Budgeting Your Staff Needs

Vol. 16 •Issue 10 • Page 34
Doing Business

Budgeting Your Staff Needs

While facing critical care shortages, managers struggle to find the talent and finances to build a successful staff.

An unprecedented and growing crisis in access to quality critical care services is sweeping the nation.

Insufficient numbers of qualified physicians, nurses, respiratory care practitioners, and other health care professionals to provide specialized care threatens patient safety and will continue to intensify as the U.S. population ages and requires more critical care services.1

RTs serve as valued and necessary members of the critical care team, and the profession’s increasing scarcity is drawing the attention of health care providers across the country. The most recent American Association for Respiratory Care’s human resource study indicated there were more than 132,000 RTs, with 74 percent of them working in the acute care setting. Unfortunately, the study also reported there were more than 11,000 vacancies for RTs.2

In their quest to ensure adequate numbers of qualified practitioners at the bedside, respiratory care managers are faced with two challenges. First, how do you recruit and retain top talent with such a critical shortage of practitioners? Second, how do you justify staff needs at a time when hospital administration is looking to respiratory care managers to reduce paid hours?

Creating a workplace of choice

Both of these issues must be addressed together. Even the most effective systems to allocate and justify staffing resources aren’t of much value if there isn’t a pool of qualified staff to get the work done.

In order to attract and retain RTs, managers must create a workplace of choice in which practitioners contribute, are engaged, and are recognized for their value. Programs that provide personal and professional growth, offer new learning opportunities, and foster excitement and fun serve as a powerful recruitment tool. They also tend to improve productivity and encourage a strong commitment to quality.

Building a workplace of choice takes time, and implementing employee teams is a good place to start. These teams meet to discuss issues that are important within the department. By involving staff in areas such as performance improvement, policy development, and building a positive work environment, they experience greater satisfaction in their work.

The respiratory care departments at the Cleveland Clinic and the University of California San Diego use employee teams, which include RTs in addition to health care workers from other disciplines.3 (See Sidebar, page 36.) This approach helps to establish strong multidisciplinary communication and teamwork that extends beyond the ICU.

It’s important to provide time for teams to meet on a regular basis; otherwise, participation in a team can create frustration. Centers that use such teams understand gains in productivity and efficiency can be achieved to offset the expense associated with meetings and project work.

Justifying the need

The second challenge respiratory care managers face is putting mechanisms in place to justify staff — not only to determine the adequate numbers of RTs needed, but also to demonstrate the time RTs need at the bedside. This is essential to providing safe and effective care, and it allows your staff the time to do the right things right. Environments in which RTs are chronically short-staffed and overworked can lead to high stress and eventual burnout.

Managers use a variety of strategies to justify staffing needs, but the ideal staffing systems quantify the demand for respiratory services. They define how much time needs to be spent at the bedside and consider other activities that comprise the RT’s workday.

Hospital census, patient days, or even respiratory care procedure counts aren’t good indicators of staffing needs because significant variability exists in the nature and type of services for each patient. In addition, there are considerable differences in the labor hours required to set up oxygen versus a ventilator.

The best indicators of work demands are derived from systems in which each respiratory procedure is associated with a time standard. By associating every RT activity, billable or not, with a time standard and having the mechanism to capture the number of procedures, you can make an accurate assessment of work demand. Retrospectively, these objective systems can be used to report productivity and assist in justifying existing and new resources to administration.

For example, at the end of the month, you might use the time standards and procedure counts to determine there are 4,500 hours of direct patient care, and you only have 4,000 hours of direct patient care hours worked. You then can present this data to hospital administrators to make the case that you need 500 additional RT hours.

Provided you can track the types of procedures and their frequencies, time-based systems also allow better assessment of the next shift or next day needs. Staffing levels can be adjusted upward or downward based on the assessment of workload.

A time-based system also is useful when your respiratory care department expands its scope of practice. Over the past several years, RTs at UCSD have assumed new responsibilities for bronchoscopies, EKG, tuberculosis control, rapid response, ventilator-associated pneumonia assessment, and numerous other new technologies. Each of these included an objective analysis of time required and the hours needed to support expansion of duties or a new clinical program.

Time tracking

The AARC Uniform Reporting Manual (URM) is considered the gold standard for respiratory care department staffing.4 Many state licensing boards as well as the Joint Commission reference it as a mechanism to ensure adequate numbers of staff. Most respiratory care managers who use time-based systems employ the AARC URM, as do many consulting and benchmarking firms.

In the example provided earlier, the administrator quickly will dismiss the request for the 500 hours of labor if there’s any doubt as to the legitimacy of the time standards and methodology employed. A respiratory care manager clearly can make the case that the URM is an accurate source for procedure time standards and represents community practice.

While time tracking can be managed using paper-based system, taking advantage of computers and spreadsheet applications can make the task much easier. The AARC URM even includes a set of spreadsheets to get managers started.

Respiratory care management information systems (RCMIS) also bring significant benefit to time-based staffing systems. With such systems, you can assess work demand at any time in the workday, and group and report it to improve assessment of all activities.

Most RCMIS software is pre-configured to incorporate the AARC URM or other time standards so assessment of workload and staffing assignments then can be automated. Gains in workforce deployment, productivity, and activity capture in the ICU frequently will justify the RCMIS investment within the first 12 to 18 months.5

The years ahead will continue to pose many challenges for respiratory care managers. By creating a workplace of choice and employing a time-based staffing system, they will have an advantage in keeping their departments and ICUs staffed with an appropriate number of trained practitioners.


1.Society of Critical Care Medicine, American Association of Critical-Care Nurses, American College of Chest Physicians, American Thoracic Society. Critical Care Workforce Partnership Position Statement: The Aging of the U.S. Population and Increased Need for Critical Care Services. November 2001. Available at: URL: http://www.sccm.org/NR/rdonlyres/10ACC715-B429-473B-BD3E-979A20D15C39/324/AgingUSPopulation2001.pdf

2.Shaw RC, Benavente JL. AARC Human Resource Survey of Hospital Employers. Irving, Texas: American Association for Respiratory Care; 2005.

3.Cleveland Clinic. Teamwork. Available at: URL: http://www.cms.clevelandclinic.org/anesthesia/body.cfm?id=282

4.American Association for Respiratory Care. Uniform Reporting Manual for Acute Care Hospitals. 4th ed. Irving, Texas: American Association for Respiratory Care; 2004.

5.Ford RM. Respiratory care management information systems. Respir Care. 2004;49(4): 367-75.

Richard M. Ford, RRT, FAARC, is director of respiratory services at the University of California San Diego, current chair of the AARC Management Section, and chair of the AARC Benchmarking Committee.

Employee Teams

A constructive work environment empowers staff to take charge of issues important to them. Facilities such as the Cleveland Clinic and University of California San Diego have found success with employee-based teams. Some examples include:


  • Technology development: The focus is to evaluate technology and how best to apply it in the clinical environment. This team also can become involved in purchasing decisions and reporting the benefits of new technology through research and publication.
  • Staffing: A staffing team can evaluate the scope of services, new programs, and how best to allocate the workload. They also can define the competencies required to work in the ICU.
  • Peer interview: A primary goal of any respiratory care manager is to hire the best, but that doesn’t mean the manager needs to conduct the interviews. A peer interview team may include several staff RTs and support staff who screen, meet, and interview applicants.
  • Reward and recognition: This team brings some fun to the workplace, which improves the staff’s ability to work together. They can plan celebrations and suggest ways to identify and recognize the unique value of RTs.
  • Performance improvement: This team works with leadership to identify opportunities for improvement and get results to share with the whole staff.


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