practical steps for applying acuity-based staffing · nursing hours determining how to measure...

PRACTICAL STEPS FOR APPLYINGACUITY-BASED STAFFING:

What Nurse Leaders Need to Know

As published in American Nurse Today, September 2016 © 2016, HealthCom Media. Printed in USA.

2 American Nurse Today Volume 11, Number 9 AmericanNurseToday.com

For more than 15 years, I’vebeen advocating for health-care leaders to replace the

term “opinion-based” with “evidence-based.” Too often,I’ve heard, “In my opinion, we should do the following.”Whether the speaker is referringto leadership or clinical prac-tice, we hear “In my opinion”far too often.

When discussing staffing andstaffing systems, we need to fo-cus on “evidence-based” in-stead of “in my opinion.” Mul-tiple well-designed researchstudies provide evidence thatpatient assignments should bebased on patient acuity ratherthan simply the total numberof patients.

Why acuity-base staffing? The definition of acuity in-cludes words like insight, keen,sharp, and alert. The complex-ity of patient care calls forstaffing systems defined bythose very words—systems cre-ated to support new ways toalign nursing talent with pa-tient and family needs. Tradi-tional staffing methods basedon the midnight census arequickly becoming obsolete.Those systems falsely assumeall patients are average and allnurses are similar in terms ofcompetency and talent.

Staffing isn’t typically associ-ated with the root cause ofhealthcare challenges, such asrazor-thin profit margins, highstaff and leader turnover, andlow patient satisfaction levels.But long-term success for man-aging these issues hinges on ap-

propriate staffing and avoidingnurse-patient assignment in-equity. High turnover at everylevel and low patient satisfac-tion are well-established markersfor financial disaster, whether inhealth care or any other indus-try. One of the drivers for bothturnover and satisfaction levelsis frontline staffing. And nohealthcare segment is exemptfrom experiencing this reality,whether it’s acute care, long-term care, ambulatory care, orany other setting.

Why now? Systems used to organize andmeasure nursing serviceshaven’t changed much over 60+years. Most of them use volume-based, reimbursement-drivenmethods to allot staff for care.They don’t consider variationsin physical layout of the careenvironment, nursing compe-tency and skill levels, or fluctua-tions in intensity of patient careneeded.

In addition, nursing care isinvisible, and good nursingcare is hard to measure. It’s of-ten thought of simply as badthings not happening. Thesedays, what’s measured are sen-

tinel events and unintended incidents.

The good news Fortunately, published research,implementation of evidence-based practices, and guidancefrom credible experts are guid-ing the paths to change. As-signing nurses to patients based on ever-changing caredemands is becoming easier,thanks to advances in elec-tronic automated systems, out-comes analysis, and the abilityto measure nursing care value.Nursing business intelligence isbeing informed by big data anda greater understanding of theindividual nurse-patient en-counter.

I’m excited to see the adventof performance-based nursingcare that better supports whatpatients need, when they needit. Such care is shaped by newevidence and real-time elec-tronic technology, intersectingat a time when these things areurgently needed. Creating theplatform for ensuring that thebest nursing care is provided inthe best care setting at the low-est cost can’t happen soonenough. When it does, “aver-age” will be used only as amath term, not a staffingmethod. And every patient,every family, every patient,and every nurse will win.

Lillee Gelinas, MSN, RN, FAANEditor-in-Chief

[email protected]

SPECIAL REPORT:PRACTICAL STEPS FOR APPLYING ACUITY-BASED STAFFING Patient assignment vs. nurse staffing:

More than just numbers

Editorial

AmericanNurseToday.com September 2016 American Nurse Today 3

SPECIAL REPORT:PRACTICAL STEPS FOR APPLYING ACUITY-BASED STAFFING

In the healthcare arena,change happens at a rapidpace. Healthcare leaders face

the continual challenge of de-livering high-quality patientcare while managing costs. A growing body of evidenceshows that patient acuity-drivenstaffing is an effective way tooptimize nurse staffing to im-prove patient outcomes andpromote clinical and organiza-tional excellence.

How do we turn that evidenceinto a transformative reality?On July 14, 2016, AmericanNurse Today and GE Healthcarecohosted a webinar that ad-dressed that question. Fournurse leaders—all of them pio-neers in acuity-based staffingresearch and implementation—presented a strong case detail-ing why acuity-based staffing isimperative, not just for patientsand nurses but also for health-care organizations as a whole.They offered practical guide-lines on how nurses can fosterchange, both across the profes-sion and within their local or-ganizations.

Why should we examinethe benefits of acuity-based staffing? Currently, 14 states have legisla-tion regarding nurse staffing inhospitals; some address nurse-patient ratios, while others re-quire various levels of reportingand accountability. This legisla-tive momentum will likely con-tinue, creating a legal impetusfor healthcare organizationsaround the country to begin im-plementing more comprehen-sive staffing systems based onacuity. Acuity-based staffing islinked to a host of benefits,making adoption of data-drivenacuity systems all the morecompelling.

Positive clinical and opera-tional outcomes linked to acuity-based staffing include decreasesin mortality, adverse outcomes,and lengths of stay. “Acuity-based systems maximize patientand nursing outcomes throughenhanced decision making, im-proved operational outcomes,and improved nurse and patientsatisfaction—all while boostingfinancial performance throughlower cost,” said Lillee Gelinas,MSN, RN, FAAN, webinar mod-erator and editor-in-chief ofAmerican Nurse Today.

Sophisticated acuity-basedstaffing systems can extract data pertaining to individualnurses caring for patients withvariable needs, allowing atransparent examination ofcost, quality, and performance.The data can then be integratedfor better clinical and opera-tional outcomes. According toKarlene M. Kerfoot, PhD, RN,NEA-BC, FAAN, chief nursing

Practical steps for applying acuity-based staffing

By Meaghan O’Keeffe, BSN, RN

Evidence showsacuity-based staffingprovides consistent,

high-quality carewhile managing

costs.

Lillee Gelinas, MSN,RN, FAAN (Moderator)System Vice President and ChiefNursing OfficerClinical ExcellenceServicesCHRISTUS HealthIrving, TexasEditor-in-Chief, American Nurse Today

John Welton, PhD,RN, FAANProfessor, Senior Scientist for HealthSystems ResearchUniversity of Colorado College ofNursing, Aurora

Jack Needleman,PhD, FAANProfessor and Chair,Department of HealthPolicy & ManagementUCLA Fielding Schoolof Public HealthLos Angeles, California

Sylvain (Syl)Trepanier, DNP, RN,CENPVice President & System Chief Nursing OfficerPremier Health Dayton, Ohio

Karlene M. Kerfoot,PhD, RN, NEA-BC,FAANChief Nursing OfficerGE Healthcare Workforce ManagementSolutionsMilwaukee, Wisconsin

officer at GE Healthcare, “If wedon’t recognize the variability[in patient care]…and providethe kinds of resources that canmatch a patient’s needs to anRN’s competencies—and do itwithin a healthy environment—we won’t be able to get thekinds of outcomes we desperate-ly need to improve our health-care system.”

Acuity-based staffing andnursing hours Determining how to measurenursing care has been a persist-ent challenge for our profes-sion. Often, nursing is seen as a cost center, not a core service.Healthcare organizations arereimbursed for medical carebased on a diagnosis or proce-

dure, but current payment sys-tems don’t account for nursingcare differences.

Patient acuity levels inacute-care settings have in-creased. What’s more, patientsare being discharged from hos-pitals at a faster pace thanever, which increases the inten-sity of care each patient re-quires. Combined with the widerange of patient variability—even within the same patientpopulation—this has madenursing care needs much moredifficult to ascertain objectively.Patient acuity data offer trans-

parency that allows accuratecalculation of how many nurs-ing hours are needed in a givensituation.

John Welton, PhD, RN,FAAN, professor at the Universi-ty of Colorado College of Nurs-ing and senior scientist forHealth Systems Research,shared data he presented at the46th annual American Organi-zation of Nurse Executives Con-ference, along with findingsthat show the calculation of direct-care hours and the cost of those hours for each patienton a medical-surgical floor. Pa-tients who stayed 1 day had amuch higher average of careneed (in mean hours) thanthose who stayed 2, 3, or 4days. Also, patients who stayed

more than 3 weeks requiredmore care on average. Al-though these patients made uponly 20% of the patient popula-tion, they required 50.4% of allavailable nursing care hoursand dollars. Additionally, pa-tients aged 65 and older (theMedicare population) required30 to 45 minutes more nursingcare per day.

Acuity-based staffing andmortality Jack Needleman, PhD, FAAN,professor and chair of the De-partment of Health Policy and

Management at UCLA’s FieldingSchool of Public Health, pre-sented findings from a 2011 ar-ticle he coauthored, which re-ported results based on datacollected from a large academicmedical center that imple-mented a patient-acuity staffingsystem. The analysis showed asubstantial increase in mortalityduring nursing shifts that fell 8 hours or more below targetstaffing levels—essentially onenurse short. When the re-searchers looked at patientturnover separately, they foundpatient mortality increasedwhen staffing wasn’t adjustedfor higher turnover rates. Acuity-based staffing andadverse outcomes Acuity-based staffing is linkedto decreased adverse events, in-cluding falls, infections, andpressure ulcers. A study by Pap-pas et al. of a transplant unitidentified patient risk factorsthat indicate a higher acuitylevel. A patient score of 4 orhigher indicated the need for alower nurse-to-patient ratio as-signment to accommodate in-creased nursing time or inten-sity. These risk factors include:• organ transplant (kidney, liv-

er, pancreas, or a combina-tion) received on current ad-mission (score of 2)

• hepatic failure (score of 2)• gynecologic surgical post -

operative patient during the first 12 to 24 hours (scoreof 2)

• high fall risk and age olderthan 78 (score of 2)

• transplant patient in isola-tion (score of 1)

• transplant patient readmis-sion (score of 1).The researchers also meas-

ured four nurse-sensitive indica-tors and compared them to anational database of similar in-patient units. The indicators in-cluded falls incidence, catheter-associated urinary tract infec-tions, central line–associatedbloodstream infections, and





pressure-ulcer prevalence. Ratesfor all four indicators decreasedafter staffing was adjusted toaccount for higher-acuity pa-tients. Study findings alsoshowed decreased overtimehours and reduced costs percase. Clinical nurses attributeddecreased overtime to havingadequate time during the shiftto complete their work.

Making the business casefor acuity-based staffing Needleman emphasized thatthe cumulative effects of thebenefits of avoided hospitaldays, avoided adverse out-comes, and avoided deathsmake a powerful business casefor acuity-based staffing sys-tems. He cited data from a clas-sic analysis that found suchsystems bring significant finan-cial advantages to organiza-tions. (See Business case analysisof acuity-based staffing).

In a healthcare environmentwhere payment structures lethospitals retain savings gainedby maximizing cost efficiencieswhile meeting quality stan-dards, nurse leaders can helpexecutives understand the ad-vantages of acuity staffing tothe organization’s bottom line.

Criteria for evaluating anacuity-based staffingsystem An important factor in decidingwhich acuity-based staffing sys-tem to adopt is how much timeand effort implementation willrequire. Optimally, the systemshould carry a minimal addi-tional workload requirement.

As a vice president and sys-tem chief nursing officer, Syl-vain Trepanier, DNP, RN, CENP,helped lead adoption of an acu-ity-based staffing system at Pre-mier Health, a not-for-profitmultihospital system in South-ern Ohio with 14,000 employeesand more than $1.6 billion inrevenue. One of his key aimswas to find a system that fit

Business case analysis of acuity-based staffing Executives typically respond to data. The tables below present data that show thefinancial benefits of acuity-based staffing. The first table shows how variousoptions for increasing staffing at all hospitals to the level of the top quarter ofhospitals would avoid hospital days, adverse events, and deaths. The first columnpresents effects based on raising the proportion of registered nurses; the secondcolumn, the effects of raising the number of licensed hours; and the final column,what happens if both proportion and hours are raised.

The second table illustrates the economic benefits of avoiding hospital days,adverse outcomes, and deaths. When taking into account the cost of raising staffinglevels compared to cost savings linked to reductions in stays and adverse outcomes,the increased cost of adequate staffing nearly pays for itself. The cost increase isnegligible—about 1.4% overall in the short run and 0.4% in the long run.

Business case analysisAvoided days and adverse outcomes

Raise RaiseRN licensed

proportion hours Do both

Avoided days 1,507,493 2,598,339 4,106, 315

Avoided adverse 59,938 10,813 70,416outcomes

Avoided deaths 4,997 1,801 6,754

Needleman J, Buerhaus PI, Stewart M, Zelevinsky K, Mattke S. Nurse staffing in hospitals: is there abusiness case for quality? Health Aff (Millwood). 2006;25(1):204-11.

Cardiac arrest and shock, pneumonia, upper gastrointestinalbleeding, deep vein thrombosis, urinary tract infection

What are the costs and cost offsets of increased nurse staffing?

Raise RaiseRN licensed

proportion hours Do both

Cost of higher nursing $811 mil $7.5 bil $8.5 bilAvoided costs (full cost) $2.6 bil $4.3 bil $6.9 bil

Long term cost increase ($1.8 bil) $3.2 bil $1.6 bilAs % of hospital costs -0.5% 0.8% 0.4%

Short term cost increase ($2.4 bil) $5.8 bil $5.7 bil(save 40% of average)As % of hospital costs -0.1% 1.5% 1.4%

Needleman J, Buerhaus PI, Stewart M, Zelevinsky K, Mattke S. Nurse staffing in hospitals: is there abusiness case for quality? Health Aff (Millwood). 2006;25(1):204-11.

seamlessly into the organiza-tion’s workflow—one in which“we could leverage what’s inour electronic health record[EHR] as it relates to nursingdocumentation and treatmentorders, patient placement, med-ication administration, and allof the activities documented inthe health record that showwhat’s going on with the pa-tient, up to and including trans-fers, admission, and discharge.”Premier Health was able to finda user-friendly commercial sys-tem that incorporated timely,actionable data—somethingthat could be acted upon on anhourly basis.

The staffing system should bebuilt on a foundation of expertnursing judgment and shouldreflect the nursing work. “Nurs-es understand their care betterthan anybody else,” Needlemanexplained.

Indicators that affectstaffing Another factor to consider whenchoosing an acuity-basedstaffing system is to ensure thatthe indicators measure patientcomplexity and required nurs-ing care. To evaluate this, lead-ers need to consider several vari-ables identified in the literaturewhen determining adequatestaffing. These variables fallinto three major categories: pa-tient needs, nurse characteris-tics, and unit and organiza-tional factors.

Patient needs To a large extent, patient vari-ables naturally drive staffingneeds. Emphasis should beplaced not just on disease orstatus but also on outside fac-tors that influence acuity—pa-tient complexity, length of stay,functional status, activities ofdaily living, need for transport,and age. All of these play a rolein determining the patient’snursing care needs. Several ad-ditional items also affect nurs-

ing workload intensity. (See Pa-tient-related factors affecting nurs-ing workload.)

Nurse characteristics Nursing staff characteristicsmust be taken into account. Aparticular nurse’s training, edu-cation, and skills should bematched with the needs of aparticular patient.

Unit and organizationalfactors These factors may include work-flow processes, documentationexpectations for nursing staff,physical layout of the floor, andexisting support, includingnursing assistance and stockingof supplies.

Commercial vs. localsystems A key decision organizationsface when choosing an acuity-

based staffing system is whetherto use a commercial system, asPremier Health did, or developone locally. Both options haveadvantages and drawbacks.

The biggest advantage ofcommercial systems is that theyoffer an already developed algo-rithm that potentially can betailored to the local nursingmodel. Commercial systems typ-ically include modules that al-low direct tracking of actual vs.target indicators to see howthose indicators affect patientprocesses.

However, many commercialsystems have a high data-entryburden, although this can bemitigated by linkage to theEHR (a feature vendors increas-ingly are working to accom -modate). Also, these systemstypically focus on patient needand don’t take into accountpatient turnover and the asso-



Patient-related factors affecting nursing workload The factors defined below play a role in determining a nurse’s workload intensity.

Medications The number of medications a patient receivesduring a 12-hour nursing shift that must be ver-ified against a medical doctor’s order and basedon standards of medication delivery

Complicated Task- and time-oriented procedures carried outprocedures to perform competent patient care in manage-

ment of disease process and prevention ofcomplications

Education Requirements for complex patient care encom-passing teaching about disease processes, pro-cedures, preventive measures, and standard fa-cility protocols

Psychosocial Nursing tasks related to monitoring and inter-vention correlating with mental disabilities,end-of-life care, and palliative care, and includ-ing personal or family dynamics

Complicated Task- and time-oriented distribution and I.V. medications monitoring of I.V. medications, blood or blood

products, or hemodynamic monitoring of vas-cular access

Harper K, McCully C. Acuity systems dialogue and patient classification system essentials. Nurs AdminQuarterly. 2007;31:284-299.



ciated increase in nursingworkload intensity.

Local systems, on the otherhand, can be adjusted for localpatient variation on specificunits or adapted to incorporatevariability the nursing staff con-siders relevant—for instance,patient turnover. But they alsocan impose a data-entry burdenif no linkage exists to track dataentry and storage, which meansdata must be collected by hand.

During rollout of a new acuity-based staffing system,Trepanier emphasized, sharedgovernance and having signifi-cant support in place are cru-cial for making the process asseamless as possible. He recom-mended that those responsiblefor implementing the systemidentify and address resistanceto change early and incorpo-rate the system slowly fromone service area to the nextrather than taking a “bigbang” approach.

Call to action Optimal staffing is linked toclinical and organizational ex-cellence. Rigorous evidence isemerging to support acuity-based staffing as way to provideconsistent, high-quality carewhile managing financial bur-den. Nationally, legislationmandating acuity-based staffingis increasing, and union con-tracts are starting to considerthe role of acuity-based staffingas well. As a result, healthcareorganizations will likely havedifficulty ignoring the moveaway from census- or opinion-driven staffing toward acuity-driven systems.

The onus now lies on nursingleadership, with many opportu-nities to help push for change.Externally, nurses can committo supporting research sur-rounding acuity-driven staffingand disseminating that workthrough presentations and pub-lications. They can support pro-fessional nursing organizations

that are spearheading change.For instance, the AmericanNurses Association is develop-ing white papers to help edu-cate nurses and support themovement.

Internally, nurse leaders needto support a move away fromopinion-based acuity staffingtoward data-driven acuity-basedstaffing. This will require edu-cating teams, management,and chief executives about thepotential for data-driven staff -ing to improve patient care andcontrol cost. “Historically, manyhave been suspicious of acuity-driven staffing,” said Kerfoot,“because it has been opinionbased. But that’s not the casenow. We have to help peopleunderstand this isn’t the acuitysystem of 20 years ago. Today’sdata-driven systems make anincredible difference.”

Kerfoot urges nurses, particu-larly nurse leaders, to advocatefor data-driven acuity-basedstaffing technology and to em-power nursing to leverage theEHR investment and use robustdata that will bring a signifi-cant return on investment.Nurse leaders must stay wellinformed to ensure that a nurs-ing voice is already at the tablewhen workforce staffing tech-nology decisions are being considered.

Acuity-based staffing isn’tjust a way to achieve better patient outcomes. It’s also anopportunity to demonstrate the significant value nursingcontributes to patient care.

Trepanier pointed out, “If wedon’t have the data to demon-strate the hard work—the prac-tice and influence we make in light of those we serve—wewon’t be able to appropriatelydemonstrate our value contri-bution.” �

Meaghan O’Keeffe is a freelance healthcare writerand clinical editor based in Framingham,Massachusetts.

Editor’s note: Access a recording of the webinar onthe American Nurse Today website.

Selected referencesHarper K, McCully C. Acuity systems dialogueand patient classification system essentials.Nurs Adm Q. 2007;31(4):284-99.

Needleman J, Buerhaus P, Pankratz VS, Leib-son CL, Stevens SR, Harris M. Nurse staffingand inpatient hospital mortality. N Engl J Med.2011;364(11):1037-45.

Needleman J, Buerhaus PI, Stewart M,Zelevinsky K, Mattke S. Nurse staffing in hos-pitals: is there a business case for quality?Health Aff (Millwood). 2006;25(1):204-11.

Pappas S, Davidson N, Woodard J, Davis J,Welton JM. Risk-adjusted staffing to improvepatient value. Nurs Econ. 2015;33(2):73-8.

Welton JM, Caspers B, Sanford K. Inpatientnursing hours and cost outcomes within ahealth care system. American Organization ofNurse Executives 46th Annual Conference.March 2013, Denver, Colorado.

Learn more about how an integrated, data-driven staffing and scheduling practice can impact the care delivery at your organization. Visit gehealthcare.com/WorkforceManagement or call 262-670-2828.

Turn Workforce Data Into Better Outcomes

1 Becker’s Healthcare survey “Aligning Organizational Goals with Workforce Management Initiatives” conducted May/June, 2015.

©2016 General Electric Company – All rights reserved.

However survey results showed that only 40% of respondents are using technology to enable

acuity-based staffing1

Healthcare Executives are making the connection between workforce management strategies and quality of care

practical steps for applying acuity-based staffing · nursing hours determining how to measure...

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