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Staffing Model Innovation in the NICU

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Like all healthcare organizations, children’s hospitals face mounting pressure to reduce costs. Hospital leaders face the challenge of hitting ambitious new financial targets without compromising the quality of care. This is an especially delicate balancing act in the neonatal intensive care unit (NICU), where many of their sickest and most vulnerable patients are located.

In their article Needing More From Your NICU, ECG consultants Shelby Jergens and Clark Bosslet urge NICU leaders to turn a critical eye to their unit processes. They identify three areas that present the greatest opportunity for impactful change—staffing models, compensation methodology, and care coordination—and offer actionable plans based on what they’ve seen work with their clients. Here, Shelby and Clark talk about the work they’ve done with pediatric organizations around staffing model innovation in particular.

You recommend that NICUs consider a provider mix that is richer in advanced practice providers (APPs). What does that look like?

We encourage NICUs to allow their APPs to work to the top of their licensure, what’s often referred to as “practicing up.” In most states, that means allowing APPs to independently evaluate, diagnose, and treat lower-acuity patients. This approach frees up specialists to focus on complex cases that require extra time. It also creates great teaching opportunities for medical learners in the unit. We acknowledge that states vary in the level of independence they give to APPs, but even in more restrictive states, APPs can work collaboratively with specialists to see patients of all acuity levels more efficiently.

You provide a tool that organizations can use to adjust staffing based on the patient census. Does that mean the NICU would send staff home every time the census drops?

No, it’s not quite that simple. The flexible models that we recommend and have seen work take into account patient census, acuity level, and new admissions. You’re not going to dismiss staff if you have too many high-acuity patients, even if your overall numbers seem low, right? This is really a resource allocation tool. Yes, some units will decide there are thresholds at which they should send people home. In those cases, transparency around when and why that happens creates a shared understanding and structure, which helps to depersonalize the situation. But NICUs can just as easily use this information to spot opportunities for their providers to reallocate time to administrative tasks that fall by the wayside when the census is incredibly high. And by the way, the thresholds work in the opposite direction too—a high census might result in adding staff to the floor if personnel are available to come in.

You talk about a “culture of continuous improvement” and its importance in implementing process changes. What are some examples of how organizations live that culture, based on your experiences at children’s hospitals?

Cultural issues are easy to diagnose but difficult to treat. We never go into a hospital and say, “This is how you do culture,” because that’s different for everyone, but what we can do is come in and facilitate a collaborative process for the organization to review and select a staffing model that works for their NICU. Going back to the first question, it’s really important to include APPs, nurses, and all other patient-facing staff in these conversations. Any large-scale change in staffing models will be far more successful if the design team is representative of the impacted clinicians.

Finally, an APP’s efficacy is going to be impacted for better or worse by their relationships with physicians and the willingness of those physicians to embrace APPs as true partners. So bringing those two parties together on equal footing helps foster a collaborative culture that facilitates actual change.

To learn more about staffing, as well as compensation methodology and care coordination improvements, download the full article, Needing More From Your NICU.

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