MMHA 6235 Week 4 Discussion

Emergency department staffing is a tactical and operational decision that requires

a workload manager to take into account many factors, such as; work standards, patient

acuity and classification, and employee skill levels. Workload managers are responsible

for scheduling, staffing, and reallocation of human resources and other tasks like creating

workload standards. Hiring and scheduling the right staff, with the appropriate skill level,

that is accountable, adheres to work standards, and meets the demands of emergency

department standards is imperative (Fried & Fottler, 2015). Staffing is a delicate balance

that affects quality of care, cost containment, employee satisfaction, and patient

satisfaction (Ozcan, 2012). “Labor costs can represent 40 percent or more of a hospital or

other health care organization’s budget, it is vital to hire only the necessary staff” (Ozcan,

2012). This has caused organizations to veer away from scheduling systems that average

in each department by looking at the organization as a whole (Ozcan, 2012).

Work standards are established amounts of time that are allotted for a specific

department or unit to ensure the department meets a suitable quality of care measurement.

For indirect nursing hours per emergency room visit, the work standard is 0.7 (Ozcan,

2012). Determining the standard of time for care for each patient can change depending

on the time of the year, the holidays, day-by-day, and even hour-by-hour (Cabrera, 2014).

Work standards include an employee’s workload, which affects productivity and patient

outcomes. Workload for emergency department staff includes triaging to determine

urgency, deciding if diagnostic testing needs to be administered, and determining if the

patient needs to be admitted, transferred, or discharged home. Because acute care in the

emergency department is typically unscheduled, annuals trends, seasonal trends, trending

on certain days of the week, and even trends regarding the time of day can assist

workload managers in determining the appropriate amount of time and the appropriate

number of healthcare employees needed (Kuntz & Sulz, 2013). Computer simulation is a

helpful tool for workload managers to use that can give a quantitative and graphic

depiction of patient census and patient flow to allow for an “on-the-spot” staffing needs

evaluation (Hurwitz, Lee, Lopiano, McKinley, Keesling, & Tyndall, 2014). This is

particularly important when emergency departments are faced with mass casualties and

emergency preparedness (The Joint Commission, 2013). Cognitive load for an employee

is another way to approach workload standards, which takes into account patient acuity

and an employee’s cognitive capacity for efficient and quality decision-making (Cabrera,

2014).

Work standards are closely tied with and based on patient acuity and

classification. Patient acuity refers to patient’s needs and not necessarily the raw number

of patients. When workload managers are looking at staffing, they may need to consider

classifying by characteristics like the age of the patient, acuity, and the diagnosis. Then

standards can be developed for the time that is required to care for a patient in that unit,

and then the total number of minutes of care can be converted into the right number of

full-time employee equivalents for skill levels. Patient acuity systems are based on

measuring the amount of care needed by any given patient. These classifications often are

categorized as either prototype or factor-analysis. A prototype system is more subjective

and easier to create the factor analysis system is more complex, challenging, and time

consuming. Patient day a common unit used for nursing units, which is adjusted for

acuity; therefore, it is called an acuity-adjusted standard (Ozcan, 2012). “Patient acuity

systems are necessary to accurately calculate the core staffing level necessary to meet

patient requirements” (Ozcan, 2012). There are different tools, systems, and methods

when classifying patients. GRASP and NPAQ are two examples of systems that can be

used to classify patients for nursing resource management (Ozcan, 2012). A study done

by the Mayo Clinic used a Delphi system for classification of patients to determine the

cause of staffing shortages in the emergency department and to decide what strategy to

use to resolve the issue. The system was based on patient census and cognitive load,

which was obtained from the intrinsic complexity of patients and looking at whether the

patient has been evaluated already or not and the Emergency Severity Index acuity level.

For example, these complexities could include classifying a patient’s complexity as

bronchitis versus Acute Respiratory Distress Syndrome and is the patient being evaluated

or are they disposition ready. Using these variables, emergency department patients were

assigned values. By using this data, the Mayo Clinic implanted a staffing strategy that

gave an 82% savings in additional hours worked by physicians. This led to a perceived

increase in quality of care and efficiency and a decrease in cognitive load (Cabrera,

2014). This illustrates the importance and the impact of patient acuity with regards to

staffing and stakeholder satisfaction.

Skill level and quality of staff is extremely important when looking at staffing.

“With specialized skills developed in the workforce centers, the pathway to eliminating

unnecessary variability is easier. We know that expertise in staffing and scheduling is

very important in achieving quality outcomes for patients” (Cavouras, 2006). Employee

education, training, and experience should be looked at, especially when staffing the

emergency department, because of the array of skills needed to treat the vast types of

patients that are seen in the ER. Healthcare staff may encounter a cardiac patient, an

infectious disease patient, a trauma patient, a child, an adult, patients from different

cultures, broken bones etc., which requires staff to have a vast knowledge of different

types of medical care and can make converting time into FTE’s (full time employees)

difficult (Kuntz & Sulz, 2013). “A recent study, which claims that professional

experience is associated with clinical judgment and education—operationalized as the

proportion of registered nurses educated to baccalaureate level of higher—shows a

positive effect of nurse education on patient outcomes” (Kuntz & Sulz, 2013). Higher

educated and experienced staff can present a cost issue, so managers must weight cost

with quality of care to make their final determination. Many organizations are using

midlevel providers to reduce cost, fill in existing care gaps, and address the low provider

availability in some areas. The use of midlevel providers and determining staffing based

on skill level should always take into consideration regulatory requirements and work

standards (Klauer, 2013). Skill level can even be looked at for environment services.

Some organizations are even outsourcing responsibilities due to skill level. For example;

a smaller emergency department may outsource environment services because another

company may have experts in this field, where the small ER may not (Laureate

Education, Inc., 2009).

Resources:

Cabrera, D. (2014). A novel automatic staffing allocation tool based on workload and

cognitive load intensity. The American Journal of Emergency Medicine, 35 (5), 467-468.

Retrieved from: https://search-proquest-com.ezp.waldenulibrary.org/pqcentral/docview/

1518116690/EA23F295EDD04C8BPQ/2?accountid=14872

Cavouras, C. (2006). Scheduling and staffing: Innovations from the field. Nurse Leader,

4 (4), 34-36. Retrieved from:

https://class.waldenu.edu/webapps/blackboard/content/listContent.jsp?

course_id=_14658592_1&content_id=_34027170_1

Fried, B., & Fottler, M. (2015). Human Resources in Healthcare: Managing For Success

(4th Ed.). Chiacgo, IL: Health Administration Press.   

Klauer, K. (2013). Innovative staffing in emergency departments: The role of midlevel

providers. CJEM: Journal of Canadian Association of Emergency Physicians, 15 (3),

134-140. Retrieved from:

https://search-proquest-com.ezp.waldenulibrary.org/pqcentral/docview/1355478027/

C7B983D670C4490APQ/1?accountid=14872

Kuntz, L., & Sulz, S. (2013). Treatment speed and high load in the Emergency

Department—does staff quality matter? Health Care Management Science, 16 (4), 366-

376. Retrieved from:

https://search-proquest-com.ezp.waldenulibrary.org/pqcentral/docview/1448958952/

C7B983D670C4490APQ/2?accountid=14872

Laureate Education, Inc. (Executive Producer). (2009). Operations analysis: Staffing and

scheduling. Baltimore: Author.

Ozcan, Y. (2012). Quantitative Methods Health Care Management (2nd Ed). Hoboken,

NJ: John Wiley & Sons, Inc.

The Joint Commission. (2013). New and revised requirements address emergency

management oversight. The Joint Commission Perspectives, 33 (7), 14-15. Retrieved

from:

http://www.jointcommission.org/assets/1/18/JCP0713_Emergency_Mgmt_Oversight.pdf