Patient Flow Enewsletter
Volume 2, Issue 1
Thursday, February 3, 2005

Best Practices
Creating a Staggered Staffing Plan to Match Patient Census

Resources in this article: Chart of RN Staffing against Patient Census New RN Staffing Pattern PowerPoint Presentation, "ED Resources and Demand Matching"

As service line manager in the emergency department (ED) at Cedars-Sinai Medical Center (CSMC) in Los Angeles, one of the largest academic medical centers in the western U. S., Flora Haus, R.N., M.S.N., C.E.N., is continually faced with staffing challenges. But when Haus started noticing that at both the end of the night shift and beginning of the day shift ED nursing crews had more staff than patients, she challenged herself to find out why.

"When I arrived in the ED each morning, I began noticing that there were plenty of night and day crew nurses, but fewer patients," said Haus. "After noticing this, I ran patient census reports to see what was going on."

Since CSMC has a computer documentation system, Haus had access to a detailed patient flow tracking system to run such reports. What she found was a static patient census and a staffing pattern that didn't match.

(Original Data Picture)

As Haus analyzed the data, she noticed several problems. While the evening shift was going off-duty at midnight, the patient census was not dropping. During the hours of 4:00 a.m. through 10:00 a.m., nursing staff was being underutilized, while staff was overwhelmed between 2:00 p.m. and 2:00 a.m. In addition to impacting patient care, this was creating conflict between shifts and ineffective staff interactions. Haus added, "We could really predict when patients were coming in - we needed a staffing pattern that supported this."

Getting Buy-in for Shift Changes

Haus immediately changed one night staff personnel to match patient census. "After I did this, the night staff became angry and frustrated; as they were not consulted, so I met with them and showed them the data," said Haus. "Once they saw the graphics and data, it made sense to them. They became more receptive to discussing staffing changes."

Haus began working with ED staff to make additional changes that would more appropriately reflect patient census. She created a formal team, consisting of a minimum of three people from each shift. Starting with the night shift, the team held meetings with as many members of the shift as possible over a three-week period.

"We heard some big concerns," said Haus. "Staff were concerned about losing differential money with the changes in shift times, the complexity of the monthly schedule and any assignment revisions that may result. Many staff had plans in place for child care, rides to work, etc. that were dependent upon their shift times."

Implementing Staggered Staffing

What resulted was a staggered staffing design with 11 shift start times instead of three to better match patient census.

Haus also gave six clinical assistant nurse managers responsibility for staff assignment reallocations and for matching staff to the new shift pattern. This gave the new system more autonomy, since these managers are closest to existing staff and most aware of their needs.

Administrative buy-in was the last step, which went quickly for Haus and her team. "I sit on a management advisory group for Human Resources. When I explained the shift changes I wanted to make and showed the staffing data, the Vice President for HR supported the staffing changes." Haus also obtained support from the Chief Nurse Officer.

Results and Lessons Learned

After being in place for one year, the new staggered staffing pattern has had a positive effect on both staff satisfaction and patient care.

(Current Data Picture)

In a recent CSMC employee opinion survey, staff reported a 95 percent approval rating for the staffing pattern, saying ED staffing is much better than it has been.

There are now sufficient nurses to meet patient needs so fewer patients are waiting in the lobby for care. The number of patients who leave without being seen has dropped from 7% to 4%. To help insure patient needs are being met on an ongoing basis, Haus and her team review patient census profiles every month.

Haus offers lessons learned for others considering a similar shift pattern. "Testing changes before they are made is extremely important. When I made a unilateral change to the night shift it backfired. It would have been better to involve them and test it first."

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For more information about Cedars-Sinai Medical Center's approach, Click Here to download Flora Haus's full presentation, "ED Resources and Demand Matching". (250 KB)

To listen to an audio recording of Flora Haus' presentation from the November 11-12, 2004 conference titled "Perfecting Patient Flow: Proven Solutions to ED Crowding," Click here for more information.

Flora Haus, R.N., M.S.N., C.E.N.
Service Line Manager, Emergency Department
Cedars-Sinai Medical Center
Los Angeles, CA