"What do nurses, musicians and play actors have in common?" David W. Lee, PhD, head of market access for USCAN, GE Healthcare, asked hospital executives at a round table at Becker's Hospital Review 7th Annual Meeting. "No productivity gains."
His answer met laughter from the participants, who freely discussed nurse staffing issues and strategized solutions to crack the labor productivity code during the roundtable hosted by API Healthcare, a Hartford, Wis.-based GE Healthcare Company.
"It takes essentially the same number of nurses to provide care as it did years ago," continued Dr. Lee. Labor typically represents 50 percent to 60 percent of a hospital’s operating expenses. "In economic speak, productivity solves all problems."
When cracking the labor productivity code, visualize labor force in terms of value. What are you getting from the labor force versus what are you paying?
Nurse staffing levels affect:
- Cost
- Clinical outcomes
- Nurse satisfaction
- Patient satisfaction
Patient satisfaction impacts revenue in terms of reimbursements and referral base. If satisfaction scores increase, profitability rises somewhat; but if satisfaction scores decrease, profitability plummets.
"We're in a new era of healthcare, again and again and again," said Karlene Kerfoot, PhD, RN, NEA-BC, FAAN, chief nursing officer, API Healthcare. "The most obvious thing is the revenue doesn't come from fee-for-service anymore, but from quality indicators."
Nurse staffing presents the challenge of optimizing nurse productivity and enabling them to work at the top of their licenses. Other staff members can often perform nurses' simpler tasks, so focus on shifting work to a lower cost structure. Successful hospital executives will explicitly define their employees' roles and outline expectations.
"Think outside the box," said the chief nursing officer of a 20-bed critical access hospital in the West. "As our workforce gets older and our nurses are retiring, it's going to get tight."
Benefits of broad skill sets
Many nurses in larger settings don't welcome cross-training, as they are acclimated to their specific units and don't enjoy moving among units.
The chief operating officer of a hospital within a 13-health center facility hospital system in the Midwest, said nurses should learn to embrace a broad-based skill set during their schooling to change this attitude toward cross-training.
If nurses are comfortable in a variety of settings, they can fill gaps in high-volume and low-volume areas as well as preop and postop settings.
The chief financial officer of a 75-bed critical access hospital in the Midwest, emphasized the importance of nursing education to ensure nurses practice at the top of their licenses.
If cross-trained in a variety of roles and responsibilities, the hospital is able to "carry less staff, overall, because our people are more competent and can practice in many areas," the CFO said.
The chief administrative officer of a 522-bed full-service hospital within a 17-hospital health system in the West, added cross-training is imperative to his staff. Expertise is essential across units as well as across the two community hospitals, so as to "break down the silence between the facilities."
In smaller hospitals, this versatility already exists as nurses are expected to hop between units because the staff is limited. Nurses still deserve the support and education to fulfill these various roles, however.
Optimizing the staff
Extreme influx periods of patients create overwhelmed and dissatisfied nurses. The chief operating officer and chief information officer of a two-hospital and four-center health system in the Midwest, emphasized level-loading provider schedules.
Certain times require all hands-on-deck while limited activity sends nurses home without pay. She suggested providers and nurses collaboratively set schedules to optimize balance and limit stressful time periods.
Standardized start times proved successful at a 201-bed nonprofit hospital within a seven-hospital system in the Midwest. The hospital's vice president of operations and chief nurse said this standardized 12-hour schedule allows the staff to stay on track.
The chief nursing officer of a 20-bed critical access hospital in the West spoke of similar scheduling issues and suggested engaging the staff to develop innovative staffing ideas. "I put it to the staff to say how are we going to figure this out?" Her hospital's limited staff size requires team nursing and LPNs, but she worries about the consequences when the LPNs start retiring.
Instead of zoning in on nursing, the chief financial officer of a 170-bed hospital in the Midwest and his team focused on non-bedside units to implement predictive staffing, because that is where they saw 70 percent of improvement opportunity. They now use a predictive staffing model to look at adjusted occupied beds.
"We feel like nursing has been a very staunch focus for a lot of organizations, and when you've made those gains, you need to find other gains elsewhere," he said.
Unit-based teams
Kaiser Sunnyside (Oregon) Medical Center implemented a unit-based team approach to gain outcomes. The teams analyze regional goals, cascading down from them to establish plans, said Justin Evander, chief financial officer hospital operations and interim chief operating officer at the medical center.
"We've empowered those teams to build initiatives to look at scheduling and look at budgeting," said Mr. Evander. "It allows us to have a database full of possible solutions to get better outcomes from the 65 different unit teams." Ultimately, the unit-based teams operate as data warehouses, creating initiatives from the ground up.
KSMC focuses on major outcomes and the utilization engagement piece of the puzzle. They want to utilize their model to promote preventive care and empty the hospital.
Pure RN model
Some nurses believe in the strength of a pure RN model, only employing those with a bachelor of science in nursing.
A potential problem associated with moving toward a pure RN model is that ample opportunities exist for nurses, especially in the outpatient setting. On the acute side especially, nursing is a difficult job. It may not be wise to push away LPNs with the threat of a nursing shortage.
"We're going to have to be very strategic in how we manage the care in our organizations," said the chief operating officer of a hospital within a 13-health center facility hospital system in the Midwest. As highly-skilled providers, nurses are often asked to perform non-valued added tasks, like documentation. Unless the industry allows nurses to perform to the best of their abilities, it may create the perfect storm resulting in a shortage.
"Patient satisfaction, nurse satisfaction and employee satisfaction and engagement reveal a lot," said the vice president of operations and chief nurse of a 201-bed nonprofit hospital within a seven-hospital system in the Midwest. "If you keep your pulse on that, you know you're heading in the right direction."