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Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
©2019'Labor'Management'Institute,'Inc.'No'duplication'or'distribution'without'the'written'permission.' 1
Perinatal Budget, Staffing and Scheduling Best Practices
6th Annual Perinatal Leadership ForumNovember 5, 2019
Jennifer Guild, RN, MSN, CNML, CSSC™
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OBJECTIVE
Identify the components of best practices in budgeting, staffing and scheduling that impact patient outcomes and fiscal accountability.
LABOR MANAGEMENT INSTITUTE, INC. © 2019 ALL RIGHTS RESERVED
DISCLOSURE
I have nothing to disclose.
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
©2019'Labor'Management'Institute,'Inc.'No'duplication'or'distribution'without'the'written'permission.' 2
LABOR MANAGEMENT INSTITUTE, INC. © 2019 ALL RIGHTS RESERVED
Healthcare is changing…• Cost
• Hospitals closing
• System consolidations
• Shrinking profit margins (Kacik, 2019)
The reality of our struggle…
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What can we as leaders' control?
Staffing
• 60 - 70% of the operating budget
• Largest percent of staffing budget
• Nursing leaders have the most impact
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Knowing & Owning Your Financial Budget
• Key to your leadership• You can’t lead if you can’t take responsibility for actual to
target variances• You can’t manage what you can’t measure • You can’t change what you can’t document• Units, service lines and departments that fail to “know
their numbers” set themselves up for changes and reductions they are helpless to change
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
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Beyond immediate financial cost…
• Safety of our patients (Liu et al., 2012 & Paulsen, 2018)
• Safety of staff
• Ramifications (Witkoski Stimpfel et al., 2013 & Paulsen, 2018)
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Beyond immediate financial cost…
• Wisconsin OB nurse charged with manslaughter
• Minnesota nurse falls asleep behind the wheel after working overtime
• Ohio nurse killed on her way home after working a 12-hour overtime shift
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Financial Management & Budget Basics
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
©2019'Labor'Management'Institute,'Inc.'No'duplication'or'distribution'without'the'written'permission.' 4
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Managing FinanciallyA Financial & Clinical Partnership
New Era
Nursing
Staff Nurses
Finance
Nurse Leaders
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Unit DescriptionsWhat kind of unit is your unit & why does it matter?
• Basis for defining your budget FTEs, Key Performance Indicators (KPIs) and ratios • Basis for your unit description, team and workload criteria (LMI, 2018)
• Benchmarking to other similar units gives you data to DEFEND your KPIs to tell your story
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Obstetric Units & Workload Measurement
Unit Name Workload Indicator Hours Per Unit of ServiceGynecology Census HPPDAnte-partum Census HPPDPost Partum Census HPPDMother Baby Couplets H/Couplet
Labor & Delivery Deliveries H/DeliveriesLabor, Delivery & Recovery Deliveries H/Deliveries
Labor, Delivery, Recovery & Post Partum Deliveries H/DeliveriesLabor, Delivery, Recovery, Post Partum & Nursery Deliveries H/Deliveries
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
©2019'Labor'Management'Institute,'Inc.'No'duplication'or'distribution'without'the'written'permission.' 5
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Labor Budget LifelineAll components must be linked for success
Budget Position Control Schedule Target Staff Workload
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Workload Units of Service (UOS)
• The foundation for telling your unit’s story
• The foundation for defending your budget
• The foundation for asking for increases
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Blended Census vs. Midnight Census
Nursing AND Finance Experience“We are full all the time, but midnight census doesn’t reflect it”
Average Daily Census (ADC) PLUS consideration forBedded OutpatientsUnit based outpatient treatments Outpatient observation and treatments
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
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Most Frequent Volume (MFV)Definition: Most commonly occurring volume (deliveries) by day of week
• Best guideline for pro-active scheduling & staffing
• Best tool to reduce over scheduling fixed by over-staffing, floating or cancelling
• Best tool to prevent under-scheduling fixed by short staffing, floating or calling-in, extra, OT & agency
L & D Unit Mon Tue Weds Thu Fri Sat Sun Avg.Budget Deliveries 20 20 20 20 20 20 20 20
MFV Deliveries by Day of Week (DOW) 26 24 26 22 16 14 12 20
# of RNs at Budget if Ratio is 1:2 10 10 10 10 10 10 10 10
# of RNs at MFV if Ratio is 1:2 13 12 13 11 8 7 6 10Variance Budget to MFV or
Over/Under-Staffed -3 -2 -3 -1 +2 + 3 +4 + / - 4
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Most Frequent Volume Worksheet (LMI, 2019)
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Budget ComponentsAdjusted annual volumes = primary + secondary workload that counts into the annual volume
LDRPN Statistics #
Annual Deliveries 2,847 (7.8/Day)Observation Hours 3,900
Total Adjusted Hours 3,900Divide by Budget Total Worked Hours/Delivery ÷ 33.43 Hours
Adjusted Deliveries 116.66
Annual Deliveries + Adjusted Deliveries = Total Adjusted Deliveries
2963.66
Divide by 365 = Adjusted Average Daily Deliveries 8.12/Day
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
©2019'Labor'Management'Institute,'Inc.'No'duplication'or'distribution'without'the'written'permission.' 7
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Other Workload Types for Obstetrics1. # of Deliveries
2. # of Couplets
3. # of Ante-partum patients
4. # of Surgical cases and Hrs. per surgical case
5. # of RN 1 to 1 events and RN hrs. per 1 to 1 event
6. # of OB triage patients and Hrs. per OB triage patient
7. # of Observation/holding patients and Hrs. per observation or holding patient
8. # of Visits and Hrs. per visit
9. # of Follow-up discharge phone calls and Follow-up discharge phone call hrs.
***Follow-up phone calls improve patient satisfaction 30 to 40% & decrease readmissions!
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Obstetrics (LDRPN) Case Study: HPPD vs. HPDelivery
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Sharing Tools For Your Tool Chest
Budget, Policies &Position Control Standards
Workload / Units of Service (UOS)
Scheduling & Staffing
Management ReportingBenchmarking
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
©2019'Labor'Management'Institute,'Inc.'No'duplication'or'distribution'without'the'written'permission.' 8
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What is the Budget?Annual plan that establishes revenue & expense relationships• Specifies the workload type demand• Identifies deficit demand • Sets the foundation for the resource management plan
Budget assumptions• Flexible or variable budgeting is the foundation of census driven schedule• Expenses and revenue will remain relative as agreed• Volume is projected for each schedule & staffing response adjusted• Worked hours are determined for each workload unit of service (UOS)
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Standard Financial Terms
Direct Hours Per Unit of Service (H/UOS): A standard measure that quantifies the direct care worked hours available to each patient by direct caregivers.
Example: Post Partum UnitCalculating Direct H/UOS (HPPD):Census: 20 Post Partum Patients
7 direct staff (6 RNs- includes charge & 1 NA) X 3 shifts = 21 direct staff per day
21 staff X 8 hrs. per shift = 168 worked hrs. ÷ 20 patients = 8.4 Direct Care HPPD
RN to Pt. Ratio: 1 to 3.3NA to Pt. Ratio: 1 to 20
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Standard Financial Terms
Indirect Hours Per Unit Of Service (H/UOS): a standard measure that quantifies the indirect care worked hours supporting the direct caregivers.
Total Worked Hours Per Unit Of Service (H/UOS): a standard measure that quantifies all (direct & indirect) worked hours in a unit or department.
Example: Post Partum UnitCalculating Total Worked H/UOS (HPPD):Census: 20 Post Partum patients
7 direct staff (6 RNs & 1 NA)
X 3 shifts = 21 direct staff
2 indirect staff (1 Mgr. & 1 Clerk) x 1 shift = 2 indirect staff
23 staff X 8 hrs. per shift = 184 worked hrs.÷ 20 patients = 9.2 Total Worked HPPD
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
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BudgetCore vs. Supplemental Staffing
• Developed with a staffing pattern as the base
• Division of direct, worked and paid FTEs and hours
• Indirect caregivers (aka: fixed)
Direct Indirect
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BudgetCore vs. Supplemental StaffingCORE• Budget FT & PT FTEs to cover the budget or target workload each shift each day
each schedule• Includes range of staffing elasticity for the budget key skill mix % and ratio
Supplemental • Budget FTEs to cover replacement of planned, unplanned absence, education,
meeting and orientation • SOURCES: Unit based PRN, Floating, Resource Pool, outside Agency and
Travelers
Direct Indirect
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Laying the Financial Foundation
• Consider the model of care delivery impacting the distribution of care hours• Core direct staff• Core indirect staff• Unit description and scope of service considerations• Reconcile the Position Control list to the unit's core schedule• Budget sitter hours and FTEs• Overtime• Outsourced supplemental staffing
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
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Calculating FTE Budget Using Target Hours/UOS
Example Unit: Labor/Delivery
Direct (Variable) FTE Based on the Target Hours/UOS (Hours/Delivery)
Indirect (Fixed) FTE Based on the Target Hours/UOS
Projected)Annual)Volume)x) Target)Total)Direct)Labor)Hours)÷
FTE)Definition)= Annual)Direct)FTEs)
9125%Deliveries%X 12.36%Hours/Delivery%%÷ 2080%= 54.22%Direct%FTEs
Projected)Annual)Volume)x) Target)Indirect)Labor)Hours)÷ FTE)Definition)= Annual)Direct)FTEs)
9125%Deliveries%X 2.06%Hours/Delivery%%÷ 2080%= 9.03%Indirect%FTEs
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Calculating Hours/UOS Using FTE RequirementsRNs• 25 Deliveries/Day x 9.78 Hours/Delivery = 244.5 RN Hours/Day
• 244.5 RN Hours ÷ 12 Hour Shifts = 20.37 RN Shifts/Day • 244.5 RN Hours/Day x 365 Days/Year = 89,242.5 Hours/Year• 89,242.5 Hours/Year ÷ 2080 Hours/FTE = 42.90 RN FTEs
PCTs• 25 Deliveries/Day x 2.58 Hours/Delivery = 64.5 PCT Hours/Day
• 64.5 PCT Hours ÷ 12 Hour Shifts = 5.37 PCT Shifts/Day • 64.5 PCT Hours/Day x 365 Days/Year = 23,542.5 Hours/Year
• 23,542.5 Hours/Year ÷ 2080 Hours/FTE = 11.31 PCT FTEs
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Position Control
• Allows leadership to monitor all filled and vacant positions
• Identifies all budgeted positions
• Identifies all new or non-budgeted positions
• Prescription to the labor budget
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
©2019'Labor'Management'Institute,'Inc.'No'duplication'or'distribution'without'the'written'permission.' 11
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Position Control PurposeAssists leadership to determine:
• FTE/Shift needed to cover the department appropriately (Suby, 2010)
• Unbudgeted labor requests• Departmental vacancy rates• Departmental turnover rates• Predict additional resources required when volume increases• Labor plan to deliver organizational outcomes
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Advantages of Position Control
• Consistency • Control and management of budget• Diminished legal risk• Reports and analytics for workforce planning• Reduction of risk of missing key positions • Reporting of the positions and vacancies in the organization• Ensures discipline surrounding positions (Lockton, 2015)
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Labor Productivity
• Measure of how efficiently your labor force is utilized• Skill mix, staffing patterns and workload scheduling• Timely and accurate information allows monitoring, maintaining and
adjusting labor resources to achieve optimal efficiency
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
©2019'Labor'Management'Institute,'Inc.'No'duplication'or'distribution'without'the'written'permission.' 12
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Creating Position Control
• Define schedule requirements
• Define positions Full-Time (FT) & Part-Time (PT) for weekend coverage
• Budget core FTEs by skill mix
• Budget Education, Meeting, Orientation (EMO) & Non-Productive (NP) FTEs
• Combine core + supplemental (EMO & NP) FTEs to plan required on-call staff, resource pool FTEs or additional unit staff if you are hiring into the FTEs (no more than 50%)
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Full-time & Part-time Ratios
Why does it matter?
• Resource for employee shift exchanges or trades
• Resource for workload fluctuation that avoids overtime
• Source to cover unit-based budgeted deficit demands
• Source to cover service-line budget deficit demands
• Determines total positions for position control
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Managing Position Control
• Determine the rules
• Maintenance
• Develop Reports
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
©2019'Labor'Management'Institute,'Inc.'No'duplication'or'distribution'without'the'written'permission.' 13
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Best in Class Position Controls
INCLUDE:
• Budget information • Staff data • Staffing plans built on budget• Workload scheduling• Vacant positions
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Position Control Example BUDGET YEAR: 2019 FTE DEFINITION: 2080
DAYS/YEAR: 365 DEPARTMENT: MOTHER BABY
COST CENTER: 6121 CAPACITY: 30
WORKLOAD TYPE: DELIVERIES BUDGETED AVG DAILY UNIT OF SERVICE: 24
E m p lID
N am e P o sitio n D esc
D irect o r In d irect
P o sitio n S h ift
B u d g etP o sitio n F T E
H ired F T E
B u d g et P o sitio n S tatu s
Jo b C lass
Jo b D esc
D ate H ired
S en io r D ate
A d jH ireD ate
L O A T yp e
L O A S tart D ate
L O A E n d D ate
O rien t C o m m en ts
8659 B enn ing ,D iana
N urse M anager
Ind irec t D ays 1 .0 1 .0 F T M G R N R SM G R
2/15 /14 2 /15 /14
7167 Johnson , A m elia
S ta ff N urse
D irec t D ays 0 .9 0 .9 F T R N S T S ta ff N urse
01 /01 /08 04 /10 /05 04 /10 /05
6571 C lark ,C assandra
S ta ff N urse
D irec t N igh ts 0 .75 0 .75 F T R N S T S ta ff N urse
6 /1 /06 C ont 12 /08 /19
4041 M orrison ,Jane lle
S ta ff N urse
D irec t D ays 0 .6 0 .6 P T R N S T S ta ff N urse
11 /30 /19 11 /30 /19
V A C A N T P C T D irec t N igh ts 0 .9 V acant 10 /08 /19
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Best In Class PC’s Capture
Departmental• Vacancy rates• Turnover rates (NSI, 2019)
• Full-time vs. Part-time percent• Operational vacancy• Totals identifying hired vs. budgeted FTEs by skill mix and
hired shift • Comparison of budgeted workload to actual workload
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
©2019'Labor'Management'Institute,'Inc.'No'duplication'or'distribution'without'the'written'permission.' 14
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Scheduling
• Short range plan based on the budget• Defines deliverable clinical resource• Manager is accountable for schedule
Right PersonRight&PlaceRight TimeRight SkillsRight&Cost
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Scheduling Principles: Weekends
• Every other weekend off policy means 1/2 of staff will be unavailable every weekend
• Every third weekend off policy means 2/3 of staff will be unavailable every weekend
• Weekend needs will determine total number of staff required on unit
• Weekend needs will determine FT & PT mix
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Scheduling Principles: Scheduling Order
Permanent Shifts• FT employees• PT employees
Rotating Shifts • FT employees • PT employees• Per diem or casual employees
Scheduling FT around PT employees incentivizes the PT at the expense of the FT employees
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
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Making the Most of Your ResourcesFlexible or Alternative Shifts are Helpful When
• The workload is > 8-hrs.
• The workload is < 8-hrs.
• The workload is variable by day of week
• Call-back hours occur within 2-hrs. of the end of the shift
• It meets the needs of the unit, service-line or department and does not cause unplanned OT or disruption in unit coverage
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Scheduling to Unit Workload CapacityWhen it’s not the Most Frequent Volume (MFV)
NOT good practice!• Increases use of non-productive (backfill) hours taking you over budget
• Increases worked hours on the unit if staffing overages not caught or if staff refuse to float or go home
• Increases risk for greater turnover because of the frequent staffing changes due to shift cancellations, floating out of the home unit or using benefit time to cover cancellations
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Constructing the Schedule1. Begin with staffing and scheduling template2. Schedule policy rules3. Update work agreements & skill mix changes4. Update block, core patterns5. Assign weekends to work & be off in order of6. Schedule preceptors with orientee’s7. Enter FMLA 8. Enter approved requests for time off based on budget 9. Schedule FT, then PT rotating staff in order of DN, DE10. Assign charge nurses and other unique skills to all shifts
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
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Constructing the Schedule
11. Check your work12. Shift audit to requirements13. If you’re scheduled shifts are < your requirements what’s your strategy to fix it in
order of least to most expensive?14. If scheduled shifts are > your requirements what’s your strategy to fix it in order of
most to least expensive15. Best Practice Schedule Audit; publish with schedule16. Audit past schedule & publish
17. Prepare for next schedule
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Be Operationally Clear & Transparent
• The schedule represents the department plan to deliver safe and effective care
• Your priority is to produce a safe schedule, only so many staff can be off at one time and still accomplish this
• You can only grant the time away budgeted
• If staff have benefit time available, they may find their own replacement, not in overtime
• Monitor and hold staff accountable for excessive absenteeism (CDC, 2018)
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OvertimeWhy do we care?Direct impact
• Increases operational costs • Reduces available funds for hiring more staff, equipment, new or expanded
programs etc.
Indirect impact• Increases risk of adverse outcomes• Increases employee job dissatisfaction, burn out, turnover• Increases employee fatigue contributing to “failure to rescue”, on-the-job
employee injuries and unplanned absences (call-ins)
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
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Guidelines for Overtime Usage (LMI, 2019)
OT% Recommended+Findings+&+Implications<+5%
Reasonable)response)to)fluctuating)workload)volumes)or)deficit)demands
5+to+7.9% Sign+of+financial+bleeding+Consider)schedule)imbalances)(e.g.,)too)many)on)the)day)shift)and)inadequate)coverage)on)the)off)shifts),)over?authorizing)employee)requests)such)as)PTO)requests)causing)staffing)shortages
8%++ Sign+of+financial+hemorrhaging+Consider)vacancies,)ADT)activity)within)the)unit)that)creates)workload)intensity)and)workload)fluctuations,)mismatched)8)&)12?hour)shift)combinations)in)addition)to)the)previous)suggestions
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How Overtime Adds Up
1-hr. per shiftX 3 shifts/day 3 hours X 365 days/year (38,325 per year)X $54.00/hour (OT rate) (US News, 2018)
$59,130 + Per Year
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Hospital Unit PlanA Variable Staffing Plan exists which does not exceed the budget
Flex when census ↑ or ↓
• A plan exists for managing low census/census fluctuation • The impact of incentives, premium pay, bonuses is demonstrated• A clear plan exists for managing overtime• Advanced planning occurs for seven to ten days • The charge role is clearly defined- responsible for staffing that follows the financial
pathway of the manager and organization• When variations from the plan occurs the leader follows up to understand and
coach if appropriate
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
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Using KPI for Staffing DecisionsBudget Data & Summary in Hours/Delivery by Day & Shift: Labor/Delivery/Recovery
Budget Data Per day 700 1500 2300RN hours / UOS (Hours/Delivery) 13.11 4.37 4.37 4.37Direct hours / UOS 16.66 5.55 5.55 5.55Indirect hours / UOS 2.72 1.08 1.08 0.54Total worked hours / UOS 18.88 6.63 6.63 6.09Total paid hours / UOS 21.14 7.38 7.38 6.84
Budget workload by day and shift BUOS / day 700 1500 2300Average daily deliveries (BUOS): 16 16 16 16
1. Assess workload & actual staff every 4-hours2. Multiply actual UOS X the selected KPI for day = delivery hrs./day ÷ 8 or = # staff
needed in 8 or 12-hour shifts3. Subtract actual staff from calculated staff = variance in staff to increase or decrease
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Monitoring for Success
• Review of labor and productivity targets by the manager daily is the most optimal method to allow for daily trending of volume and labor hours
• Daily monitoring encourages the department to respond to changes in the volume/work units on a real time basis to ensure appropriate use of staff
• Educate and coach charge nurses to be part of the solution
• Monitoring by managers & directors each pay period allows unit managers to course-correct for the next pay period with measurable results in the fiscal or monthly reports
“What gets measured, gets done.”
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Our Goal….
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
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Thank You!
If you have any questions or would like to chat, please stop by BOOTH 47
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References CDC (2015). Worker Illness And Injury Costs U.S. Employers $225.8 Billion Annually. Retrieved from https://www.cdcfoundation.org/pr/2015/worker-illness-and-injury-costs-us-employers-225-billion-annually
Kacik, A. (2019). Operating margins stabilize, but not-for-profit hospitals still vulnerable. Retrieved from https://www.modernhealthcare.com/providers/operating-margins-stabilize-not-profit-hospitals-still-vulnerable
Labor Management Institute, Inc. (2018). PSS Annual Survey of Hours Report (28th ed.). Bloomington, MN.
Labor Management Institute, Inc. (2019) Clinical Staffing and Scheduling Certification. Bloomington, MN.
Liu, L., Lee, S., Chia, P., Chi, S., & Yin, Y. (2012). Exploring the Association Between Nurse Workload and Nurse-Sensitive Patient Safety Outcome Indicators. The Journal of Nursing Research, 20, 300-308.
Lockton, M. (2015). Position Control 101: It helps manage an organization’s structure. Retrieved from https://www.hr.com/en/topleaders/all_articles/position-control-101-it-helps-manage-an-organizati_i8x5ayua.html
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References cont.
Nursing Solutions Inc. (2019). 2019 National Healthcare Retention and RN Staffing Report. Retrieved from http://www.nsinursingsolutions.com/Files/assets/library/retention-institute/2019%20National%20 Health%20Care%20Retention%20Report.pdf
Paulsen, R. (2018.) Taking nurse staffing research to the unit level. Nursing Management, 7, 42-48.
Suby, C. (2010). Controlling Overtime Through Position Control. Healthcare Financial Management Association Healthcare Cost Containment, 4.
US News (2018). How Much Does a Registered Nurse Make? Retrieved from https://money.usnews.com/careers/best-jobs/registered-nurse
Witkoski Stimpfel, A., Lake, E., Barton, S., Chavanu Gorman, K., & Aiken, L. (2013). How Differing Shift Lengths Relate to Quality Outcomes in Pediatrics. Journal of Nursing Administration. 43, 95-100.
Position'Control'Management,'Automation'and'Payroll'Leakage'Presented'by'Labor'Management'Institute'at'the'Minneapolis'HR'Summit'on'June'12,'2019
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