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Internal agency nurses provide an integrated, centralized staffing solution


Use of various just-in-time staffing solutions (unit PRN staff, facility float pool, overtime, per diem agency, and travelers) to meet patient care needs creates a struggle for hospitals to remain within budget to achieve adequate staffing.

At Novant Health, a large, not-for-profit, integrated healthcare system that serves patients in North Carolina, South Carolina, Virginia, and Georgia, we found that the 14 medical centers within the system didn’t have a sound structure to quickly share and provide staffing resources where needed. Staff could be placed off or on call for low census in some hospitals, while others used overtime, incentive pay, or agency staffing to fill needs. The decentralized float pools at each hospital made it difficult to swiftly react to changes in patient census across the system.

To better address system needs, we created an internal centralized staffing structure that reduced use of costly reactive (rather than proactive) staffing processes. 

Right staffing

The purpose of this innovation was to provide the right staff, at the right time, in the right amount, and at the right location through a totally integrated centralized staffing solution. Goals for the central staffing and scheduling office include a simple process for managers and staff to reduce the time spent at the unit level searching for staffing coverage, optimization of staffing resources, and availability of shifts and schedules to promote work-life balance.

Strategy and implementation

A multidisciplinary team, including human resources, as well as individual facility and float pool nurse managers, directors, and chief nursing officers, collaborated for more than a year to transform clinical staffing resource availability and create a central staffing and scheduling office for the healthcare system.

A central staffing office concept was trialed in one of the large markets to oversee staffing and scheduling for select units in two hospitals. Project deliverables included

  • consolidation of float staff and budget into a centralized staffing office
  • recruitment of competent staff
  • understanding and appropriate utilization of services
  • development of competency and flex staffing capabilities across facilities.

Implementation was budget neutral as we consolidated staff and dollars from local float pools into a new system-wide cost center. All existing float pool staff had the opportunity to join. Initial recruitment efforts focused on external hiring only for the first few months to prevent depletion of unit staff. Once positions opened up to internal staff, negotiation of transfer dates allowed for the time needed for back-filling of unit positions and to reduce unit hardship.

A phased approach was planned, with registered nurses and certified nursing assistants for phase 1, covering critical care, medical/surgical, and behavioral health units in the two largest markets (nine hospitals). Emergency services and patient safety attendants (sitters) were added later as phase 2 and 3 the following year.


Allocation of staffing resources is accomplished by the central staffing office in a variety of ways:

  • direct placement staffing for leaves of absence and vacancies
  • prescheduled staffing for weekly pre-planning needs to fill day-to-day staffing gaps
  • just-in-time staffing for volume increases and last-minute call outs.

Staffing coordinators pull census and staffing data for entry into an allocation tool each shift. Based on unit census, the tool calculates productivity based on current staffing levels and established unit staffing grids. Color-coding in the daily allocation tool allows for a quick visual of departments with the greatest need, and easily identifies units that may have extra staff to share. Deployment of float staff is now fair and consistent based on established unit staffing models.

Monthly data is pulled by market, facility, individual units, skill set, shift, and job class and shared with nursing and operational leaders quarterly and more frequently as requested.

Flexible self-scheduling (with PRN up to full-time hours with benefits available) enables nurses to work in a variety of settings within their geographic area of choice. Nurses have the option to work in two to five hospitals within a defined market and in all units they are deemed competent to work.

Orientation is individualized based on previous experience, with 2 years minimum required in at least one of the specialties we serve.

Active involvement

Our internal resource pool nurses have benefited from the central staffing and scheduling office. They are actively involved in facility, market, and system-wide shared governance councils and serve as chairs and chair-elects of councils. Being in multiple areas provides opportunity for best practices to be shared across our organization in real time by our own internal resource team. Service lines now included in the program are medical/surgical, telemetry, critical care, behavioral health, emergency, radiology, women’s, and perioperative services.


A goal in setting up the central staffing office was to be competitive, yet affordable to our internal customers. By year two of operation, we covered our overhead cost through cost avoidance based on internal float staff utilized versus the cost of contract labor and special pays.

2013 outcomes:

  • successful go-live
  • implementation of Phase 1
  • filled 60% of the RN positions

2014 outcomes:

  • implementation of Phase 2 and Phase 3
  • reduction in the number of in-scope unit travelers from 73 to 4
  • safety event involvement of float staff dropped from 4 to 1
  • quality measure misses involving float staff dropped from 14 to 1
  • 92% of leader customers would recommend our services
  • 90% overall float staff employee satisfaction
  • 68% of the unit RN requests were filled

2015 outcomes:

  • expansion into radiology, women’s, and perioperative services (Phase 4)
  • right-sized our positions by job class, shift, and skill set based on recommendations around plans for unit surges above and beyond budgeted average daily census
  • 85% of our leader customers would recommend our services
  • no serious safety event involvement
  • expanded into an additional market (northern Virginia)

A valuable resource

Having our own internal staffing personnel who are vested in our mission, vision, values, and culture is helping us provide safe, quality, affordable care. We use our experience, knowledge, and data within the central staffing and scheduling office to offer creative staffing solutions to customers, facilitate re-deployment of unit/facility staff, provide supplemental staffing to our medical centers in a systematic and fair way, and oversee the centralization and management of contract labor.

Stacy Byram is director of the central staffing and scheduling office at Novant Health in Winston-Salem, North Carolina.

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