The five rights of staffing: Maximizing the clinical and financial benefits of an acuity system

By Nancy Barton, MSN, RN, and Heather Wood, MBA, RN
08:39 AM
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Hospitals and health systems often purchase acuity systems as a valuable tool to allocate nursing resources based on patient care needs. However, these organizations don’t always use their acuity systems to their full capability. In many cases, at least one of what we call “the five rights of staffing” is absent.

According to “the five rights of staffing,” an acuity system should give hospitals:
1)    the right number of staff
2)    with the right skills
3)    at the right location
4)    at the right time
5)    with the right assignment

The maximum benefits from an acuity system can be achieved when these five aspects are used together to efficiently leverage existing nursing resources, preventing the need to rely on expensive options such as outside staffing agencies. To do this, managers must assess more than just patient census and hours-per-patient day. They must also look at the hours of care the patient needs, based on workload, and the patient’s unique professional care requirements to effectively match staff to patients.

This requires taking both the acuity and complexity of patients into account when making assignments. A patient who needs a higher level of nursing intervention, for instance, should be assigned a more seasoned nurse instead of one right out of school. Looking at the complexity and acuity of care is likely to result in more efficient staffing levels, improved patient safety, and better patient outcomes.

A case example: Evaluating staffing patterns with acuity

Northeast Georgia Medical Center in Gainesville, Ga., offers one example of a facility that uses acuity to evaluate its staffing patterns—at both the executive and unit levels—to drive efficiencies. However, that wasn’t always the case. A few years ago, the facility’s nursing leadership and finance department met to discuss its staffing processes. They had an acuity system, but it wasn’t being fully utilized. The group believed that nursing resources should be based on the needs of patients. As a result, the team decided that it was necessary to incorporate patient needs-based staffing processes into the organizational culture.

The transformation began through the development of acuity-based budgets on a day-to-day, shift-by-shift basis. A team approach with the finance and nursing departments developed an environment of trust, as well as parameters for data measurement and analysis. For three months, the team met every two weeks to evaluate and assess the data. Even now, years later, the group meets once a month to answer key questions, such as: Do we have our targets set appropriately? Is our skill mix right? Does our shift distribution need to change? Do we have the right positions open in recruitment to meet the needs of the units?

At the 40,000-foot level, Northeast Georgia uses acuity data to help determine the best core staffing patterns for every shift. In addition to deciding whether a float nurse is needed, for instance, data also shows where to place her to achieve the greatest impact on patient care. Graphic trend reports allow CNOs to see a picture of what’s happening at a quick glance.

Drilling down to the unit level, the unit managers and the central staffing office look at variance in acuity—how recommended staffing compares with the actual patient workload and complexity on the unit—in order to make proactive staffing changes. In fact, charge nurses are asked to review data every four hours to be sure they have the right staff mix to care for their patients.

From reactive to proactive: the importance of acuity-adjusted data

As Northeast Georgia illustrates, the more data available, the more proactive hospitals and health systems can become. Among the benefits experienced when “the five rights” are supported:
•    Increased patient safety: Staffing levels can be compared with patient outcomes to proactively address potential safety issues. A facility could look at the number of falls on a particular unit, for example, and restructure staffing levels during times of peak occurrence.
•    Improved patient outcomes: Linking workload-adjusted staffing to nurse-sensitive outcomes at a daily and shift-level basis helps healthcare organization’s identify the best staffing practice models to move from simply measuring outcomes to managing outcomes. This approach can have a direct impact on minimizing transfers and shortening length of stay.
•    Greater transparency: Nurses no longer need to go into the application to classify patients when the data is received automatically through the course of clinical documentation within EHR systems. In addition to eliminating a manual step for nurses, it removes individual indicator interpretation from the picture. If the care patients need is documented accurately and in a timely manner, the acuities will follow.
•    Increased productivity: Rather than rely on traditional staffing patterns, facilities can better match workload to staffing based on data. Patient workload can be analyzed by hour of day and day of week to facilitate creative staffing shifts—aligning resources to workload.  Using this analysis, the need for specific roles at various times or days can also be determined.
•    Enhanced staff satisfaction: Taking patient acuity and complexity into account allows for more equitable workload distribution. While the number of patients assigned to each nurse might not be the same, nurses can be satisfied that their workloads are equal.
•    Reduced staffing expense: Efficient use of available nursing resources can lead to a reduction in overtime, as well as prevent the need to turn to supplementary staffing from outside agencies. Costly nurse turnover rates might also be reduced with higher rates of staff satisfaction.

Without acuity-adjusted data, hospitals don’t receive the full picture when comparing benchmarks, gauging productivity, or determining patient needs. Maximum benefit from an acuity system is achieved only when it consistently helps facilities put the right number of staff:
•    with the right skills
•    at the right location
•    at the right time
•    with the right assignment


Nancy Barton is director of Clinical Resource Management at Northeast Georgia Health System and Heather Wood is QuadraMed’s AcuityPlus Product Manager.