Improving efficiency in care delivery improves healthcare quality and nurse morale while reducing costs from overtime, agency use, and turnover
Our company recently posted a social media link to an article about how stress is overwhelming nurses. The post received many responses, mostly from exasperated caregivers imploring that providers “just hire more nurses.”
Finance leaders understand that sentiment but often feel pressure to maintain or reduce nursing headcount. Hospital leaders typically manage their nurse labor pools through schedule planning, daily reconciliation of time scheduled to time worked, staff deployment with automated scheduling systems, and open shift filling.
However, these approaches do not always effectively predict and match nursing resources with patient clinical demand. That discrepancy can lead to undesirable outcomes—frustrated nurses, overstaffed or understaffed units, costly overtime and agency staffing, and possible lapses in care.
The following are five signs that your hospital can better match clinical demand with capacity to capture labor savings while boosting morale.
Sign No. 1: Productivity And Efficiency Challenges
Has your hospital failed to reach peak productivity and efficiency in care delivery? Even asking this question can concern many nurses and clinical leaders because they regard efficiency programs as code for cutting corners and increasing workloads.
Not so, says Scott Wolf, DO, MPH, FACP, president, Mercy Medical Center, Springfield, Mass. Mercy embarked on a clinical transformation initiative in 2013 that has built efficiency and continuous improvement in care coordination from admission to discharge.
“It’s not about doing more with less,” says Wolf, citing an efficiency mantra that many have come to dread. “It’s about doing different with different.”
His hospital adopted a new, hub-and-spoke care model that has improved point-to-point communications, bottlenecks, and poor care handoffs. This foundation for efficiency may drive more accurate staffing and lead to happier nurses.
Sign No. 2: Agency Staffing Use
Do you depend heavily on agency resources and overtime? Overtime and outside nursing resources can be costly when used to meet unanticipated demand. Mercy Medical Center Chief Nursing Officer Jessica Calcidise, RN, believes the remedy for this is better anticipation of that demand. “When you make the operations and outcomes of care delivery reliable and predictable, you also make patient clinical demand more predictable,” Calcidise says. “The whole system and the units know which patients are going where, for how long, and what the care path will be. It makes staffing more precise and attentive to the needs of all patients.”
When you make the operations and outcomes of care delivery reliable and predictable, you also make patient clinical demand more predictable.
Calcidise cites Mercy’s rapid, dramatic reductions in overtime and agency labor, which dropped from more than 17 percent to approximately 5 percent over three years from the launch of its care coordination initiative.
“We credit these results to our care coordination initiative,” says Calcidise. “By taking a systemwide approach to care delivery, we can much more precisely predict and staff for patient demand. And the nurses are much more focused on patient care instead of wearing out shoes and phone lines tracking down information, test results, people, and equipment.”
The hub-and-spoke model at Mercy has contributed to an overall annual financial benefit of $7.8 million, driven by throughput efficiencies that have significantly reduced both inpatient and observation length of stay, increased case-mix index, and lowered rates of readmissions and leaving without treatment.
Mercy Medical Center’s new care model, along with other internal initiatives, has also contributed to an $858,000 reduction in costs for nursing agency and overtime labor.
Sign No. 3: Nurse Satisfaction
Are you struggling to keep your best nurses happy—and employed? According to a 2016 research survey published by NSI Nursing Solutions, the average cost of turnover for a bedside registered nurse ranges from $37,700 to $58,400, resulting in the average hospital losing $5.2 million—$8.1 million at the 2015 turnover rate of 17.9 percent. So nursing turnover costs hospitals millions while disrupting care continuity, damaging morale, and creating staffing challenges. Many factors lead to nurse dissatisfaction—understaffing, compensation, and lack of growth opportunities (Teeter, K., “Relationship Between Job Satisfaction and Nurse to Patient Ratio with Nurse Burnout,” Nursing Theses and Capstone Projects, 2014, Paper 39).
But one of the core stresses for nurses is the fear that distractions and activities unrelated to care will create situations in which they could potentially harm patients. A 2014 nursing survey by Jackson Healthcare highlights the concern that chaos in care coordination robs nurses of time they should spend with patients (“Practice Trends and Time at Bedside,” Jackson Healthcare and Care Logistics, 2014). Specifically, poor care coordination can lead to the following problems.
Poor communication among nurses, doctors, hospital leaders, and staff on units and service areas
Time wasted arranging, tracking, and following up on patient tests and procedures
Nurses needing to divide their time among more patients
Nurse fatigue from excessive overtime
To avoid these negative consequences, healthcare leaders should focus on the efficiency of the system. “The value of streamlining nursing workflows and finding ways to make nursing care more efficient is immeasurable,” says Brittney Wilson, BSN, RN, an author and a blogger also popularly known as “the Nerdy Nurse.” “Nurses are tired of spending their time communicating the same things multiple times. It takes them away from their patients and reduces their ability to provide well-rounded care.”
Bethesda Health, Boynton Beach, Fla., also adopted a centralized care model that connects and coordinates the right people and care activities, giving nurses the time back to spend at the bedside, not on the phones and running the hallways.
“The centralized care management model empowers the nurses,” says Mary McClory, RN, LHRM, CPHQ, vice president of quality, Bethesda Health. “For example, daily progression huddles on the unit gather nurses, doctors, and other caregivers responsible for ensuring that patient care plans and discharge targets stay on track.”
In addition, the optimized care model gives nurses and other staff the tools, platform, and freedom to shine in their positions.
“We’ve seen some of our best nurses grow and flourish,” McClory says. “They identify challenges to care and throughput, and apply problem-solving tools to coach hospital leaders during weekly rounding to improve all aspects of patient care and the patient experience.”
Sign No. 4: Patient Satisfaction
Are patient experience scores lagging? It makes sense that understaffing would spread nurses thin across too many patients and diminish patient satisfaction. But it is about more than just numbers. It is about what the nurses are empowered and asked to do, and how much they are allowed to focus on patient care and treatment.
For example, some suggestions for improving patient satisfaction seem to have little to do with providing better care and a more satisfying experience. One example is encouraging nurses to say the word “always” frequently when interacting with patients because that is the desired answer to each of the HCAHPS survey questions.
Such attempts to finesse higher survey scores are aimed in the wrong direction. Hospitals should focus on processes and tools that allow nurses and teams to coordinate quality care for all patients. If hospitals reliably can get that right and keep improving, happy and satisfied patients and nurses will likely follow.
Sign No. 5: Nurse-to-Patient Ratios
Do nurse-to-patient ratios fail to closely match clinical demand with nurse capacity on the units? Nurse-to-patient ratios do not always accurately match clinical demand with nursing capacity. This is an area where many hospitals are applying new technologies to improve staffing precision.
Holy Cross Hospital, Fort Lauderdale, Fla., adopted software that provides demand visibility across the units from a central hub, with a staffing coordinator continuously matching unit patient demand and nurse capacity for upcoming shifts.
“It makes real-time scheduling and staffing objective, rather than subjective,” says Brandon Charette, operational performance coordinator. “We can tell at a glance whether upcoming unit shifts properly match the clinical needs of the patients, and adjust assignments accordingly.”
He says the system looks ahead in onehour increments, which helps them account for continuous changes in workload, admissions and discharges, and patient clinical needs across the hospital.
“We used to track it on paper as best as we could,” Charette says. “Now the system tells us immediately: Are we flexing appropriately? Are we understaffed? Are we floating people appropriately? Is it affecting our discharge times? It’s really advancing the objectives of our care coordination initiative.”
Predicting and Planning
“One of the most interesting things about working in a hospital is dealing with a fluctuating census,” author and blogger Wilson says. “With the feast or famine world in staffing needs, hospitals are throwing money down the drain if they are not actively working to predict and plan for clinical demand.”
As you wrestle with reducing and forecasting labor costs, consider the five signs that your hospital may benefit from creating a better match between clinical demand and capacity. In addition, consider approaching the remedies not as isolated cost containment projects, but as opportunities to transform care delivery to continuously improve quality, experience, throughput, and flow.