The healthcare industry is appropriately renowned for its breathtaking pace of innovation in so many important areas. Cutting-edge treatments, breakthrough discoveries, and dramatic progress in disease prevention, infection control, and other aspects of patient care have helped this nation's healthcare system maintain its status of excellence around the world.
In recent years, though, as systemic costs have exploded, the industry's focus has widened to encompass not only the quality of patient care itself, but also the underlying infrastructure, methods, and costs of the care delivery processes. In many ways, the healthcare industry has fallen short of its goals of efficiency, cost-effectiveness, and timeliness. Nurse executives are constantly challenged with meeting all three objectives due to the staffing schedules they must create and maintain. The fact is, despite all of the fancy devices, tests, treatments, and equipment in units, departments, and labs, innovation and technology have largely failed to reach the nurse manager's office when the time comes to devise the monthly or biweekly schedule.
Case in point
BayCare Health System, a community-based organization in the Tampa Bay, Fla., region, features 10 not-for-profit hospitals and approximately 200 other locations (such as outpatient facilities, clinics, labs, and offices). BayCare employs approximately 17,500 people, including more than 4,000 nurses. With such a broad workforce distributed across multiple facilities, there was a high degree of variance in scheduling procedures, some of which were paper-based. Due to this detachment, each department had its own rules and processes for scheduling.
In effect, each location was its own “island.” There was no fluidity to the scheduling process, which created numerous costly inefficiencies. For instance, it wouldn't be uncommon for a nurse to—with the best of intentions—”hide” another nurse in the schedule or have people on-call to protect against unplanned staffing shortages. Schedulers couldn't see the basics––who, what, where, and when, which created several challenges. First, it left the facility vulnerable to costly contract labor and overtime charges that, with better planning, could've been avoided. It also created staff-mix issues. Some days, the team was heavily skewed to numerous graduate nurses with less experience, forcing a shuffle of the deck to rebalance staff by transferring people to other departments. Other times, there were too many nurses because schedulers simply didn't know who was coming in. The “house supervisor” nurse would look at the schedule every day at 5 a.m. and decide who would need to float to which unit, when to call in more people, and when to send some home early.
Naturally, nurses didn't hold this unreliable system with very high regard, which may have contributed to a higher-than-desired annual turnover rate of 11%. It was difficult to achieve regularity in the schedule, so nurses always struggled with constantly changing shifts. Staff members called in on emergency were often sent home without working, and with a level of variability that sometimes seemed arbitrary, there were times when perceptions of favoritism were abundant.
Of course, these manual methods were also time-intensive. Nurse managers spent anywhere from 4 to 24 hours on manual scheduling. This work distracted from patient satisfaction, clinical outcomes, mentoring, and more. As BayCare was preparing to launch a broad electronic medical record initiative, managers needed to be out on the floors and in the departments, not stuck behind a desk, buried in paper schedules.
A time for change
In 2008, manual methods were hindering BayCare's efforts to reduce costs and improve nursing satisfaction. Although scheduling difficulties hadn't materially impacted patient care, they created too many obstacles for nurses and nurse managers. The tipping point arrived when staff began working with a healthcare operations consultancy. They were advocating processes based on free scheduling, transparency, and fluid staffing––but BayCare didn't have the technology or information needed to make that happen.
BayCare had previously implemented an enterprise-wide time and attendance solution and, based on the success of that system, approached the same vendor for workforce management and scheduling analytics. A liaison at each hospital activated one or two units at a time. This took place across the entire BayCare system. In less than 18 months, more than 90% of nursing departments were up and running with the new system.
Although different departments had varying needs, it generally took about 3 months to bring a unit online from “start to live.” The Information Systems team was indispensable in this process, working to build background rules regarding the number of paid-time-off requests allowed, weekend rules, and other parameters. The biggest paradigm shift for nursing staff was that the schedule now started with “employee self-service.”
Was the changeover from manual to automated electronic scheduling trouble-free? Not always. There were pockets of uncertainty and concern given the potential for disruption. BayCare started with one of its hospital's respiratory units: the biggest in-patient unit for full-time equivalent nurses. Next, the technology launched in the float team pool, essentially making floaters “missionaries” for the new system. When their peers saw how float nurses requested their own shifts, it created a pull effect and raised the anticipation for their own units to adopt the new scheduling system.
When that first schedule came out, there was certainly a palpable anxiety among the staff members, who were wondering about the impact on their own shift preferences and lifestyle. But with careful preplanning and explanations that no one would endure a “bad” schedule, the many benefits of this new approach quickly became apparent.
Using the web application, a nurse can request his or her upcoming schedule with just a few mouse clicks—a huge improvement over manual requests. Requesting PTO is also just as easy. These tasks have near-zero impact on the workday, as requests can be entered remotely. Nurses can also express their preferences for “float” positions or willingness to be “called off” first. Not surprisingly, after the first schedule, the nursing team's initial concerns disappeared quickly. Virtually every unit has experienced 100% compliance from its nursing staff.
For the better
For nurse managers, automated scheduling represents a dramatic reduction in administrative burdens. For example, BayCare has reduced its scheduling time from 8 to 12 hours to just 2 hours every 4 weeks. Managers across all units report similar productivity improvements. From a contract-labor perspective, the new system has had a tremendous impact. In 2008, BayCare's expense for contract labor and traveling nurses was $2 million. Today, that number is zero, as the organization relies on its own internal float team to meet any staffing shortages.
The larger impact has occurred out on the unit floors across BayCare's 10 hospitals. With the new scheduling system, BayCare achieved a level of transparency that's without precedent. Managers can locate which departments are “working short” and which have too many nurses. They can see a few days into the future and identify departments that are significantly short and adjust the staffing plan. Now, managers are accountable for balancing the schedules with the appropriate mix of skills and seniority. Another advantage is that these schedules are visible to everyone, creating a subtle but important pressure for nurse managers to get things right.
Proper schedules are extremely helpful at BayCare. As a Florida-based health system, it experiences wide seasonal swings in patient volumes. There are spikes in patient visits during winter months, as the “snowbirds” come to the Tampa area. Also, usage patterns change as inpatient volumes ebb and outpatient volumes increase. All of this calls for a far greater level of flexibility in scheduling, one that can adapt every few hours (if necessary), as opposed to a weekly recalibration. For instance, if a manager needs to cut a shift, he or she first targets nurses working overtime. Then, the manager moves nurses from the float team elsewhere.
Attendance is another key issue for virtually any nursing staff manager. One or two unplanned absences can ripple through a shift and create havoc. A suboptimal schedule can contribute to that problem because it conflicts with a nurse's needs, almost inviting him or her to call in sick when those conflicts can't otherwise be resolved. Many of BayCare's departments have seen absences decrease by as much as 20%. Not only does that mean lower overtime costs for nurses to cover those vacancies, it also means a greater consistency in clinical care. Nurses know who they're working with and can function more cohesively with smoother clinical processes.
Job satisfaction has increased for nurses at BayCare. If there's one thing a nurse doesn't like, it's an inconsistent schedule with unplanned changes. After arranging other elements of life (such as child care), no one wants to report to work as planned only to be told they won't be needed that day and to return home, without pay. Through both new software and smarter processes, BayCare now has a better option than “Go home.” The organization has reduced the sizes of its on-call float team, reduced staffing shortages, and reduced unnecessary overtime.
This new scheduling system was a unique opportunity for BayCare to embrace meaningful change. It was a catalyst to review processes and leverage innovative software to reduce the steps needed to create effective schedules. Thanks to this new organizational tool, talented nurses can focus less on administrative tasks and more on delivering excellent patient care.