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Staffing changes save ED more than $200K a year
Atypical shifts, flexible internal pool key strategies
In three years, the ED at Dameron Hospital in Stockton, CA, has achieved total savings of $650,000 through a combination of staffing optimization, creation of atypical shifts and a flexible internal pool, and providing staff the option to take open shifts, all while still meeting the challenging nursing ratios required by the state. These changes were made in concert with The Optime Group, a consulting firm based in Evanston, IL.
For some patients, such as Code 3 trauma, the ratio is 1-to-1, explains Janine Hawkins, RN, MBA, the hospital's chief nursing officer. "It's 1-to-2 for cardiac patients receiving tPA [tissue plasminogen activator], and for lesser acuity patients, it can be 1-to-4," she says. "The challenge was to learn how to have the manpower when we needed it, but to not be overstaffed at other times."
When Jordan Geiman, MBA, staffing manager for nursing, joined the staff in 2006, her title was director of nursing finance. Six months into the year, the nursing department was $1.8 million over budget, she recalls. "They wanted to add a person just to focus on the execution of the plan that Optime Group had come up with, which was not really embraced by the former leadership," Geiman said.
Geiman concedes that many of the recommendations were "tough concepts to follow," but adds that "there is a science to all this — matching staffing to demand, which is very much a culture change." By the end of the year, she says, "We were under budget."
One of the keys was the atypical shifts, Hawkins says. The team reviewed hour-by-hour workloads with Optime. "Instead of having seven nurses at 7 a.m., for example, we now have five, and then add two at 11 a.m. and another at 3 p.m.," she says. Hawkins adds that the results were "magical." "Our rate of left without treatment was in the teens; now it's 2%," she shares.
In addition, Hawkins says, nurses throughout the division were categorized by skill level and then assigned to shifts in a way that guaranteed a balanced skill level for every shift.
Flexible use of registry nurses also contributed to the success of the initiative. "All registry nurses utilized in the ED have to be available to the ICU and CCU as well, but if they're needed in the ED to fulfill a ratio, they can do that," notes Geiman.
Hawkins says, "I've not seen a work force like that, and I've been in several hospitals. The nurses are hired to the critical care/ED pod; hour to hour, you can pull them from the ICU down to the ED to give a hand with resuscitation, for example." In fact, she adds, this applies to all nurses. "On the hiring agreement, it explains that this is how we work here, and registry nurses follow the same program," she explains.
Finally, says Hawkins, all RNs have access to a computer portal, which posts any open shifts. When they log in, any nurse in the ED or capable of working in ED can sign up for that shift.
Initially, says Geiman, the changes weren't implemented easily. "People were angry at first," he says. "They complained that, for example, they were now working on Fridays and they had always had Fridays off, or that they had been working with the same group of nurses 'forever,' and they didn't want the group broken up."
How did he deal with the complaints? "We explained why we were doing this — that it was all about patient care and having the right number of nurses and the right skill mix," Geiman notes.
The administrators also shared the data with them, recalls Hawkins. "After the changes were made and they saw the cost savings come along, they began to come along," she says. "They realized if we continued to be over budget, that something else would have to give."
"We held monthly staffing forums to put the data in front of them and let them know there was a science behind what we were doing — and things did get better," she adds. Hawkins supplemented the forums with a monthly newsletter. Persistence paid off.
"Once they tried it, they loved it, and they'll never go back," Hawkins says. "They loved the fact that they had enough staff when they needed it, as well as not being overstaffed during slow periods of the day."
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