Cathe Clapp, RN, MN Barbara Hyland-Hill, RN, MN, CNAA-BC

1. BRINGING YOUR NURSE STAFFING COMMITTEE TO LIFE:Staffing, Scheduling & Budgeting for the Bedside Clinician Cathe Clapp, RN, MN Barbara Hyland-Hill, RN, MN, CNAA-BC June 22, 2010 - Wenatchee June 23, 2010 – Spokane June 24, 2010 – Renton July 14, 2010 - Lynnwood Ruckelshaus Nurse Staffing Steering Committee

2. WA State Staffing Legislation – House Bill 3123(2008) • All hospitals must establish a Nurse Staffing Committee • Composition at least 50% direct care nurses • Create staffing plans • If the CEO does not adopt staffing plans, must provide written explanation • Staffing plans must be posted in public area • Collect data on 5 NSQI and submit to WSHA • Report nurse staffing with adverse events reporting Ruckelshaus Nurse Staffing Steering Committee

3. Our Objectives • Provide you with basic concepts about: • Budgeting (Staffing/Labor Budget) • Staffing and Scheduling • Nurse Sensitive Indicators • Staffing Committee Effectiveness • Have you apply the concepts • You leave with a toolkit (tools and resources) • You will be able to share your learnings with your committee members (Train the Trainer) Ruckelshaus Nurse Staffing Steering Committee

4. Agenda • Budgeting 101 • Staffing and Scheduling Made Simple • Nurse Sensitive Indicators for Dummies • Making the Staffing Committee Work • Putting It All Together – Case Application Ruckelshaus Nurse Staffing Steering Committee

5. Budgeting 101

6. Personal Budget • Income • Salary – Pay check • Interest/investment earnings • Expenses • House payment or rent • Utilities • Food • Insurance • Car payment • Gas • Etc Ruckelshaus Nurse Staffing Steering Committee

7. What is a budget? A Plan • Coordination of revenue and expenses • Specific period of time – usually 1 year • Formalized → written down • Forecast the future An Educated Guess Ruckelshaus Nurse Staffing Steering Committee

8. Functions of the Budget • Financially operationalize an organization’s goals and objectives • Keep management informed • Evaluate performance • Refine program development and plan • Educate • Increase cost awareness Ruckelshaus Nurse Staffing Steering Committee

9. Budgeting Process • Understand your organization’s process, forms, timeline, terminology, fiscal year • Planning • Department Goals & Objectives • Projected Units of Service (Volume and Acuity) • Preparing • Monitoring and Controlling • Reporting Ruckelshaus Nurse Staffing Steering Committee

10. Staffing Budget(Labor, Personnel, Manpower)

11. Basic Concepts – Units of Service • Unit of Service (UOS) – measure of product or service produced by the department • For Nursing Departments • Inpatient Units Patient Days • Outpatient Units Visits • Emergency Department Visits • Surgical Units Procedures (Major & Minor) Minutes • Labor & Delivery Deliveries Procedures (Ante partum) • OP Oncology Treatments Ruckelshaus Nurse Staffing Steering Committee

12. The Story of Your Unit • Who are your patients? • DRG, age, drugs/therapies/treatments used • What are their needs? • Acuity, severity of illness • What are your hours of operation? • 24/7 • Other: Mon-Fri, 8 am – 5 pm • Collect information on: • Volumes • Length of stay • ADT ratio/churn factor • Number of procedures • Do you have outpatients or 23-hour stay patients? • Is the census done at midnight? Ruckelshaus Nurse Staffing Steering Committee

13. Basic Concepts – NursingHours Ruckelshaus Nurse Staffing Steering Committee

14. Required Care Hours • Projected UOS volume • Determination of workload hours • Direct nursing care hours per pt day (or UOS) standard • Patient Classification System – Case Mix • Desired Fixed Staffing Coverage Ruckelshaus Nurse Staffing Steering Committee

15. Basic Concepts - FTEs • FTE = Full Time Equivalent • Equivalent of 1 full-time employee working for 1 year • 1.0 FTE = 2080 hrs/yr (8 hrs X 5 days X 52 wks) = 40 hrs/wk(8 hrs X 5 days) = 80 hrs/2 wks (8 hrs X 10 days) • FTEs are converted to positions which are filled by employees Ruckelshaus Nurse Staffing Steering Committee

16. Workload Hours - DNCH Ruckelshaus Nurse Staffing Steering Committee

17. Workload Hours - Acuity = X Ruckelshaus Nurse Staffing Steering Committee

18. Workload Hours - Fixed Ruckelshaus Nurse Staffing Steering Committee

19. Workload Hours - DNCH Ruckelshaus Nurse Staffing Steering Committee

20. Workload Hours - DNCH Ruckelshaus Nurse Staffing Steering Committee

21. Workload Hours - Allocation • Staffing Model • Total pt care, Team, Modular, Primary Care, Partnership (Dyad) • % RN, % LPN, % NA-C • Length of shifts – 8, 10, 12 hr • % care allocated per shift Ruckelshaus Nurse Staffing Steering Committee

22. Required DNC Staff Per Day Ruckelshaus Nurse Staffing Steering Committee

23. Required DNC Staff Per Day Ruckelshaus Nurse Staffing Steering Committee

24. Required DNC Staff Per Day Ruckelshaus Nurse Staffing Steering Committee

25. Required DNC FTEs Per Year

26. Required DNC FTEs Per Year

27. Required DNC FTEs Per Year

28. Non-Productive Hours • Coverage for anticipated time off (backfill or replacement) • How does your organization define Non-Productive Hours? • PTO, Vacation, Sick Leave, Holiday, Bereavement, FMLA, Education/Professional • What categories of staff must be replaced • RN, LPN, NA-C, HUC, Monitor Tech, Surgical Tech, etc Ruckelshaus Nurse Staffing Steering Committee

29. Non-Productive Hours • How does your organization budget for Non-Productive coverage? • Ave % of non-productive time Vacation 15 days Holiday 9 days Average sick 6 days Education 2 days 32 days = 256 hrs (8 hr shift) 2080 - 256 = 1824 prod DNCH 256/1825 = 14% 46.1 DNC FTEs X 1.14 = 52.6 – 46.1 = 6.5 NP FTEs Ruckelshaus Nurse Staffing Steering Committee

30. Non-Productive Hours • How does your organization budget for Non-Productive coverage? • Calculate by category of staff replaced and type of NP time • Vacation • Sick leave • Holiday • Education/Professional leave # days by staff category X 8 hours X DNC FTE 2080 Ruckelshaus Nurse Staffing Steering Committee

31. Productive – Fixed Staff • Positions whose hours are set and do not adjust with pt census, volume or acuity • Manager, CNS, Unit-based educator • Health Unit Coordinator, Monitor Tech • Need to know: • # of days/week and shift coverage • Are they replaced when off? Ruckelshaus Nurse Staffing Steering Committee

32. Non-ProductiveImpact Ruckelshaus Nurse Staffing Steering Committee

33. Indirect Care Hours • Paid, worked hours related to unit/dept function • Orientation • Inservice education – CPR, mandatory education • Staff meeting time • Shared governance meetings • Committee time/work • QA, Clinical Pathways, Standards, etc Ruckelshaus Nurse Staffing Steering Committee

34. Indirect Care Hours • Calculated by type of activity by skill mix # staff X # hrs X # times = hrs • Orientation • Turnover by category • Anticipated Retirements • Ave # days oriented • New graduates • Do you take? • Do you have a Residency Program? How long is it? • Are the new graduates hours expensed centrally or to unit? Ruckelshaus Nurse Staffing Steering Committee

35. Indirect Care Hours

36. Staff Per Day & FTE Budget + + + Ruckelshaus Nurse Staffing Steering Committee

37. Premium Pay • Shift differential • Weekend differential • Charge nurse, certification, preceptor differential • Overtime • Standby and call back pay Ruckelshaus Nurse Staffing Steering Committee

38. Basic Concepts – Hours Per UOS • UOS are compared in a ratio to paid or direct hours required to deliver the service or product • Common Productivity Standard in Nursing • Nursing Hours Per Pt Day (HPPD) • Direct Care Hours • Productive Hours Paid/UOS • Total Hours Paid/UOS Ruckelshaus Nurse Staffing Steering Committee

39. Basic Concepts – Formulas • Average Daily Census (ADC) Total pt days # of days (week, month, year) • Average Length of Stay (ALOS) Total pt days # of discharges • Percent Occupancy Total pt daysCensus or ADC Total # bed days available Beds available or Ruckelshaus Nurse Staffing Steering Committee

40. Basic Concepts – Formulas • Total Direct or Total Productive Hrs/UOS Total direct or productive hrs Patient days or UOS • Total Paid Hours/UOS Total paid hrs Patient days or UOS Ruckelshaus Nurse Staffing Steering Committee

41. Basic Concepts – Formulas • Average Hourly Rate Total salary $ Total hours paid • Total Productive Salary Expense/UOS Total productive salary $ Patient Days or UOS • Total Salary Expense/UOS Total productive salary $ Patient Days or UOS Ruckelshaus Nurse Staffing Steering Committee

42. Sample Cost Center Report Ruckelshaus Nurse Staffing Steering Committee

43. Basic Concepts – Variance Analysis • A variance is the difference between the Budgeted amount and the Actual results • Favorable versus Unfavorable variance • Variance analysis is a component of budget monitoring to investigate and explain whydifferences occurred • Individual manager accountability for budget variances Ruckelshaus Nurse Staffing Steering Committee

44. Basic Concepts – Variance Analysis • Flexible Budget Variance Analysis • Variance is a function of: • Volume (output) (Patient Days or UOS) • Price or Rate (Ave Hourly Rate) • Quantity or Use (Nursing Hours Used) f(Volume + Quantity + Price) Ruckelshaus Nurse Staffing Steering Committee

45. Basic Concepts – StaffingCosts What affects Staffing Costs? • Volume (UOS) • Total Hours Paid • Direct Care Hrs – Pt Acuity, ADT ratio, staffing to matrix • Indirect Care Hrs – Orientation of new staff, mandatory inservices or meetings • Non-Productive Hrs – Sick leave, vacation, FMLA, holiday • Average Hourly Rate Paid • Overtime or premium pay situations • Registry or Traveler use • Skill mix used Ruckelshaus Nurse Staffing Steering Committee

46. Staffing and Scheduling Made Simple Ruckelshaus Nurse Staffing Steering Committee

47. Creating Position Control and Schedules DEMAND Patient Type Patient Volume and Acuity Demand Variations (churn, time of day, days of week, months, seasons) RESOURCES Roles (Fixed and Variable) FTE Mix Days of the week Shifts Ruckelshaus Nurse Staffing Steering Committee

48. Staffing Model Revisit, or build from the ground up, so allows manager and staff to understand all of the elements of staffing and resource use Start with budgeted average daily census (DEMAND)and the direct care staff FTE budget (RESOURCES) 48 Ruckelshaus Nurse Staffing Steering Committee

49. From Budget to a Balanced Schedule… you need Unit Census and FTE Budget Staffing to Census (and Acuity) Matrix Core Daily Staffing Model(at census or occupancy target) Add in Non Productive FTEs Position Control (Personnel Budget) Ruckelshaus Nurse Staffing Steering Committee

50. Indirect Care Hours Paid hours related to unit/dept function not in DNCHs Orientation Inservice education – CPR, mandatory education Staff meeting time Shared governance meetings Committee time/work QA, Clinical Pathways, Standards, etc Ruckelshaus Nurse Staffing Steering Committee