EP9
Staffing, Scheduling, and Budgeting Processes EP9
- Provide an example, with supporting evidence, of a time when clinical nurses collaborated with an assistant vice president (AVP)/ nurse director to evaluate data in order to address an identified unit-level staffing need.
AND
- Provide one example, with supporting evidence, when nurses collaborated with an AVP/nurse director to evaluate data, in order to meet an operational need (not workforce related).
Example a: Clinical Nurses Evaluate Data to Meet a Unit-level Staffing Need in the Greenwich Hospital Operating Room
Operational Need
The national shortage of operating room (OR) perioperative nurses is well known. Greenwich Hospital (GH) includes a main hospital-based OR and the Helmsley Ambulatory OR, which together function as one department with nurses moving back and forth between sites to provide coverage as needed. In 2016, GH saw an increase in Operating Room cases due to the onboarding of six orthopedic surgeons. At the same time, GH saw a decrease in perioperative nurses because the largest group of surgeons in the hospital opened a new ambulatory surgery center four miles from GH and 15 OR employees left, including six perioperative nurses. GH, like other hospitals across the country, struggled to recruit experienced OR nurses. This, combined with the increase in volume and loss of experienced clinical nurses required a different solution to fill OR nurse vacancies. The GH OR nurse vacancy rate was 18% as of July 2016.
Clinical Nurses Collaborate with Director to Evaluate Data
On August 4, 2016, Marie Pham, BSN, RN, CNOR, OR Nurse Manager, and Rey Delacruz, BSN, RN, CNOR, OR Educator, Clinical Nurse, collaborated to review and evaluate the OR perioperative nurse vacancy data with Anna Cerra, DNP, MSN, MSHA, RN, Director of Perioperative Services (at the time). In evaluating the data, Pham, Delacruz and Cerra acknowledged the challenge of addressing the OR unit-level perioperative nurse staffing needs. There were vacancies for perioperative nurses throughout the U.S., and GH Human Resources’ recruitment efforts were not bringing experienced OR nurse candidates to Greenwich Hospital.
Pham and Delacruz collaborated with Cerra to discuss initiating an OR Perioperative Nurse Residency Program as an innovative way to address this need. The goal of this program would be to recruit and educate experienced clinical nurses who had no previous OR experience and provide these nurses with a comprehensive orientation to the OR nurse role. (Evidence EP9a-1, Meeting Minutes August 2016 and 2016 OR Vacancy Rate)
Understanding the urgency to implement the OR Perioperative Nurse Residency solution, Pham and Delacruz later that day presented a proposal for the OR Nurse Residency Program to Cerra; Sue Brown, BSN, RN, SVP Patient Care Services/Chief Nursing Officer (at the time); Sue Migliardi, DNP, RN, Director of Quality Improvement; Priscilla Sterne, DNP, RN, NEA-BC, Director of Magnet/Nursing Programs; and Jennifer Rich, Human Resources Recruiter. This group of leaders came together because they are the decision makers representing hiring, leadership and quality who can make decisions regarding staffing and program development. (Evidence EP9a-2, OR RN Residency Proposal Presentation, Pham Calendar Invite)
Delacruz had previous experience in developing and administering an OR Perioperative Nurse Residency Program based on the AORN Perioperative 101 curriculum. In anticipation of approval of the program at GH, Delacruz developed the content and format for the GH OR Perioperative Nurse Residency Program based on the AORN Perioperative 101 curriculum. The 10-month comprehensive perioperative program consists of four rotations:
- Teaching methods based on classroom didactic
- Laboratory and skills validation
- Looping: All OR nurse residents go to all Perioperative departments to be able to apply the knowledge they have learned from lectures and gain insight into the roles of the clinical staff members assigned to the department
- Clinical rotation working side by side with a preceptor to develop basic skill sets for each role
The main concentration of the training is for the OR nurse residents to perform circulating responsibilities, as that is their primary role. In addition to this role, they are trained to develop the skills of scrubbing as primary scrub and second assistant.
In September 2016, Pham and Delacruz presented the design of the OR Perioperative Nurse Residency Program to Cerra and received her support and approval to launch the program. (Evidence EP9a-3 Cerra Memo to Pham and Delacruz, Perioperative Nurse Program Curriculum)
Pham met with the Vacancy Review Committee and received approval for the RN positions to hire into the OR Perioperative Nurse Residency Program.
Addressing Operational Need
In October 2016, Pham and Delacruz began recruiting nurses for the OR Perioperative Nurse Residency Program. The interview process included current OR clinical nurses participating in peer interviews to help select potential nurse residents. In December 2016, a class of six perioperative nurse residents were chosen and offered the opportunity to participate in the program.
On January 21, 2017, the 10-month OR Perioperative Nurse Residency Program was launched. The program began with a cohort of six clinical nurses with one to two years of clinical, non-OR experience. Following the curriculum developed by Delacruz, the nurses met five days a week over10 months, participating in didactic education and practice-based learning.
In January 2018, Greenwich Hospital graduated the first cohort of its OR Perioperative Nurse Residency Program. Five of the six nurse residents are currently employed as OR nurses at GH, with one resident leaving due to relocation out of the community. With the addition of the new OR nurse residents, the OR RN vacancy rate decreased to 12% for January 2018. The graduates were celebrated in the February 2018 GH. On Call newsletter. (Evidence EP9a-4, January 2018 OR Vacancy Rate) (Evidence EP9a-5, On Call February 2018)
Pham and Delacruz intend to launch a second OR Perioperative Nurse Residency Program, tentatively planned for fall 2020.
Example b: Evaluation of Data to Meet an Operational Need at Bendheim Cancer Center
The Greenwich Hospital Oncology Service line comprises inpatient Medical Oncology and the Bendheim Cancer center (BCC), an ambulatory unit consisting of 15 chemotherapy infusion chairs, a medical oncology office practice and radiation oncology. Due to increasing demand, the Greenwich Hospital (GH) outpatient oncology clinic staff at the BCC were experiencing higher workloads and increasing delays for patients. As the navigation and coordination of services in cancer treatment centers can be complex, streamlining areas that are considered “bottlenecks” in a clinic can improve patient flow and increase patient satisfaction.
Clinical Resource Nurses Nancy Scofield, RN, OCN and Marybeth Lantz McFadden, RN, OCN noted increases in delays and patient wait times in the GH outpatient oncology clinic. Scofield and McFadden collaborated with Kristina Capretti, MSN, RN, OCN, ANP-BC, Clinical Program Director, Oncology Services, to identify contributing factors. They reviewed the current workflow and identified the registration process as one bottleneck in the outpatient clinic, with the reception staff reporting that this process was cumbersome and time consuming. One registration duty the reception staff was expected to perform was to place a call to the clinic infusion nurses to inform them that their patient was ready for treatment. These calls were frequently not answered due to the business of the clinic; voice messages were left for the clinical nurses but often not picked up, causing delays in the patient being sent to the infusion area. Clinical nurses and registration staff had frequently voiced complaints about the inefficiency of this process.
In September 2017, Scofield, McFadden and Capretti hypothesized that implementing changes in the electronic medical record (EMR) software could eliminate the need for staff members to communicate by phone, enabling the reception staff to focus on their essential duties and improving patient wait times and satisfaction. To support their hypothesis, they decided to collect data on call volume and average length of call. (Evidence EP9b-1, BCC Oncology Staff Meeting Minutes, September 2017)
Clinical Nurses Collaborate with Director to Evaluate Data
Scofield, McFadden and Capretti collected data over two weeks (October 2, 2017 through October 13, 2017). Front desk staff members tracked the number of phone calls they made to the infusion nursing staff to inform them that patients were ready for treatment, and they tracked the length of each call. Over the two-week period, the reception staff made a total of 134 calls, ranging from 10 seconds to 60 seconds, to alert or leave messages for the infusion nurses that their patients were ready for treatment. The total time spent performing this function for the 134 calls was 3,947 seconds, or 65.3 minutes. (Evidence EP9b-2, BCC Call Volume October 2017) Scofield and McFadden also recognized that many calls were being missed or messages were not picked up in a timely manner, thus increasing patient wait times. They also observed that the large number of calls was distracting to the nursing staff and took time away from patient care. (Evidence EP9b-3, BCC Oncology Staff Meeting Minutes, November 2017)
Addressing Operational Need
Based on the results of their analysis, Scofield, McFadden and Capretti collaborated to determine appropriate interventions to eliminate the need for staff members to communicate by phone. Scofield, McFadden and Capretti worked with Bret Morrow, Epic Clinical Application Coordinator, to create an electronic tracking “dot system” in the EMR to enable all staff members to identify where a patient is in their visit, such as in the lab, with the physician, ready for treatment or visit completed. Each phase of the visit is identified by a different colored dot placed next to a patient’s name on the electronic schedule for the day. The color of the dot is changed as the patient finishes the various steps of their visit and are ready for their chemotherapy treatment. The use of the dot system eliminated the need for staff members to try to communicate by phone, thereby streamlining workflow. In addition to the colored dots, the nurse’s initials appear on the patient’s appointment so all staff members caring for the patient know who the assigned treatment nurse is. (Evidence EP9b-4, RN Initials and Dots)
Conclusion
Training on how to use the new system was provided in May 2018, and it went live the following week. This has resulted in nurses at the Bendheim Cancer Center experiencing improved communication throughout the department. They also have observed a reduction in patient wait times as a result of interventions recommended by Scofield, McFadden and Capretti. Staff members are now able to view patient status directly on the electronic patient schedule, eliminating the need for the reception staff to call the infusion nurses. (Evidence EP9b-5, In-service Record, Tips and Tricks Sheet)