Provide TWO examples, with supporting evidence, from different practice settings where trended data was used during the budget process, with clinical nurse input, to assess actual-to-budget performance to redistribute existing nursing resources or to acquire additional nursing resources. Trended data must be presented.
Example One- Birthing Center
Background In 2009, Thompson embarked on a journey to review and revise the way we managed our most expensive commodity (our associates). We engaged a consultant to review our method of measuring productivity. The new productivity system was based on the premise that achieving efficacy was essential to reducing cost while maintaining quality of care: essential in a health care setting. Our previous methodology had revolved around measuring ourselves against "national benchmarks" and a once a year salary budget. The new methodology is much more fluid and hence responsive to the changing health care environment, service development and local landscape. Our new model is based on our own performance, that is, we benchmark against ourselves at a unit level. This allows the nurses and Directors to review on a bi-weekly basis the successes and opportunities for improvement. New processes can be evaluated for effectiveness and impact on unit efficiency. In the new methodology, there is an opportunity at any point in the year to review and revise the unit model to adapt to changes in the internal or external environment. Two examples are presented below to describe the additional resources acquired in the past 12 months; one as a result of a change in our internal environment and the other as a result of an external change that led to a sudden increase in patient volume. Nurses at the bedside using this methodology are able to quickly identify trends and work with their Directors and the CNO to advocate for the additional resources necessary to meet the needs of our patients.
Obstetrics is a challenging specialty in which to evaluate productivity. Staffing patterns range from a 2:1 nurse: patient- ratio at delivery, to a 1:6 nurse- patient ratio in postpartum. Larger medical centers have separate areas for Labor and Delivery, postpartum, GYN surgery, and outpatient testing. They are able to use hours per patient day (HPPD) for inpatients, hours per delivery for Labor and Delivery, and hours per procedure for outpatients. Community hospitals often combine all of those modalities on one unit. Additionally, community hospitals vary widely in the meaning of their "Level I" acuity status. Some community hospitals accommodate Vaginal Birth After Cesarean (VBAC), keep newborns with mild respiratory distress, infants with IVs and antibiotics. Other Level I hospitals do not accommodate these clinical situations and refer them to a tertiary care center. At FF Thompson Hospital the practice is to keep newborns with transitioning difficulty in our Nursery, as long as they do not require intensive care or ventilator support. Some of these newborns have running IVs which require hourly monitoring and strict intake and output. Most of them are also receiving intravenous antibiotics. We accept admissions of neonates for phototherapy, as well as neonatal transfers from a higher level of care who require temperature and feeding support. We selectively offer a trial of labor after cesarean section, which requires a 1:1 nurse-patient ratio during labor. It was a complicated challenge to develop an acuity model to capture the actual work of the unit and translate that to a productivity model. The Department of Obstetrics staff and Director developed a productivity data collection tool based on nursing care time for procedures, such as labor care and outpatient testing, as well as hours per patient days for infants, postpartum patients, and GYN surgery patients. The procedural data is easily captured through charge reports generated on a biweekly basis. That data is then combined with worked hours obtained from payroll software to create the "OB Scorecard". The data collection tool can be modified to support the introduction of new procedures. For example, the nurses recently began performing oxygen saturation testing on neonates to aid in the detection of congenital heart disease. This procedure will be added to the charge sheets, and added to the data collection spreadsheet. The Director is meeting with coding experts from Health Information Management to find out how to accurately track patients who are pre-eclamptic, eclamptic, or experience postpartum hemorrhage to adjust the HPPD and nurse hours per labor hour for these special needs patients. The coders will also be able to help differentiate the types of "boarder babies" who stay in the nursery after the mother's discharge. Some are simple phototherapy patients, while others are complex neonates requiring frequent monitoring and assessment.
A marked increase in volume from 2013-2014 resulted in a rise in overtime and call-back time, and a decrease in worked hours per unit that was unmanageable (Exhibit EP10.1).
Exhibit EP10.1
The Director consulted with staff nurses to determine what they perceived as their greatest needs to manage the volume. They concluded:
The change in the charge role was accomplished by re-arranging existing positions. The Director, with the support of the CNO, advocated for the new tech and RN positions with the Productivity Review Committee in May, 2014. Based on the data presented, all four positions were approved. As described above, budget management is evaluated on a bi-weekly basis, not as an annual process. This frequent assessment of performance encourages active management of productivity and staffing, overtime and call-back time. Example 2
Medical Surgical Nursing Over the last 18 months Thompson Health has seen tremendous growth in their owned physician practices. We have gone from 5 to 9 practices and our inpatient volume is up 5% year over year. Additionally, our observation patient volume is up 32%. Prior to this surge in volume 2 West, a Telemetry/Medical-Surgical floor, was staffed to accommodate 12-15 patients. Average Daily Census on 2W has steadily been on the rise with no changes to staffing on the unit. Based on the increased volume from 2013 to 2014 the Director Consulted with staff RN's to determine what they perceived as their greatest needs to manage the volume. They concluded:
The change in the charge role was accomplished by re-arranging existing FTEs from the other 2 medical/surgical units. The Director, with the support of the CNO, advocated for several new positions and hours for existing hours. This included additional Charge Nurse hours, two 0.9 FTE RN's, a total of 1.4 FTEs for Tech, and 0.9 FTE of HUC. In April 2014 this information was presented to the Joint Executive Committee. Based on the data presented, all positions were approved.