Right Time, Right Nurse

When Ann M. Barrett, MBA, RN, NE-BC, took over as director of nursing resource management at The Miriam Hospital, she had some serious staffing issues to tackle.

The Providence, RI, facility was working to reduce wasteful incentives offered to nurses who helped fill vacant shifts, as well as reduce its reliance on staffing agencies and other outside sources of labor.

"We had been paying premium dollars and using other incentives like gift cards for people - in addition to paying overtime or double overtime for their shifts," she explained. "We needed a better way of letting people know what shifts were available for additional work, and also decrease our reliance on contract labor."

The staffing situation had the potential to get worse as the hospital was planning an expansion.

"We were looking at opening a new 36-bed unit in the next year or so," Barrett explained, "and with the vacancies we already had, we were going to be stuck with more vacancies in the near future. So we needed something to help us deal with that, as well."

A New Approach

Several years before, when Barrett was a nurse manager, she learned about some new Web-based staffing tools that would enable nurses to access scheduling and bid for open shifts. At the time, her efforts to explore the idea with hospital leaders were delayed.

By the time she took on her current role in resource management, she found a more receptive audience among hospital leaders.

"My CNO had gotten an e-mail from a San Diego-based company called Concerro Inc. about a Webinar detailing the staffing tools they had developed," Barrett said. "She said, 'This is what you had spoken about a few years ago; if you want to pursue it, check it out.'"

Barrett did exactly that, taking in the promotional program while also researching companies with similar products. She also spoke to someone who had brought the same vendor's system online at Beth Israel Deaconess Medical Center in Boston. Barrett heard nothing but rave reviews about the concept of nurses bidding on shifts and the specific software the vendor offered to allow that.

"Finally, I brought it to the entire nursing executive team at Miriam, and they were sold on the idea," Barrett said. "We believed with this product - and our nurses - we could finally do away with contract labor."

Evidence-based Staffing

The product Barrett and her colleagues finally approved, known as ShiftLinks, provides nurses 24/7 access via the Web to a centralized list of all open shifts at the hospital, several weeks before the shifts occur.

Graham Barnes, CEO of Concerro, said the software developed by his company reflects a measured, evidence-based approach to staffing.

"Interestingly, there are no national standards on defining excellence in staffing, and yet we know staffing in healthcare has a huge impact on patient safety, outcomes, staff satisfaction and a whole range of critical issues in healthcare," he explained. "So in an attempt to try and provide a more evidence-based approach to the whole healthcare staffing challenge, we sponsored an initiative to get several staffing experts together for a roundtable to discuss what staffing excellence is and to start gathering the evidence to help support those definitions."

Ultimately, this led to the creation of a white paper (available at www.concerro.com) the company published in conjunction with a number of different organizations "in order to try and put a stake in the ground and to start a dialogue around defining and ultimately creating standards in staffing," Barnes said.

This gave the company some general principles that enabled it to embed in the product some of the best practices elicited in the white paper, "things like fairness, transparency, autonomy, culture and innovation," he said.

"Eventually, our goal is very simple, and that's to provide the right nurse for the right shift, and we do that through a Web-based tool because that's the one that's most successful and transparent," Barnes continued. "It's one users can exercise at any time, and it eliminates some of the barriers associated with having to have access and having to be physically in a certain place. So it leverages the ability for the staff to participate more in the process."

Taming the Critics

According to Barrett, the system was met with some initial skepticism. Customization of the software templates was a big concern.

"Some managers felt their staff would not want to float anywhere else because we have a somewhat decentralized model of staffing here," she explained. "Our model is nurses on a given unit need to downsize and upsize based on the needs of that unit. So people need to pick up extra shifts on their own unit, which is a good thing for many because floating to another unit can provoke anxiety in a lot of nurses. But that limits flexibility, as well."

In addition, because there were many new grads throughout the hospital, managers were hesitant to put the system in place because they did not believe their nurses were going to look for shifts elsewhere in the hospital.

"But we found once we put the system in, 25-30 percent of the shifts being signed up for were being signed up for by nurses from other units, so that fear did not reflect what actually happened," Barrett said. "People are willing to go to other units and check out other parts of the organization. If that shift is convenient for them - it's a time when they can find a babysitter or their spouse is home, etc. - then it does not matter whether it's on their home unit or not.

"What we thought was going to be a tough sell was not a tough sell at all," she said.

Paying Dividends

The difference the software has made in scheduling at Miriam cannot be overstated, Barrett said; neither can its effect on the hospital's culture.

"We used to have a very different process that would often result in putting out fires, making phone calls at the last minute and generally struggling to fill shifts; sort of day-to-day management," she said. "And while there is always an element of that when you are staffing a hospital, we are no longer starting out that way. Before we had so many vacancies and shifts that needed to get filled, we just could not get them all filled. It would be a situation where we had already asked everybody and been refused by everyone asked, so we were subsequently calling and more or less begging at that point, offering whatever we could."

With the new system, staff from all parts of the hospital can see open shifts and sign up for the ones that are convenient for them. Likewise, managers can ensure they are getting the best fit in terms of a unit's needs and the staffer's skill sets. Because shifts are posted well ahead of time, they can wait for the match that's most appropriate, as well as most cost-effective.

Level Playing Field

In addition, the software helps level the playing field, so to speak, for staff.

"The prior method was just a sign-up sheet with a first-come, first-serve basis, and there could be some bullying going on, simply because the people who worked full time tended to see the sheets more than the part-time or per-diem employees because they were here more often," Barrett said. "They were more likely to be here when the sign up list went up on the board."

A full-time nurse signing up for those shifts was likely to earn overtime at that point, she continued, and employees who could come in at a cheaper rate (i.e. their regular hourly rate) might be hesitant to do so.

"Straight-time employees often would not dare sign up because they might say to themselves, 'Oh, that's Jane, and she has two kids in college, and all she talks about is how she needs money. I do not want to put my name under or next to hers because she's always in charge and she might give me an unfair assignment,'" Barrett said.

A poll of the managers on each unit found this was the case across the board, she added. "And from a manager's perspective, they did not look too much further because they were busy, and there was someone already signed up for the shift, so why not take that and run with it?"

The new electronic system has helped Miriam avoid such uncomfortable situations while also improving its bottom line.

"Managers do not have to approve shifts right away, and if it's a shift that's 3 weeks away, they do not have to be so quick to grab someone that's going to be earning an overtime rate," Barrett said. "They can wait a week or two and approve someone at a straight-time rate."

Better Than Expected

Barrett said the scheduling software also proves useful in getting the word out about other opportunities employees may want to take advantage of.

"We have used it for educational opportunities, posting classes and in-services rather than posting a shift, and nurses can go in and sign up for that class at their convenience," she said.

Whatever initial skepticism hospital employees and leaders may have had regarding the tool is a thing of the past, Barrett said, and the support she's received from nursing leadership has been pivotal in its success.

"We've done away with contract labor in the inpatient area, and we never have to go down that incentive route ever again," she said. "We start out every day in a much better place than we did before."

Timothy A. Mercer is a contributor to ADVANCE.