Strive for balance to achieve improved outcomes.
- Nurse staffing is influenced by an organization’s structure and culture.
- Centralized staffing manages staffing through a central office. Decentralized staffing occurs at a hospital or unit level. A hybrid model combines centralized and decentralized staffing.
- A holistic staffing approach respects the need for accountability, preserves nursing staff input, and creates transparency and flexibility.
NURSE STAFFING and scheduling is a complex and dynamic process that’s influenced by organizational structure and culture. Some organizations manage staffing and scheduling with centralized systems through a central staffing office. Others are decentralized and schedule at a hospital or unit level. No one solution fits all organizations, so nurse leaders must create systems that fit the unique needs of their organization and staff. The following case studies illustrate how adhering to evidence-based staffing principles can lead to positive organizational outcomes and staff satisfaction. (See Key to success.)
Case study: Legacy Health
Legacy Health (Legacy) is a regional health system (eight hospitals and a network of ambulatory clinics and healthcare services) in Oregon and Washington with more than 13,500 employees and 4,200 nurses. A centralized system was developed in partnership with unit charge nurses to achieve efficiency and effectiveness across Legacy’s multiple sites.
Legacy uses over 200 internal central resource pool full-time equivalents (FTE) composed of nurses and certified nurse assistants to support the daily staffing needs of 60 inpatient nursing units that use standard 12-hour shifts. The central staffing office operates around the clock with one to four employees, depending on need, to manage staffing demands. Legacy’s peak staffing times are 0300 to 0730 and 1500 to 1930. Each staffing office employee is responsible for interacting with unit charge nurses in specific areas (critical care/intermediate care/respiratory, med-surg in the three largest hospitals, pediatrics and med-surg in the remaining hospitals, and women’s health/emergency/psychiatry in all hospitals) to collaboratively assess unit and nurse needs, patient census, and overtime shifts. Based on that information, internal float pool nurses are deployed to the right unit at the right site for each shift in all eight hospitals.
In addition to the central staffing office, Legacy’s staffing model is supported by system-level staffing and scheduling policies, division of nursing central staffing and scheduling technology, standard shift lengths and start times, a standard scheduling cadence (schedule length and timing for publishing schedule), and an enterprise resource pool that can float to all eight hospitals.
In 2017, Legacy transitioned to central recruitment with open shift notification technology. Previously, recruitment happened at the unit level and resource need wasn’t communicated back to the central staffing office, making efficient enterprise-level nursing resource management impossible. Now, the central staffing office proactively manages recruitment that aligns with system pay practices and the staffing policy. To ensure adherence to the process, unit-level access to specific pay codes in the scheduling and recruitment technology is restricted to the central staffing office.
Benefits and challenges
Centralized staffing allows an organization to streamline processes and create business operation efficiencies related to policy development, technology, pay practice, and resource management. It also significantly reduces the chance of error. Floating, cancellation, standby, vacations, and schedule lengths are universal for the health system, increasing adherence when the staffing office and charge nurses make in-the-moment staffing decisions.
A centralized staffing approach isn’t without challenges. It can cause hospitals within a system to feel a loss of control and identity. Because each site has a unique patient population and culture that influence its work, system staffing policies must be broad enough to set the framework for operations but allow room for individual tailoring. For example, every nursing unit at Legacy was expected to have a 6-week schedule, and the scheduling cadence had set times for publishing, scheduling periods, and trades. However, each unit determined if it would use self-scheduling, pattern scheduling, or a combination of both. This allowed for a standard system-wide approach, with opportunities for units to identify their own scheduling method that meets staff needs.
Changes may take longer to initiate in a centralized model. Requests for policy, workflow, or technology changes must be evaluated at an enterprise level, which requires investigation, testing, pro and con analysis, and shared governance vetting. Once approved, the change must be communicated and rolled out, which requires planning and coordination. Legacy’s shared governance model ensures that site or specialty concerns move through the right channels to the system level and that staff input guides staffing and scheduling practices.
Overall, Legacy’s centralized approach has created a variety of positive system-level changes. Employee engagement results for adequacy of resources and staffing has improved from 2017 to 2018. This is an exceptional accomplishment considering Legacy’s staffing and scheduling transformation for 126 nursing departments and 5,000 end-users (nurses, certified nursing assistants, and other staff with roles within nursing) began in 2015 and was completed November 2017. Legacy continues to pursue positive staffing and scheduling outcomes and frequently evaluates the process and technology to ensure the right tools and frameworks are accessible and relevant for all users.
Case Study: VCU Health
VCU Health (VCU) in Richmond, Virginia, is a Magnet®-recognized 770-bed, not-for-profit, academic medical center. It offers many unique services (level one pediatric and adult trauma care, pediatric and adult burn care, pediatric and adult extracorporeal membrane oxygenation and artificial heart program, National Cancer Institute–designated bone marrow transplant program) to the region, making access and appropriate nurse staffing critical operational functions.
Demand for VCU’s unique services has increased the overall inpatient census and emergency department (ED) volume. From 2013 to 2017, the inpatient census grew approximately 20%, and ED visits increased by about 10%. In addition, the case mix index and patient acuity levels have risen. These changes require flexibility and strategic options to maintain appropriate nurse staffing levels.
The early stages of this growth revealed deficiencies in the hospital’s previous staffing and scheduling processes. Perceptions of staffing adequacy on VCU’s RN satisfaction survey fell below the Magnet mean, and reviews of the unit’s staffing plans and unit schedules showed a high level of variability between like units and across different shifts. Unit staff focus groups revealed themes of excessive staff reassignment (floating) and an occasional unacceptable mix of experienced and inexperienced staff on off shifts.
A staffing and scheduling committee (composed of staff nurses and unit level managers from all departments) was developed as part of the hospital’s shared governance structure to analyze the process and make recommendations. The team implemented several important initiatives that capitalized on VCU’s overall decentralized philosophy and leveraged the shared governance structure for decision-making.
Benefits and challenges
The staffing and scheduling committee implemented an electronic nurse scheduling system to increase accountability and transparency across the organization. The committee developed the request for proposal for the system and served as the primary evaluators in the vendor selection process. The chosen product was widely adopted by nursing units because both nurse managers and staff nurses had outlined their requirements and ensured the system met their needs. Shortly after implementation, unit schedules were managed in real time within the electronic scheduling system, making unit staffing visible and transparent.
The staffing and scheduling committee also helped drive accountability and flexibility for scheduling practices. Previously, VCU used consistent, standardized nurse staffing and scheduling policies, but accountability was challenging without the transparency of an electronic scheduling system.
Improved accountability and increased flexibility are achieved with two important decentralized strategies: daily staffing meetings with a nurse manager from each division and weekly staffing meetings with nurse directors. The goal of the daily meeting is to review and plan staffing for the next 24-hour period. After current and projected census and projected acuity levels for each area are reviewed, available nursing resources are identified and are reallocated as needed. Unit managers can specifically address their area’s needs and better match available resources to areas of like competency. One benefit of this approach has been a decrease in unit-based nurses floating to other units; more often needs are filled from an internal float pool, which includes staff who are better prepared to move to multiple areas. In addition, since the units are projecting staffing needs for the next 24 hours, more flexibility exists to adjust staffing if the needs are greater for one shift.
At the weekly staffing meetings, nurse directors review unit schedules, deploy short-term staffing resources from the internal staffing pool to address unplanned scheduling issues, and assess for trends that may prevent a unit from appropriately staffing its area. When issues are discovered, their root causes are identified, and strategies are developed to help the manager correct the problem.
In addition to the daily and weekly meetings, new tools were developed to help unit managers address staffing needs. For example, incentivized shifts promote self-directed floating. Unit managers use incentives to fill less-desirable shifts with available staff who are willing to work outside of their home unit and can be reassigned to a similar area of competency. A limited number of shifts can be posted per manager, and they can only be posted 7 days before the time the shift will be worked. This eliminates issues with staff waiting to cover shifts only if bonus dollars are assigned and rewards staff who are proactive and flexible.
VCU’s decentralized staffing model has improved organizational and staff outcomes. Since the inception of the staffing and scheduling committee, staffing performance has improved. The budget to actual hours per patient day for nurse staffing is consistently on target, and VCU continues to demonstrate strong clinical performance in nurse-sensitive indicators. Although many other factors contribute to financial and clinical performance, VCU demonstrates that efficiency and high quality can be achieved in a decentralized staffing environment.
Take a holistic approach
No single approach to staffing and scheduling works for all organizations. Nurse leaders must evaluate their current staffing model, their organizational goals, and their team members to determine the staffing and scheduling system that will work best in their environment. (See Ask the right questions.)
The decision to refine current systems or implement a centralized, decentralized, or hybrid staffing model must be consistent with the organization’s overall philosophy and culture. Whatever model is used, take a holistic approach that respects the need for accountability, preserves nursing staff input and decision-making power, and creates transparency and flexibility.
Danielle Bowie is vice president of nursing workforce development at Bon Secours Mercy Health in Cincinnati, Ohio. At the time this article was written, she was systems director of clinical resource management at Legacy Health in Portland, Oregon. Kathy Baker is associate vice president of nursing at VCU Health in Richmond, Virginia, and adjunct faculty at VCU School of Nursing.
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