Staffing and Scheduling – Part I

1. Staffing and Scheduling – Part I HCM 540 – Operations Management

2. Labor Resource Management • “[Nurse] Staffing is one of those timeless topics that has meaning in every type of health care environment and situation.” • Staffing costs are the largest component of most healthcare delivery organizations • managers are obligated to develop, use and maintain a high quality staffing process that balances service levels and costs • General staffing principles • Details depend on specifics of department and institution

3. High Level Staffing Framework Budgeting and Planning Budget, staffing plan, policies • Annual or as needed • Planned capacity • Staffing/scheduling policies Operational staffing/scheduling Staff schedule • Every 2-6 weeks • Target staffing levels • Create employee schedules for core staff Daily allocation Tactical Staff Scheduling Analysis • Ongoing • Reacting to staffing variances • Floating staff, overtime, contract staff, agencies Realized shortages and surpluses Adapted from Abernathy et. al. (1973), Hershey et. al. (1981), Warner et. al. (1991)

4. Labor Resource Management Framework Quantify Staffing Requirements 4. Ongoing Management of Resources 1. Understanding you Workload r Labor Resource Management Framework 3. Developing Staff Schedules 2. Converting Workload to Staffing Requirements

5. Staffing Related Challenges • Hospital downsizing • Qualification level of caregivers decreasing • Hospital trained “generalist” caregivers replacing specialist, professional caregivers • Specialist caregivers taking on wider range of tasks and responsibilities • Patient acuity levels increasing • Nursing shortage • Patient focused care model • decentralization of support services, new staff types (e.g. care partner), redefined roles • jury still out on impact on quality of care, patient safety, cost • New JCAHO Requirements to assess Staffing Effectiveness (July 1, 2002)

6. JCAHO Staffing EffectivenessScreening Indicators • Staffing Effectiveness is defined as the number, competency, and skill mix of staff involved in providing health care services. • Links between staffing effectiveness and patient safety have become the focus of national concern • JCAHO has concluded that mandating specific staff-to-patient ratios will be unsuccessful to address the issues • An approach based on the use of screening indicators to monitor staffing effectiveness, analysis of the data, and action based on that analysis would be more successful.

7. JCAHO Staffing EffectivenessScreening Indicators • Each organization selects and implements a minimum of 4 screen indicators • one HR screening indicator • one clinical / service screening indicator • 2 additional • Overtime (HR) • Family Complaints (C/S) • Patient Complaints (C/S) • Staff vacancy rate (HR) • Staff satisfactions (HR) • Patient Falls (C/S) • Adverse drug event (C/S) • Staff turnover rate (HR) • Understaffing as compared to organization’s staffing plan (HR) • Nursing care hours per patient day (HR) • Staff injuries on the job (HR) • Injuries to patients (C/S) • Skin breakdown (C/S) • On-call or per diem use (HR) • Sick time (HR) • Pneumonia (C/S) • Post-operative infections (C/S) • Urinary tract infection (C/S) • Upper gastrointestinal bleeding (C/S) • Shock/cardiac arrest (C/S) • Length of stay (C/S)

8. Labor Resource Management There is a science and an art to labor resource management • The Science: • measuring and predicting workload demand • translating demand to staff • scheduling • The Art: • the “People” dimension of staffing • choosing proper model or approach to specific staffing problems

9. Staffing Methods Depend on the Nature of the Work System • Inpatient Nursing • Episodic care • ER, Surgical Recovery, Surgical Suites, Short Stay Unit, LDR, OP Clinics, Card. cath, PT/OT, Resp. care • Lab, Imaging, Pharmacy • Medical records, transcription, financial services • Appointment scheduling, other call centers • Maintenance, transport, materials management

10. About Labor Resource Management . . . • No single staffing method or model is the right one • Hundreds of ways to organize staffing • How do you measure success of a model? • Are standards for quality and customer satisfaction met? • Is staffing delivered at an affordable and sustainable cost?

11. Factors of Labor Resource Management • Workload volumes are budgeted or projected annually • Actual Workload will be variable • Staffing plans are driven by workload requirements • But staffing response plans must be flexible and variable • Increased Staff Flexibility is necessary and desirable • Costs must continue to be stable or decrease • Managers are accountable for labor cost per unit of service • Resource management must be tough on costs, and particularly tough on “waste”

12. How do organizations traditionally staff? Starting with the Budget . . . Budget the Same Number of FTEs Each Month Unit budgeted for an ADC of 18 across both busier months and traditionally slower months. Anywhere Hospital 2001 Nursing Salary Budget Unit: 3 South-Medical Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ADC 18 18 18 18 18 18 18 18 18 18 18 18 Hours Required 4,026 4,026 4,026 4,026 4,026 4,026 4,026 4,026 4,026 4,026 4,026 4,026 FTEs Required 23.3 23.3 23.3 23.3 23.3 23.3 23.3 23.3 23.3 23.3 23.3 23.3 HPPD 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 Where did the workload driver for the budget come from in the first place? Same number of FTEs allocated to each month

13. How do organizations traditionally staff? • Many organizations staff according to a fixed number of shifts. • Hospitals usually have 2 or 3 shifts per day,with pre-specified durations and starting times. • The majority of the staff are often full-time, 40 hour per week employees. • Ignore or simplify details of time of day based staffing needs as well as service level requirements such as test turnaround times and patient wait times.

14. How do organizations traditionally staff? A Struggle to Staff Each Day Significant reliance on expensive overtime and agency labor to staff up quickly Unit often ends up running short-staffed when census spikes, a big dissatisfier for the staff. Budgeted ADC =18 Staff sent home or floated, or unit remains overstaffed when census drops. What should the core staff level be? The mean, the 75th, 85th, 95th percentile?

15. How to meet the dailystaffing demand • Full-time & part-time, regular (“Core”) • Float pool • Overtime • Contingent • Agency • Contingent & Agency OT • Part-time

16. What you don’t want to do . . .

17. 1. Understanding your Workload • What are the primary workload drivers for your department? • What does it look like on week-ends vs. week-days? • Shift based vs. time of day based? Size of planning period (e.g. ½ hourly, hourly, 4-hour, 8-hour etc.) • What does it look like by time of day and day of week? • Has the workload shifted over time? Trend up or down? • Is your workload seasonal? • Do you utilize a tool to collect, track and trend your workload? Why not? • Different classes or types of workload? • Service levels by class? Different priorities? • Degree of scheduling of work?

18. Operations Analysis Before Staffing Analysis Just as we don’t want to IT enable a bad process, we don’t want to staff a bad process. • What is being done? • classification of workload • Should it be done? • appropriateness, practice pattern variation • How is it done? • methods analysis, work measurement, workplace design • Who is doing it? • appropriate skill level • When is it done? • time of day, day of week, • When must it be done by? • response time • How well is it done? • quality

19. Charting Workload – A 1st Step

20. Productivity and Productivity Management See Chapters on Productivity and Staffing that I handed out. • Related concepts • work measurement • work simplification • operations analysis • staffing analysis • workforce planning Many ways to define the outputs and inputs depending on the situation

21. Labor Productivity Inputs • Usually expressed in labor hours or $ • Subdivide into productive and non-productive • Data usually available from time & attendance or payroll systems (e.g. Kronos) Total labor hours = worked hours + non-worked paid hrs • more control over worked hrs • worked hrs usually used in productivity calculations • non-prod. hrs may be included as “tracking variable” • Managers & sec’s often treated as fixed • regular • OT • premium • agency • contingent • vacation • sick • personal • holiday

22. Labor Productivity Outputs • Multitude of output measures depending on dept. • Implicitly, the measures are usually related to time or $ • Data may be available from one of numerous departmental or hospital information systems CAP

23. Work Measurement Techniques • Time studies • standard time required for a trained employee to produce one unit of output at an acceptable quality level using the approved method • direct measurement of task duration • take many samples and use statistics to develop “raw time” • apply personal, fatigue and delay (PFD) allowances (5-15%) to inflate raw time and create “standard time” • Work sampling • Expert judgement • low volume tasks

24. Time Standards in Healthcare • Attempts since the 1960s to apply industrial work measurement techniques to healthcare • Use “time studies” to estimate standard amount of time to do some task • Success has depended on the nature of the department • degree of similarity with manufacturing • simultaneity of tasks complicates things • difficult to capture assessment and decision making tasks • some areas such as lab have had many years of R&D put into development of accurate standards • Time standard based productivity systems can be very difficult to maintain

25. Work Sampling • “a measurement technique for the quantitative analysis of non-repetitive or irregularly occurring activity” • observer takes series of random observations on a “thing” of interest (e.g. clinic staff) and observes its “state” (direct patient care, indirect patient care, stocking supplies, on break, answering phone, etc.) • appeal to statistical sampling theory to conclude that: • Easier to perform than time study, especially for irregular work such as health care delivery • Difficult to capture “knowledge work” such as nursing assessment • Used, along with time studies, in the development of nursing classification systems, estimation of indirect or constant activities

26. HME members interested in Palm PC and Handheld PC as data collectors: We now have put our "Computer-Aided Work Samplng [CAWS/E] Manual (COMPLETE)" up on the COMPUTER page of the C-FOUR website << http://www.c-four.com >> for anyone to download (if you have Adobe Acrobat). We plan to have our Computer-Integrated Time Study [CITS] Manual (COMPLETE)" up sometime next week. Both systems use either the handheld PC (H/PC) or the Palm PC as data collectors. These are fairly technical manuals that may be of interest to the more advanced Mgt. Engineers. There are some other downloads available from that page also. Carl Carl R. Lindenmeyer VP and President Elect, IIE Chapter #247 (Upstate SC) Professor Emeritus of Industrial Engineering President, C-FOUR 102 East Main Street, Post Office Box 808 Pendleton, SC 29670-0808 (864) 624-1234 (voice) (864) 646-2450 (fax) website: http://www.c-four.com HME Yahoo Group

27. Variable and Constant Tasks • Variable tasks are dependant on workload • total time required related to volume of procedures, patients, patient days, tests, etc. • Constant tasks are less dependent on workload • in-service, orientation, staff meetings, supply mgt, quality assurance, other admin • total constant activities can be converted to total hours per day • constant time actually related to staff size and thus should be modified as staffing levels change W = total hours of workload in D days si = standard hours for work type i Vi = volume of work type i in D days c = constant task hours per day D = # of days

28. Aggregate vs. Disaggregated Workload • Use 80/20 principle to classify workload into a manageable number of types • different workload types may require vastly different levels of resources • productivity monitoring is less sensitive to changes in workload mix • can assess effects of changes in workload mix • make sure you can get the data for each workload type you define • can apply labor standards, RVUs, or other detailed resource adjustment methods to disaggregated data

29. Sources of Workload Data • Department Information Systems • Lab Information System (LIS) • Radiology Information System (RIS) • Patient census & acuity system • Hospital Systems • Registration System (hospital admissions, patient visits, etc.) • Billing Systems • Log sheets, tally sheets • Examples: OBLog Spreadsheets • Use Data Validation rules if collecting data with Excel

30. Example Productivity Monitoring System Report appt99c.xls So, what’s the target? Standard hours based on weighted average time standards for numerous appt types

32. The Labor Hour Inputs Bi-weekly pay data rolled carefully into monthly data

33. These volumes & standards are NOT accurate; for illustration only

34. Using Productivity Reports • Tracking general trends in workload, labor use, and productivity • large changes trigger deeper investigation • combine with service or quality measures • graphs along with tabular data • Can be very difficult to develop a “goal” or “target productivity” • depts with highly variable workload and significant response time or turnaround time constraints (service level targets) • 100% productivity is NOT necessarily a good goal • May need queueing or simulation models to address service level effects • May need optimization models to address scheduling issues • Basis for staffing analysis and labor budgeting • time standard based outputs facilitate this • Benchmarking • use of commercial systems or widely used workload measurement methods facilitates comparisons with other institutions (e.g. LMIP from College of American Pathologists or HMC)

35. Why Not 100% Productivity? • Service level constraints for systems with significant queueing component • Minimum required staffing levels • e.g. 2 RNs in PACU at all times • Peaks and valleys in demand • Staff scheduling inefficiencies • Total control of labor supply is impossible

36. Staffing Analysis Preview Full Time Equivalent =40 hrs/wk variable workload driven by incoming phone calls for appts From scheduling analysis (next time) Queuing model used to find staffing levels to meet STA targets. Percentage of working days in year subject to paid time off (vacation, holiday, sick, personal). Typically around 10-15% effect of service level on staffing weighted avg of split specific goals

37. Patient Classification (Acuity) Systems • A widely used approach to help manage staffing and define services in nursing units, recovery rooms, EDs • Develop patient classes and associated indicators defining each class • weights (times) associated with each class • direct and indirect patient care components • How many hours of nursing labor at what skill level are needed which balance patient outcomes and rational resource use? • 1-3 shift ahead staffing predictions, retrospective staffing analysis for budgeting • The “First” PCS – Wolfe and Young, “Staffing the Nursing Unit”, Nursing Research, Summer 1965, 14, 3. • 3 classes – 1.Self-care, 2.intermediate care, 3.total care • I = 0.5N1 + 1.0N2 + 2.5N3 (total direct care index estimate) • Patient acuity = I + 20 (20 hrs of indirect care per 8hr shift per 30 bed unit) • work sampling to develop direct/indirect relationship

38. Issues with PCS • Traditional time study roots– discrete standardized tasks, frequency, standard times, census by class, non-productive time  realities of nursing • high task variability • admissions/disch/transfer impacts • physical, social, ethical, emotional, financial interactions • clinical decision making • non-linear nature of the work • patient plays role in care • Multi-tasking • Variability across caregivers (delivery and rating) • acuity creep • standards maintenance • massive distrust of many systems in practice

39. Commercial Systems • OneStaff • GRASP • ENEPCS • Home grown (50%-70%)!!!

40. Evolution of Nursing PCS • 1970s – Historic nurse to patient ratios • no cost incentive to adapt to census • 1980s – Industrial based PCS emerges • DRGs, managed care, provide incentive • 1990s – Incremental improvements to PCS • hospital downsizing vs. call for legislated minimum nurse:patient ratios (California AB 394, 1999) • shortcomings of industrial based PCS still not addressed

41. Minimum Nurse Staffing Ratios in California Acute Care Hospitals www.chcf.org • “minimum, specific, and numerical licensed nurse-to-patient ratios by licensed nurse classification and by hospital unit” • Some evidence that higher n:p are related to a number of positive outcomes • Currently wide variation in delivered n:p, RN HPPD • Implementation issues • relationship to mandated PCS (Title 22 of Cal. Code) • will the min become the average? if so, so what? • nursing shortage in California • cost implications for hospitals staffing below the min (4.6%-30.7%) on already stressed system • Different groups (nurse union based and hospital based) are proposing widely different ratios • See Table 1 • PCS are attacked as being manipulated for budgeting purposes and are “acuity fraud”

42. Recent version of law seems to indicate 1:5 ratio • SEIU is the Service Employees International Union • CHA is the California Hospital Associationhttp://www.calhealth.org/

43. PCS – The Next Generation? • Malloch et al. • Proposed Framework • time/motion + expert nurse estimation • clear job descriptions • expert caregivers – categorization, allocation, validation, outcomes • Table 4. Comprehensive Unit of Service • standardized nursing nomenclature (NIC, NOC) • incorporate caregiver variability • low cost, implementable software (good luck)

44. Many (over 1000) PCS Applications • PACU (ASPAN) • Typically 3-6 classes with associated nurse to patient ratios • admit – monitor – discharge phases • Inpatient OB • ACOG standards • Emergency Nursing • EMERGE (Medicus based) • Cardiac Cath Lab • Urbanowicz, “An evaluation of an acuity system as it applies to a cardiac catheterization laboratory”,Computers in Nursing, 16, 3, 1999, 129-134.

45. One Use of PCS - Inpatient UnitStaffing Requirements – The “GRID” These staffing ratios are for illustration purposes only

46. 2. Converting Workload to Staffing Requirements • Detailed methodology depends on the specific situation, but general approach (see Appointment Center example on previous slide): • convert forecasted future work to minimum core staff required staff using time standards (variable & constant tasks, HHPPD), classification/acuity systems, nurse to patient ratios • do the above for the “appropriate” time interval (hourly, shift, daily, etc.) • make necessary upward adjustments to account for service level constraints • simple normal distribution of work assumption (analogous to choosing an overflow percentage limit in bedsizing) • queueing or simulation models • before doing this, back out constant activities and variable activities that are NOT time sensitive (i.e. can be delayed and done when time permits)

47. 2. Converting Workload to Staffing Requirements (cont) • Do “Scheduling Analysis” to develop a workable set of scheduling policies and practices that allow you create schedules that meet your staffing requirements, conform to institutional work rules, attempt to satisfy preferences of the staff, and do it at minimum cost • can be very complex; we’ll do this next time • realities of scheduling will often lead to a small upward adjustment of total staff needed • Steps 3 and 4 gives you some excess staff that may be utilized for constant activities or other less time sensitive variable activities • make judgment as to whether excess staff is sufficient for such activities; if not, add additional staff based on hours of work needed • Finally, calculate Benefit Allowance as a percentage of total working days per year that are eligible (or taken) as paid time off and increase the total paid staff budget by this amount.

48. A Few More Staffing Examples • Inpatient OB, PACUs, short stay units, emergency • forecasted volume by patient type based on historical data and/or trends in patient demographics • used nurse:patient ratios by patient type (ACOG) • used simulation model to estimate distribution of staffing needs • used an upper percentile of staffing needs and reduced it by managerial judgment of “degrees of freedom” available to cope with high demand • scheduling analysis to match staff with demand • similar approach but using Hillmaker instead of simulation can be used with retrospective data • Operating room nurses and techs • hours of operation for each OR • nurse & techs needed by OR (service dependent) • additional staff as “floaters”

49. A Few Staffing Examples • Appointment center, hospital operators, registration areas • historical volume data from ACD, hospital IS • time standards for high volume work classes • used queueing models to estimate staffing needs subject to service level targets • scheduling analysis • Other approaches • use FTE:workload indicator ratios based on benchmarks from other institutions and/or managerial judgement • Time standards for high volume procedures with productivity goal adjusted based on work sampling or managerial judgement • just like target occupancy for beds

50. Staffing a Centralized Appointment Scheduling System in Lourdes Hospital • Very nice application of a simple queueing model to appt center staffing (class project) • Advantages of centralized scheduling? • Service dissatisfiers? Impacts? • Prior emphasis on “high staff utilization” was the wrong goal • Well accepted approach of using M/M/c queueing model with time of day specific arrival rates • found service time were NOT exponential but that M/M/c worked very well anyway (insensitive to actual distribution of call time) • Created staffing tables to facilitate managerial use (see Table 2) • Used heuristic (common sense and trial and error) approach to adjust staff schedules to implement new staffing patterns with no staff adds Interfaces 21:5 Sept-Oct 1991 (pp. 1-11)