Continually looking to improve quality of patient care, Sharp Memorial Hospital and its 7 West progressive care unit (PCU) participated in AACN’s Clinical Scene Investigator (CSI) Academy to develop an innovative healthcare initiative — a team staffing model that improved patient and nurse safety and satisfaction.
The Problem
In 2015, Sharp’s 32-bed, medical cardiopulmonary PCU team identified several opportunities for improvement: staff and patient satisfaction, patient safety related to falls, hospital-acquired infections and staff sprain and strain injuries. So, Sharp’s PCU team of nurses, who would eventually participate in the AACN CSI Academy program, thoroughly examined their existing nurse staffing model.
Boni Bogart, BSN, RN, PCCN, charge nurse and clinical lead for the high-acuity PCU, recounts the primary patient care model was driven by a staffing plan that allocated only one or two healthcare assistants per shift. At the time, a sole nursing aide assigned to a shift could serve up to 32 patients and assist up to 13 nurses. As a result many times, a nurse was unable to use a nursing assistant’s help during their shift. The inability to delegate reduced the nurses’ time for the critical thinking and planning that is ideal for delivering excellent patient care.
According to Rendell Beltran, BSN, RN, a PCU nurse, the staffing model wasn’t using resources to their fullest, and that created barriers to optimal patient care and staff satisfaction.
“Nursing assistants were spread thin among nurses and patients, leading to low responsiveness to call lights and increased wait times,” Beltran explains.
Unit nurse Teresa Sao, ADN, RN, recalls that staff nurses identified the need for changes in their work environment.
“A common concern among both nurses and nursing assistants was there wasn’t enough staff to handle their workflow,” Sao adds.
Sao says this led to “inconsistent teamwork, trouble with time management and task-oriented care.”
To help address these issues the team participated in AACN CSI Academy starting in January 2016 and kicked off their new staffing project in June 2016.
The Solution
Four staff nurses from Sharp’s PCU — Beltran, Bogart, Sao and Julie Tarbell, BSN, RN — were selected to participate in CSI Academy, a hospital-based nurse leadership and innovation training program.
The AACN CSI Academy program focuses on empowering bedside nurses as leaders of change projects to improve clinical as well as fiscal outcomes. Participants bring innovative ideas to the table, and CSI Academy leaders provide guidance, knowledge and skills on how to craft, implement and sustain the project. This support and consultation helps nurses lead their peers in creating and implementing unit-based change that can be easily scaled.
Once they began participation in the CSI program, the Sharp team identified opportunities to optimize their patient- and family-centered care delivery model, plus staffing and resource allocation concerns as the foundation of their project. The objective was to include staff nurses and leadership to create a plan for enhancing each process in the unit’s patient care delivery system.
The team also recognized that an improvement to the unit’s patient care model could lead to other positive outcomes. They established a series of goals, which included decreasing patient falls, reducing staff injuries, increasing patient perception of staff responsiveness on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and improving staff perception of adequate staffing.
The plan was to shift PCU staffing to a more teamwork-based nursing method, and it started with redesigning the nursing matrix.
The new model changed the staffing composition by adding more nursing assistants to support the nurses, teaming one nurse with at least one other nurse and one aide. The adjusted balance of staff freed the nurses for direct patient care. Sharp also features a robust program that onboards new nurse graduates and requires thoughtfulness when staffing.
“Our new matrix takes many factors into consideration,” says Sharp PCU nursing manager Christine Prewitt, MSN, RN, “such as acuity, skill mix of patients, admits, discharges and number of novice nurses.”
Measures of Success
The previous model staffed 13 nurses and two nursing assistants on the day shift and 12 nurses with two assistants on the night shift. The new staffing matrix teams 11 nurses and four assistants on the day shift, and 10 nurses plus three assistants on the night shift. Further, the new staffing matrix always takes patient acuity into account. Now, the staffing is more balanced, capping each assistant’s patients at 12 per shift. Each team also includes a charge nurse and a relief nurse.
Since fully implementing the new staffing approach in June 2016, Sharp’s CSI Academy nursing team reports these results:
- Thirty percent fewer patient falls
- Zero workers’ compensation claims for strains or sprains in fiscal year 2017
- Zero catheter-associated urinary tract infections for the last 18 months
- Zero central line-associated bloodstream infections for the last 20 months
- Hospital-acquired pressure ulcers decreased from six to two
- HCAHPS scores increased from 40th percentile to 70th percentile for “nurses always communicated well” item
- Fourteen percent improvement in staff perception of staffing loads
- National mean exceeded on the NDNQI for staffing and resource adequacy, job enjoyment and retention the year after being below the mean in each category
- No-rest/no-meal break occurrences decreased more than 40 percent
- Budget to actual dollar variance shifted from “unfavorable,” or money lost, to “favorable,” money gained — resulting in significant cost savings
The Sharp team indicates the new staffing matrix could potentially save the hospital more than $1 million a year in costs associated with payroll, patient falls with injury, and staff injuries.
True Collaboration
“Teamwork Leads to Dreamwork” is the title of Sharp PCU’s staffing initiative. And it took teamwork to implement the new staffing matrix.
During an annual budget planning meeting, unit staff nurses voiced concerns to their nurse leaders about inefficient workflows and inconsistent teamwork with support staff. The Sharp PCU nurse team collaborated to create a staff survey and collect responses. Survey results indicated inefficient unit staffing patterns and an inappropriate skill mix.
“Getting the front-line nurses’ input and keeping this as a project driven by nurses was important for success,” Bogart says.
Badge holders, pens, candy, water bottles and scrub tops branded with the “Teamwork Leads to Dreamwork” logo also help build and maintain staff awareness and interest in the new staffing model.
Appropriate Nurse Staffing
The team assessed their exact staffing challenges by conducting a comprehensive workflow analysis for each unit role and by detailing a breakdown of all responsibilities for an entire shift. They also defined the ideal focus of each role.
According to Tarbell, this exhaustive accounting of the workflow led to the team matrix model. In turn, the model took less-critical duties out of the nurses’ hands, delegated them to assistants and opened up more time for direct patient care.
“By working as a team with another nurse and an aide, our nurses had more time to safely and effectively take care of their patients,” Tarbell says.
To ramp up nurses for the new staffing model, the unit’s CSI team held two-hour mandatory sessions that featured the organization’s professional practice model, nurses’ scope of practice, patient care scenarios, role play and group exercises.
The sessions clarified roles and mapped out how the new collaborative team approach works.
“Under the new care delivery model, the plan of care focuses on patient engagement, cultivates quality and optimizes wellness,” Sao says.
Lessons Learned
Change was met with slight resistance, especially since the ratio of patients to nurses increased slightly under the new model.
“Changing a culture is not easy,” Tarbell says. “We needed to have staff buy-in, engagement and get them excited and to feel empowered.”
Two things the nurse leaders didn’t anticipate were the need to teach nurses how to effectively delegate tasks to the aides that did not require RN licensure, and the need to include float and travel staff in the mandatory two-hour sessions from the outset.
“When you’re trying to perform your professional practice and spend more time on education and proper discharge, holding onto tasks you can delegate will slow you down,” Tarbell says. “We had to teach the nurses to delegate properly.”
To achieve project success, CSI Academy leaders promoted the importance of connecting with all key contributors, and the Sharp team crafted the plan to educate unit nurses, float and travel staff, inform nursing assistants and teach the RNs to delegate.
Now, healthcare assistants have been educated and empowered to perform new duties. Another positive result is float nurses who affirmed the program and asked to work on this unit.
Advice to Nurses
For nurse leaders who want to institute and sustain an appropriate staffing matrix like the one created by the Sharp PCU, the team recommends the following:
- Survey staff on their feelings about the workflow before and after implementing a new staffing model
- Create standardized workflows
- Maintain open communication among all unit staff members
- Openly receive staff feedback when proposing change
- Perform routine rounding and auditing
- Communicate project updates
- Recruit champions to promote the program
- Reward and recognize participation and performance
- Celebrate monthly goal achievements
Staffing must ensure the effective match between patient needs and nurse competencies. Evidence indicates that appropriate staffing is linked to healthier work environments, which can result in nurses providing a higher proportion of care hours (compared to routine tasks) and better patient outcomes.
“We continue to see gains with our nurses and nursing assistants being enthusiastic about their work and their own well-being, giving them a sense of self-worth,” Bogart says.
Now, the CSI nurses report that Sharp will consider expanding this model to their other PCUs.
“Not only does the AACN CSI Academy prepare front-line nurses with the needed skills to implement innovative change,” says Devin Bowers, AACN’s practice excellence director, “we go beyond that to facilitate the learning that helps these CSI nurse innovators take their project and spread its success throughout their hospital.”