Using Technology to Achieve Fair and Manageable Patient Assignments Through Appropriate Staffing and Better Nursing Practice
At Children’s Hospital Los Angeles (CHLA) a high-tech acuity approach led to a staffing solution that uses reliable data to match the right nurse with the right patient, and nurse leaders there say it resulted in more efficient staffing budgets, balanced patient loads and improved patient and nurse satisfaction.
CHLA’s staffing dilemma was clear. In 1999 California was the first state to enact nurse-to-patient ratio laws and later rolled out strict acuity rules. In 2014, to comply with California’s mandated nurse ratios and tighter new acuity guidelines, CHLA implemented a hospital-wide computer-based patient acuity classification system that helps leaders make objective, data-driven staffing decisions for all 13 of their inpatient hospital units across 357 active beds, including 106 pediatric critical care beds.
Past American Association of Critical-Care Nurses (AACN) board member Nancy Blake, PhD, RN, CCRN-K, NEA-BC, FAAN, was CHLA’s nursing director and executive sponsor of the project at the time. She remembers that the previous acuity system was entirely subjective, based on what the nurses saw on the unit, informed by their tasks and how busy they judged themselves to be.
“We were always beating our head against the wall with the finance department to show what staffing we needed,” says Blake, currently a UCLA School of Nursing assistant adjunct professor. It was clear to Blake that this outdated system just wasn’t working. “So, we were on a search for an acuity system that actually measures the acuity of the patient and then matches nurses’ competencies with the acuity,”
CHLA rolled up their sleeves and got to work looking for just the right technology for the new staffing model they envisioned.
Gayle Luker, MSN, RN, CPN, the operations manager for nursing resources at CHLA, was part of a team assembled – from the “C-Suite” to the bedside nurses – and tasked with the search for a way to quantify what was previously subjective.
Luker recalls, the goal was to find “a valid, reliable system that would help them begin to staff to acuity and not just to the straight fixed ratios, which do not account for all of the flexibility that happens within a patient from the time they enter our facility and the time they leave.”
CHLA found what they were looking for in a workforce management technology from Cerner called Clairvia, which uses real-time charting data to help charge nurses balance patient care staff loads appropriately across their teams.
After robust testing and validation, the new system was implemented. Here’s how it works:
- The charge nurse assigns a patient load to bedside nurses in the unit.
- The bedside nurses care for their patients and perform charting.
- The system is based on Nurse Outcome Classification (NOC) and pulls the clinical documentation data and runs it through a mapping catalog.
- The mapping catalog calculates and establishes a patient’s acuity number.
- The patient’s acuity number is tracked in real time.
- The acuity numbers enable the system to calculate for each unit the exact number of nursing hours of care per patient based on needs.
- As the bedside nurse continues care and charting, the changing acuity is monitored.
- The charge nurse views a quick and easy on-screen dashboard to assess patient acuities, which allows the flexibility to reassign staffing appropriately on the fly.
- Quick-view summaries show exactly how many patients fall within each acuity category and calculate the precise number of demand hours of care.
- Daily, weekly or monthly productivity reports provide the finance department an accurate picture of the acuity activity in each unit and precise staffing numbers.
Measures of Success
For CHLA, key indicators of the system’s success are:
- Maintained compliance with state and local nursing ratio laws
- Improved charting practices
- No additional work required of the bedside nurse, the charge nurse or on the unit level
Although the bottom line is important, a true measure of success is that CHLA has the flexibility to reallocate resources accordingly to meet their patients’ needs, aligning appropriate staffing not just with costs but acuities.
The system allows CHLA managers to visualize the actual changes occurring in the unit, with each patient, and the ebb and flow of nursing care that is needed throughout any given shift or day.
“It’s there to see in the productivity and utilization of staff reports,” says Luker. “The success is that we are staffing appropriately to meet the demand needs of the patient and looking at patient safety numbers to see if our outcomes are better because we are better staffed.”
Another triumph emerges in what CHLA patients now experience. Do patients and their families notice something different about their care under this fair and manageable assignment system?
“Patients realize that their nurses are not so busy and can spend more time with them,” Luker tells us. “We’re not overworking our nurses therefore the patient gets to see their nurses. They don’t have that feeling of, ‘I’m constantly pressing on my call button and nobody is coming!’ Because nurses are being assigned appropriately based on the acuity of their patients, they have more time to be with their patients.”
To expand on other measures of success, CHLA participated in a new study to analyze the value of nursing based on outcomes under this new staffing model. The data collection is complete, but the full results of the research have not been released. Still, Luker says that initial data indicate a rise in patient and employee satisfaction. She also suggests that future research may look at statistics on mortality rates, lengths of stay and readmissions.
It took a village to implement CHLA’s acuity-based staffing system. Luker reports that many people from varying levels in the nursing, human resources, finance and IT departments – from officers to managers to the bedside – were involved in the actual implementation and operation of the system. The system also requires a full-time administrator, a role Luker has filled for three years.
Additionally, Luker assigns two or three auditors from each unit to perform random monthly reviews of the system’s acuity ranking precision. Luker also schedules quarterly group audits. Plus, the finance department plays a continual role in monitoring the data reports.
“The acuity number is one piece as it calculates the demand hours of care,” Luker explains. “Then the budget information is an underlying component of the system, generating reports to make sure that we are allocating the right amount of staff to the right units to meet the patients’ demands.”
Appropriate Nurse Staffing
Still, at the core of it, the nurses drive this system’s success.
“Historically, nurses have been overworked and we now have higher volumes of patients, with higher acuities, who come into the hospital much sicker than ever before,” Luker says. “Nurses have always asked for more staff, but now this data gives nurses a voice on how much work load they have and it is heard by the people that make the decisions to increase support for that work load.”
The nurses knew this staffing model would have a significant impact on them, their practice and their patients. Luker acknowledges that nurses came into this with a different mindset for how acuity is measured. But, they quickly shifted their view from task-based acuity to an acuity number calculated on where the patient is on the health continuum and how nurse interventions move them along that path. Plus, nurses were able to see some of the pitfalls of nurse-to-patient ratios.
“It’s not just a ratio number. It’s not just how many heads in the beds at midnight,” Luker says. “Our nurses see the value of calculating, for the whole 24 hours, how many hours of care you need for each patient as their acuity changes.”
Luker adds that the system provides the data nurses needed to take to those departments that “only see things in numbers and helped them realize that we needed more staffing for the nurses.”
CHLA learned many lessons as they replaced their outdated staffing models – lessons that may help other organizations looking to implement acuity-based staffing technology.
“Definitely have the proper departments – human resources, nursing, finance, IT – sitting in on all the discussions from the outset,” Luker advises. “That was instrumental in moving this project forward and our ultimate success.”
Another misstep to avoid, according to Luker, is attempting to customize each unit’s individual scheduling system.
“We wanted nursing involved but we allowed too many builders in the system and we shouldn’t have done that,” Luker recalls. “We have house-wide staffing and the units needed consistent standardization across the organization. That was a difficult one to clean up after the fact.”
CHLA is a free-standing, individual hospital. So, if you’re part of a multi-facility system Luker suggests you make sure that any system considered has the capabilities and functionalities to meet the needs of your organization.
Advice to Nurses
AACN believes that a meaningful shift in the staffing paradigm will only occur if nurse staffing is considered an investment in patient safety and exceptional outcomes, rather than just an operating cost. But, the discussions must start now.
Luker’s advice for nurses who want to begin a dialogue about staffing with hospital leadership (especially those in the finance department) is to highlight the benefits of system’s like the one CHLA employs:
- Objective versus subjective
- Reliable and valid
- Cannot be manipulated
- No double entry
- Data can be trusted
- Improves charting
- No extra work for bedside nurses
Luker also points out that in the first six months after implementing the system, CHLA saw between 90 to 105 percent productivity among all its nurses, an 8.5 percent reduction in overtime and double time hours and 2,000 fewer skilled nursing hours.
“By aligning our staffing to our actual demand, this acuity driven system has helped us hit that triple aim of providing high quality care with the right skill mix of nursing staff and staying within budget,”
Also, only 13 states have ratio laws. Luker thinks nurses in states without mandated ratios may not fully understand the importance of a system like the one in use at CHLA.
“It’s all about patient safety, measuring acuity and translating it to the nursing,” Luker reminds. “That’s a different mindset for nurses currently using task-based systems and fixed numbers.”