Solving staffing conundrums: A system-wide domino effect

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Staff scheduling is an ever-present headache in hospitals and health systems of all sizes. Facilities incur major financial expenses and opportunity costs crafting schedules that account for staff availability, qualifications and the budget and needs of the facility itself, among other things. The hurdles resulting from staffing conundrums are attributed to inefficient systems negatively affecting morale, patient outcomes, and ultimately, reimbursements.

But new technologies are allowing for improved scheduling that can create a domino effect across a system, resulting in cultural shifts within hospitals, improved outcomes and significant savings, according to Karlene Kerfoot, PhD, RN, chief nursing officer for API Healthcare.

"If you look at the way staffing has been done traditionally, it has been on paper and pencil and spreadsheets," Dr. Kerfoot says. "Further back than that in staffing offices you'd see little yellow stickies or magnets on the wall."

In the past, scheduling managers or nursing administrators would physically move the magnets or pieces of paper that represented different staff members to create a schedule. The next evolution of these clunky, analog systems was the spreadsheet, which is more sophisticated than a wall chart but still not equipped to solve major scheduling issues or account for the complexities that arise from managing a large staff.

"The problem is that wall boards don't think and spreadsheets don't think," Dr. Kerfoot says. "They don't give you data to really look forward to see what's happening and look backward to see what happened, so you're limited to a very primitive way of doing things."

In recent years electronic recordkeeping in healthcare has become the standard, with approximately three-quarters of all physicians adopting some type of EHR to better manage patient care and data. But for whatever reason, staffing procedures and scheduling systems have often been left in the dust, relegated to inefficient sticky notes on a wall or cluttered Excel spreadsheets. This problem is only compounded when mergers and acquisitions come into play.

"For systems that are acquiring five hospitals, 10 hospitals, surgery centers and so on — there could be a huge variety in the way people do staffing and scheduling, all the way from paper and pencil to one or two different scheduling systems that don't talk to each other," Dr. Kerfoot says. "The administration can't get a view of the entire system, including staffing, quality and finance, with those tools."

For Tulsa, Okla.-based Hillcrest Healthcare System, a six-hospital system with more than 6,000 employees and 1,800 physicians, staffing needed to be streamlined following a merger. API Healthcare's ShiftSelect technology not only addressed immediate staffing needs, but anticipated new problems before they arose.

Paring down to a single staffing system

Jennie Bible, RN, director of the Hillcrest Health System Resource Team, witnessed complications in managing staff scheduling since the beginning of her career. With more than 30 years of practical and management experience in hospital, home health, education and long-term care settings, she headed up Hillcrest's staffing overhaul and is now responsible for the development and direction of more than 140 employees.

"Our goals were to lower agency usage across the division and hire nurses in their place," Ms. Bible says. "So it seemed simple. We thought we would just determine where these agency nurses were working and then fill those spots. Well, it turned out that just to find out where they were staffed was a challenge."

When the resource team began looking through the disparate facilities' scheduling systems, they found some hospitals were using pen and paper, some were using computerized systems, and some had scheduling managed by a handful of people, all with different information that needed to be taken into account.

"It was even difficult to figure out who to talk to at each respective facility," Ms. Bible says. "We had nurses with specific qualifications who wanted certain shifts in certain units on certain days, and we'd have to call and email their managers to navigate their individual schedules."

Writing policies and procedures for a large teaching hospital in addition to a rural facility and a handful of others was an enormous workload that took a lot of time for a little return. If a facility had 10 nurses, Ms. Bible says, it may be a task that a CNO or administrator could do in a number of hours, but when dealing with over 100 nurses, it became clear that Hillcrest needed to expand to an automated system.

Once ShiftSelect was expanded across all of Hillcrest's facilities, administrators and staff were able to make changes in scheduling by clicking through an electronic system, doing away with the need to make contact by phone or email to confirm shift coverage or availability. The automated system allows for details about particular staff members, such as experience, certifications or unit preferences, which can be taken into account during scheduling.

"Because the systems were so quick, the nurses were able to see things that administrators may have missed, too," Ms Bible says. "They know what their respective skill sets are and whoever is making the schedule may not remember that a nurse is also qualified to work in a different area. The system has the ability to search for all of the shifts staff members are qualified for, it also enables us to broadcast open shifts, so nurses save time by logging on and making requests."

But in addition to the autonomy the upgrade granted nurses and the other staffing messes it untangled, the system's adoption of API Healthcare's ShiftSelect yielded other important results: Hillcrest attributes a savings of $2 million annually to streamlined staffing.

"We attribute our savings to the fact that if we hadn't developed our resource team and had stayed on the same sort of trajectory we were on, we'd be spending more than we'd realize on overtime and agency costs," Ms. Bible says.

Resolving staffing issues to improve a facility overall

A smarter system's impact on staff morale can generate long-lasting change in a hospital or health system. Research shows that reducing the amount of overtime worked and minimizing lengthy back-to-back shifts lowers turnover as job satisfaction increases. The same goes for patient outcomes — the less overworked members of a care team are, the lower the likelihood of medical errors. Additionally, the more a staff member feels their opinion matters, the more invested they are in the culture of a facility.

"In the older, more industrial model of running a hospital, staff members were sort of seen as widgets, pegs to fill a hole," Dr. Kerfoot says. "The more people feel that way the less they interact, they don't make suggestions, they don't improve practices."

One way to fix the widget problem is by moving toward a shared governance structure, the development of which Dr. Kerfoot says is directly linked to improving staffing system-wide. A shared governance structure can take the form of a nursing committee or any staff-led organization that takes into account the concerns of frontline healthcare workers.

After forming its resource team, Hillcrest reached out to representatives from all of the parties affected by staffing decisions at its facilities to hear their respective needs. The meeting of CNOs and unit managers enabled each group to share its feelings about the way staffing was handled and to ensure that the new system would account for everyone's interests. Ms. Bible says that this sort of relationship-building practice has noticeably lowered staff turnover and significantly boosted employee satisfaction response and support ratings to over 90 percent.

Beyond the savings that add up from a reduced reliance on agency nurses, overtime and a high rate of shift coverage — 83 percent at Hillcrest— using electronic systems equipped to think can produce a variety of useful metrics for hospitals, such as predicting shortages in specific units and providing focused feedback that can be applied to hiring criteria.

"Smarter staffing systems are an opportunity to think beyond just the unit or beyond the hospital," Dr. Kerfoot says. "The way you become effective as a system is to connect your different facilities and units. Once you get the big picture of what's going on with staffing, then you can start to make changes that really do make a difference."

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