by Kristie Huff, RN, MSN, and Kristi McMillan
By developing processes for forecasting nurse staffing needs, Lee Memorial Health System (LMHS) was able to save more than $11 million in one year alone.
The savings are due to the elimination of agency nurses, or travelers, as of May 2008. A new model for predicting staffing needs has also helped the Fort Myers, Fla.-based system refine its bed management approach at five acute hospitals, leading to a 20 percent daily increase in the number of beds filled across the system.
The Roots of the Problem
Back in 2000, the number of nurse travelers—agency nurses with 13-week contracts—hit a historical peak at LMHS. Following the 2006 acquisition of two area hospitals, 350 travelers were on the combined payroll at the system’s five acute care facilities. Each traveler cost the health system twice as much as a staff nurse.
One of the major factors was that nursing directors overstaffed their units, fearing last-minute sick calls and spikes in census. It was like the human resource equivalent of supply hoarding. Call it staff hoarding.
Predicting Demand, Beds, and Staff
To tackle the problem, leaders at LMHS created a forecasting tool that would help directors predict staffing needs by day and shift. With such a model, nursing leaders could determine their staffing needs and use in-house PRN nurses from the system’s centralized staffing department to fill “holes” in a more efficient way.
LMHS chose a model that uses census points, or forecasted admissions. Census points are derived from using actual census figures and applying current and historical trends to determine the following month’s census—by shift, by day of the week, and by unit.
Here’s how it works: The operations improvement team collects census data from about 50 units at the five hospitals and plugs these data into spreadsheets, which generate frequency distribution models. Census points serve as “targets” for unit directors. Eighty percent of the time, a unit should be at—or under—its census point within a calendar month. For example, if a unit’s census point is 30, the unit is estimated to be at 30 or fewer patients, 80 percent of the time. Twenty percent of the time, the unit is expected to be above 30. Unit directors need a plan to flex their staffing up during high census times.
Each month, census points are used to determine staffing needs and the ideal number of beds to keep open on all nursing units. The goals are to maximize productivity and efficiency and improve nursing’s ability to meet census fluctuations. This means better use of all nursing staff.
Changing How Unit Directors Think
Forecasting scheduled needs by shift and day of the week requires unit directors to match their staffing based on forecasts, rather than average daily census. About four weeks before the start of a schedule, unit directors receive their forecasted census and staffing needs from the centralized staffing department. Directors review the census points and must suggest any changes to the forecast within two to three days. For example, a director would want to point out if a physician is on vacation and won’t be admitting patients to a unit, thus decreasing the estimated census point and reducing the scheduled staffing need.
To balance their schedules, unit directors must plan for the number of RNs and LPNs they need to cover their anticipated census on a given day of the week (see the exhibit). A weekly schedule is considered unbalanced if there is an opportunity on any day to shift staff to fill needs.
A scorecard was developed to monitor directors’ efforts to balance their schedules. LMHS leaders use the scorecard to analyze trends and set goals for system improvements. In the fall of 2007, only 16.7 percent of schedules across six pilot units were balanced. In June 2008, the six units scored 42.7 percent, a 26 percent improvement.
Early Signs of Success
Currently, three of the health system’s acute care hospitals use census points to adjust staffing to demand. The remaining two facilities will move to the process later in 2009.
LMHS has seen immediate results from its staffing improvements, including an $11 million savings in nurse labor costs. Twelve months into this initiative, LMHS was using 50 percent fewer travelers. After 16 months, the number of travelers was zero. In May 2008, leaders had enough confidence to cancel traveler contracts, replace travelers with internal staff, and ultimately bring the system in under budget by $6 million dollars in contracted labor.
In addition, LMHS has seen the following positive changes:
- A 20 percent improvement in daily bed fill rate
- A 200 percent increase in direct placement PRNs
- A 23 percent drop in PRN cancellation rates after one year
- Better staff coverage on units
- Reduced nursing overtime by 3 percent at three campuses
After a year of trial and error, unit directors at LMHS trust the process and know that if they need staff in a pinch, they can get additional nurses from the system’s centralized staffing department. In other words, the processes work to ensure that staffing needs are met and patient safety and quality care are consistently maintained.
Kristie Huff, RN, MSN, is system director for resource management and staffing, Lee Memorial Health System, Fort Myers, Fla. (kristie.huff@leememorial.org).
Kristi McMillan is operations improvement coach, Lee Memorial Health System, Fort Myers, Fla. (kristi.mcmillan@leememorial.org)