Published by Hiro Kawashima on May 18, 2019
This week, our guest is Christopher Looby, an experienced healthcare executive, a faculty member at the American College of Healthcare Executives, and professor at various colleges. He started his career working in hospitals.
HIRO: Let’s start with your experience overseeing operations in hospitals. How do you plan for unit coverage today?
CHRIS: The way that I plan for unit coverage in the acute care environment that I managed for many years and the type of patients we were going to see, and we thought about the typical work that was involved with that patient load, and then we did that in relation to how much time so that we could calculate the hours of care that would be needed for the volume we expected to see.
HIRO: What are some challenges you’ve seen or heard of when it comes to optimizing unit coverage?
CHRIS: Well the challenges are going to be, first of all, the variability in volume that is experienced. There are some units that are very stable but other units have a wide variability of volume that is different day to day and there is not a pattern per se that people can readily perceive. Often those patterns if they are there, are not perceived because they are subtle more than humans can readily detect. Part of that variability is the type of patients that will be seen and the amount of care that the volume of patients will need.
HIRO: What benefits do you see when optimizing unit coverage?
CHRIS: I think that the key thing when organizations are thinking about optimizing coverage is getting the right people, in the right amount, in the right place at the right time. The right people in the right amount, if you have very severe patients, severely sick or acutely ill and sick, they require more time, so do you have enough people to handle the workload and how do we balance that out across the people who are caring for the patients so that no one feels overloaded. If I’m a nurse and I have four patients, do I have the four sickest patients or do I have least sick patients or a combination of sick and not so sick people, so that I can make the rounds, get to everybody, and provide the care they need.
HIRO: When you align the right nurse with the right patient at the right time, right place, what benefits do you see when it comes to throughput and ALOS?
CHRIS: The key thing is that the team can apply the care that is needed. They can make sure that the medication is given, the appropriate checks are made, and particular things like bed turns and pain management, these key factors that can drive length of stay or cause individuals to remain in the hospital longer than they might otherwise. If the nursing team can’t get back to the patient frequently enough, they might miss picking up some signs of increasing pain on the part of an individual, or difficulty emulating, or some other things that can cause a length of the stay increase. We really want to make sure that the nursing team can see all of the patients under their care with enough frequency and on an appropriate basis to monitor, manage, and intervene when appropriate.
HIRO: Today, most hospitals are still utilizing antiquated systems when it comes to determining what type of staff and how many staff members are needed for coverage.
CHRIS: That’s pretty much the case. In fact, what’s really interesting, even in one of the continuing education nursing documents that is currently in use (published last year, this is a training manual), it says that the nursing manager must make an educated guess as to how many full time equivalents are needed to cover departmental needs a majority of the time. In another spot, they are still talking about the use of the midnight census as the key indicator of how they are going to staff the unit. And it says that every nurse leader struggles with the midnight census being the measurement of work because it doesn’t reflect the activity that goes on throughout the day time shift of admissions, discharges, transfers. So they are using a finance driven and reimbursement driven metric, the midnight census, to drive their staffing model when the day time census double that of the midnight census or the workload might be dramatically higher because of admissions and discharges. This is in a training manual - one of the continuing education pieces that nurses can access online and receive continuing education credits by reading how to do this in such an antiquated fashion. It’s quite surprising!
HIRO: How do you think forecasting can help nurses better optimize unit coverage?
CHRIS: Forecasting can take all of the guess work out because we are thinking about at midnight we are going to forecast what the midnight unit volumes are going to be and maybe even acuity if that is available for forecasting, but we can also have a separate differential forecast for six in the morning, at noon, and at three in the afternoon. In fact, depending on the departments and their variation of how they work and variability of volume, say the emergency department, that can be predicted on an hourly basis and fluctuate. As that fluctuates you can determine how you are going to staff, and since you can’t change staffing hourly, it does help the nursing team prepare for what’s going to happen an hour or two from now so that they can better pace themselves with the workload they are dealing with right now if they know workload is going to go up in a couple of hours or if it is likely to go down in a couple of hours due to what the predicted forecast might indicate what the volumes are going to be.
HIRO: How do you suggest that some of these institutions adopt forecasting or even nurses adopt forecasting? Obviously change management in healthcare is a very difficult process. What have you seen and what would your advice be to nurses out there?
CHRIS: That is a great question. Having talked with a chief nursing officer when I was giving a seminar on the use of analytics to drive better success in an organization, this particular chief nursing officer said that what they do in their organization is as a nurse signs on to their computer or workstation in their unit, the first screen that they see, that they have to acknowledge that they taken a look at it, is a screen that shows them what the upcoming volume is expected over the next four to six hours on the unit. And then separate from that, what is the outlook for the next shift. What she said she’s found is that nurses now pay attention to what their workload is so that they don’t, for a lack of a better term, leave work or dump it on the next shift. They make sure that, differently than what she’s seen before (this is a chief nursing officer of long duration, very experienced individual), she has seen a definite behavior change in the nurses on each shift making sure that they have all of their work done because the next shift knows that what they’re dealing with in the evening shift, the potential for their workload was seen by the earlier shift. So people are paying more attention to what they leave behind for the next crew.
HIRO: These types of triggers or even nudges are what’s going to drive changes in hospitals.
CHRIS: She said that feedback is quite clear from the floor nurses she’s visited in the units that they are pleased and they are not complaining. They like this availability of information so that they can plan their work better, they feel better that they’ve done a better job, and that they’ve left things in a more orderly and tidy manner for the next shift.Next post: Ep 3 - How to achieve optimal unit coverage with Dr. Harneet Bath