Rees, Susan DNP, RN, CPHQ, CENP; Houlahan, Beth MSN, RN, CENP; Lavrenz, Dennise MBA, RN
Author Affiliations: Vice President (Dr Rees), Development, Nursing & Patient Care Services; Senior Vice President of Patient Care Services/Chief Nursing Officer (Ms Houlahan); Director (Ms Lavrenz), Nursing Operations Support, University of Wisconsin Hospital and Clinics, Madison.
The authors declare no conflicts of interest.
Correspondence: Dr Rees, University of Wisconsin Hospital and Clinics, 600 Highland Ave, H4/822, Madison, WI 53792 ( firstname.lastname@example.org).
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jonajournal.com).
A tertiary healthcare organization provides specialty care in addition to primary care. Admissions and referrals originate from both inside and outside the local market where other healthcare organizations may not offer the tertiary services needed. The long-term viability of specialty care programs depends on the ability to accept and care for these patients. Receiving a patient in transfer requires an accepting physician/service, an available bed, and staff to care for the patient/family, all elements of capacity management.
Capacity planning and management in healthcare organizations have been widespread areas of focus in recent years.1 Creating a bed management system and bed management team has been reported as contributing to success in reducing bed turnover time, thus facilitating patient flow.1
In 2011, this 566-bed academic medical center located in the Midwest was unable to accept 87 patients and their families because of either a lack of beds or lack of staff. Diversions had become commonplace and were in total contrast to the mission, vision, and values of the organization. To meet the goal of accepting all appropriate patients seeking services, preparedness strategies were undertaken by planning for bed capacity and ensuring adequacy in staffing.
Reversing the Trend
In 2012, the organization began implementing strategies to enhance capacity management and ensure the ability to meet the mission to provide excellent tertiary care. The reasons for diversions were varied and complex. The following strategies were put in place over approximately 1 year to ensure flexibility in staffing to meet fluctuations in capacity and to ensure that the organization was always “a bed ahead.” Strategies fit into the categories of communication plans, staffing guidelines, morning rounds, proactive planning, and an escalation process.
Each strategy was led by the director of Nursing Operations Support. This department managed the flexible staffing resources (float pool, per diem staff, agency staff) for the organization as well as the nursing coordinators. Nursing coordinators are a group of nursing leaders who are present 24/7, 365 days per year, and are accountable for patient placement and nurse staffing. In addition, this department is also responsible for a group of nurses called Save Our Shift (SOS) staff. The SOS nursing team has 2 to 3 RNs scheduled per shift on a 24/7/365 basis, and each carries a pager. The SOS team is composed of experienced nurse clinicians who do not have a direct patient care assignment in order to provide support to the clinical care settings in medical, surgical, and critical care areas. They respond to acute situations when additional resources are needed to support patient care, changes in patient condition, transport of patients needing to be monitored during procedures, moderate sedation for unscheduled procedures, and any additional support as needed. These nurses also participate in all rapid responses, codes, traumas, and any situation needing their expert skills. The job description of the SOS nurse is available as Document, Supplemental Digital Content 1, http://links.lww.com/JONA/A292.
It was noted that a standard communication plan was not in effect to address times of high census or staffing shortages. The 1st intervention included the launching of plans for capacity management and restriction avoidance to adequately respond to higher-than-budgeted census. This included escalating communication among many areas as census increases. When the census is higher than budget, nursing operations support staff send out a high census alert (HCA) e-mail in the morning to a group distribution of those with key responsibilities to respond to the need. The HCA informs organizational leaders that beds or staffing are tight, and efforts to expedite discharges should be undertaken. Another mechanism used is a group page notifying nurse managers and care team leaders to assist in mobilizing throughput. This means taking patients from the postanesthesia care unit (PACU) and emergency department (ED) as soon as possible. Currently, the organization has a goal of taking patients from the ED within 45 minutes.
During extremely high census periods, banner communications that scroll across the computers in each department are posted with directions for action. Nursing operations support has a process in place to call emergency bed meetings and staffing huddles. These emergency meetings have been effective in developing plans to handle unexpectedly higher than budgeted volumes. An “all hands on deck” approach is utilized to have nursing leaders who are not routinely involved in direct patient care be present on the unit and assist as their comfort and competencies allow.
While the number of monthly diversions had historically been part of the organization-wide dashboard, these data additionally became the goal of each nursing coordinator by being included in their personal goals, discussed during annual performance evaluations, and monitored throughout the year. Also, the rare diversion and monthly success of zero diversions have been shared with nursing leadership, the chief executive officer, and the chief medical officer on a regular basis. These data are also presented at the monthly organizational leadership meeting by the chief financial officer.
In addition, it was found that there were not standardized guidelines for staffing used by all inpatient units. Standardized staffing guidelines were implemented to ensure that all areas operationalize the same principles and consider consistent options when making staffing decisions. This area of process focus has been the development of a flexible workforce approach along with the development of Staffing Guiding Principles (see Document, Supplemental Digital Content 2, http://links.lww.com/JONA/A293). Staffing principles were developed to ensure consistent processes from unit to unit. Core components include ensuring that all units are flexing at the same levels, evaluating the need for patient safety attendants (PSAs), considering care team leader patient assignments, considering managers briefly filling charge roles, and deploying clinical nurse specialists to assist with patient care.
While morning rounds, held at 8:45 AM each morning Monday through Friday to plan for capacity and staffing for the day, had been in place for years, it was determined that there were key nursing areas that had not been involved. Morning staffing rounds were expanded to include the ED and SOS staff. Daily morning team meetings are conducted to review available resources and clinical activity. The team consists of inpatient nurse managers, care team leaders, nursing staffing office, ED, PACU representatives, SOS staff, and, in extremely high census, the Access Center staff. The group evaluates and plans staffing and patient placement for the next 24 hours.
Including SOS staff in morning rounds, as well as initiating routine check-ins of the SOS staff with the nursing coordinators, allowed the SOS staff to gain a more global picture of all areas in the organization to ensure they are aware of the greatest needs and thus deploy staff accordingly. This strategy helped to ensure that bed capacity and/or staffing were expanded to meet patient/family needs to the greatest extent possible (Figure 1).
In addition to morning rounds Monday through Friday, proactive planning for unit needs was deemed to be necessary. As census increases, looking beyond the next shift and projecting needs 20 hours in advance while planning for weekend staffing on Thursdays were initiated. The most important strategy is the proactive planning process to ensure that as unit census increases, the organization is flexible enough to meet the needs to be able to work to capacity. An at-a-glance staffing needs report (see Table, Supplemental Digital Content 3, http://links.lww.com/JONA/A294) is sent out on a daily basis to secure resources in advance and alert units as to the status of resources needed and available. A weekend at-a-glance report is sent out on Thursdays to ensure adequacy of weekend staffing and to strengthen the early attempts to obtain additional resources. Similar to other organization successes, key areas of focus have been predicting capacity, predicting demand, developing a plan to ensure ability to flex to capacity and staff accordingly, and evaluating our plans as we moved forward.2
It was determined that prior to a denial/diversion, there would be an escalation process to contact the nursing operations support director 24/7/365 when the potential denial/diversion situation was due to lack of beds or staffing. This ensures all strategies have been exhausted before determining the inability to accept a patient. Additional leadership staff is contacted as necessary to ensure all efforts have been considered. The significance of this escalation process was found to be in the message that it sends to all staff—we must do all we can to care for the patients/families who request and need our services.
In addition to the strategies previously mentioned, some additional interventions are sometimes necessary. This has included the hiring of travel nurses to respond to short-term volume increases and/or long-term staff medical leaves. The organization has also expanded its float capacity by adding 20 full-time equivalent RNs and nursing assistants to the float pool. This ensures that more flexible resources are available to respond to areas with high census. The organization has also formed a team to focus on PSA usage and examine processes to request a PSA. There is also a team focusing on evaluating opportunities to improve the discharge process.
These strategies are making a difference. In 2012, the organization was unable to accept only 2 patients, and thus far 8 months into 2013, the organization has been unable to accept only 2 patients (Figure 2). The above interventions have been hardwired into daily practice and are more commonplace, therefore allowing the organization to be more flexible in the ability to accept all patients. It is now viewed as a failure to not be prepared to care for all patients seeking services. This success is a result of strengthening communication, systems, and processes for capacity management.3
Reducing diversions has also allowed the organization to rebuild relationships with patients, their families, referring physicians, and healthcare organizations. Both local and regional referral rates have increased significantly (Figure 3), and relationships with referring providers have improved as a result. The organization is always looking for ways to improve and appreciate staff input and guidance to ensure a readiness to care for all patients and families. Changing a culture to accept all patients seeking services has evolved over the past year, and staff continue to identify opportunities to work together to ensure the ability to provide the capacity and staffing to effectively care for these patients.
In conclusion, work to change a culture to become more flexible in the ability to accommodate all patients seeking services was successful. Through the identification of issues preventing the organization to maximize capacity, identifying an action plan to become more flexible, defining metrics for managing census, monitoring data to better understand our opportunities, sharing our data with key stakeholders, and taking action, there has been a strong improvement in patient flow and capacity management to maximize throughput. The goal of being “a bed ahead” has been achieved, and the desired outcomes of decreasing diversions obtained.