As a required condition of participation in the Medicare program, the federal government prescribes broad and generalized directions to hospitals on the provision of nurse and patient care staffing. Federal regulations state that “nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed.” Concerns about unsafe staffing levels have led unions, state governments, and the federal government to increasingly promote minimum nurse staffing guidelines, which in turn is placing pressure on hospitals and health systems because that legislation will specify mandatory levels of nurse staffing for acute care hospitals. Currently, 14 states have laws that address nurse staffing, but California is the only state requiring minimum nurse-to-patient ratios for every unit in the hospital, at all times.
Reviewing, analyzing, and benchmarking your organization’s current staffing models and daily management systems now may mitigate the potential impact of nurse staffing legislation in the future and improve long-term financial viability without compromising patient safety, clinical quality, and the patient experience. The first step toward optimizing your nurse staffing models is to analyze your current staffing plans by unit or department and by shift, then compare your organization’s nursing models to those at similar hospitals in your region. The types of benchmarks you should consider using are:
- Staffing Levels: Utilizing multiple metrics, compare current nurse and unlicensed assistive personnel levels to identify opportunities to adjust your staffing levels.
- Acuity/Intensity: Compare average acuity, by unit, in relation to staffing levels, to further assess and understand the staffing levels required to deliver the best patient care.
- Skill Mix: Compare current skill mix, by unit, to identify opportunities to make adjustments so that nursing staff can work at the top of their license.
- Agency Nurse Percentage: Hospitals often use nurses from staffing agencies to fill temporary personnel gaps. Understanding how your organization compares to similar hospitals in your region in this regard may offer insights into higher-than-expected expenses and prompt the development of a more sustainable strategy to address gaps in nurse staffing.
In addition to benchmarking current nurse staffing levels, it is imperative to review operational processes within your hospital or health system that drive variations in nursing assignments and negatively affect productivity, clinical quality, patient safety, and patient experience. Below are some key areas to examine as you aim to ensure streamlined procedures and practices:
- Operational Staffing Assessment: Review current processes for staffing to the ideal levels by patient census, shift, and weekend/weekday. Evaluate the complement of part-time and full-time staff to determine whether greater flexibility in staffing would better enable the organization to accommodate changes in patient census. Examine float pool composition and staffing procedures to minimize agency dependency and determine appropriate staffing levels to accommodate changes in census and patient intensity.
- Patient Flow: Late afternoon and early evening patient discharges from inpatient units make it difficult for the staffing office and nurse managers to determine the proper level of staffing needed for evening and night shifts, often resulting in staffing that is either over or under the ideal and budgeted level.
- Paid Time Off: Variability in how nursing care units and departments budget for and manage paid time off requests can have a significant impact on staffing levels and expenses.
ECG has performed nursing staff labor productivity assessments for multiple hospitals in the Southeast. In one instance, ECG identified over $4 million in labor opportunity and helped implement recommendations that resulted in $1.5 million in savings in the first year. ECG also identified over $1.5 million in savings opportunity through staffing-mix changes and productivity improvements for another midsize community hospital.
Most recently, ECG worked at a five-hospital health system in the Northeast to evaluate operational processes and compare current nurse staffing metrics to two nationally accredited benchmarking databases. In this nurse labor assessment, ECG reviewed and helped standardize nursing best practices throughout the system where possible and deployed tools and tactics for nurse managers to track and adhere to established nurse-to-patient ratios. As a result of this work, which optimized the nurse staffing mix and use of float pool nurses, the health system was able to reduce volume-adjusted productivity expenses by more than 50% compared to earlier in the year and reduce its agency nursing cost by 50%.
Ensuring your organization has the right nurse staffing to meet its overall goals can have positive impacts throughout your organization, potentially improving patient care and the patient experience as well as increasing nurse satisfaction and reducing unnecessary agency labor expenses. Performing operational assessments and reviewing nurse staffing best practices, along with benchmarking nurse staffing levels and skill mix, will highlight current gaps and areas to begin improvement efforts.