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Demand a staff scheduling system that is easy to use, empowers your staff, and slashes budgets!

Consider the following scenario. A nurse manager of a medical care unit (MCU) in a hospital is preparing a staffing schedule for a six-week period that includes the holidays of Thanksgiving, Christmas, and New Year's Day. Zack, a registered nurse on MCU, wants to be sure he has every Tuesday afternoon and Friday evening off for the next four months so he can attend classes at the local college. Debbie, a nursing assistant on MCU, can only work the day shift on Wednesdays and Thursdays because of childcare issues. Shelly, a licensed practical nurse on MCU, only works part time on the evening shift. Bill, another MCU registered nurse, is complaining that the schedule is not fair and he is going to quit if his frequent requests are not honored. Mary, a unit clerk on MCU, will be on six weeks of maternity leave starting the next scheduling period.

What is staff scheduling and what are the challenges facing managers?

Staff scheduling is a systematic way of planning the necessary or appropriate number and skill mix of nursing staff for patient care functions and related administrative tasks for every hour over the period for which scheduling is done. The numbers and skill mix of staff needed for a specific unit can be derived from two sets of data. The first set comes from required nursing staff hours for the group of patients typically cared for on the unit. This is calculated from standards of hours per patient day needed to care for acuity categories of patients. The second set comes from forecasts on hours needed based on a set of variables including the numbers of admissions, discharges and transfers (ADT); seasonal factors; and any other predictors of patient count and condition.

The above scenario reflects only a very small fraction of what a nursing unit manager needs to take into account for every staff schedule that is created. It can take over 40 hours of the nurse manager's time to manually generate the work schedule for a four-week schedule period and keep it in balance as changes occur (Naidu, Sullivan, Wang, and Yang, 1997). The following items may impose additional burdens in scheduling decisions:

* Staff desire for involvement in schedule creation

* Management desire to reduce staff turnover by providing acceptable staff schedules

* Staff requests for schedule adjustments

* Changes in patient census or acuity

* Union contracts or government rules for mandatory nurse-patient ratios, rest times, or overtime

* Budget considerations to avoid over- or under-staffing

* Skill mix (RN, LPN, Nursing Assistants, etc.), number of staff, and experience level of staff needed to provide safe patient care

* Shift and rotation patterns of hired staff to cover staffing needs for 24 hours per day. Work schedules may involve a variety of shift lengths (e.g. 4, 6, 8, 10, and 12 hours)

* Weekend and night commitments of hired staff

* Hospital and unit policies, principles of fairness, and staff preferences

* History of past and current staff requests, approvals and denials, and accommodating special situations

* Workload--determined principally by bed occupancy and patient acuity, but can also be greatly affected by patient turnover (Winstanley, 2002).

* Daily ADT activity typically experienced by the unit

* Costs of employing multiple staff types at various levels of utilization

Why is nurse/staff scheduling important?

Every nurse needs to plan for work and family time and every patient should be assured that there be skilled, adequate staff to provide safe, competent care. Moreover, keeping employees satisfied and at work is an expensive activity for hospitals as the total cost of replacing a medical-surgical RN costs from $42,000-$50,000, and the cost of replacing a critical-care nurse may be as high as $65,000 (Kemski, 2002; Public Policy Associates, Incorporated, 2004). One of the reasons nurses leave is the dissatisfaction with their work schedule.

In addition to trying to honor the needs and requests of staff members, the nurse manager must control the cost of employing staff, control overtime costs, and reduce dependence on costly agency staffing (Schuerenberg, 2004). The nurse manager uses schedule information to manage daily adjustments due to changing requirements and uses retrospective schedule data for reporting and statistical information. Ineffective scheduling has the potential for costly consequences: under-scheduling from a patient care viewpoint, or over-scheduling from financial standpoint. Meeting and not exceeding the budget for the unit (or gathering the statistics needed to justify increasing the budget for a unit) is a major concern for the nurse manager as well as for hospital executives. In 2000, the healthcare consulting firm CampbellWilson surveyed hospital administrators and identified nurse-staffing issues as the second budgeting issue (American Nurse's Association, 1999).

Another important issue for nurse managers and administrators to address is the Joint Commission on Accreditation of Hospital Organizations (JCAHO) standards for 2002 to assess staffing effectiveness. Hospital compliance with these standards is determined by the consistency of its adherence to its staffing plan (i.e., its staff-to-patients ratios.)

"During onsite evaluations, Joint Commission surveyors specifically examine:

* The rationales for the indicators selected, and the setting of performance targets,

* The data actually gathered.

* The organization's analyses of the data (i.e., what do they think the data mean.)

* The actions taken on the bases of the analyses.

* Evaluation of the effectiveness of the actions taken and periodic reports on this activity to the organization leaders" (Staffing Effectiveness, 2002)

What is the Potential Operational Value of an Automated Nurse/Staff Scheduling System?

Operational value of a scheduling system is the usefulness or significance related to the mandate, role, or mission of an organization. The following list identifies some of the operational values ascribed to an automated nurse scheduling system:

* Provide the right number and mix of staff to care for the number and acuity of the patients.

* Provide appropriate scheduling of personnel based on skill, schedule history, seniority and overtime status.

* Reduce the amount of time required by the nurse manager and central staffing office to generate and manipulate a staff work schedule.

* Save expenditure on overtime and agency fees.

* Provide staff empowerment and enhance staff satisfaction via their active participation in self-scheduling and having input into scheduling decisions.

* Track and forecast overtime costs.

* Provide data required to forecast staffing needs. Nurse Managers need a way to quickly forecast various "what-if" models. Automated tools provide ease of use and modeling predictions (Pilla and Fryling, 2000).

* Use flexible company-defined overtime codes, responses, actions, totals and formulas.

* Use configurable settings to support a wide range of overtime hours.

* Allow any scheduling period with unlimited future scheduling.

* Provide cost and conflict checking for vacations, employee skill sets, seniority, overtime and schedule overlaps.

* Recommend appropriate staff to work available shifts.

* Track dates for past attendance exceptions, current work, and future training.

* Deliver comprehensive reports, schedules and calendars.

* Provide data to assess staffing effectiveness, as needed for JCAHO reporting.

Ease of Use

Ease of use of an automated scheduling system comes from two dimensions. The first is from better scheduling technology that can truly do automated and exact balancing while considering all the rules and preferences, and the online technology that allows easy adjustment of schedules for unplanned events that change the workload. The second is from usability-engineered and cognitively sensitive screen designs, both for managerial inputs for generating the planning schedule and daily adjustment steps, as well as staff input of schedule information, requests, and messaging. (See Table 1 for usability features to consider when selecting an automated scheduling system.)

On a daily basis, adjusting and tracking the constant changes to the planned schedule can impose a heavy manual burden if these functions are not automated. ADT changes and the last minute call-ins must be tracked so that adequate staff is on hand (Tarber, 2002). In addition, other daily decisions must constantly be made--honor or deny staff requests, replace workers with due consideration of skill levels and work patterns, invoke overtime policies (mandated or voluntary), or request services of temporary pool or agency staff. Without electronic connectivity, the activity required to gather needed information and to communicate and implement these decisions can become overwhelming to a manager already burdened with many other responsibilities.

Common Myths about Automated Staff Scheduling Systems

Scheduling technology and usability engineering has advanced so much that ALL of the items below are indeed myths. You CAN demand a scheduling system that makes them myths!

Myth 1: Automated schedule balancing while satisfying all the organizational policies, variations unit-by-unit, and giving staff desirable schedules, is not possible.

Myth 2: As long as a scheduling system gives a rough staffing plan that can be manually adjusted and can produce a myriad of reports, you really cannot expect more from a staff scheduling system.

Myth 3: It is not reasonable to expect a scheduling system to be so easy to use that all the staff and managers can readily participate in the process and feel empowered.

Myth 4: Managed self-service in scheduling is utopian.

Myth 5: There is great value in hundreds of pre-designed reports. (Scheduling system vendors who promote the value of preintegration, printability of dozens of pre-designed reports, or the use of a scheduling system as a general database may not provide the best value. A more desirable feature is a report-writing environment that enables creation of customized reports that can combine data from the scheduling system as well as other interfaced systems such as in human resources (HR) and a time

and attendance system.)

Myth 6: A scheduling system needs to be a pre-interfaced part of a time and attendance system or some other hospital information system. (What is needed is a periodic, infrequent flow of a very limited number of data elements between these systems. From an operational point of view, what really needs to be integrated?

* Interface with a time and attendance system and/or payroll. For management purposes, to identify and reconcile any discrepancies of the actual time worked with what was scheduled is needed. For cost control of operations, a connection to the payroll system from the time and attendance system so that accurate payment can be reached. If the time and attendance system vendor is unable to interface with payroll then the scheduling system vendor needs to do that.

* Interface with the HR system. The HR data needed within the scheduling function may include: name, address, date of birth, skill level, contact phone and pager numbers, email addresses, emergency contact, certifications and special training including dates of license expiration, in-service education completed, annual leave scheduled, taken and accrued, and past attendance discrepancies and behaviors)

The Value and Functionality Conundrum

Many nursing chief executives of patient care organizations may not know what they are entitled to demand from a staff scheduling system. In addition, the vendors in the industry have largely failed to provide scheduling technology that is of true value to organizations and their governing boards. Some vendors have persuaded their clients to believe that as long as the system holds the schedules that have needed many hours of manual adjustment, and have produced reports, that the system doesn't need to automatically produce a schedule that is highly acceptable to both management and staff with only a very low level of manual intervention.

Oftentimes, the schedules generated from these systems are hard to use, and are unacceptable to management while staff satisfaction isn't even attempted. Several scheduling systems that are currently installed in many hospitals are used as databases and report generators. A scheduling system must do a lot more than that! (See Table 2 for a list of key criteria that should be considered for selecting an automated nurse scheduling system.)

Determine what functionality staff, nursing managers and hospital executives need from a staff scheduling system. Then DEMAND from the system vendor this functionality that is easy to use, empowers your staff, and improves the bottom line.

References:

American Nurse's Association. (1999). Principles for nurse staffing. Retrieved March 5, 2005, from http://www.nursingworld.org/readroom/stffprnc.htm

Kemski, A. (December, 2002). Market forces, cost assumptions, and nurse supply: Considerations in determining appropriate nurse to patient ratios in general acute care hospitals, R-37-01. SEIU Nurse Alliance. December 2002. Retrieved March 5, 2005, from http://www.dpeaflcio.org/policy/factsheets/fs_2004_staffratio.htm (Note: When retrieved on December 27, 2005, this URL points to a fact sheet from the Department of Professional Employees, AFLCIO, Washington D.C. with this article title: The costs and benefits of safe staffing ratios.)

Naidu, K. D., Sullivan, K.M., Wang, P.P., & Yang, Y. (1997). Managing personnel through staff scheduling algorithms. Retrieved March 1, 2005, from http://www.ee.duke.edu/~yy/publications/scheduling.pdf

Pilla, L. and Fryling, K. (Eds.). (2000). Hospital administrators challenged by nurse staffing, survey finds. Retrieved on March 5, 2005, from: http://www.nurses.com/content/news/article.asp? docid={3445836f-5e62-11d4-8c55-009027de0829}

Public Policy Associates, Incorporated. (2004, June). The business case for reducing patient-to-nursing staff ratios and eliminating mandatory overtime for nurses; prepared for the Michigan Nurses Association. [Electronic Version.] Lansing, MI:Author. Retrieved March 5, 2005, from http://www.psna.org/c_research_MNA04research.htm

Schuerenberg, B. K. (2004) Making time for scheduling. Health Data Management. Retrieved September 28, 2004, from http://www.keepmedia.com/pubs/ HealthDataManagement/2004/02/02/542054

Staffing effectiveness: Testimony before the Work Environment for Nurses and Patient Safety Committee, Institute of Medicine, November 20, 2002. (testimony of Dennis S. O'Leary, M.D., President The Joint Commission on Accreditation of Healthcare Organizations). Retrieved on March 5, 2005, from http://www.jcaho.org/news+room/on+capitol+hill/dsotestimony_1102.htm

Tarber, P. (August 2002). Staff scheduling shifts into high gear. Health Care Informatics Online. Retrieved September 28, 2004, from: http://www.healthcare-informatics.com/issues/2002/08_02/trends.htm

Winstanley, G. (2002). A hybrid AI approach to staff scheduling. Retrieved March 1, 2005, from http://www.it.bton.ac.uk/staff/gw4/papers/SWAT_SGES2002.pdf

Dr. Anura deSilva is CEO of Care Systems. Sonali Jayawardena is project manager for Care Systems. Kathleen Smith serves on the Advisory Board for Care Systems. More information about Care Systems, Inc, is available at http://www.caresystemsinc.com
Table 1: Design for Ease of Use

Usability The software should be natural and intuitive to
 use, for the people using it everyday.

User control Users need to be able to "undo" and "redo" actions
 and need to be able to recover from mistakes.

Error prevention Software design should prevent errors from
 occurring.

Consistency and Software should use consistent words and actions
standards through the application. Follow platform
 conventions making information appear in a natural
 and logical order.

Feedback The system should provide clear, understandable,
 and accurate information as well as deliver a
 schedule that is easy to read and understand.

Instruction The system should speak the users' language, with
 words, phrases, and concepts familiar to the user.
 Instructions for use of the system should be
 visible or easily retrievable whenever appropriate.

Objects, actions Users should not have to remember information from
and options one part of the dialogue to another. The system
recognizable should include shortcuts for frequent actions.

Adapted from:

Nielsen, J. (1994) Ten usability heuristics. Retrieved June 27, 2005,
from http://www.useit.com/papers/heuristic/heuristic_list.html
Pan American Health Organization (2001). Usability Principles for User
Interfaces. In Building Standard-Based Nursing Information Systems
(p. 73).

Shneiderman, B. (1998). Designing the user interface: Strategies for
effective human-computer interaction. Reading, MA: Addison Wesley
Longman, Inc. User rights IBM ease of use design concepts.
Retrieved June 27, 2005, from
http://www-3.ibm.com/ibm/easy/eou_ext.nsf/publish/12

Table 2: Key Criteria For Selecting An Automated Scheduling System

Staff Satisfaction:

* Methods to quickly and easily communicate requests and changes
in the schedule

* Tools to provide a schedule that is fair and equitable to all
staff

* Method for each staff member to know the work assignment

* Method for participation in scheduling by individual staff
members

Ease of Use:

* Ease of use by all system users at all levels: staff, managers,
schedulers, and supervisors

* Management of multiple requests and schedule trades from staff

* Method to easily track holiday and vacation requests from year
to year, including calendar views

* Method to create any variety of shifts and shift times

Management Functions:

* Ability to change the projected number of nurses needed based
on fluctuating staffing requirements

* Ability to change the status of a specific staff member
on-line and in real time (Call- off, sick time, float to a
different unit, etc.)

* Cost effective use of staff

* Method to quickly find additional qualified staff for
changing staffing needs

* Method to look at multiple units for staff adjustments and
staffing requirements

* Method to track staff credentials and certifications

* Alternative methods to fill empty shifts (a type of shift
bidding application)

* Ability to provide consistency of work patterns

* Method to project the impact of changing staffing patterns
and its affect on the schedule.

Additional differentiators to consider during the selection process:

* Is this a true "Turnkey Delivery" product? Will the vendor
go "the extra mile" to ensure successful adoption and
continued use?

* Is this an "Intelligent" Scheduler? Is there an optional tool to
help fill in the schedule gaps before you reach out to
external sources?

* What is the reporting capability? Do I have the ability to easily
create reports using off-the-shelf report-writing software "on the
fly" or on my data, or do I have to use the vendor-developed
reports? Do I have access to a data dictionary?

* Does this scheduling system provide a fully relational data
warehouse?

* What functions and features help manage the scheduling
process? Does this scheduling system support self scheduling,
restricted scheduling, and cyclic scheduling types, or a
combination of these scheduling types?

* How is the scheduling system deployed? Is it provided as an
Application Service Provider (ASP--hosted remotely) or is the
software contained in-house? Is it web-based or client-server
based?

* Is the software accessible through the internet or intranet?

* Does the vendor have a Product Advisory Council? Will you have
the opportunity to provide input for product direction and
enhancements?

* Can it accommodate strong and moderate preferences of the staff
member in automatically generating a schedule?

* Can it assign different weights to different preferences?
COPYRIGHT 2005 Capital Area Roundtable on Informatics in Nursing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2005 Gale, Cengage Learning. All rights reserved.

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Author:deSilva, Anura; Smith, Kathleen; Jayawardena, Sonali
Publication:CARING Newsletter
Geographic Code:1USA
Date:Dec 22, 2005
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