Nursing Care Delivery Models & Staffing (6Q)

*When calculating paid nonproductive time, which should the nurse manager consider?* A. Overtime pay and evening and night shift differential B. Total hours available to work C. Insurance benefits and educational hours D. All hours that are paid but not worked in the assigned unit

D. All hours that are paid but not worked in the assigned unit

Inpatient Unit

Hospital unit able to provide care to patients 24 hours per day, 7 days per week - Utilizes data from all sources - You can build staffing plan to meet needs of patients, staff, and organization - Use ADC to calculate staffing plan

Patient Acuity

Measure of nursing workload generated for each patient -Used to predict the amount of nursing time needed; as acuity rises so does nursing time -Ex: Acuity of 1 = 3 care hours; 3 = 6; 5= 15

FTEs (Full-Time Equivalents)

Measure of the work commitment of a full-time employee - 1.0 FTE = full time employee who works 40 hours per week - 0.9 FTE = employee who works 36 hours - 0.5 FTE = part-time employee who works 5 days/week *FTE hours are a total of all paid time (includes worked and non-worked time)

NHPPD

Nursing Hours Per Patient Day • Reflects only productive nursing time available based on the following: ○ Midnight census ○ Past unit needs ○ Expected practice trends ○ National benchmarks ○ Budget negotiations

Average Length of Stay (LOS)

Refers to the average number of days a patient is hospitalized *Hospitals paid same amount for caring for a DRG group regardless of LOS of specific patient - this promoted initiatives in hospitals to reduce LOS (clinical pathways and case management surfaced as a result)

Total Patient Care

The nurse is responsible for the total care for the nurses' patient assignment for the shift -RN is responsible for several patients -RN can assign care to the LPN or delegate to the NAP but the RN retains accountability

Average Daily Census

Total numbers of patients at census time (usually midnight) over period of time (weekly, monthly, yearly) and dividing by the number of days in time period *Many institutions budget based on ADC and then adjust for patient census and acuity changes

FTE Hours

Totality of all paid time -Includes worked and non-worked time

Unit of Service

Variety of volume measures that are used to reflect different types of patient encounters and indicators of nursing workload • Nursing workload dependent of nursing care needs of patients ○ Contributors: -Work intensity -Patient volume - used in budget negotiation to project nursing needs of patients and to assure adequate resources for safe patient care -Nursing Hours Per Patient Day (NHPPD): amount of nursing care required per patient in a 24-hour period

Primary Nursing

• Clearly delineates responsibility and accountability of RN • Places RN as primary provide of care to patients • Patients assigned primary nurse ○ Primary nurse responsible for developing plan of care with patient ○ Other nurses caring for patient follow this plan (associate nurses) ○ Primary nurse has authority, accountability, and responsibility to provide care for group of patients

Considerations in Developing a Staffing Plan

• Skill Mix • Staff Support • Historical Information

Patient-Centered or Patient-Focused Care Disadvantages

○ Can be extremely costly to decentralize major services in organization ○ Some perceive model as way of reducing RNs and cutting costs in hospitals

Disadvantages of the Factor System

○ Cannot predict change in patients condition ○ Does not capture patients psychosocial needs

Advantages & Disadvantages of Functional Nursing

○ Care can be delivered to a large number of patients ○ Utilizes other types of less skilled workers when there is a RN shortage • Often results in technical nursing care, rather than professional • Decision making usually at a level of charge nurse ○ Patients likely to have care delivered by several staff members and may feel care is disjointed

Benchmarking

○ Tool used to compare productivity across facilities to establish performance goals and improve outcomes ○ Does not always reflect quality of care indicators that can link quality patient care outcomes to productivity measures ○ Can be helpful in establishing starting point for staffing pattern

Historical Information

○ What has worked in the past? ○ Were staff able to provide the care that was needed? ○ How many patients were cared for? ○ How many staff were utilized?

Nonproductive Hours

- Benefit time such as vacation, sick time, and education time

Care Delivery Management Tools

-DRGS: payment system for hospitals -Average Length of Stay (LOS): used to determine payment

Modular Nursing

-Kind of team nursing that divides a geographic space into modules of patients -Each module has a team of staff led by RN -Useful with decentralized nursing stations -RN responsible for overall care on their module

2 Ways to Generate a Staffing Plan

1. Determining required ratio of staff to patients; nursing hours and total FTEs are then calculated 2. Determining the nursing care hours for specific patients and then generate FTEs and staff-to-patient ratio needed *Use a combination of methods to validate plan

Concerns for Scheduling

1. Impact on Patient Care: ○ Possible disruption of continuity of care ○ Weekend staff should be familiar with patients and recent care events 2. Financial Implications ○ Weekend programs more expensive than traditional staffing patterns-recruitment and retention tool for nursing leadership

*A new graduate asks the manager what she meant when she mentioned "benchmarking." Which response is most correct?* A. A comparison of productivity data for similar nursing units B. A method to measure cost of care C. A comprehensive measure of good quality D. A set of written standards of care

A. A comparison of productivity data for similar nursing units

*Which of the following would you take into account when developing a staffing schedule starting next week and running for six weeks? (Select all that apply)* A. An RN took four vacation days last month and has three days scheduled this month. B. An RN comes out of nursing orientation next week. C. There is scheduled maintenance on the water system for six rooms next week. D. The unit secretary is scheduled for vacation and a float-pool secretary will take that place next week. E. There are 22 nurses with over 10 years' experience on the unit. F. A hospital-wide lift team will start in two weeks.

A. An RN took four vacation days last month and has three days scheduled this month. B. An RN comes out of nursing orientation next week. C. There is scheduled maintenance on the water system for six rooms next week. E. There are 22 nurses with over 10 years' experience on the unit.

*In developing a staffing plan for your unit, which of the following considerations would you include? (Select all that apply)* A. Data from census and staffing from the past quarter B. Benchmark against the organization's NHPPD from the previous year's data C. Presence of a mini pharmacy on your unit that stocks medications D. The hiring of three new nurses for your unit E. Your hospital is located in Modesto, California F. The scope of practice for nursing assistive personnel on your unit

A. Data from census and staffing from the past quarter C. Presence of a mini pharmacy on your unit that stocks medications E. Your hospital is located in Modesto, California F. The scope of practice for nursing assistive personnel on your unit

*Patient classification systems measure nursing workload required by the patient. The higher the patient's acuity, the more care the patient requires. Which of the following statements is a weakness of classification systems?* A. Patient classification data are useful in predicting the required staffing for the next shift and for justifying nursing hours provided. B. Patient classification data can be utilized by the nurse making assignments to determine what level of care a patient requires. C. Classification systems typically focus on nursing tasks rather than a holistic view of a patient's needs. D. Aggregate patient classification data are useful in costing out nursing services and for developing the nursing budget.

A. Patient classification data are useful in predicting the required staffing for the next shift and for justifying nursing hours provided.

Team Nursing

Assigns staff to teams that are responsible for a group of patients -Each team led by a RN -Team leader supervises and coordinates all care provided by team -Mostly made up of LPNs and NAPs but occasionally another RN -Care divided into simple components and assigned to appropriate provider

*If your RN staff members receive 4 weeks of vacation and 10 days of sick time per year, how many productive hours would each RN work in that year if she utilized all of her benefited time?* A. 2,080 productive hours B. 1,840 productive hours C. 1,920 productive hours D. 1,780 productive hours

B. 1,840 productive hours

*The medical-surgical unit provides 200 hours of care daily to 20 patients. Their NHPPD is which of the following?* A. 1 B. 10 C. 20 D. 200

B. 10

*Which statement best explains how informatics supports staffing?* A. Determining the flow of information throughout the organization B. Organizing data from multiple sources into information for taking action C. Facilitating the development of an individualized care model D. Reinforcing staffing without considering variables

B. Organizing data from multiple sources into information for taking action

*As a new manager learning about staffing patterns and schedules, which is the most important variable that affects staffing patterns and schedules?* A. Organizational philosophy B. Budget allocation and restrictions C. Delivering safe, quality patient care D. Personnel policies regarding shift rotation

C. Delivering safe, quality patient care

*Patient outcomes are the result of many variables, one being the model of care delivery that is utilized. From the following scenarios, select which is the worst fit between patient need and care delivery model.* A. Cancer patients being cared for in a primary-nursing model B. Rehabilitation patients being cared for in a patient-centered model C. Medical intensive care patients being cared for in a team-nursing model D. Ambulatory surgery patients with a wide range of illnesses being cared for in a functional-practice model

C. Medical intensive care patients being cared for in a team-nursing model

Factor System

Classification system that uses units of measure that equate to nursing time -Nursing tasks assigned time or weighted to reflect time needed to perform task -EFFECTIVE due to capability to project care needs

Patient-Centered or Patient-Focused Care

Designed to focus on patient needs rather than staff needs ○ Required care and services are brought to the patient ○ All patient services decentralized to patient area (radiology and pharmacy) ○ Staffing based on patient needs • Care teams established for group of patients ○ Care team includes all disciplines ○ Disciplines collaborate to ensure patients receive care they need ○ Staff are kept close to the patients in decentralized work stations

Utilization of Classification System Data

• Acuity data used to plan nursing staffing during next 24 hour period ○ Can be used to cost out nursing services for specific patient populations ○ Can be used to prepare month-end justification for variances ○ Can be benchmarked with other organizations • Helps negotiate payment reimbursement from third party payers

Team/Modular Nursing Advantages & Disadvantages

• Advantage: RN able to get work done through others • Disadvantage: patients sometimes receive fragmented, depersonalized care; the shared responsibility and accountability can cause confusion and lack of accountability *These models require the RN to have good delegation and supervision skills

Total Patient Care Advantages & Disadvantages

• Advantage: consistency of one nurse caring for same patient; relationships develop and RN gets more opportunity to observe and monitor progress • Disadvantages: high level of RN nursing hours and more costly

Prototype System

• Allocates nursing time to large patient groups based on average of similar patients (diagnostic-related groups - DRGs) • Data allows hospitals to determine costs of patient care and to negotiate with payers for specific patient populations ○ Reduces work because daily classification not needed ○ DRGs do not accurately reflect patient's nursing needs

Establishing a Staffing Plan

• Articulates how many and what kind of staff are needed by shift and day to staff unit or department

Models of Care Delivery

• Care delivery models organize work of caring for patients • Choose care delivery model based on needs of patients and availability of competent staff

Employee Classifications

• Direct Care: time spent providing hands-on care to patients (RN/LVN) • Indirect Care: time spent on activities related to patient care (mangers, unit clerk...)

Functional Nursing

• Divides nursing work into functional duties; duties are then assigned to one of the team member ○ Each care provider has specific duties/tasks

Boundaries of Self-Scheduling

• Form committee made up of unit staff who report to manager ○ Define roles and responsibilities of each committee member • Establish generic boundaries regarding fairness, fiscal responsibility, evaluation of self-rescheduling process, and approval process • Educate staff

Patient Outcomes and Nurse Staffing

• Many professional nursing organizations have defined safe staffing • Nurses feel safe staffing helps sustain healthy work environment

Nurse Intensity

• Measure of amount and complexity of nursing care needed by a patient • Dependent on many factors that are difficult to measure: ○ Severity of patient's illness ○ Patient dependence for ADLs ○ Complexity of care ○ Amount of time needed for care ○ Patient turnover

Patient Classification Systems (PCS)

• Measurement tool used to determine nursing workload for specific patient or group of patients over specific period of time -Acuity

Case Method

• Oldest model for nursing care delivery • Nurses care for one patient exclusively • Total Patient Care is the modern day version

Determination of Staffing Needs

• Patient census historically used to determine staffing needs (has proven inaccurate since patient care needs vary greatly) • Key Terms -FTEs -Productive and Nonproductive Time -Direct and Indirect Care -Nursing Workload -Units of Service

Self-Scheduling

• Process in which unit staff take leadership in creating and monitoring work schedule while working within defined guidelines • Increasing staff control over their schedule; major factor in nurse job satisfaction and retention • Nurse manager mentors employees, provides communication, and holds everyone to equal expectations

Scheduling

• Responsibility of manager • Manager must ensure that schedule places appropriate staff on each day and shift for safe, effective care • Even number of staff should be available throughout the week

Nurse Staffing and Nurse Outcomes

• Staff's perception of adequacy of staffing should be tracked • Staff should be able to communicate staffing concerns both verbally and in writing (managers should follow up on staffing issues) • Outcomes from ineffective staffing patterns and nursing care can be devastating to both patients and staff

Patient Care Redesign

• Started in the 1990s to redesign how patient care was delivered • Motivated by need to reduce costs • Goal: make care more patient-centered not caregiver-centered while reducing costs • Reduces number of caregivers patient has to interface with thus increasing patient satisfaction • Idea to have caregivers cross-trained so they can intervene in more situations w/o using other resources (Ex: RN's draw labs instead of phlebotomist; RN's give breathing treatments instead of calling RTs)

Case Management

• Strategy to improve patient care and reduce hospital costs through coordination of care • Coordinates care and establishes goals from pre-admission through discharge • Evaluates patients outcomes daily and compares them to predicted outcomes articulated in clinical pathway • Works with all disciplines to facilitate care -Ex: If a post-surgical patient has not met ambulation goals according to clinical pathway, the CM must work to determine what is preventing the patient and may refer them to PT

Shift Variations

• Traditional Staffing Patterns: generally 8 hour shifts; start times varied by organizations or unit • Shift Variations Occur to Meet Needs of Patients and Staff: 12 hour shifts; weekend programs

Clinical Pathways

• Used to reduce LOS, enhance outcomes, and contain costs • Care management tools that outline expected clinical course and outcomes for specific patient type (should be evidence-based) • Pathways that outline the normal course of care for a patient; it is the expected outcomes that patient progress is measured against • Pathways include expected outcomes specified for each day of care • Any variance in patient progress or outcome can be noted and acted upon to get patient back on track

Primary Nursing Disadvantages

○ High cost (higher RN skill mix) ○ Person making assignments must be knowledgeable about all patients and staff to ensure appropriate matching of nurse to patient ○ Lack of geographical boundaries within unit may require nursing staff to travel long distances at unit level to care for primary patients ○ Nurses often perform functions that could be completed by other staff ○ Nurse-to-patient ratios must be realistic

Productive Hours

○ Hours worked and available for patient care * When considering the number of FTEs you need to staff a unit, you must count only the productive hours available for each staff member

Diagnostic-Related Groups (DRGs)

○ Implemented in 1983 by federal government as payment system for hospitals -In DRGs, the national average LOS for a specific patient type is used to determine payment for that grouping of Medicare patients

Patient-Centered or Patient-Focused Care Advantages

○ Most convenient for patients ○ Expedites services to patients

Staff Experience

○ Novice nurses take longer to accomplish same task than experienced nurse ○ Experienced RN can handle more workload and higher acuity patients

Patient Need

○ Nurse-intensive activities need to be supported by work shift ○ Any time patient populations change, staffing and NHPPD should be assessed ○ Higher the patient acuity, more consistent the staffing needs are across shifts -Ex: If chemo and blood infusions typically occur on the evening shift, more staff is needed at night to support these intense activities

Scheduling Considerations

○ Patient type and acuity ○ Number of patients ○ Experience of staff ○ Supports available to staff

Primary Nursing Advantages

○ Patients and families able to develop trusting relationship with nurse ○ Accountability and responsibility of nurse developing plan of care with patient and family defined ○ Facilitates continuity of care ○ Authority for decision making given to nurse at bedside

Skill Mix

○ Percentage of RN staff to other direct care staff (LVN, UAP) ○ Should vary according to care required and care delivery model utilized -Ex: On a critical care unit the RN skill mix will be much higher than in a nursing home

Staff Support

○ Supports in place for operation of unit or department -Ex: Systematic process to deliver medications, patient transport services, secretarial services *The less support available the more nursing hours needed to provide care