management/administration using a nursing …ccn.aacnjournals.org/content/31/6/55.full.pdf ·...

plans and manage staffing prudently.This measure, developed by theAmerican Nurses Association forthe National Database of NursingQuality Indicators (NDNQI),1 is avalid alternative to using an acuitysystem to manage staffing. Nursingcare HPPD refers to the number ofnursing care hours needed relativeto the patient workload.1 The cost todeliver nursing care has been steadilyincreasing. For example, the averagelabor cost per patient day in ourintensive care unit (ICU) in fiscalyear 2002 was $473; in fiscal year2009, it was $680.

Our HPPD values are derivedfrom hospital direct care hours andcensus data, individualized to eachnursing unit. Workload demandsand expectations vary within clinical

Erin McKenna, RN, BSN, MBAKristina Clement, BAElizabeth Thompson, RN, BSN, MBA, CCRNKathy Haas, RN, BSWilliam Weber, RN-BC, MSNMichelle Wallace, RN, BSNCindy Stauffer, RNJan Frailey, RNAimee Anderson, RN, BS, CCRNMissy Deascenti, RN-BC, BSNLisa Hershiser, RN, MSN, MHAPatricia Inama Roda, RN, BS

Using a Nursing ProductivityCommittee to Achieve CostSavings and Improve StaffingLevels and Staff Satisfaction

Management/Administration

surgery, trauma/neurology, inter-mediate care, telemetry, medical/surgical, level IIIb neonatal inten-sive care, pediatrics, oncology, andwomen and babies units.

Part of the NPC’s original chargewas to manage staffing by using theconcept of nursing care hours perpatient day (HPPD). Our chief nurs-ing officer introduced HPPD as areliable metric to establish staffing

In 2002, a Nursing Productiv-ity Committee (NPC) wasestablished at our 640-bed,not-for-profit, Magnet-desig-nated, level II trauma center,

community hospital. The hospitalhas a comprehensive range of inpa-tient critical care and other servicesincluding intensive care, open heart

Challenged by rising costs, higher registered nurse vacancy rates and decliningstaff morale, a Nursing Productivity Committee was formed to analyze productiveand nonproductive hours and seek improvements in our staffing models and sched-uling processes. The changes implemented led to lower nurse to patient ratios, bettercontrol of labor costs, elimination of agency staff, greater staff satisfaction, and intro-duction of new technologies. Nurse managers, nursing supervisors, and frontline staffare now more knowledgeable and empowered to use creative solutions to managetheir budgets and schedules in these times of fluctuating census and varying vacancyrates. (Critical Care Nurse. 2011;31[6]:55-65)

©2011 American Association of Critical-Care Nursesdoi: http://dx.doi.org/10.4037/ccn2011826

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settings; more hours are requiredfor a critical care unit than for amedical/surgical unit. As workloaddemands increase, nurse to patientratios must decrease.

At the time of the committee’sinception, nursing leaders facedenormous challenges because of thediminishing number of skilled nurs-ing staff available during a criticalnational nursing shortage. We werealso experiencing record growth inour inpatient and outpatient census.Existing critical care units werebeing expanded to meet demand,and additional telemetry units werebeing opened. Change was constant.

Along with the need to staff totarget HPPD, many initiatives wereimplemented to achieve improve-ments in throughput of patients and

to address workload concerns. Asrecommended by the AdvisoryBoard,2 these initiatives includeddesignation of a patient flow coordi-nator solely to manage bed place-ment at all times, the establishmentof a target discharge time of 1 PM,aggregation of patients by physiciangroup/specialty, and inaugurationof morning “bed” census meetings.These meetings are attended by theacute care managers to review actualand projected patient census andstaffing for the next 24 hours.

At that time, staff were markedlydissatisfied with our nurse to patientratios, high workload, constantlychanging agency staff, and high staffvacancy rate. In 2002, the vacancyrate was close to 20% for the nursingdepartment as a whole, peaking at

25% in 2007, and turnover was high.In fiscal year 2007, vacancy rates forcritical care increased to as high as35%. Internal turnover was also achallenge because our highly skillednurses were transferring to theexpanding procedure and perioper-ative areas, which offered a betterwork-life balance. Nurse to patientratios were often 1 to 8 on the nightshift in the medical/surgical andtelemetry units and 1 to 3 in thecritical care areas.

We were relying on expensiveagency personnel for both per diemand contracted traveler support.Not only was there a dollar costfrom escalating use of agency per-sonnel, but turnover and retrainingwere taking a significant toll on thestaff and nurse managers.

Ensuring appropriate staffing isa key element within the AmericanAssociation of Critical-Care Nurses’standards for healthy work environ-ments. Essential to those standardsis a process “to evaluate the effectsof staffing decisions on patient andsystem outcomes” and “facilitateteam members’ use of staffing andoutcomes data to develop and imple-ment effective staffing models.”3

Inadequate staffing ratios can resultin adverse outcomes for patients.4-6

As an organization, we neededto stabilize our workforce, reduceour vacancy rate, and increase staffsatisfaction so that we could achievea healthier work environment forour staff and a safer environmentfor our patients. As a committee, wewere tasked with supporting themanagement team in achievingthose objectives. By using HPPD asour productivity measure to improvestaffing, we hoped to be able tomanage more effectively, addressour increasing costs for agency

Erin McKenna, formerly a nursing informatics analyst, is currently a physician trainer for theintegrated electronic medical record at Lancaster General Health, Lancaster, Pennsylvania.

Kristina Clement, formerly a nursing data analyst for Lancaster General Health, is cur-rently a financial analyst for Children’s Hospital of Philadelphia, Pennsylvania.

Elizabeth Thompson is nurse manager of a cardiac telemetry unit at Lancaster GeneralHealth, Lancaster, Pennsylvania, and contributing editor for management and adminis-tration for Critical Care Nurse.

Kathy Haas (now retired) was formerly assistant director of staffing and patient logisticsat Lancaster General Health.

William Weber is nurse manager of a cardiac telemetry unit at Lancaster General Health.

Michelle Wallace is nurse manager of the neonatal intensive care unit at Lancaster Gen-eral Health.

Cindy Stauffer, formerly nurse manager of the total joint unit, is currently manager ofclinical applications at Lancaster General Health.

Jan Frailey is an administrative nursing supervisor at Lancaster General Health.

Aimee Anderson is nurse manager in the intensive care unit at Lancaster General Health.

Missy Deascenti was formerly nurse manager of a medical-surgical unit at LancasterGeneral Health.

Lisa Hershiser, formerly nurse manager of the neuroscience unit, is currently a staff educatorat Lancaster General Health.

Patricia Inama Roda is nurse manager of the open heart step-down unit at Lancaster GeneralHealth.

Authors

Corresponding author: Elizabeth Thompson, RN, BSN, MBA, CCRN, Lancaster General Hospital, 555 North DukeStreet, Lancaster, PA 17604 (e-mail: [email protected]).

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].

56 CriticalCareNurse Vol 31, No. 6, DECEMBER 2011 www.ccnonline.org




personnel and staff turnover, andbenchmark our data to the NDNQI.1,2

In this article, we describe thecomposition of our committee, itsgoals, calculations of HPPD, the sup-porting technologies necessary toachieve our goals, and the processto eliminate use of agency personneland enhance employee satisfaction.Where applicable, examples fromthe ICU are used to support the dis-cussion topics; however, we empha-size that the issues experienced inthe critical care areas were commonthroughout the nursing department.

Committee Structure and Goals

The NPC is made up of nurse man-agers representing our free-standingWomen and Babies Hospital, med-ical/surgical units, telemetry units,ICU, and the emergency department.Chaired by the assistant director ofstaffing, the committee also includesthe nursing informatics analyst, thenursing department data analyst,and an administrative nursing super-visor. Our data analyst is skilled atdata and file management and is anessential member of the NPC. Shecalculates nurse to patient ratios andcreates spreadsheets to compare avariety of metrics that the committeeis charged with monitoring (eg,HPPD). Initially, the NPC’s maingoal was to educate and ensure allnurse managers had a comprehensiveunderstanding of staffing calcula-tions. It was also necessary to estab-lish a common language (Table 1).

The primary focus was on ourregistered nurses (RNs), but supportstaff issues were addressed as needed.For purposes of HPPD calculationonly, licensed practical nurses (LPNs)are considered equivalent to RNs.

The few LPN positions remaining innoncritical care units are being con-verted to RNs by attrition. The roleof the 1 LPN remaining on a teleme-try unit is being redesigned to act asa support to the RNs on the day shift.Our RN/LPN skill mix has increasedfrom 94% RNs and 6% LPNs in fiscalyear 2007, to 96% RNs and 4% LPNsin fiscal year 2009. To facilitate tran-sition to RN status, we have initiatedan LPN-RN scholarship program.

Overall, our goals for the com-mittee were as follows:

1. Review/revise staffing formu-las for budgeted full-time equivalent(FTE) requirements

2. Understand HPPD, productiveand nonproductive hours, how thestandards are determined, and howvariances occur

3. Establish standards for produc-tive and nonproductive time

4. Discuss staffing strategies toreach target HPPD on all nursing units

5. Analyze computerized staffingreports to ensure accuracy and to

determine opportunities forimprovement

6. Collaborate with nursingcouncils to address staff moralerelating to turnover and workload

7. Seek opportunities to makecost savings without adverselyaffecting patient care

As “business managers” of theirrespective nursing units, it is imper-ative that all nurse managers havean in-depth understanding of whatconstitutes productive vs nonpro-ductive time and be able to defendtheir staffing decisions. They neededto be able to evaluate staffing metricreports and justify HPPD variances,for both professional and nonpro-fessional staff, and understand thesteps necessary to correct thosevariances to bring costs back inalignment. Nurse managers neededto continually educate and reinforcethese concepts and expectations atthe staff level.

Administrative nursing shiftsupervisors (ANSs) are essential to

Table 1 Definitions and relevant terms

Productive hours

Nonproductive hours

Hours per patient day (HPPD)

Professional staff (for HPPDreporting purposes)

Support staff (for HPPDreporting purposes)

Supplemental staff

Agency

Sitters

Census

Patient days

Number of hours worked providing direct patient care

Number of hours worked not providing direct patient care(ie, meetings, education, shared governance activities)

Number of productive hours ÷ number of patient days

Registered nurses and licensed practical nurses (nomanagement)

Patient care assistants

Staffing float pool that comprises registered nurses,licensed practical nurses, patient care assistants, andunit clerks (secretaries) who work where the need is

Contracted employees

Patient care assistants who are assigned to 1 patient fordirect observation

Number of inpatients and outpatients occupying a bed

Calculated by taking the average of 3 census snapshotseach day at 4 AM, noon, and 8 PM

Unit Definition





providing input to the committeeand supporting nurse managers andunit staff nurses to make appropri-ate and cost-effective staffing deci-sions. The ANSs assist and supportthe nurse managers in maintainingtheir unit’s nurse to patient ratios,adjusting staffing on the basis of the

HPPD appropriate for a given cen-sus, and distributing supplementalstaff according to calculated vacancyrates. Special emphasis is placed onusing our “voluntary pull” policy for professional staff to maximizethe use of scheduled staff, maintainour target HPPD requirements,

eliminate overtime, and maintainstaff satisfaction. The NPC devel-oped a professional nurse staffingalgorithm and a critical staffingalgorithm (Figures 1 and 2) to pro-vide guidance to the ANS in ensur-ing consistent guidelines to meetcore staffing needs.


Figure 1 Professional nurse staffing algorithm. Abbreviations: ANS, administrative nursing supervisor; designee, person covering in nurse manager’s absence; NM, nurse manager.

Follow staffing plan

Notify ANS of plan

Assign supplemental staff to unit

Make schedule change in OneStaff

Implement critical staffing algorithm

NM/designee or ANS identify opportunities torevise schedule to meet

core staffing needs

Follow unit-based voluntary pull algorithm

Core staffing needs met?

Staffing meets anticipated unit census/activity?

Unassigned supplemental staff

available?

No

Yes

Yes

Yes

Yes

Yes

No

No

No

No

Notify ANS

Core staffing needs met?

Able to managethrough schedule

revision?




Hours Per Patient Day In industry, productivity is a

measure of how much an employeeproduces for each hour worked. Inhealth care, employees work a varietyof shift lengths, only some of whichare spent providing direct patientcare. It is those direct care hoursthat equate to our HPPD measure.On a yearly basis, to ensure we arecorrectly projecting the staff needed,we calculate the required FTEs fromthe annual budgeted patient daysand target HPPD (Table 2). Actual

productive HPPD, on the other hand,is calculated by taking the totalhours spent providing direct patientcare each month and dividing it bythe actual patient days (see Table 3for ICU example).

It is important to distinguishnonproductive, indirect hours fromnonproductive, nonworked hours.Nonworked time includes paid timeoff for vacation, holidays, and sicktime. Nonproductive, indirect hoursrefer to the hours devoted to sharedgovernance (professional practice)

activities, meetings, orientation,and education. The nonproductivefactor of 20% used in Table 2 is acombination of nonproductive,indirect and nonproductive, non-worked hours. Based on 6 monthsof historical data, standards formonthly professional nonproduc-tive, indirect hours were establishedfor the inpatient units by the com-mittee. A factor of 10% exclusivelywas allocated for shared governance,meetings, and education. Thesehours are monitored closely by the

Figure 2 Critical staffing algorithm for professional nursing staff. Abbreviations: ANS, administrative nursing supervisor; designee, person covering in nurse manager’s absence; NM, nurse manager.

Notify ANS of change

ANS notifies assistant directorof staffing to consider unit

census management

If NM/designee is unavailable, unit facilitator

should notify ANS

Unit facilitator contacts unit personnel to cover

critical staffing deficiency

Follow steps in professional nursestaffing algorithm

Unit facilitator notifies NM

NM calls ANS

Is NM able to fix critical

deficiency?

Is staffing deficiency resolved?

No

No

No

No

No

Yes

Yes Yes

Yes

Was professional nursestaffing algorithm

followed?

Are unit personnel willing to cover critical

deficiency?





committee forunit complianceand variances(Table 4).

HPPD tar-gets were estab-lished after therollout of ourcomputerizedscheduling sys-tem. It becamecritical thatemployees’ timebe correctlycoded in thissystem, eitheras productive ornonproductive,to supportdirect patientcare needs,

defend our requests for more staff,and ensure adequate time for sharedgovernance activities. Initially, HPPDconcepts were challenging for manycommittee members to understand.The education and rollout tooknearly a year as we examined reportsand then correlated HPPD to staffingpatterns and patient days. Over theyears, we have revised those stan-dards to reflect the changing vol-umes and health care environment.Tables 5 and 6 list HPPD targets forprofessional and nonprofessionalstaff within the whole nursing depart-ment and the applicable nurse topatient ratios.

Once NPC members felt com-fortable articulating HPPD andproductive vs nonproductive time,the information was cascaded tothe rest of the nursing managementteam through workshops led by thechief nursing officer and committeemembers. A key accountability foreach NPC member was to mentorand educate other inpatient nursemanagers in their respective servicelines to understand their HPPD andproductive and nonproductivereports and achieve compliance.Each of these nurse managers wasmentored in building a staffingplan, ensuring accurate coding ofnonproductive time within the pay-roll system, reviewing monthly

Table 2 Calculating budgeted registered nurse (RN) full-time-equivalent (FTE) requirement for the intensive care unita

Annual budgeted RN FTEs

(productive HPPD +nonproductive

HPPD)

82.8

Nonproductive FTE(productive FTErequired per year× 20% [nonpro-ductive factor])

13.8

Productive hours per FTE per year(productive hoursrequired per year ÷

annual hours per FTE[2080])

69

Productive hours required per year

(patient days×HPPD)

143685

Target RN hoursper patient day

(HPPD)

15

Annual budgeted patient days in fiscal year 2009

9579

a Total productive hours required per year are calculated by multiplying budgeted annual patient days times budgeted HPPD. To determine FTE, productive hours aredivided by annual hours per FTE, that is, 2080 per year. This generates the budgeted FTE for direct productive hours.

Table 3 Calculating monthly actual productive registerednurse (RN) hours per patient day (HPPD) for the intensivecare unita

Actual productive HPPD(productive hoursworked ÷ patient

days)

14.9

Actual patient days

812.2

Actual RN productive

hours worked

12110

aActual productive HPPD are calculated by taking the total hours providingdirect patient care monthly and dividing it by the actual patient days.

Table 4 Year-end nonproductive full-time equivalents(FTEs) for the intensive care unita

Total

5.7

10% Target

8.0

Meeting

3.4

Education

2.3

aA 10% target for indirect worked time is incorporated into the overall 20%allocation for nonproductive time for registered nurses. This table shows asignificant variance between target and actual indirect FTEs (target, 8.0 FTEs;actual, 5.7 FTEs).

Table 5 Current target for hours per patient day (HPPD) in the inpatient nursing areas

Unit

Medical/surgical and telemetrya

Intermediate care

Critical care

Pediatric medical/surgicala

Neonatal intensive care

Total

8.9

12.1

17

10.5

10.5

Nonprofessional

2.9

3.1

2

2.5

—b

Professional

6

9

15

8

10.5aLicensed practical nurses are counted in professional HPPD calculations for the medical/surgical and telemetry units.

b Patient care assistants in the neonatal intensive care unit do not provide direct patient care and thus are not included in HPPD calculations for that unit.

HPPD





reports for target HPPD vs actualHPPD, monitoring vacancy rates,and maintaining their average nurseto patient ratios (Tables 5 and 6).NPC mentors helped the nurse man-agers understand the impact of over-time on higher HPPD values and theimplications of cost overruns.

The committee’s next step wasto focus on engaging unit staff nurserepresentatives serving on our hospital-wide recruitment, retention,and staffing council. Nurses at thepoint of care were educated on therelationship between HPPD andstaffing ratios. This strategymarkedly enhanced communicationand partnership between the nursemanager and council representa-tives. Unit shift facilitators now havea greater sense of accountability forachieving HPPD targets.

Addressing ICU HPPD Variances

Our ICU, like many critical careareas, has several challenges withrespect to HPPD. Critical care units

often have fluctuating HPPD becauseof the changing workload and census.As a result of throughput issuesresulting from our greatly increasedvolumes, the ICU is often caring forpatients awaiting transfer to teleme-try or medical/surgical units. Med-ical/surgical or telemetry patientsrequire only 6 HPPD, equating to anurse to patient ratio of 1 to 4. How-ever, the ICU cannot routinely staff tothose decreased ratios because emer-gency admissions routinely occur,requiring an immediate shift to lowerratios. The critical care areas alsoparticipate on code blue and rapidresponse teams, requiring furtherresources not reflected in the HPPD.

In fiscal year 2008, the ICU pro-fessional nurse HPPD target wasincreased from 14 to 15 hours perday. This increase was to betterprovide for a nurse to patient ratioof 1 to 1 when the acuity of thepatient warranted. The desired nurseto patient ratio is 1 to 2 in criticalcare units. During this time frame,however, the ICU was facing a 33%vacancy rate and agency personnelwere being eliminated. A concertedeffort had to be made to ensure thatretention of new hires was suffi-cient to meet the escalating needfor ICU beds, given that the averagecost to replace a professional nurseis $64000.2

Subsequently, we hired a largenumber of new graduate nurses.Orientees all receive a 16-week ori-entation, during which time theyare not included in the HPPD. Whennew graduates complete orienta-tion, their “productivity” calcula-tion is no different from that for anexperienced RN. However, to ensuresafe patient care, the ICU nursemanagers must constantly evaluate

the skill level of professional staffon each shift and adjust the staffingmix on the basis of the level of RNexperience. Still, with so many newgraduates coming off orientation inthe ICU at the same time, the nursemanager needed to develop a strat-egy to support them. The nursemanager solicited ideas from theNPC. On the basis of the commit-tee’s suggestions, the nurse man-ager instituted a staff nurse mentorprogram for the off shifts becausethose shifts had the heaviest per-centage of new graduates. The roleof the mentor was to support thenew nurses’ critical thinking andassist them with becoming compe-tent in unfamiliar procedures. Men-tors’ hours were included in theirHPPD calculation. In addition, themanager increased the target HPPDfor patient care assistants to pro-vide more “hands-on” care. Addi-tional supplemental staff wereallocated as much as possible.These measures have been effectivein reducing the ICU staff turnoverrate to about 5%, markedly enhanc-ing staff satisfaction, limiting over-time, reducing ratios, and stabilizingthe HPPD fluctuations (Figure 3).

Supporting TechnologiesAutomation enhances one’s

ability to manage the workforceand make more informed and cost-effective decisions.7,8 Technologyhas been integral in supporting ourcommittee’s goals to understandproductive and nonproductivehours and financial data, introduceinnovation and efficiencies, makeeffective and informed decisions,and monitor results.

The committee analyzes produc-tivity reports from an automated

Table 6 Relationship betweentarget for hours per patient day(HPPD) and nurse to patient ratios

Target HPPD

24.0

12.0

8.0

6.0

4.8

4.0

3.4

3.0

2.7

2.4

2.2

2.0

Nurse to patient ratio

1:1

1:2

1:3

1:4

1:5

1:6

1:7

1:8

1:9

1:10

1:11

1:12





staffing and scheduling system andcounsels managers to rein in shift-overlap overtime when it occurs,because it drives up the HPPD. Whenwe sought to change our organiza-tion’s reliance on agency personnel,we turned to an open shift manage-ment, Web-based software, accessi-ble at work or at home, to empowernursing staff to seek additional shifts.Communication and informationsharing were facilitated by electronicmail and personal productivity soft-ware. Today’s environment requiresnurses at all levels to understandthe workload as well as the monetaryeffects of their staffing decisions.9

Specific technology solutionsused by the NPC included

1. McKesson’s One-Staff—Staffing, Scheduling and Productiv-ity Reporting (McKesson, SanFrancisco, California)

2. Concerro’s Open Shift Man-agement System: BidShift (Con-cerro, San Diego, California)

3. Microsoft Office, electronicmail, and shared network drives(Microsoft, Redmond, Washington)

OneStaff is used to reportHPPD. Time and attendance data

are imported into OneStaff every 2weeks, and census snapshots takenat 4 AM, noon, and 8 PM are uploadeddaily. Routine monitoring of reportsby the NPC showed spikes in HPPDafter a new time and attendancesystem was implemented. We dis-covered that a significant contribu-tor was overlap between the earlyshift and the late shift because ofimplementation of new pay rules.

More recently, we have focusedon a subset of overtime caused byemployees who consistently do nottake a lunch break. We asked thenursing management council to takeownership of this issue, in conjunc-tion with the recruitment, retention,and staffing council, because not tak-ing a lunch break not only increasescosts but also affects work-life bal-ance and can influence employeesatisfaction and retention. We haveseen a 46% decrease in “no lunch”breaks in fiscal year 2009 whencompared with fiscal year 2008.This decrease equates to a savingsof approximately $140000.

Nursing care hours are expen-sive. A critical factor in achievingcost reduction is to flex staffing to

changing volumes. Having the his-torical data to support these deci-sions is essential. Flexing of staff,however, must always be influencedby both the current census and theskill mix.2,5 Nonproductive time isalso monitored to ensure that unitsdo not exceed targets. Analysis bythe committee revealed some depend-ence from the supplemental staffingpool to meet shared governancetime on selected inpatient units.Managers were reeducated on pro-cedures for coding nonproductivetime accurately in the time and atten-dance system and were reminded tomanage nonproductive staffingneeds within their own departmentas much as possible. In reviewingproductive and nonproductive timeacross the week, we recognized animbalance in staffing patterns onmany units. Now, managers arestriving to “smooth” out their shiftschedules to address this issue.

In April 2005, our hospital wasthe first in the state to implementthe open shift bidding managementsoftware. We branded the systeminternally as Shift +. It is a Web-based program that allows nursingstaff to view and request to work 4- or 8-hour open shifts for whichthey are qualified. The systemoffers staff flexibility, convenience,and the potential to explore newterritory within the hospital. Whileit is designed to allow eBay-likereverse bidding and monetary shiftincentives, we elected to bypassthose features and simply postopen shifts. For those units thatrequire on-call, the system can alsobe used to post these shifts. Over-all, Shift + has proven to be a realtime-saver and has yielded costsavings for staff and managers,

Figure 3 Inverse relationship between actual nurse to patient ratios and hours perpatient day (HPPD) in the intensive care unit.

12.5

13.5

14.5

13.0

14.0

12.01.65

1.70

1.75

Nurse to patientratio

HPPD

1.80

1.85

1.90

1.95

2.00

2.05N

urse

to p

atie

nt r

atio

HPP

D

Fiscal year 2007 Fiscal year 2008 Fiscal year 2009





who no longer need to spend hourstrying to get shift coverage.

One of the unexpected chal-lenges we faced late in fall 2008 wascensus lulls, even in critical careafter the additional need to covercode blues, rapid response team calls,and unpredicted acuity levels wasfactored in. Supplemental staffemployees were being routinely can-celed. Here, the ANS played a piv-otal role in the constant flexing ofstaff every 4 hours to meet house-wide demands. In response to thisnew challenge, the committee modi-fied the sign-up process in Shift +,implementing staged shift postingsas an alternative. Instead of posting4 weeks of open shifts (correspond-ing to a schedule cycle), with noregard for the available supplementalpool, managers now post openings 2weeks at a time after supplementalstaff has been assigned. This madefiscal as well as operational senseand added to staff satisfaction.

In analyzing their clients’ shift-bidding characteristics, our vendorhas noted an interesting trendnationwide. That trend is towardmore “self-directed floating” or staffchoosing to work shifts off theirhome unit.

Floating was not part of thegoal of the study, but surfacedas a positive, unintendedconsequence of implement-ing a flexible approach tostaffing supported by Web-based technology.10

Douglas et al10 report that nation- wide RNs are floating off their unitsaround 25% of the time and non-RNs around 40% of the time. At ourhospital, we have seen percentagesfor RNs at about 12% and 65% for

patient care assistants. We feel ourlower RN percentage is attributableto our culture in which professionalstaff still prefer filling needs on theirhome units. Additionally, we have asupplemental pool of RNs, of whom33% pick up additional shifts. Ourhigh percentage of patient careassistants using self-directed floatingis partly attributable to the attrac-tiveness of sitter shifts.

Agency EliminationIn May 2007, the nursing man-

agement team made a critical deci-sion to eliminate contracted agencystaff. The NPC was charged withassisting the nurse managers inachieving their goal. We were pay-ing premium dollars and our costshad increased to approximately$600000 per month. The agencypersonnel included professionalsand nonprofessionals, the latterfunctioning as sitters to patients athigh-risk for falling, but whose con-tract prohibited them from provid-ing patient care. Not only wereagency personnel expensive, butmany times they did not meet ourstandards of performance orembrace our nursing philosophyand commitment to excellence. Thiscontributed to a high turnover ofcontracted personnel, and highstress levels for staff and nurse managers alike.

Our initial focus was the elimi-nation of agency sitters throughoutour organization. On average, wewere contracting for 4 to 6 personsa shift, at approximately $100000 amonth, and the ANS were spendingan inordinate amount of time seek-ing personnel from local staffingagencies. Sitter use in the ICU is lim-ited because of the nurse to patient

ratios but still averages 107 hoursper month, equivalent to 0.6 FTEof patient care assistants. Uponreview, the committee determinedthat no standard process was beingused to determine the actual needfor a sitter. Therefore, a sitter justi-fication and allocation process wasdevised within the committee foruse by the nurse managers, ANSs,and staff nurses. With eliminationof agency sitters in October 2007,our patient care assistants readilyembraced Shift + by picking up sit-ter shifts, knowing they wereexpected to also provide directpatient care.

The NPC heatedly debated thepros and cons of eliminating profes-sional agency staff, including poten-tially increasing the nurse to patientratios for the short term, andincreasing workload and overtime,but universally agreed that the ben-efits outweighed the risks. The NPChad previously developed a processwhereby RN agency personnelcould be approved only if a request-ing unit’s staff vacancy rate was 25%or greater. Calculated vacancy rates,for purposes of justifying additionalstaff on a given unit, include truevacancies as well as staff on orienta-tion or leave of absence.

Elimination of agency personnelwas an aggressive goal that requiredcollaboration and cooperationamong the whole nursing manage-ment team as some individual unitswere hovering with vacancy rates at50% or greater. The tenure of allexisting agency nursing staff wasscrutinized. Some individuals hadbeen working solely for our organi-zation for more than 2 years. The agency personnel were theninformed that they could contract





for a maximum of 26 weeks, butthen needed to leave permanently.

Guidelines were established bythe committee to assign supplemen-tal pool nurses to units on the basisof vacancy rates, that is, those unitswith the highest vacancy rates wereassigned supplemental staff first,before the units with lower vacancyrates. This guideline was also fol-lowed at the daily census meetingwhen unexpected or long-standingstaffing “holes” prevailed. By March2009, all remaining professionalagency contracts had been com-pleted. We did hire several nurseswho were willing to relocate perma-nently or who already lived in thearea and whom we had found to besuperior nurses.

Employee SatisfactionLetvak and Buck11 examined fac-

tors that influence workload andproductivity and the intent of staffRNs to remain in the nursing field.They found that reducing highnurse to patient ratios reduces stressand improves the quality of patientcare provided.11 Nursing outcomescorrelate directly with patients’ out-comes, whether because of lowmorale, turnover, or short staffing.These problems can translate intoreduced satisfaction among patientsand poorer outcomes for patients.5

Having adequate staffing is also 1 ofthe key elements important tonurses in Magnet hospitals.12 Since

2006, when staff vacancy rates wereat their peak, we have successfullyimproved our ratios by reducing ouroverall vacancy rate. Currently, ourICU and many of our other nursingunits have no staff vacancies.

Employee satisfaction is meas-ured by an annual employee opin-ion survey administered by MSAHR Capital (MSA HR Capital, writ-ten communication, 2009). We haveseen a steady increase in staff satis-faction overall in the past few years.Specific questions from the surveywere analyzed to determine staffmorale in the ICU in relation to jobsatisfaction (Table 7). All the itemsexceed the national norm for com-parable ICUs. The results for “leav-ing work satisfied” are equivalent tobest practice.

“Contributing to the extraordi-nary experience” was a new ques-tion this year and reflects the prideall our staff have in their organiza-tion and in the awards they receivefor excellence in clinical care andsafety. Ours is a Top 100 Hospital(Thompson Reuters) and Top 50Hospital (Health Grades). The hos-pital has received the Health Gradesaward for the past 5 years forpatient safety excellence and hasdisease-specific certification from

the Joint Commission for stroke,myocardial infarction, and conges-tive heart failure and for patientswith ventricular assist devices.

ConclusionNurse managers in critical care

units face unique challenges becauseof the high acuity of their patients,variety and complexity of equipment,need to respond to rapidly changingpatient situations both within theirdepartments and house-wide (codeblues and rapid response team calls),and the need to ensure a continuallyappropriate skill mix to managethese complex patients.

Critical care nurse managersshare many similarities with therest of the in-patient managementteam, however, including recruit-ing and retaining competent andsatisfied staff, adjusting staffing inresponse to fluctuations in censusand acuity, reducing agency use,understanding target vs actualHPPD and nonproductive timeand defending variances, and hav-ing to analyze and understandtheir data. Whether in critical careor general medical/surgical areas,ensuring that appropriate staffinglevels are in place and HPPD goalsare achieved to meet the needs of

To learn more about staffing issues in thecritical care setting, read “Perception ofAdequacy of Staffing,” by Schmalenbergand Kramer in Critical Care Nurse, 2009;29(5):65-71. Available at www.ccnonline.org.

Table 7 Results of employee opinion survey in intensive care unit

Survey question

I would recommend organization as a greatplace to work

I am proud to work for this organization

I leave work with a feeling of satisfaction

I contribute to the extraordinary experience

Ratinga

National mean, 2009b

4.9

4.0

4.5

4.9

2009

5.3

5.2

4.9

5.3

2008

5.1

5.0

4.6

—c

aRating on a scale of 1 (least satisfied) to 6 (most satisfied). (MSA HR Capital.13) b National mean comparison is with like intensive care units across the country.c The annual survey was revised in 2008; therefore, previous comparative data are unavailable.





our patients requires daily monitoring and collaborationbetween nursing supervisors, nurse managers, and staff.

The NPC can be a valuable and complementary supportto nursing departments challenged with cost overruns,staffing imbalances, and low morale. We believe that wehave been able to foster a collaborative relationshipbetween nursing units and the nursing leadership team andintroduce innovative solutions and supportive technolo-gies. With their increased understanding of HPPD calcula-tions, the nurses have felt empowered to make betterbusiness decisions. This collaborative environment hasgone a long way to achieving our goal of providing morecost-effective care in this time of economic volatility whilecontinuing to aspire to our vision to provide an extraordi-nary experience for our patients. With the stabilization inour RN vacancy rate, we are now beginning to adjust ourtarget HPPD for patient care assistants to be within industrystandards. CCN

Financial DisclosuresNone reported.

References1. National Database of Nursing Quality Indicators (NDNQI): Guidelines for

data collection and submission on quarterly indicators. Version 9.0. 2009:45-51. https://www.nursingquality.org. Accessed July 2, 2009.

2. Nursing Executive Center. Heart of the Enterprise: Optimizing Nursing Produc-tivity in an Era of Deepening Shortage.Washington, DC: The Advisory BoardCompany;2001:47-75.

3. American Association of Critical Care Nurses. AACN standards for establish-ing and sustaining healthy work environments: a journey to excellence. Am JCrit Care. 2005;3:187-197.

4. Pappas SH. The cost of nurse-sensitive adverse events. JONA. 2008;18:230-236.5. Unruh L. Nurse staffing and patient, nurse, and financial outcomes. Am J Nurs.

2008;108:62-71.6. Dunton N, Gajewski B, Klaus S, Peirson B. The relationship of nursing work-

force characteristics to patient outcomes. Online J Issues Nurs. 2007;12(3):1-10. 7. DiCroce H, Grohar-Murray M. Informatics in nursing. In: Leadership and

Management in Nursing. 3rd ed. Upper Saddle River, NJ: Prentice Hall;2003:318-333.

8. Wadsworth B, Kurilla ML. An automated solution for managing your work-force. Nurs Manage. 2009;40:(6)49-51.

9. Finkler S, Jones C, Kovner C. Financial Management for Nurse Managers andExecutives. St Louis, MO: WB Saunders; 2007:36.

10. Douglas K, Pledger R, Schulman C. Self-directed floating: nurses are acceptingits benefits. RNWeb. http://rn.modernmedicine.com/rnweb/Modern+Medicine+/ArticleStandard/Article/detail/596884. Accessed May 1, 2009.

11. Letvak S, Buck R. Factors influencing work productivity and intent to stay innursing. Nurs Econ. 2008;26:159-165.

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Now that you’ve read the article, create or contribute to an online discussion about this topicusing eLetters. Just visit www.ccnonline.org and click “Submit a response” in either thefull-text or PDF view of the article.





Cindy Stauffer, Jan Frailey, Aimee Anderson, Missy Deascenti, Lisa Hershiser and Patricia Inama RodaErin McKenna, Kristina Clement, Elizabeth Thompson, Kathy Haas, William Weber, Michelle Wallace,Levels and Staff SatisfactionUsing a Nursing Productivity Committee to Achieve Cost Savings and Improve Staffing

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