it is important to understand healthcare throughput challenges within an organization. As the nurse leader, you must have an understanding of and be involved in the planning, developing, and evaluation of throughput, any issues or concerns within nursing, and an understanding of the overall organization.
Adequate staff ratios have a direct influence on the quality of patient care and its outcomes (Roussel, 2015). Movement of a patient from the point of admission to the point of discharge can be delayed without adequate staffing to meet the needs of the patient and the organization. Having the appropriate number of skilled and trained staff in an area to meet the variations of patient complexity is a challenge for nurse leaders.
Many areas within healthcare settings tend to utilize a decentralized-staffing approach. With a decentralized approach, the nurse leader or designee is responsible for completing a schedule that provides coverage for sick time, absences, holidays, patient acuity, vacations, and time off for education as applicable (Marquis & Huston, 2014). Generally the nurse leader is responsible for the overall budget of the area as well. By having oversight of the staffing schedule for his or her area, the nurse leader can have more control over the budget and work to contain staffing costs. Flexing staff members’ work times or roles to accommodate a low census can, over time, save thousands of dollars on a set budget. Some nurse leaders have implemented self-scheduling in their areas to allow staff to have more flexibility and control of their work schedules. Specific guidelines should be in place to ensure that employees schedule themselves for the appropriate hours, shifts, and required holidays. Holiday scheduling is generally a challenge for many areas. Many organizations may have a lighter surgery schedule, because physicians may not be admitting as many patients or they may be on vacation, which may allow more staff to have holidays off rather than work.
However, the opposite may be true if you work in an emergency-room setting and the census stays the same or increases due to general-practice healthcare providers having reduced or no office hours for holidays. Staffing requires constant monitoring to try to maintain the safest staff-to-patient ratio to cover the patient acuity in an area. Many nurse leaders will monitor staffing at least every 4 hours or less, depending upon the specific area.
Along with the self-scheduling option, a variety of shifts may exist within an area, such as 4-, 8-, 10-, or 12-hour shifts. Some units have other variations to try to find the best mix to meet the patient needs and stay within or under budget. Knowing your position control (the number and type of personnel per shift) and staffing budget will help guide your master-staffing plan. Having a master-staffing plan with the number and type of staff per shift is helpful for the nurse leader and scheduling office to ensure that staffing needs are met. Due to the amount of time that is needed to review requests and develop the schedule, many nurse leaders may designate a charge nurse to complete and oversee this task. Once completed, the staffing scheduler typically submits the schedule to the nurse leader for review and approval. When it is approved, a copy is also sent to the central staffing department if applicable.
Some organizations may utilize a centralized-staffing approach with a central-staffing office to provide coverage throughout the specified areas. The staffing coordinator may not necessarily be a nurse. In most cases, the nurse leader may not have any control over who is sent to the leader’s area to cover a staff vacancy in the schedule. Many organizations have their staffing schedules entered into a computer system so they can easily print out a schedule as needed. Many workload-measurement tools exist, and some organizations or units have tried a variety of tools to find the right balance to successfully meet their staffing needs.
The standard formula for calculating workload is, typically, nursing-care hours (NCH) per patient-day (PPD) equals the nursing hours worked in 24 hours divided by the patient census (Marquis & Huston, 2014). Many nurse leaders have tried to incorporate patient acuity into predicting staffing needs; however, a patient’s condition may change very quickly in certain situations, and this variation is difficult to predict 4 or 8 hours ahead. In addition, other unforeseen issues may arise that must be considered when planning your staffing needs, such as environmental emergencies.
Review Figure 10-3
Please review Figure 10-3, Planning for Staffing (page 401 of the Management and Leadership for Nurse Administrators textbook).
Though staffing within an organization can be a great challenge, ensuring that patients are transported to and from various tests and procedures and admitted and discharged timely are other important issues to consider regarding organization throughput. As mentioned earlier in the lesson, many organizations have a central-staffing office to ensure adequate staffing to assist patients in meeting their hospital goals and being discharged by the target date.
In addition to a central-staffing office, many organizations also have a central transportation department to move patients from one location to another. Discharge may be delayed due to tests not being completed or doctors and/or other healthcare providers not completing the required evaluation, paperwork, or orders. Working interprofessionally with the transportation department and medical staff is a great way to build relationships and help support patients being picked up and returned timely after various tests and procedures. Incentives for some team members to meet discharge targets have been utilized at some agencies, such as doctors rounding early in the morning to write discharge orders to encourage early discharges. Working collaboratively as a team throughout the organization will help ensure that the patients meet their set goals and are discharged timely.
Quality of Healthcare
As the nurse manager, you have an overall ethical and fiscal responsibility for the quality of patient care provided for your area. The quality of patient care within an organization or a specific area can be measured by many outcome measures, such as patient satisfaction or infection rates. The nurse leader reviews the outcome data to determine if further evaluation or additional steps need to be implemented. Ensuring adequate staffing is a major factor that can affect the quality of care your patients receive. As we discussed earlier, ensuring adequate staff to support the number of patients and the complexity of patients can be a challenge. When nursing staff are overworked, and staffing is stretched beyond a safe limit, more frequent patient errors can occur (Roussel, 2015). The nurse leader must ensure that the organization follows required organizational, state, or other mandated staffing ratios and policies to help maintain quality patient care and meet necessary requirements and regulations.
Recruiting and retaining quality nursing staff can be challenging at times. With the staffing shortage, organizations and nurse leaders have gotten creative with their marketing and incentives to attract qualified personnel to their organizations or areas. Some programs have included internships, a clinical ladder program, and tuition reimbursement. In addition to creative recruitment and retention approaches, some organizations have utilized travel or agency nurses to help supplement staffing when they are unable to recruit the needed nursing personnel within their areas.
This week, we explored healthcare organization throughput and the role the nurse leader plays within this process. Next week, we will reflect upon the course and provide input and feedback on the quality of healthcare presentations shared by your peers.
Marquis, B.L. & Huston, C.J. (2015). Leadership roles and management functions in nursing: Theory and application (8th ed.). China: Wolters Kluwer Health.
• Chapter 17: Staffing Needs and Scheduling Policies
Roussel, L. (2015). Management and leadership for nurse administrators (7th ed.). Boston: Jones & Bartlett Learning.
• Chapter 9: Maximizing Human Capital
Platzke, S.M. & Andrabi, I.A. (2012, Aug). Focusing on white space to improve patient throughput. Healthcare Financial Management: Journal of the Healthcare Financial Management Association, 66(8), 102–6, 108.
Mchugh, M., Van Dyke, K. J., Howell, E., Adams, F., Moss, D., & Yonek, J. (2013). Changes in Patient Flow Among Five Hospitals Participating in a Learning Collaborative. Journal For Healthcare Quality: Promoting Excellence In Healthcare, 35(1), 21-29. doi:10.1111/j.1945-1474.2011.00163.x
Marquis, B.L. & Huston, C.J. (2014). Leadership roles and management functions in nursing: Theory and application (8th ed.). Philadelphia: Lippincott Williams & Wilkins.
Roussel, L. (2015). Management and leadership for nurse administrators. (7th ed.). Boston: Jones & Bartlett Learning.
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