shift show first hand the condition of the patient, but ideally, the patients themselves can participate in managing their plan of care. Expert care assignments and proficient shift reporting requires critical thinking on the part of caregivers to organize themselves for effective staff utilization. By engaging staff in "state-of-the art" utilization practices, nurse leaders can cruise along with a high-performance, 6-cylinder staffing engine. Dr. Sandra Shelley, the founder of Sandra Shelley & Associates, Inc., has published and lectured extensively on the topics of transformed work environments, change management and leadership development. In her consulting practice, she specializes in organizational effectiveness, patient care delivery, clinical resource management and general hospital operations. She has held several senior administrative nursing positions in both tertiary and community hospitals and has a Master of Science in Nursing from Boston University and a Doctorate in Behavioral Science from Rush University in Chicago. She is an advanced certified nurse administrator. Dismayed by the lack of scientific evidence identifying specific nurse-patient ratios, Lynn Unruh, associate professor at the University of Central Florida, reviews the scientific literature in the January 2008 issue of the American Journal of Nursing. Unruh questions why more attention hasn't been paid to the relationship between nurse staffing and patient outcomes, despite the fact that national reports suggest that inadequate staffing is directly linked to adverse events in patient care. Evidence also suggests that a hospital's balanced workload is linked both to its nurses' job satisfaction and its financial performance. In "Nurse Staffing and Patient, Nurse and Financial Outcomes," Unruh reports that most studies find that inadequate nurse staffing and the stress of excessive workload contribute to poor job performance, which leads in turn to adverse patient events. One study found that each patient added to an average nurse's workload produced a 7% increase in the likelihood of failure to rescue. Studies addressing the effects of staffing levels on nurses have found that working in an imbalanced staffing environment can cause job dissatisfaction, burnout and illness — all of which are associated with higher turnover rates. Only a few studies have investigated the relationship between nurse staffing levels and hospitals' financial outcomes. One study found that increasing the proportion of RNs in the skill mix, without changing nursing hours per patient day, was the least costly staffing improvement hospitals could make. Unruh concludes that although specific nurse-patient ratios haven't been scientifically determined, nurses' workloads should be a primary consideration for efforts to improve patient care. Read the article.

See McKesson Events Calendar McKesson™ Time and Attendance, March 3 eShift™ in a Centralized Staffing Environment, March 12 Web Reporting - ANSOS One-Staff™ 3.6, March 18 Sneak Peak at eShift™ Release 2.7, March 18 By using a centralized staffing office with automated staffing, Sharp HealthCare is optimizing staffing resources to avoid agency usage, improve patient care and empower nursing staff. Learn how Finance and Nursing at Marlborough Hospital partnered to implement an enterprise productivity management solution that automated staff scheduling and reduced agency costs. Learn how to address the shortage of healthcare staff with integrated workforce management tools that attract and retain the best and help improve patient outcomes.