Staffing and Scheduling – Part I

HCM 540 – Operations Management

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

High Level Staffing Framework

Budgeting and Planning

•Annual or as needed

•Planned capacity

•Staffing/scheduling policies

Operational staffing/scheduling

•Every 2-6 weeks

•Target staffing levels

•Create employee schedules for core staff

Daily allocation•Ongoing

•Reacting to staffing variances

•Floating staff, overtime, contract staff, agencies

Adapted from Abernathy et. al. (1973), Hershey et. al. (1981), Warner et. al. (1991)

Budget, staffing plan, policies

Staff schedule

Realized shortagesand surpluses

Tactical Staff Scheduling

Analysis

Labor Resource Management Framework

1. Understanding you Workload

2. Converting Workload to Staffing Requirements

3. Developing Staff Schedules

4. Ongoing Management of Resources

r

LaborResource

ManagementFramework

Quantify Staffing Requirements

Staffing Related Challenges

Hospital downsizingQualification level of caregivers decreasingHospital trained “generalist” caregivers replacing specialist, professional caregiversSpecialist caregivers taking on wider range of tasks and responsibilitiesPatient acuity levels increasingNursing shortagePatient 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)

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 concernJCAHO has concluded that mandating specific staff-to-patient ratios will be unsuccessful to address the issuesAn 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.

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)

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

Staffing Methods Depend on the Nature of the Work System

Inpatient NursingEpisodic care ER, Surgical Recovery, Surgical Suites, Short

Stay Unit, LDR, OP Clinics, Card. cath, PT/OT, Resp. care

Lab, Imaging, PharmacyMedical records, transcription, financial services Appointment scheduling, other call centersMaintenance, transport, materials management

About Labor Resource Management . . .

No single staffing method or model is the right oneHundreds of ways to organize staffingHow do you measure success of a model? Are standards for quality and customer

satisfaction met? Is staffing delivered at an affordable and

sustainable cost?

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”

How do organizations traditionally staff?

Starting with the Budget . . . Budget the Same Number of FTEs Each Month

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov DecADC 18 18 18 18 18 18 18 18 18 18 18 18Hours 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 23.3HPPD 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2

Anywhere Hospital2001 Nursing Salary Budget

Unit: 3 South-Medical

Unit budgeted for anADC of 18 acrossboth busier monthsand traditionallyslower months.

Same number of FTEs allocated to each month

Where did the workload driver for the budget come from in the first

place?

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.

How do organizations traditionally staff?

A Struggle to Staff Each Day

Medical Unit Daily Census

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Significant reliance on expensive overtime and agency labor to staff up quickly

Unit often ends up running short-staffedwhen census spikes,a big dissatisfier for thestaff.

Staff sent home or floated, or unit remainsoverstaffed when census drops.

What should the core staff level be? The mean, the 75th, 85th, 95th percentile?

How to meet the dailystaffing demand

Full-time & part-time, regular (“Core”) Float pool

Overtime

Contingent Agency

Contingent & Agency OT

Part-time

What you don’t want to do . . .

Required vs. Scheduled Staffing

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Required Staff Hours per hour - Avg Scheduled Staff

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?

Operations Analysis Before Staffing Analysis

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

Just as we don’t want to IT enable a bad process, we don’t want to staff a bad

process.

Charting Workload – A 1st Step

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Preop/Post-op Space Planning - Option 1Preop B Simulated Occupancy

Preop for Area A and Phase 2 for Area C

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Simulated preop occupancy based on average preop time of 90 minutes. Though capacity exceeded by 95%ile under 10% growth scenario, results for Preop D suggest 90 minute preop time too long.

Capacity=9

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Productivity and Productivity Management

Related concepts work

measurement work simplification operations

analysis staffing analysis workforce

planning

ProductivityOutput

Input

Many ways to define the outputs and

inputs depending on the situation

See Chapters on Productivity and Staffing that I handed out.

Labor Productivity InputsUsually expressed in labor hours or $Subdivide into productive and non-productiveData usually available from time & attendance or payroll systems (e.g. Kronos)

Total labor hours = worked hours + non-worked paid hrs

regular OT premium agency contingent

vacation sick personal holiday

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

Labor Productivity OutputsMultitude 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

Nursing units Patient days (by acuity)LDR # deliveries, # c-sectionsGeneral surgery Patients, procedures, surgical hoursRecovery room Patients (by acuity)Emergency Dept. Visits (by acuity)Hematology patients, procedures, CAP SBTsAmbulance service Trips, milesPhysical Therapy ModalitiesRadiation Therapy Patients, proceduresRadiology - Dx Procedures (type)Admitting # admissions, # transfersAppt Center appts scheduledOP Clinic visits, RVUs

CAP

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 samplingExpert judgement low volume tasks

Time Standards in Healthcare

Attempts since the 1960s to apply industrial work measurement techniques to healthcareUse “time studies” to estimate standard amount of time to do some taskSuccess 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

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:

#proportion of time doing activity

#i

jj

Observationsi

Observations

Easier to perform than time study, especially for irregular work such as health care deliveryDifficult to capture “knowledge work” such as nursing assessmentUsed, along with time studies, in the development of nursing classification systems, estimation of indirect or constant activities

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

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

1

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W sV cD

W = total hours of workload in D dayssi = standard hours for work type i

Vi = volume of work type i in D days

c = constant task hours per dayD = # of days

Aggregate vs. Disaggregated WorkloadUse 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

Sources of Workload DataDepartment 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

Example Productivity Monitoring System Report

1999 CORPORATE APPOINTMENT CENTER PMS REPORT 1993 CORPORATE APPOINTMENT CENTER PMS REPORT

CURRENT YEAR PREVIOUS YEAR

Utilization % Hours Utilization %

Reporting Work Overtime/ Vacation/ Work Actual MONTHLY HRS WORKED

Period Units Monthly YTD Actual Standard Contingent Sick/LOA Units Hours Monthly Y.T.D.

J anuary 21,076 69.9 69.9 5,178.0 3,618.4 758.4 299.4 22,153 4,909.9 73.1 73.1

February 18,669 69.4 69.7 4,684.7 3,251.3 682.6 428.3 20,039 4,972.1 66.5 69.8

March 21,626 71.9 70.5 5,244.7 3,773.5 727.3 394.4 22,099 5,296.8 67.0 68.8

April 19,532 70.3 70.4 4,889.1 3,439.1 687.1 429.9 21,924 5,148.0 68.8 68.8

May 18,160 68.7 70.1 4,714.6 3,238.5 775.2 622.9 19,700 5,041.3 64.5 68.0

J une 20,830 75.0 70.9 4,744.2 3,557.2 785.8 695.9 29,956 4,909.1 71.7 68.6

J uly 18,620 72.5 71.1 4,558.7 3,306.1 711.3 527.1 31,318 4,777.8 76.4 69.6

August 0 0.0 #DIV/0! 0.0 0.0 0.0 0.0 28,692 4,775.3 72.4 70.0

September 0 0.0 #DIV/0! 0.0 0.0 0.0 0.0 28,887 4,618.8 73.9 70.4

October 0 0.0 #DIV/0! 0.0 0.0 0.0 0.0 29,129 5,470.5 64.9 69.8

November 0 0.0 #DIV/0! 0.0 0.0 0.0 0.0 26,312 4,933.9 65.5 69.4

December 0 0.0 #DIV/0! 0.0 0.0 0.0 0.0 25,555 4,523.0 70.8 69.5

Standard hours based on weighted averagetime standards for numerous appt types

So, what’s the target?

appt99c.xls

Productivity Monitoring Report

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Productivity

The Labor Hour InputsHours Worked and Year to Data Calculcations

RC 1254 DIV 12 REGULAR YTD YTD

MONTHLY HRS WORKED HOURS WORKED BY J OB SERIES ACTUAL STD

Month REG OT CONT VAC SICK LOA PPE REG OT CONT VAC SICK LOA HRS HRS

(Reg. Clerk II Hours Only)

J AN 4419.61 47.84 710.52 106.79 106.93 85.71 1/02 1553.30 2.80 278.10 310.00 25.00 0.00 5178.0 3618.4

FEB 4002.14 26.75 655.84 135.07 133.21 160.00 1/16 2092.30 19.70 318.80 24.00 73.00 0.00 9862.7 6869.7

MAR 4517.42 40.60 686.65 87.43 129.79 177.14 1/30 2071.20 27.90 348.10 60.00 28.00 80.00 15107.4 10643.2

APR 4201.94 52.71 634.40 130.57 93.57 205.71 2/13 2032.20 0.50 332.60 9.00 58.00 80.00 19996.4 14082.3

MAY 3939.46 90.93 684.24 137.71 142.29 342.86 2/27 1970.70 25.30 325.80 121.00 77.00 80.00 24711.0 17320.8

J UN 3958.38 66.12 719.70 300.71 52.29 342.86 3/13 2021.50 13.80 296.70 80.00 33.00 80.00 29455.2 20878.0

J UL 3847.36 78.79 632.54 405.86 46.93 74.29 3/27 2059.20 24.50 330.80 0.00 82.00 80.00 34013.9 24184.1

AUG 0.00 0.00 0.00 0.00 0.00 0.00 4/10 2033.90 11.50 281.20 46.00 60.00 80.00 0.0 0.0

SEP 0.00 0.00 0.00 0.00 0.00 0.00 4/24 1934.40 34.90 297.90 72.00 22.00 80.00 0.0 0.0

OCT 0.00 0.00 0.00 0.00 0.00 0.00 5/08 1901.10 22.40 316.50 60.00 67.00 160.00 0.0 0.0

NOV 0.00 0.00 0.00 0.00 0.00 0.00 5/22 1837.80 44.70 322.30 12.00 104.00 160.00 0.0 0.0

DEC 0.00 0.00 0.00 0.00 0.00 0.00 6/05 1776.80 58.50 316.90 160.00 0.00 160.00 0.0 0.0

Bi-weekly pay data rolledcarefully into monthly data

Original Volumes and Standard Hours Calculations Original Volumes and Standard Hours CalculationsPOSTCARDS HAVE BEEN REMOVED!!!

Total Total YTD AVG

Advanced Cat Mammo- Endo- Nuclear OB Outpatient Work Normalized Normalized

Anesthesia Testing Scan (CT) graphy MRI Ultrasound scopy Medicine Ultrasound Inpatient Surgery Units Work Units Work Units

JAN 173 1492 1162 2347 849 945 530 599 795 344 1338 21076 21144 21144

FEB 118 1349 954 2632 751 1054 518 602 727 306 816 18669 20290 20717

MAR 163 1436 1267 2727 1103 1179 550 709 819 460 1303 21626 20892 20775

APR 105 1397 1118 2526 918 1068 529 600 810 292 1111 19532 19595 20480

MAY 132 1330 1160 2333 921 927 450 444 478 250 842 18160 18218 20028

JUN 95 1378 1163 2696 1000 1089 609 572 739 312 847 20830 20897 20172

JUL 107 1250 1047 2496 938 1054 599 479 628 269 1006 18620 17988 19646

AUG 89 1322 1139 2846 994 1162 604 560 717 321 1394 20914 20981 19762

SEP 149 1342 1215 3079 1099 739 523 569 659 288 870 21225 21293 19829

OCT 111 1289 1066 3104 1071 881 453 497 687 335 1201 20586 20652 20005

NOV 231 1297 1138 2959 1112 1017 432 393 654 223 1241 21674 21743 20592

DEC 0 0 0 0 0 0 0 0 0 0 0 0 0

Advanced Cat Mam m o- Endo- Nuclear OB Outpatient Total Total Total

Anes thes ia Tes ting Scan (CT) graphy MRI Ultrasound scopy Medicine Ultrasound Inpatient Surgery Variable Hrs Constant Hrs Std Hrs

Std Hrs 0.12 0.19 0.20 0.18 0.22 0.16 0.12 0.14 0.15 0.14 0.17 17.86

Std Mns 7.36 11.52 11.73 10.7 13.12 9.6 7.03 8.6 8.97 8.34 10.49

J AN 21.22 286.46 227.17 418.55 185.65 151.20 62.10 85.86 118.85 47.82 233.93 3136.21 482.22 3618.43

FEB 14.47 259.01 186.51 469.37 164.22 168.64 60.69 86.29 108.69 42.53 142.66 2804.77 446.50 3251.27

MAR 19.99 275.71 247.70 486.32 241.19 188.64 64.44 101.62 122.44 63.94 227.81 3309.12 464.36 3773.48

APR 12.88 268.22 218.57 450.47 200.74 170.88 61.98 86.00 121.10 40.59 194.24 2974.78 464.36 3439.14

MAY 16.19 255.36 226.78 416.05 201.39 148.32 52.73 63.64 71.46 34.75 147.21 2774.13 464.36 3238.49

JUN 11.65 264.58 227.37 480.79 218.67 174.24 71.35 81.99 110.48 43.37 148.08 3092.86 464.36 3557.22

JUL 13.13 240.00 204.69 445.12 205.11 168.64 70.18 68.66 93.89 37.39 175.88 2823.88 482.22 3306.10

AUG 10.92 253.82 222.67 507.54 217.35 185.92 70.77 80.27 107.19 44.62 243.72 3208.25 464.36 3672.61

SEP 18.28 257.66 237.53 549.09 240.31 118.24 61.28 81.56 98.52 40.03 152.11 3114.34 464.36 3578.70

OCT 13.62 247.49 208.40 553.55 234.19 140.96 53.08 71.24 102.71 46.57 209.97 3078.04 482.22 3560.26

These volumes & standards are NOT accurate; for illustration only

Using Productivity ReportsTracking 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)

Why Not 100% Productivity?

Service level constraints for systems with significant queueing componentMinimum required staffing levels e.g. 2 RNs in PACU at all times

Peaks and valleys in demandStaff scheduling inefficienciesTotal control of labor supply is impossible

Corporate Appointment CenterEstimated Staffing Needs

Variable and Constant Workload

Average Total ActualStandard Utilization Hours/Month

Split Hours/Month (1) Goal (2) Needed (3) FTEs (4)22 1738.0 65% 2673.8 15.423 592.0 65% 910.8 5.324 669.0 100% 669.0 3.9

Constant 511.6 #N/A 511.6 3.0

Subtotal A 27.5

+ Coverage (5) 2.5

Subtotal B 30.0

+ Benefit Allowance (6) 3.1

Total (based on 30 second STA goal) 33.1

Note: A 60 second STA would require approximately 1.5 FTEs less.

Target Utilization (7) 70.1%

(1) Based on Volumes reported in 1999 Productivity report.(2) Utilization goals less than 100% reflect the 30 second speed to answer service level.(3) Standard hours/utilization goal(4) Total hours needed/173.8 hours per month per FTE (4.345 wks/mo)(5) Reflects staff needed due to peaks and valleys in workload and staff scheduling constraints.(6) Based on Vacation/Sick report.(7) The weighted average overall utilization goal. The average standard hours per month used

to calculate this utilization was increased by 137 hrs/month to take into account the addresscards that are filled out during idle times for Split 22.

variable workloaddriven by incomingphone calls for appts

weighted avg of split specific goals

effect of service level on staffing

Staffing AnalysisPreview

Full Time Equivalent=40 hrs/wk

Percentage of working days in year subject to paid time off (vacation, holiday, sick, personal). Typically around 10-15%

Queuing model used to find staffing

levels to meet STA targets.

From scheduling analysis (next time)

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

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

Commercial Systems

OneStaffGRASPENEPCSHome grown (50%-70%)!!!

Evolution of Nursing PCS1970s – 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

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 outcomesCurrently wide variation in delivered n:p, RN HPPDImplementation 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 systemDifferent 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”

Recent version of law seems to indicate 1:5 ratioSEIU is the Service Employees International UnionCHA is the California Hospital Associationhttp://www.calhealth.org/

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)

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.

One Use of PCS - Inpatient UnitStaffing Requirements – The “GRID”

Med / Surg Unit

No. of Patients Staffing1 - 12 pt 2 RN13 - 21 pt 3 RN22 - 28 pt 4 RN29 - 32 pt 5 RN

No. of Patients Staffing1 - 14 pt 2 RN15 - 24 pt 3 RN25 - 32 pt 4 RN

No. of Patients Staffing1 - 20 pt 2 RN21 - 30 pt 3 RN21 - 32 pt 4 RN

These staffing ratios are for illustration

purposes only

2. Converting Workload to Staffing Requirements

Detailed methodology depends on the specific situation, but general approach (see Appointment Center example on previous slide):

1. convert forecasted future work to minimum core staff required staff using time standards (variable & constant tasks, HHPPD), classification/acuity systems, nurse to patient ratios

2. do the above for the “appropriate” time interval (hourly, shift, daily, etc.)

3. make necessary upward adjustments to account for service level constraints1. simple normal distribution of work assumption (analogous

to choosing an overflow percentage limit in bedsizing)2. queueing or simulation models3. 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)

2. Converting Workload to Staffing Requirements (cont)

4. 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

5. 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

6. 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.

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”

A Few Staffing ExamplesAppointment 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

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 goalWell 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)

The Challenge of Staff Scheduling

So…, how much staff is needed and how should they by scheduled?

Postpartum Staffing Needs

0

5

10

15

20

25

30

35

40

45

Su

n 1

2 am

Su

n 0

6 am

Su

n 1

2 p

m

Su

n 0

6 p

m

Mo

n 1

2 am

Mo

n 0

6 am

Mo

n 1

2 p

m

Mo

n 0

6 p

m

Tu

e 12

am

Tu

e 06

am

Tu

e 12

pm

Tu

e 06

pm

Wed

12

am

Wed

06

am

Wed

12

pm

Wed

06

pm

Th

u 1

2 am

Th

u 0

6 am

Th

u 1

2 p

m

Th

u 0

6 p

m

Fri

12

am

Fri

06

am

Fri

12

pm

Fri

06

pm

Sat

12

am

Sat

06

am

Sat

12

pm

Sat

06

pm

Nu

rses

Position Tour Type FTE Sun Mon Tue Wed Thu Fri Sat

1 (8 hrs, 5 days/wk) 1.0 O 7a-3p 7a-3p 7a-3p 7a-3p O 7a-3p2 (8,5) 1.0 O 3p-11p 3p-11p 3p-11p 3p-11p 3p-11p O3 (8,3) 0.6 O 8a-4p 8a-4p 8a-4p O O O4 (10,4) 1.0 O 7a-5p 7a-5p O 7a-5p 7a-5p O

5 (10,4) 1.0 O 7a-5p 8a-6p 7a-5p O 8a-6p O

6 (12,3) 1.0 O O 7a-7p 7a-7p O 7a-7p O7 (12,4) 1.0 7a-7p 7a-7p O 7a-7p 7a-7p O O

FTE = Full Time Equivalent (40 hrs/wk = 1.0 FTE)

Tour Type Tot FTEs

(8,5) 30.0 (8,3) 6.6 (10,4) 4.0 (12,3) 22.0

62.6

1

32

Staff Scheduling - It’s a Problem

Policies and practices affect total labor cost. little “tactical” scheduling analysis done

Overstaffing increases labor costs while understaffing may impact quality of care or service

Presents difficult combinatorial problems.

Consumes costly managerial time and effort; ad-hoc methods are the rule.

Bias often to favor employee over institutional needs.

Large impact on employee dissatisfaction and turnover

Not only in healthcare - police, fast food, call centers, airlines

Computerized systems under-utilized and often require inputs which themselves are the solution to a difficult scheduling analysis problem.