EP9 ExB Advocate BroMenn Medical Center 1

Exemplary Professional Practice STAFFING, SCHEDULING, AND BUDGETING PROCESSES

EP9 – Nurses are involved in staffing and scheduling based on established guidelines, such as ANA’s Principles for Nurse Staffing, to ensure that RN assignments meet the needs of the patient population.

Example B: Provide one example, with supporting evidence, when input from clinical nurses was used to modify RN staffing assignments and/or adjust the schedule to compensate for a change in patient acuity, patient population, resources, or redesign of care.

Staffing Guidelines

Staffing guidelines and the staffing grid for the Mother Baby Unit (MBU) were developed using staffing recommendations from the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). The staffing grid is an Advocate BroMenn Medical Center (ABMC) working document where the total number of nurses, nursing technicians and secretaries needed for staffing of the unit is based upon the number of laboring mothers, postpartum mother/well baby dyads and nursery babies (infants requiring level II advanced nursery care). The grid was developed using the current AWHONN recommendations for safe staffing, balanced with the budgetary requirements of the unit to maintain safe patient care and to meet productivity measures (Exhibit EP9.B.1 MBU Staffing Grid).

The charge nurse (clinical nurse) is responsible for assessing the staffing needs of the oncoming shift and for adjusting the staffing plan for the current shift as needed. She develops the plan by evaluating each of the following:

the number of patients in each category (labor, postpartum, well baby and sickbaby)

the acuity of the patients

the number and type of associates needed

Acuity is assessed through an electronic acuity assessment completed for each patient, and through communication between the charge nurse and the nurse caring for the patient. Accommodations are made to increase or decrease staffing as needed and the appropriate staff are notified.

Staffing Assignment Modifications to Compensate for Change in Resources

Stephanie Wollenberg, MSN, RNC-OB, MBU Nurse Manager and Lori Harper, MBA, MSN, RN, NE-BC, Director of Nursing Practice and MBU, utilized feedback from the October 2014 Associate Satisfaction Survey and from the MBU Shared Governance Council meetings to identify concerns surrounding staffing and assignments. Patient volumes were steadily increasing and there were open positions at the time. One

EP9 ExB Advocate BroMenn Medical Center 2

specific concern communicated from the clinical nurses was the lack of nursing technician support for the nurses to assist with their patient assignments. As noted in the ANA’s Principles of Nurse Staffing, effective and efficient support services are imperative for appropriate nurse staffing and nurses must be engaged and participatory in decision-making (ANA, 2012). On January 23, 2015, Stephanie sent an email to the department associates asking for clinical associate volunteers to participate in a short- term task force to address the staffing/assignment issues of concern. The goal of the task force was to make changes in the staffing pattern to increase the number of staff providing hands on patient care while remaining cost and full time equivalent (FTE) neutral.

Interested associates came forward to participate, including the following clinical nurses:

Sarah Church, BSN, RN, Night shift RN-Registry Tier III, Labor/Postpartum

Jessica Baker, BSN, RNC-OB, Day shift Charge Nurse and Scheduler

Heather Jackson, BSN, RN, Day shift Charge Nurse

Shannon Lane, MSN, RN, Night shift Nurse Clinician II, Labor/postpartum

Susan Wilkins, BSN, RNC-OB, Night shift Nurse Clinician III –Weekender, Labor/Postpartum

Kathy Macy, RNC-MNN, Night shift Nurse Clinician III, Nursery/Postpartum

Hillary Watkins, BSN, RN, Night shift Nurse Clinician II, Nursery/Postpartum

Rachael Keighin, BSN, RN, Day shift Nurse Clinician II, Labor/Postpartum

Kim Ochsner, RN, Day shift Nurse Clinician II, Labor/Postpartum

Brenda Drury, MSN, RNC-MNN, Day shift Nurse Clinician III, Nursery/Postpartum

Angela Philpott, BSN, RNC-LRN, Day shift Nurse Clinician III, Nursery/Postpartum

Nurses, nursing technicians and unit secretaries were represented on the task force. The task force met on February 4, 2015, February 23, 2015, March 31, 2015, and April 14, 2015 (Exhibit EP9.B.2 Staffing/Assignment Task Force Minutes 3/31/15). Though the associate satisfaction survey revealed opportunities for improvement in staffing and assignments, more information was needed. Specific staffing and assignment issues were identified at the initial meeting. The issues were reviewed and the top four were prioritized. One of the priorities voiced by the nurses was nursing technician and secretary assignments. Nursing technicians were oriented to secretarial duties in order to serve in the secretary role when needed. Two technicians/secretaries were assigned to the secretary role each shift. The decision was made to reduce the amount of time that nursing technicians were assigned to the secretary role and to shift the technician assignment to assist the nurses with direct patient care, thus decreasing the nurse’s workload and improving the use of valuable resources.

A time study was planned and implemented for seven days to provide data regarding how much time was spent in the various duties of the secretary role for both the secretaries and the nursing technicians. In reviewing the data, the birth certificate

EP9 ExB Advocate BroMenn Medical Center 3

process accounted for a significant amount of time, in part because the process required multiple handoffs.

Benchmarking was done with other Advocate Health Care hospitals to determine how the birth certificate process was managed. It was found that many hospitals use the Birth Certificate Registrar model. This model assigned one qualified and trained associate to focus only on birth certificates during designated hours. Fewer handoffs resulted in increased efficiency, consistency and improved quality of the final document. A Birth Certificate Registrar position was created for ABMC MBU (Exhibit EP9.B.3 MBU Secretary Redistribution). Because there was an open secretary position, no change in overall FTEs was required. The registrar works 10:00 a.m. to 2:00 p.m. Monday through Saturday. Any birth certificates that must be completed on Sunday (or when the registrar is off) are done by the Unit Secretary who is trained in the process.

The implementation of the Birth Certificate Registrar allowed for a reduction in and redistribution of the duties of the unit secretary role. One associate is now assigned per shift to perform secretary duties, where previously two associates (sometimes nursing technicians) were assigned secretarial duties. All other scheduled nursing technicians are now assigned only patient care duties. These changes resulted in at least 12 additional hours per calendar day of support and assistance for the nurses. The new staffing pattern was implemented in May, 2015.

At this same time, the task force decided to alter the start time of the nursing technician and secretary roles. Previously all associates for the shift started the shift at the same time-either 0700 or 1900. The group suggested that nursing technicians and secretaries start their shift 15 minutes earlier—at 0645 or 1845. This change allowed a smoother transition from shift to shift as the nursing technicians start their shift and are already beginning their duties while the nurses receive handoff report (Exhibit EP9.B.4 MBU Staff Meeting PowerPoint April 2015, Slides 13-16).

These changes support and allocate additional hands on resources to the assignments of the clinical nurses, thus improving the nursing workload. The redistribution of resources has been well received throughout the department.

References

American Nurses Association. (2012). ANA’s principles for Nurse Staffing. Retrieved

from http://nursingworld.org

8.4.16 jlm

2016 Staffed Hours Per Shift Based on Patient Census - BudgetDepartment

Mgmt

CN Labor PP Nsy Tech Sec CN Labor PP Nsy Tech Sec Hrs.

56 806.96 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 247.75%

55 792.55 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 243.33%

54 778.14 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 238.91%

53 763.73 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 234.48%

52 749.32 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 230.06%

51 734.91 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 225.63%

50 720.50 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 221.21%

49 706.09 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 216.78%

48 691.68 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 212.36%

47 677.27 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 207.94%

46 662.86 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 203.51%

45 648.45 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 199.09%

44 634.04 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 194.66%

43 619.63 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 190.24%

42 605.22 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 185.82%

41 590.81 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 181.39%

40 576.40 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 176.97%

39 561.99 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 172.54%

38 547.58 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 168.12%

37 533.17 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 163.69%

36 518.76 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 159.27%

35 504.35 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 154.85%

34 489.94 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 150.42%

33 475.53 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 146.00%

32 461.12 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 141.57%

31 446.71 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 137.15%

30 432.30 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 132.73%

29 417.89 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 128.30%

28 403.48 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 123.88%

27 389.07 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 119.45%

26 374.66 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 115.03%

25 360.25 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 110.60%

24 345.84 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 106.18%

23 331.43 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 101.76%

22 317.02 2 3 2 2 3 2 1 3 2 2 2 1 25.71 325.71 97.33%

21 302.61 2 3 1 2 3 2 1 3 1 2 2 1 25.71 301.71 100.30%

Productivity

at Staffed

Hours

NightsDays

MBU

Variable Target Worked Hours 14.41

Patient) Earned

Worked

Hours/Day

Staffed

Worked

Hours/Day

Exhibit EP9.B.1 Advocate BroMenn Medical Center

2016 Staffed Hours Per Shift Based on Patient Census - Budget20 288.20 2 3 1 2 2 2 1 3 1 2 2 1 25.71 289.71 99.48%

19 273.79 2 3 1 2 2 2 1 3 1 2 2 1 25.71 289.71 94.50%

18 259.38 2 3 1 2 2 1 1 3 1 2 2 1 25.71 277.71 93.40%

17 244.97 2 3 1 2 2 1 1 3 1 2 2 1 25.71 277.71 88.21%

16 230.56 2 3 1 1 2 1 1 3 1 1 2 1 25.71 253.71 90.88%

15 216.15 2 3 0 1 2 1 1 3 0 1 2 1 25.71 229.71 94.10%

14 201.74 2 3 0 1 2 1 1 3 0 1 1 1 25.71 217.71 92.66%

13 187.33 2 3 0 1 1 1 1 3 0 1 1 1 25.71 205.71 91.07%

12 172.92 2 3 0 1 1 1 1 3 0 1 1 1 25.71 205.71 84.06%

11 158.51 2 3 0 1 1 1 1 3 0 1 1 1 25.71 205.71 77.06%

10 144.10 2 2 0 1 1 1 1 2 0 1 1 1 25.71 181.71 79.30%

9 129.69 2 2 0 1 1 1 1 2 0 1 1 1 25.71 181.71 71.37%

8 115.28 2 2 0 1 1 1 1 2 0 1 1 1 25.71 181.71 63.44%

7 100.87 2 2 0 1 1 1 1 2 0 1 1 1 25.71 181.71 55.51%

6 86.46 2 2 0 1 1 1 1 2 0 1 1 1 25.71 181.71 47.58%

5 72.05 2 1 0 1 1 1 1 1 0 1 1 1 25.71 157.71 45.69%

4 57.64 2 1 0 1 1 0 1 1 0 1 1 0 25.71 133.71 43.11%

3 43.23 2 1 0 1 1 0 1 1 0 1 1 0 25.71 133.71 32.33%

2 28.82 2 1 0 1 1 0 1 1 0 1 1 0 25.71 133.71 21.55%

1 14.41 2 1 0 1 1 0 1 1 0 1 1 0 25.71 133.71 10.78%

March 2015 Staffing/Assignment Task Force Meeting

Meeting Date: 3/31/15 Meeting Time: 1600 Meeting Location: CR5&6

AGENDA ITEM SUMMARY OF DISCUSSION ACTION (WWW) Wins & Safety Moments Good Month: 91 days with NO falls

Review Issue Grid

New Registrar Position

Triage Role

Discussion

Nurses need to delegate and sec/techs need to take and respect the delegation.

Beginning in May there will be a new position: Birth Certificate Registrar. These hours come from Brenda Eames’ position as Brenda is going to registry status in May. This position will be 4 hours a day, 4 days a week. Signs will be posted in patient rooms with the Birth Registrar’s hours, so they can plan accordingly. Hours are still being developed. This should free up our sec/techs to be at the bedside. We will also be firmer about completing VAP forms for patients. If the FOB is not available when we go in to do the birth certificate, we will give them the paperwork for them to complete and file themselves.

There were mixed reviews on the Triage nurse assignment. Night shift really likes it and day shift is not so sure. Determined that each shift may need to do what works best for them.

Should we consider having the sec/tech hours a little different than the nurses in order to get a jump start on the day? Perhaps beginning at 0630 or 1830? What process is the best for the Nurse to Tech handoff in the morning?

Exhibit EP9.B.2 Advocate BroMenn Medical Center

What makes a good day? Break out session

Discussion of Tech duties

Day shift / Night shift: Discussion on top things to do at the start of the shift to perpetuate a good day/night 1st round of water Make sure patient has: menu, phone, call light Pull trash and dirty linen Make sure linen is available for showers (dads at night) Pull any trays Update board

Some nurses prefer to do own vitals – still discussing Other tasks that tech can be responsible for: I&Os PKU Heart Screen

Stocking of servers needs to occur After patient care, not Instead of patient care.

Next Meeting Tuesday, April 14 @ 0730 in CR #3

ATTENDEES:

Name: Present Absent Stephanie Wollenberg RNC, MSN X Lori Harper RN MSN, MBA, NE-BC X Jessica Baker RNC, BSN X Heather Jackson RN, BSN X Kim Ochsner, RN X Kathy Macy RNC X Susan Kaufman RNC, MSN X Angela Philpott RNC, BSN X Kathy Olson, Unit Secretary X Dee Starks, Unit Secretary X Diane Matthews, Technician X Hillary Watkins, RN X

2

MBU Secretary Redistribution of Duties: 3/2015

The Assignment and Staffing Task Force brought up many opportunities for improvement. The goal of the task

force is to improve our efficiency, use our resources wisely and drive as much staff as possible to the bedside to

care for patients.

One of the priorities that was identified at the task force was Tech/Sec assignments. The goal was to clarify

assignments and allow for more time to be spent in the tech role assisting with patient care, thus providing

increased assistance to the nurses.

A time study was done for 7 days to provide us with data regarding how much time was spent in the various

duties in the Secretary and Tech/Sec roles. In reviewing the data, and in conversation, the birth certificate

process is a consistent topic that accounted for a significant amount of time, not only because the process is not

standardized, but also because the current process requires multiple hand-offs.

We benchmarked with the other Advocate sites to determine how they manage the birth certificate process.

Several use the Birth Certificate Registrar model. One other factor came into play at this time. We have open

secretary hours which will allow us to redistribute duties. Based on this information, we are going to make

some changes that will increase our efficiency, and allow us more Tech hours to assist the nurses with patient

care. Please note: This change will NOT affect any current associates’ hours. No one will “lose” hours. Rather,

this process will increase Tech hours at the bedside. There will be changes to the current Secretary and

Tech/Sec roles. Changes to the current process will include:

1. Implementation of a Birth Certificate Registrar position. This position will allow for several

improvements:

a. Improved efficiency. One person will manage the birth certificate, not multiple people, and the

process will not require multiple visits to the patient.

b. Improved accuracy resulting from fewer handoffs.

c. Consistent hours for our patients that birth certificates will be completed (which will be posted

in the patient rooms.)

d. The position will also manage VAPs, denials and complimentary birth certificates.

e. The above duties will no longer be the responsibility of the secretary role.

2. Using a portion of the open secretary position, we will post a 32 hour per pay period position for a Birth

Certificate Registrar. The position will be 4 four-hour shifts per week, including two Saturdays per

month and a holiday requirement. Exact hours are to be determined, but will be late morning through

early afternoon. The position will be 4 shifts per week, but this role will be accomplished 6 days per

week (Monday through Saturday.) The remaining two days will be filled by Jeanne and an associate

currently in the secretary role (when the current 4 hour overlap occurs.) A downtime process will be in

place for those few occurrences when a patient delivers on Saturday and is discharged prior to the Birth

Certificate Registrar hours on Monday. Jeanne will serve as the back up to this role. We will also look to

one of the current secretaries to serve as an additional backup.

3. The remaining hours that are open from the secretary position will be posted and filled as a Tech/Sec

position.

Exhibit EP9.B.3 ABMC

MBU Secretary Redistribution of Duties: 3/2015

4. One secretary or tech/sec will be assigned to secretary duties per shift. This position will be based out

of Nurses Station #1. Other Tech/Secs who are scheduled for the shift will be assigned patient care

duties.

5. Associates who are in the tech/sec role will maintain their secretary skills and will be assigned the

secretary role when a secretary is not scheduled.

6. Implementation of the Birth Certificate Registrar role will occur in May. The weeks between now and

May will allow us to post and fill the position, provide education as needed and plan for

implementation.

The changes above will result in at least 12 additional hours per calendar day that will be devoted to the tech

role and patient care.

MBU APRIL 2015

STAFF MEETING

Exhibit EP9.B.4 Advocate BroMenn Medical Center

Thank you…� Maggie Durbin

� Lisa Gilmore-Reiss

� Rachel Keighin

� Jen Scott

� Bekah Regenold

� Brenda Drury

� Joan Yoder

� Kim Ochsner

� Emily Frasier

� Karen Travis

� Lori Pearson

� Ann Groonwald

� Sarah Church

� Teresa Boyle

� Tonya Retter

� Mandy Huber

� Karen Travis

� Janice Westpfal

� Samantha Wheeler

� Heather Jackson

� Katie Worthen

� Megan Snyder

� Lori Troyer

� Emily Coley

� Liz Morris

� Joselyn Kimbrell

� Cathy Toohill

� Linda Baer

� Susan Wilkins

� Rachel Schneider

� Hillary Watkins

� Shannon Lane

� Lydia Whitted

� Kaylee Kelley

� Melissa Eskridge

� Norrene Love

� Courtney Tutoky

� Cait Wilson

� Melinda Hazlett

� Amy Baker-Moore

� Jane Lawrence

� Jaime Carpenter

� Justine Lee

� Michelle Braun

� Jessica Baker

� Holly Massey

� Katie Brown

� Deanna Swope

� Sandy Osman

� Marta Griffin

� Mary Tosh

� Kelly Smith

� Lori Pearson

Congratulations!!!!

Patient Satisfaction

92nd Percentile

Falls

108 Days

March Caring Award

Joan Nalley

Maggie Durbin

Unit Updates

� Safety Coaches

� Susan Kaufman-leader

� Jessica Baker

� Justine Lee

� Rachael Keighin

� Hillary Watkins

� Cait Wilson

� Katie Brown

� Jaime Carpenter

� Janice Westpfal

� Mandy Huber

� Katie Thomas

� Safety/High Reliability Training

� Alex assignment due by 6/12/15

� Required training at June staff meeting

Physician Rounding

� Follow up from physician sat survey

� Pediatricians are not feeling part of the team

� Rounding with physicians is a challenge

Meditech/QS

Interface

Documentation

DOWNTIME

• Downtime can occur unexpectedly or can be scheduled.

• Master downtime forms are located in a binder in charge nurse office. Some are forms that can be charted on and

then put in hard chart. Some are worksheets to use to enter data when system is back up.

• Copies of the downtime forms will need to be made.• Downtime forms are only used if system is off for longer

than 1 hour. • When system is back up, certain documentation will need

to be charted in CPN.• Admission record, delivery record, intraoperative record,

Infant admission are examples of what will need to be entered into CPN after the system is active.

• When CPN system is down, remember that you are not archiving strip. STRIPS MUST BE SAVED. No surveillance at

nurses stations.

DOWNTIME

Scheduled for May 5 at 0800.

Diane will notify staff when they need to document in the flowsheeton the scheduled downtime item. (located at end of flowsheet). You

will then exit out of system. CPN login may come up on computer screen but do not use system until you are informed that it is okay.

Save fetal monitor strip.

Strip must be labeled at start of downtime. If you tear a piece of strip off, you must tape it back in chronological order with tape on the

back side. When system is back up, remove that portion of strip that is in one piece and place in plastic bag with downtime pink label and

patient information label. Place in chart.

• Screen shots of new changes and processes

• Demonstration of new processes in training environment• Time for questions

Assignment/Staffing Task Force

� Priority list

� Triage and triage nurse

� Tech sec

� Baby care

Assignments/Roles

Birth Certificate Registrar:

� beginning end of May, the registrar will be on the unit from 10am-2pm

� Will manage birth certificate process

� 6 days week

� Downtime process

Secretary

� 1 secretary will be assigned to secretarial duties

� All other sec/techs will be assigned as techs to increase hours at the bedside

� Sec/techs will be back-up to secretary if needed

Tech/Sec

� Assigned to RN’s

OB/OR

� May be assigned to labor patients or to tech/sec role with RN for delivered patients

Tech/Sec assignments and duties

� Beginning 4/27, Start time for secretaries, tech/secs and OB/OR Techs will be 0645 & 1845 (15 minutes earlier than the current start time.)

� Standard Operating Procedure:

� Charge office @ 0645 and 1845

� Pick-up phone, card & get assignment

� Huddle with off-going tech for report (5 min)

� Assemble items for 7am/7pm rounding (water, linen)

� Begin rounding as the nurses begin bedside shift report

Tech/Sec assignments and duties

� Rounding to include:

� Fresh Water

� Linen (whatever is needed for the shift, including dad linen at night.)

� Empty Trash

� Remove any remaining trays

� Update Whiteboard with oncoming information

� Ensure phone, call light & menu within reach

� Huddle with assigned RN’s by 9am (as a team—to determine the plan for the shift)

� The tech assigned to the room is responsible for stocking supplies and linen (after patient care is complete)

� OB/OR tech assigned to Labor patients will stock Triage, c-section and empty rooms.

Responsibilities

� Nurses:

� It is your responsibility

� to huddle with your tech before 0900 and determine the plan for the day

� to delegate to your tech

� Techs

� It is your responsibility

� to begin rounding at 0700 to all assigned rooms

� to huddle with your nurses before 0900

� to accept delegated duties from your assigned nurses

White Boards & Rounding Logs

� Odd hours tech/Even hours Nurse

� Tech rounding not done while in Labor unless requested by RN

� Rounding logs

White Boards

• Expectation for all patients from all staff

• Tech to update white board during 7am & 7pm rounds

• Complete appropriate information

• RN will complete their portion during bedside report

Time

Supply Needs

Everything you need at the

bedside

Trash pulled

Trays out

Room clear of clutter

Bathroom Clean

Comfort Needs

Pain Control

Positioning

Informational Needs

Last Infant Feeding

Ordering Food

Menu

Personal Needs

Toileting

Shower

Walking in Hall Init

ials

0600

0700

0800

0900

1000

1100

1200

1300

1400

1500

1600

1700

1800

1900

2000

2100

Every 2 Hour Rounds

2200

2400

0200

0400