As military leaders know, no battle plan survives its first contact in battle; too many variables exist. The same can be said of nurse staff¬ing. In health care, the “first contact” occurs when staff members call in sick and patient numbers or acuity increase or decrease more than planned.
Scheduling and staffing aren’t simply a matter of achieving a certain ratio; the cost of mistakes can be measured both in dollars and human lives. Applied technology is improving our ability to assemble real-time, actionable information to support staffing decisions and resource allocation. New evidence-based software computes large amounts of data and applies algorithms that help match the right nurse to the right patient at the right time—and at the right cost. This article describes how nursing leaders are using and benefiting from technology that integrates patient demand, nursing workforce as a resource, and evidence-based practice for staffing.
Resource-demand management
Catholic Health Initiatives (CHI) has combined technology, business processes, and a collaborative care management strategy to optimize care delivery and manage length-of-stay benchmarks. A national nonprofit health system based in Colorado, it operates nearly 90 hospitals in 18 states. To update each patient’s progress continuously, CHI uses a solution with real-time interfaces with the hospital’s admissions, discharges, and transfers (ADT); the electronic health record; and concurrent coding systems. As nurses document patient care, acuity is calculated based on the whole patient, including activities of daily living; physical, psychosocial, educational, and perceived needs; and family support. The system automatically calculates the staffing levels and skill mix needed to help the patient progress and adjusts the levels based on ADT activity.
The healthcare team rounds together in the patient room and uses the information obtained to manage the patient’s care toward a single departure date and time. Carol Wahl, chief nursing officer (CNO) at CHI’s Good Samaritan Health Systems in Kearney, Nebraska, states, “Patient satisfaction has skyrocketed… caregivers report that combining care management with case management is delivering better, more coordinated patient care.”
Workforce-management solutions
Midland Memorial Hospital (MMH), a not-for-profit hospital serving northwest Texas, uses workforce-management technology to optimize the quality of care and control costs. Centering on a web-based portal for real-time schedule management, the software is fully integrated with human resources, education, and time and attendance data. MMH has automated its scheduling, established self-scheduling practices, and created a fatigue-management guideline. Selected nursing competencies, such as advanced cardiac life support, are visible on the staffing page, alerting nurses to keep their licensure and certifications active. Nurses can self-schedule into an open slot only if they meet the requirements of that role.
MMH also uses a patient-assignment tool that recognizes the importance of continuity of care. The technology helps nurses and leaders achieve balanced assignments while creating an electronic record of primary and relief assignments. The nurse leader can use drag-and-drop functionality to assign nurses additional duties, such as crash-cart checks, narcotics counts, and refrigerator checks. Transparency of assignments can change nurses’ perception of the fairness and equity of those assignments (a key component of nurse satisfaction).
ShiftAlert is an important tool that frees up time for staffing offices and charge nurses, who typically spend hours each day calling nurses to fill gaps in the upcoming shift. This system communicates urgent, short-term staffing needs to qualified staff via text messages, email, and interactive voice response. Using the unit’s supporting business processes, ShiftAlert first offers the open shift to nurses qualified to work on that unit who wouldn’t be earning overtime or premium pay. The software eases the administrative burden of charge nurses, helping them focus more on patients and staff development.
The technology MMH uses to optimize the workforce and progress of patient care has yielded significant returns. According to CNO Bob Dent, “The improvements in costs were captured in the reduction in and elimination of high-cost labor, such as overtime and agency usage. At MMH, the return on investment for the technology happened within the first year.”
Technology that integrates operations
Florida Hospital System, an integrated system serving central Florida, is installing command centers to serve as operational headquarters where staff can see at a glance whether patient flow, staffing, and care coordination are operating at equilibrium. “Dashboard” views display bed management, surgery, emergency department, transportation, environmental services, and equipment status simultaneously in real time. Such integration of operations that previously existed in silos helps staff make actionable decisions to maximize operational efficiency and clinical excellence.
Nursing leaders make decisions on staffing resources every day, but determining if those decisions are good ones can pose a challenge. Dan Roberts, associate director for nursing at Stony Brook Medicine, a teaching healthcare system in Long Island, New York, uses technology to inform the following questions: “Did we maximize people, processes, and tools? Did we have the right patient on the right unit with the right plan of care with the right staff doing the right things?” He comments, “These new operational ‘rights’ of nursing point to access, quality, and cost. If you have these rights as a part of your nursing model, how do you know you have them correct…in real time? These questions are particularly important as governments and payers encourage reductions in length of stay and tie reimbursement to measures of quality and satisfaction.”
Systems that provide real-time staffing information
CHI, MMH, Florida Hospital System, and Stony Brook Medicine use technologies that provide
real-time, actionable information on safe staffing. These technologies give nurses transparency about patient acuity, intensity, stability, and progress so they can more easily make assignments that take into account continuity of care, educational and professional characteristics, skill mix, and work environment. Nurses can use reports to predict patients’ needs prospectively and can use shared-governance models to create schedules using systems programmed to account for unit characteristics, union contracts, and labor law. With the aid of this technology, they can fill staffing gaps and understand the financial impact of moment-to-moment decisions. They can link demand for care and hours worked to nursing-sensitive quality measures.
Imagine a future where nursing is reimbursed for the value nurses bring—where nurses have easy access to staffing, patient progress, and financial information; where they maximize technology to clearly establish the relationships between an investment in nursing care and better patient outcomes; where they work with the finance officer to make the right investment. Imagine a future where technology helps us match the right nurse to the right patient at the right time. That future is now.
Selected references
American Nurses Association. ANA’s Principles for Nurse Staffing. 2nd ed. Silver Spring, Maryland: Author; 2012.
Caspers BA, Pickard B. Value-based resource management: a model for best value nursing care. Nurs Adm Q. 2013;37(2):95-104.
Creating value for patients for business success. Leadership. 2011;25-8. www.hfma.org/Content.aspx?id=3685 Accessed September 24, 2013.
Dent R, Bradshaw P. Building the business case for acuity based staffing. Nurs Leader. 2012;10(2):26-8.
www.nurseleader.com/article/S1541-4612(11)00341-7/abstract. Accessed September 24, 2013.
Garcia A. A patient acuity checklist for the digital age. Nurs Manag. 2013;44(8):22-4.
The authors work at Cerner Clairvia in Kansas City, Missouri. Amy Garcia is the chief nursing officer and Kate Nell is the director.
