85
Chapter 11
Staf๎ng and Scheduling
Kelly Arnold
Introduction
Many industries and organizations understand that the most valuable resource they apply to their
e๎orts are human resourcesโpeople. ๎is concept is true as well in any healthcare organization,
particularly hospitals. Healthcare has been and is projected to continue being one of several indus-
tries that will contribute heavily to economic recovery and job growth in the United States. At
the same time, there will be mounting pressure on healthcare providers to reduce the cost of care.
๎ese two facts make a complete and thorough understanding of sta๎ng and scheduling in hos-
pitals essential. ๎is chapter will give the reader a better insight into the complexities of utilizing
human resources in a productive and e๎cient manner in a healthcare setting.
Contents
Introduction ...............................................................................................................................85
Sta๎ng De๎ned ........................................................................................................................ 86
Scheduling De๎ned ................................................................................................................... 86
Types of Sta๎ng ........................................................................................................................ 86
Skill Mix ................................................................................................................................... 86
Scheduling Patterns ................................................................................................................... 87
Workweek Hour Commitment ................................................................................................. 87
Productivity Impact on Sta๎ng and Scheduling ........................................................................ 88
Regulatory Factors ..................................................................................................................... 88
Self-Scheduling ......................................................................................................................... 89
Acuity Impact on Sta๎ng and Scheduling ................................................................................. 89
Workforce Implications ............................................................................................................. 90
Technology Impact on Sta๎ng and Scheduling ..........................................................................91
Healthcare Reform and Quality Implications Impacting Sta๎ng ................................................ 91
Management Engineerโs Role in Sta๎ng and Scheduling ........................................................... 92
86 โพ Kelly Arnold
Staf๎ng De๎ned
Sta๎ng in a healthcare organization essentially refers to the same thing that it does in any other
industry or organization. Sta๎ refers to the persons that it takes to e๎ectively deliver the service
that is sought and paid for by the consumer (typically referred to as the patient). ๎e complexity,
variability, and life-or-death (in some instances) nature of service provided makes hospital sta๎ng
uniquely challenging and more complex than any other service industry.
Scheduling De๎ned
Scheduling is simply de๎ned as how you assign the sta๎ in any area across service type, hour of the
day, or day of the week. Again, the complexity and variability of patients requiring service or care
makes the task of scheduling more di๎cult than in most other industries. An additional consider-
ation for e๎ective scheduling in a hospital is that service or care is provided in two di๎erent types
of settings. ๎ese settings are inpatient and outpatient areas.
Types of Staf๎ng
Whether sta๎ng is for an inpatient, outpatient, or support department setting, there are two types
of sta๎ng patternsโ๎xed and variable. Generally, ๎xed departments will have the same numbers
of sta๎ regardless of the numbers of patients receiving care in the hospital. Variable departments
will vary sta๎ng up and down as the volume of patients increases or decreases. Support depart-
ments are those that support the areas that provide care to the patients. ๎ere are many support
departments in a typical hospital today. Examples of support departments include ๎nance, envi-
ronmental services, nutritional services, information technology, materials management, building
services, and education services, just to name a few. Most of these areas will have ๎xed sta๎ng,
but there has been movement recently to move some of these areas to variable sta๎ng patterns
whenever possible. Most clinical areas serving inpatients and outpatients are expected to sta๎ on
a variable basis, which rises and falls with patient volume. Many clinical areas that sta๎ on a vari-
able basis will reach a low point of volume that results in sta๎ng minimums. Minimums will be
discussed in detail later in the chapter.
Skill Mix
Hospitals, over the years, have become organizations with a large number of specialized types of
workers or employees. In some hospital settings, there can be 500 or more di๎erent types of employ-
ees with di๎erent skill sets. While this number may seem surprisingly high, most clinical areas
will generally have less than 6 types of direct personnel. Nursing is the largest area in any hospital
in terms of labor, both numbers of sta๎ or full-time equivalents (FTEs) and expense. An FTE is
de๎ned as the total hours worked in a speci๎c period that is considered full-time. In a week, this is
40 hours (8 hours a day for 5 days) and for a year, 2080 hours (40 hours a week for 52 weeks a year).
๎e speci๎c needs for direct care personnel types in nursing areas is captured by the term skill mix.
Skill mix in these areas will generally be divided into two categoriesโprofessional and assistive
personnel. As discussed previously, it is important to schedule enough total personnel to meet the
Staf๎ng and Scheduling โพ 87
care needs of the patient. Skill mix is an additional scheduling consideration, in that the ratio of
professional and assistive personnel must be appropriate for care needs. As an example, it is a poor
use of RN professional time and skills to be performing tasks that an assistive person can perform.
By contrast, too many assistive personnel will result in the higher level care needs of patients being
unmet due to inadequate numbers of professional sta๎. You might wish to give examples of a few
professional or clinical tasks versus that of assistive personnel. Professional sta๎ typically perform
tasks that require critical thinking and assessment skills (calculation of IV medication administra-
tion rates, for example). Assistive sta๎, by contrast, are primarily working with patients to assist in
activities of daily living (ADL). Several examples would be bathing, feeding, and toileting.
Scheduling Patterns
Scheduling patterns are an additional contributing factor to the innate complexity of a healthcare
organization. Some industries (manufacturing, for example) will operate on a 24-hour-per-day
basis for periods of time. Healthcare is unique because hospitals operate 24 hours a day, 365 days
per year; in other words, they never close. Having su๎cient numbers of sta๎ to meet this service/
care requirement is a signi๎cant and ongoing challenge. A second challenge is how to schedule the
sta๎ across the always-open-for-business operation that hospitals have become. Support depart-
ment schedules can fall into normal business hour patterns, Monday-Friday, 8 a.m. to 5 p.m., or
they can also be required to provide service at all times.
๎e more di๎cult areas to establish e๎ective scheduling patterns are primarily clinical areas.
Scheduling in these areas has evolved over the last 15โ20 years to allow employees to work more
than the normal 8 hour days and have longer stretches of time o๎. ๎e most popular scheduling
pattern in many clinical areas is 12-hour shifts. ๎is scheduling pattern allows sta๎ to work 6 days
(not consecutive) and be o๎ 8 days in a two-week period. Outpatient areas are more likely to have
8- and 10-hour shifts than inpatient areas. ๎e dominant 8-hour scheduling pattern has historically
been 3 shifts (7:00 a.m. to 3:30 p.m., 3:00 p.m. to 11:30 p.m., and 11:00 p.m. to 7:30 a.m.) ๎ere
are still signi๎cant numbers of departments in hospitals that utilize these scheduling patterns. ๎is
is true for support departments, as well as those providing care to inpatients and outpatients. As the
workforce in healthcare organizations age, there is an increasing awareness that the 12-hours shifts
are more di๎cult for sta๎ to work. ๎is will be discussed in detail later in this chapter.
Workweek Hour Commitment
Scheduling of available sta๎ is impacted by the type of workweek hours commitment to which
each employee has agreed t. ๎ere are primarily 3 types of commitments into which an employee
could fall. ๎e ๎rst is full-time hours, which would be 40 hours in one week. ๎e second type
would be part-time hours, which vary greatly in a week. In order for an employee to be eligible
for employer-paid bene๎ts (typically health insurance), the minimum part-time hours are 30โ32
hours per week. However, many employees will be in a part-time position of less than 30 hours per
week. ๎e third category of workweek hour commitment is known as PRN. ๎ese positions are
established to have an employee work as needed and have no bene๎ts. ๎ere are increasing numbers
of healthcare workers who elect this option as they do not need bene๎ts and this a๎ords more ๎ex-
ibility of when to work or be o๎. In some clinical areas the numbers of PRN sta๎ can approach
20% of the total contract sta๎ng.
88 โพ Kelly Arnold
Fluctuations in available healthcare workers have occurred over the past several decades. As a
result, contract or agency employees have become an increasing part of the hospitalโs total work-
force. ๎ese types of employees are similar to temp personnel that are seen in other industries. ๎e
majority of these contract employees are clinical, but other areas may also have signi๎cant num-
bers, primarily in ๎nance areas. ๎ere are signi๎cant premiums paid to these employees amount-
ing to an incremental expense of $20โ$25 per hour for registered nurses. Contract employees are
typically hired for a de๎ned period of time ranging for 4โ13 weeks per contract. Should the work-
load decline in an area that is utilizing these employees, they will be still be paid the guaranteed
hours whether or not they work. Many areas that utilize these employees have concerns about the
quality of care delivered by a person who is unfamiliar with the facility, patients, and physicians.
One of the advantages to hiring contract employees on a short-term basis is that they are typically
ready to work on day one and do not require a lengthy orientation as new hires will.
Productivity Impact on Staf๎ng and Scheduling
As margins in healthcare organizations get tighter and payers decrease levels of reimbursement, there
is increasing pressure on sta๎ng and scheduling to be as e๎cient and e๎ective as possible. Managers
of all areas in hospitals understand the need to achieve productivity targets, but some are less pre-
pared to do so than others. Managers of clinical areas are frequently promoted to their position
because they have been a high performer in a previous clinical role. Many of these managers have
little or no previous education or experience dealing with productivity or ๎nance. As a result, they
tend to approach sta๎ng and scheduling from the perspective of a sta๎ member. ๎e end result is
frequent sta๎ng levels and schedules that result in variance from desired productivity and ๎nancial
goals. Organizations attempt to address this knowledge gap by o๎ering periodic classes to new or
experienced managers. While this approach is somewhat helpful, if there is not ongoing reinforce-
ment and support for materials taught, the manager will not retain as much as needed. Managers in
hospitals are no di๎erent than those in other industries in that they have large numbers of priorities
to address daily. ๎ose in hospitals, especially clinical managers, will allow productivity and ๎nance
to be a lower priority as clinical issues are usually viewed as more urgent. A clinical manager is likely
to allow sta๎ng levels to rise above target if concerns about patient care and safety or complaints
from physicians and family are more urgent. It is not uncommon for clinical managers to fall back
on what they know best (patient care) and sort out issues of sta๎ng versus productivity later.
As volumes fall to low levels in clinical areas (typically on weekends and holidays), sta๎ng
decisions are frequently made with consideration of minimum sta๎ng numbers. A good example
of application of minimum sta๎ng would be an inpatient clinical area that has 1 to 3 patients.
While a professional caregiver is capable of meeting the care needs of these patients, the possibility
of rapid changes in a patientโs clinical status dictates the necessity of 2 caregivers. ๎e thinking
behind this sta๎ng model is both ๎nancial (lawsuits for bad outcome) and quality based (patient
death or injury). While these types of sta๎ng models at minimums are not common, they occur
in many clinical areas across hospitals.
Regulatory Factors
Healthcare is one of the most heavily regulated industries by virtue of the heavy in๎uence of
governmental payment sources. ๎ese regulations extend to most areas of hospital operations,
Staf๎ng and Scheduling โพ 89
but are most applicable in matters of sta๎ng and scheduling. ๎e most well-known regulatory
agency is the Joint Commission (JC; formerly known as the Joint Commission on Accreditations
of Hospital Organizations, or JCAHO). While the JC does not set sta๎ levels for hospitals or spe-
ci๎c areas, it does expect the organization to have a well-de๎ned and articulated sta๎ng plan. ๎e
focus of this plan is always about providing consistent and safe care to patients.
Another example of regulatory impact on sta๎ng and scheduling can be found in California.
In 2001, the California Nurse Association was successful in having mandated nurse-to-patient
ratios established as state law. In addition to mandated ratios, the law also addresses required break
times and ratios for other caregivers. ๎e law obviously makes scheduling decisions easier as they
are de๎ned by law. Implementation of these sta๎ng levels are impacted by many of the factors
discussed in this chapter. ๎e end result is that de๎ned sta๎ng levels cannot be achieved. ๎e dif-
๎culty for hospitals is most obvious in increased cost of care of the front end. ๎e impact on total
cost for a patient across a continuum is not well understood. Examples of where this cost could be
lowered would be through reductions of errors, rework, and readmissions. ๎ere has been ongoing
research regarding the implications of mandated ratios to mortality and morbidity in hospitals.
Even 12 years after the establishment of the law, the discussion is still ongoing with arguments for
and against the continuation and expansion of these ratios. It is likely that in an increasingly tight
reimbursement environment, signi๎cant expansion to other states is unlikely.
Self-Scheduling
A relatively recent development in hospitals has been the advent of self-scheduling of employees in
their areas of work. ๎is development is based on the idea of empowering employees, resulting in
happier, satis๎ed, and more productive employees. ๎is scheduling model is most commonly seen
in nursing areas. Self-scheduling can be approached in two di๎erent waysโcommittee and indi-
vidual employee. Many specialized areas like the intensive care unit (ICU), labor and delivery, and
emergency departments will have scheduling committees composed of sta๎-level employees. ๎e
committee members will create the initial schedule for a coming period (usually 4 weeks) for all sta๎
employees. ๎e initial schedule is then reviewed by individual sta๎ and managers for ๎nal approval.
Managers have the ๎nal approval authority and individual sta๎ can make requests for changes for
speci๎c reasons. Areas that allow individual employees to self-schedule will post a blank schedule
asking each employee to ๎ll in their hours for the coming period. Each person must meet their
hours commitment in the period based on their hours commitment (full-time, part-time, or PRN
as discussed earlier). ๎e ๎nal approval of individual hours and total schedule is made by managers.
Acuity Impact on Staf๎ng and Scheduling
In most industries, the complexity of a product built or service delivered determines the amount of
labor that is utilized. ๎is is particularly true in healthcare with the general measure of complexity
of care captured by acuity. A high-level, widely known measure of acuity in healthcare is CMI or
case mix index. ๎is measure is calculated on a facility-speci๎c basis as determined by data sub-
mitted to Centers for Medicare and Medicaid Services (CMS). ๎ere are a number of other acuity
measures that give more speci๎c indication of complexity at an area or department level. Hospital
areas that have speci๎c acuity indicators include lab, nursing, radiology, respiratory therapy, sur-
gery, and emergency departments to name a few.
..................Content has been hidden....................
You can't read the all page of ebook, please click here login for view all page.