Trial Research Project Initiative
QE Staffing & Scheduling Methods© For Nursing Homes
An Initiative of the QE Foundation, Inc.
Objective of Initiative:
To encourage nursing homes to participate in trial research projects, however small in scale, using the QE Staffing & Scheduling Methods.
Objective of Methods:
To maximize quality and efficiency (cost effectiveness) in methods of hiring, organizing, training, and scheduling of a very short supply of nurses and nurse assistants to care for patients, and to minimize patient abuse, neglect, accidents and treatment errors/mistakes due to exhaustion, burnout, low morale and turnover of the nursing staff.
Basic Staffing and Scheduling Problems:
Excessive movement, switching, and use of overtime, temporary, and part-time nursing personnel create major problems for nursing homes and their patients. Also, nursing homes are so overly consumed and focused on getting enough hours of coverage to meet adequate staffing levels that they fail to see the staffing and scheduling issues in depth. Defining adequate staffing levels with numbers or ratios, however, is a major cause of the problem.
(Note: Most nursing home management practices dictate that budgeted hours, rather than actual expenditures, be used as the most practical measure for meeting either state mandated ratios, if applicable, or for their own cost reporting budget requirements.)
The problem of defining adequate staffing levels by numbers of ratios prevents focusing on many of the following staffing and scheduling problems:
Low Compensation, Poor Staff Training and High Turnover
Too Many Part-time, Temporary and Overtime/Overworked Staff
Harmful “Day Off/Day On” Scheduling Patterns and Rotations
Harmful Weekend Off Policies and Weekend Only Staffing
Confusing and Time Consuming Ad Hoc Nursing Assignments
No Teamwork and Little Staff Responsibility and Accountability
Solutions and Innovation:
The fist step in finding solutions and innovations for better staffing and scheduling practices is to properly define "adequate staffing levels" unrelated to numbers or ratios. It is also important to realize that it is better for patients to be cared for by small numbers of well educated, paid, trained, organized and scheduled nursing teams than by large numbers or ratios of chaotically organized and scheduled individual nurses and assistants.
“Adequate Nurse Staffing Levels” can better be defined with the following Principles:
The compensation level for nurses and assistants must be maximized to attract and keep a qualified staff. This principle goes against budget and reimbursement requirements focusing on meeting ratios rather than costs.
The competency level for every qualified nurse and assistant must be maximized by emphasizing continual on the job training. This principle is based on the fact that even well qualified nurses and assistants need continual training to better relate and understand the ever changing needs of their patients.
The consistency level of daily numbers and types of staff per shift must be maximized to avoid problems caused by large variations of under and over staffing. This principle goes to the heart of the reported understaffing problems.
The continuity level for each patient must be maximized by better organizing and scheduling a regular full-time staff, and not rely on part-time, pools, temporary, weekend only and overtime staff for adequate staffing levels. This is the most important principle for minimizing confusion, communication errors and mistakes leading to abuse and neglect.
The cohesiveness level of the nursing staff must be maximized via organized and synergistic nursing teams in order to maximize job satisfaction and quality patient care. This principle amazingly enables less staff to provide more care.
The comprehension, courtesy and confidence levels of nurses and assistants must be maximized through continual communication and collaboration with patients and families. This principle will minimize most of the misunderstandings that result in costly abuse and neglect lawsuits.
These principles focus on quality rather quantity, and it is the quality that will assure the correct quantity of nurse to patient ratios; not the other way around. Administrators and nurses spend too much time focusing on ratios supposedly to assure adequate staffing levels, and they often fail to realize the crisis that is created by having too many part-time, temporary, weekend only, pool, overtime, and overworked nurses and assistants that are continually detailed in the nursing home primarily to meet adequate staffing level ratios.
Once the focus is changed to emphasize the above principles instead of ratios, The QE Foundation is ready to help nursing homes find solutions for adequate staffing levels via a Trial Research Project Initiative utilizing the QE Staffing and Scheduling Methods.
These Methods are based on certain concepts and characteristics that focus on being able to utilize a limited number of nurses and assistants to provide optimal patient care. Important factors that are considered in the solutions are as follows:
· There is a shortage of well-trained nurses and assistants and increasing the numbers/hours required to provide nursing care exacerbate the shortage.
· It is better for patients to be cared for by a small number of well trained and organized staff members than by just large numbers of staff members.
· A tired and badly scheduled nursing staff makes mistakes that result in treatment errors, accidents, and increase the possibilities for abuse and neglect of patients.
· Temporary, part-time and weekend only staff lack the necessary day-to-day patient familiarity needed to provide consistency and continuity in their care.
· A cohesive staff will work and perform better, communicate better with their co-workers and understand patient needs better.
The work in developing the solutions and innovations were developed and designed to deal with these facts and certain important concepts and characteristics listed below.
Concepts:
· To develop high performance teams, rather than individuals, which are responsible and accountable for the every day care required by the patients.
· To provide optimal quality and efficiency of care with a reliance on staffing synergy* rather than mandated hourly ratios as the best standard of care.
The term synergy comes from the Greek word ‘sunergos’ meaning working together supersedes individual actions. In other words, the outcomes of people working together are greater than the sum of people working on their own and/or in parallel.
Characteristics:
· Consistency: Use the same number and type of scheduled staff everyday.
· Continuity: Use a minimal number of the same scheduled staff everyday.
· Cohesiveness: Group and schedule the staff to assure teamwork everyday.
QE Staffing Method:
The staffing method starts with grouping three staff members at a time to create unique team partnerships whereby two of the staff members are paired to work together while one staff member is off. The paired staff members work together on job assignments and share responsibility and accountability. Each staff member will work an equal amount of time together and have the same kind of work schedule (no better or worse schedule*). Each team member becomes equally familiar with the patient and family and it is the team itself that is accountable for the care provided. (Note: The unique schedule itself would allow team members to fill in for each other if one is unable to work on their assigned day of the week*.)
In a nursing home setting, there would be three charge nurse team members for each shift and each defined patient section (e.g. rooms, wing or floor). Nursing assistants would in turn be grouped in three’s and assigned to care for certain patient sections on each shift. (See Nursing Assistant Partnership Program for more information). For a graphic outline of the 8-hour shift schedule model refer to the following web page:
QE Staffing and Scheduling Method Eight Hour Shift Model for Nursing Homes.
The actual number of teams that are needed and the size of any defined patient section would obviously have to depend on acuity measures and regulatory requirements, but the important criteria should be focused providing maximum quality and efficiency.
The way that the teams are created is a very important factor in the success of the QE Staffing and Scheduling Methods. There have been a myriad of suggestions with regard to grouping staff members according to personal and logistical characteristics, but the most effective appears to be putting a new inexperienced staff member together with two experienced staff members. It helps in training and it assures continuity in care by having at least one experienced and familiar staff member assigned to a patient everyday. (See High Performance Team Concepts and Dynamics for more information)
Other advantages in using the team partnership staffing method is that the team itself is accountable and responsible for quality care and the team itself will most likely empower itself to weed out bad individual employees. There could also be opportunities to develop leadership qualities within the teams and there could be team (rather than employee) of the month recognition awards.
Most important, however, is the synergy effect that will result in better care by fewer employees that will increase quality and efficiency (cost effectiveness) for the nursing home. This team partnership system, however, is dependent upon the QE Scheduling Method, and each method must be integrally related to each other to form one system involving team partnerships using one unique scheduling pattern.
The QE Scheduling Method:
The scheduling sequence pattern of the QE Scheduling Method was developed over a period of one year and involved a great deal of study, research and analysis as follows:
· Studying hundreds of many different kinds of nursing home scheduling patterns and the effects on staffing methods and patient care.
· Using computer aided mathematical analysis techniques of workable sequence patterns within different scheduling periods that were realistically possible.
· Using various safe and practical scheduling constraints related to “day on/day off” rotations to find the most workable sequence pattern.
· To specifically look for sequence patterns that would allow for, and maximize, the implementation of the team partnership system.
The end result was that there was only one workable sequential pattern for eight-hour shift employees that resulted in the best possible fit for our criteria. Although some may criticize a few minor features, there is no better sequential pattern that can be utilized to maximize quality and efficiency.
The example and model shows the actual sequential pattern, but a few of its features, especially related to eliminating the exhaustion factor, are listed as follows:
· No team member is scheduled to work more than four 8-hour days in a row.
· No team member is scheduled to work more than 40 hours in any week.
· No team member is scheduled to work just one day between days off.
· Every team member has two weekends off every six weeks.
· Every team member has one three-day-in-a row off period every six weeks.
· Every team member has an equal type of schedule in the six-week period.
The most important features related to teamwork and synergy, are the following:
· Every team member will spend an equal amount of days working together in pairs during each six-week period.
· One team member will always be available to fill in (back up) for a team member who cannot work on a scheduled day.
The QE Staffing and Scheduling Method are solutions and an innovation that nursing homes should utilize to solve staffing problems. Quickly implementing it, however, in an existing facility will be difficult, but there are several ways it can be done via several stages of trial research projects.
*Please note that customized schedule adjustments are made for vacation, personal and holiday times depending upon facility benefit packages and preferences by individual staff members for either extra pay or time off. The customization process requires negotiations to minimize conflicts between the use of the QE Staffing and Scheduling Methods and the concerns of both the employer and employees. For details contact qefoundation@aol.com
Trial Research Projects (Options):
Small Scale Team Formation Trial Research Projects: Requires that a nursing home find three nurses or assistants that are willing to form a team partnership and adhere to the required schedule. The focus should be on creating compatible team members. This trial project’s purpose is to explore the potential synergy and work performance of each team that is created. A minimum of two schedule periods (12 weeks) and two teams are recommended for a workable assessment. In this trial project, teams could work in any shift (e.g. one day & one evening) and assigned as a float team or to any specific patient section.
Trial Research Projects Utilizing One Patient Section & One Shift: Requires that at least one specific patient section on a specific shift be assigned to a specific team of nurses and/or assistants. (e.g. See 60 Bed Patient Section Example and Model in Appendix B) A minimum of two schedule periods (12 weeks) is recommended for a workable assessment of the patient care in that section.
Trial Research Projects Utilizing One Patient Section for Day & Evening Shifts: Requires that a specific patient section be assigned to a full compliment of nurse and nursing assistant teams during the day and evening shifts. A minimum of two schedule periods (12 weeks) is recommended for a workable assessment and should include comparisons (subjective and/or objective measures) of other patient sections that do not use the QE Staffing and Scheduling Methods.
Observations of Staffing and Scheduling Problems in Nursing Homes
Little or No Teamwork: It is not uncommon to see nurses and nurse assistants bumping into each other trying to figure out who is supposed to be taking care of which patients. The staff sometimes is not only unfamiliar with the patients and their significant family members but also with their own co-workers. Patients in long-term care facilities need the staff to be cohesive and know each other and the patients and families well enough to communicate about the specific needs that are required for quality care. The problem is further exacerbated when staff is moved from one section to another to meet budgeted hours and ratios without concern for continuity or consistency. Although this is not true in all nursing homes, there are far too many observations and reports about this problem.
Harmful “Day Off/Day On” Scheduling Rotations: It is not uncommon for the staff to work eight-hour shifts for 5, 6, or even 7 days in a row, and it is not uncommon for some to work twelve-hour shifts for 2, 3, or even 4 days in a row. The result is patients are often cared for by a very tired, overworked and exhausted staff that makes mistakes. Our observations indicate a trend of accidents and neglect when patients are care for by staff working at the end of long rotations. This problem is further exacerbated by the fact that many part-time, temporary and weekend only staff work many other days at other jobs to supplement their income. The harm caused by a tired and exhausted staff is a very big problem that cannot be over emphasized.
Ad Hoc Nursing Assignments: It is not uncommon to see a lot of confusion and chaos at every shift change in a nursing home. The staff is usually waiting around and debating about who is going to do what for whom in terms of nursing assignments. Since there is very little teamwork, regular responsibilities, or ongoing day-to-day accountability by the staff that is scheduled to care for the patients, it usually develops into a time wasting “ad hoc” nursing assignment problem. For the patients, it is like playing the lottery. They may get a well-rested regular staff member to help them with their care, or not.
Insufficient Training and Accountability: It is a well-known fact that most patient abuse and neglect complaints and lawsuits focus on the issue of insufficient training and accountability of the staff. One example is when a patient develops bedsores and no one can explain why it happened. Since prevention of bedsores is an important part of any training program (nurses and nurse assistants), it is assumed that training was insufficient. If the training was insufficient, someone must be accountable for either not training a staff member properly or some staff member failing to follow the training. Insufficient training and accountability is more of a staffing and scheduling problem issue. It is usually not a matter of a nurse or nurse assistant not being properly trained. Insufficient training and accountability referenced in abuse and neglect cases is really caused by poor staffing and scheduling methods. Bad trainers and/or trainees are not the problem.
Every Other Weekend Off Policy: This policy is a major cause of the unnecessary increase in nursing costs and the unnecessary decrease in quality patient care.
It results in an unnecessary 25% to 40% increase in staffing costs.
It results in half of the regular staff being off every weekend while requiring unnecessary staff to work on certain weekdays.
It results in an unnecessary dependence on overtime, part-time, PRN, and irregular weekend only staffing.
It results in unnecessary call outs and unnecessary staff switching reassignments.
It results in an unnecessary exhausted staff and unnecessary attrition.
This policy makes it impossible to maintain consistent cost-effective quality patient care.