Staffing: A Path to Fewer Patient Falls

Jul 03, 2018

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By designing a more thoughtful pattern for its staffing assignments, Emory University Hospital (EUH) overcame unit “geography” obstacles with their innovative care zones model. Shockingly, the model cost nothing to implement and they report it has improved their patient outcomes and nurse workflow.

The Problem

In 2014, EUH’s 24-bed general medicine unit was experiencing high call-light volume and low patient satisfaction. The unit also fielded increased nurse workflow complaints and experienced excessive incremental overtime. More importantly, the unit’s spread-out, U-shaped configuration increased the distance nurses traveled between their patients, which led to a rash of patient falls.

In fact, by the beginning of 2015, they had reported six consecutive quarters of patient fall data in the red zone — about five or six per month — on the unit nursing quality index.

The tipping point came when two patients on opposite corners of the unit each fell within moments of each other. Both patients were assigned to a veteran nurse who hadn’t had a single patient fall in his six-year career.

“That was a perfect illustration of the unit’s geography problem,” recalls unit charge nurse William Bodnar.

The unit’s inefficient layout led to more than patient falls. EUH Specialty Director Greg Kingsley-Mota, MSN, RN, NEA-BC, who was unit director at the time, identified multiple challenges for nurses, patients and staffing budgets, including:

  • High call-light volume
  • Ineffective handoffs
  • Increased incremental overtime
  • Lower patient and family satisfaction
  • Nurse dissatisfaction with workflow and assignments
  • Long distances between assigned patients

EUH, which originally had an inflexible pod system, then implemented the AACN Synergy Model. But with no standardized acuity tool or system, the model alone wasn’t effective, and the pod morphed into subjective assignments that crisscrossed from one end of the unit to another. The staff often felt assignments were unfair. The general consensus: There’s a problem with the acuity system.

“I had nurses in my office in tears because they felt we had not set them up for success because of the way they were assigned,” Kingsley-Mota says. “Individual clinicians felt like they were being targeted or penalized for having more in-depth skills. They were worn out. Meanwhile, others were perceived as getting lighter assignments.”

He realized that too much depended on the clinician’s level of experience and length of time in practice. Varying feedback from multiple nurses on patient acuity was driving how the charge nurses made nurse-patient assignments.

The Solution

The EUH team found parallels in the research literature from similar university health systems, but nothing matched perfectly. Their front-line clinicians needed scheduling flexibility and fluidness to adapt to patient flow. The team envisioned that a new system must stay as equitable as possible throughout a 12-hour shift, account for existing resources and keep a commitment to the AACN Synergy Model of matching nurse competencies with patient needs.

For EUH, it was time to get creative and innovate.

We needed to work smarter and more efficiently and in a timelier manner.


Because of the unit’s layout and staffing model, each nurse covered almost 6 miles per shift traveling from patient to patient. EUH clinical nurse specialist Barbara Hill, MSN, APRN, AGCNS-BC, ACCNS-AG, CCRN, called their path a “chaotic, spaghetti pattern.”

“You can’t go through walls,” Hill says. “So the old system caused a lot of safety-related issues for nurses and patients.”

Although many of the unit’s obstacles stemmed directly from the layout, there was no budget available for physical changes to unit infrastructure. So, the team designed innovative care zones featuring:

  • Attention to unit layout
  • Patients grouped into acuity zones
  • Nurses with skills matched to patients' needs
  • Nurses zoned closer to assigned patients
  • A streamlined path for nurses to their patients
  • A buddy system pairing two nurses per zone
  • Schematic flip chart pocket guides with flexible assignment options
  • Balanced workloads
  • Timely, streamlined handoffs

Kingsley-Mota says, “We didn’t have resources to redesign and get our teams closer to their assignments. Care zones cost absolutely nothing to implement in any of our units.”

Measures of Success

The proof of the care zones’ success became apparent very quickly.

“After about a week of testing, the entire team asked to expand care zones to the whole floor, and that was music to our ears,” Kingsley-Mota recalls.

Care zones launched in March 2015, and their success was solidified within six months:

  • Patient falls decreased by 58 percent
  • Patient call lights dropped by 49 percent
  • Average distance walked per nurse, per shift decreased by 1.5 miles
  • Incremental overtime was reduced by 60 percent

After 18 months of sustained success, EUH continues to replicate the model in other units throughout the health system. The first unit in which they replicated care zones was a newly built 10-bed medical unit, and the data has supported these efforts.

“That unit has met their falls and patient satisfaction targets since the opening of the unit in 2016,” Kingsley-Mota adds.

Nurses and nursing support staff are all actively zoned. Physicians and other interdisciplinary team members collectively use the care zones model to help determine the order in which rounds occur.

True Collaboration

EUH emphasizes shared governance programs. At first, they asked for volunteers to help launch the pilot program.

“We didn’t twist anyone’s arm,” Kingsley-Mota says. “But people stepped up on all shifts to be a part of the test of change.”

Unit practice councils meet and ask for staff input. By collaborating on multiple levels, the team can move “from buy-in to believe-in.”

“In a very short time we pulled together as a team, walked the unit and realized there were things within the infrastructure we couldn’t change,” he says. “We needed to work smarter, timelier and more efficiently to meet the needs of our patients and staff.”

Unit practice council members took the lead and excitement spread. Posted care zones signage prompted questions from other staff and promoted awareness of the new program. Nurses were encouraged to share and communicate their positive experiences, and the program gained further momentum.

“When care zones were implemented it genuinely felt like a grassroots process, because staff was included from the beginning,” Bodnar says.

Inclusion and a more appropriate staffing model improved the nurses’ overall well-being.

Appropriate Nurse Staffing

Care zones group patients by acuity and pair two or more nurses per zone. The shift handoff process is streamlined to one or two nurses on average, significantly decreasing incremental overtime.

“Previously, you might not know where the handoff nurse was. I had to chase nurses around,” Bodnar recalls. “This solved it very naturally, which was immediately apparent in payroll.”

Previous assignments often made shifts feel frenzied, but the care zones structure has turned that situation around.

“One of our more veteran nurses said the chaos and distance traveled between patients made her struggle with the idea of retiring,” Bodnar adds. “But now she’s staying because the new care zones make patient loads more efficient.”

Care zones also allow for flexibility. A nurse might start a shift with three patients and finish with four. But the staff know that staffing is appropriate, and they won’t be asked to flex beyond a certain point.

“We used to feel like the patients ran us,” Bodnar says. “Now, with this structure, it feels like the nurses run the unit.”

Lessons Learned

The nurse leaders at EUH recognized that remodeling their unit-staffing technique would take innovation. They also knew that once they landed on the appropriate staffing model they would have to pilot the program and adapt it along the way.

“We needed the nurses’ support to make a new model work, so we decided to go small with the first care zone,” Kingsley-Mota says.

This approach helped EUH adapt, expand and replicate the system in other units.

The process also opened them up to overcome challenges they weren’t even aware of. It created new accountability.

“It gave us the opportunity to fill gaps in our practice by pairing nurses and helping them improve,” he says. “It’s amazing what you will learn about your staff when you start to position the staffing differently.”

Bodnar recalls an example involving a nurse who was struggling with some areas of her practice, although she had been there for some time.

“These issues didn’t manifest themselves in performance issues, events or poor patient outcomes,” Bodnar recounts. “But we were able to discreetly match this clinician with someone she valued and respected, and partner them in the same care zones to help improve her organizational skills.”

Advice to Nurses

Kingsley-Mota advises nurses to provide feedback, voice concerns and stay involved. Leaders need to learn their team’s strengths and spend time examining the unit’s workflow.

However, for front-line nurses and leaders alike, he advises that this model does not address or fix the issue of being understaffed, including not having enough nurses.

“You must be open to address even the issues that don’t feel comfortable,” Kingsley-Mota says. “Remember, the whole goal is to improve your practice.”