When patient volume variation and staffing inconsistencies converge
Newton Medical Center is the only acute care hospital located in Newton, N.J., serving patients from Sussex and Warren Counties in New Jersey, Pike County in Pennsylvania and southern Orange County in New York. The 148-bed hospital is the recipient of widespread recognition and numerous awards.
Despite this enviable recognition and market position, Newton nonetheless faced challenges. To manage widely variant patient volumes, the hospital adopted staffing practices to assure there were always enough nurses to handle periods of peak admissions and low patient volume. At times this resulted in a staffing-to-workload imbalance.
New processes and efficiencies yield success
Another notable event happened at Newton in 2014 — the arrival of a new management team, including Joe DiPaolo, president and CEO, and Denise Fochesto, director of nursing and operations. The leadership team quickly identified a number of pressing needs: optimize labor utilization, increase patient throughput, improve cash flow and boost employee and patient satisfaction across all 24 hospital departments.
“Many problems persisted despite efforts to address them, as a result of older, ineffectual processes” recalled DiPaolo.
“Bottom line, we needed to align staff with our patient volume and budget,” Fochesto said. “If patient volume was above budget, we’d obviously need more staff; if not, then we needed fewer staff on the floor.”
This was not an easy calculation to parse, however. The hospital needed a way to align its workforce with this variation.
Newton’s leadership team determined another requirement. “We knew we needed a partner who could help us effectively control our costs while preserving our ability to deliver safe, high-quality patient care,” said DiPaolo.
To that end, Newton Medical Center partnered with Vizient, which already helped the hospital improve its supply management, pharmacy, revenue cycle and process improvement practices and protocols. Based on prior work, Newton knew the Vizient team would roll up its sleeves and get into the trenches to deliver practical results.
“The people at Vizient are known for diving into operations as deeply as they do into data and figures. That kind of immersion into the culture is key to a successful implementation of changes, as opposed to a report of recommendations with no execution strategy,” DiPaolo said.
The hospital prioritized what to focus on first and members of the Vizient team quickly established relationships with key department figures. Rather than taking a punitive approach, the Vizient team gained trust by partnering with the Newton team and collaborating on how the departments would benefit from new initiatives.
“There is always some reluctance to be expected when staff are being evaluated by a stranger,” explained DiPaolo. “However, the embedded Vizient consultants became so entrenched as a positive force for change that they gained enthusiastic support rather than resentment.”
Soon, all Newton employees were actively involved and participating in the project. Using Workforce Optimization and new methodologies, Newton and Vizient developed detailed process maps and recommendations to improve operations.
The program was phased in to one unit at a time, and used a number of proven processes for scheduling and workforce optimization. One of the most essential was a daily huddle with staff from multiple departments to review a broad range of daily census data. They assessed current length of stay (LOS), volume, turnaround time in ED, worked hours/unit of service and more. Scheduling and assignment budgets were then tailored accordingly.
The process was completely transparent and involved all stakeholders: the executive team, the director and manager of finance, clinical departments and even support service areas such as housekeeping and security. Department managers were encouraged to bring their coordinators to the huddles to help identify problems and brainstorm solutions.
Vizient helped Newton develop a visual management dashboard based on a productivity measurement called WHPUOS — worked hour per unit of service. Green, yellow and red indicators let the nursing managers and the staff know where they stand based on the number of staff, admissions, discharges and the acuity of their patients.
For most participants, this was the first time they had visibility into budgetary and productivity issues. For Newton employees, this was a welcome opportunity to be a part of the process and make the hospital successful. It also enabled a cultural shift to viewing hospital operations more holistically. “Everyone now understands that what happens in their area affects many other areas within the hospital — and that we’re at our best as a team,” said Fochesto.
From a scheduling perspective, the daily trends analysis helped Newton identify the right skill mix and staff-to-patient ratios. Making the subsequent changes in scheduling, however, was more difficult. To mitigate potential reluctance, employees helped lead the desired changes.
Changing a work culture does not happen overnight, especially in the health care environment. Newton was able to fast-track their success and the shift took about a year — and all signs point to a permanent and positive change.
Overall milestones met
“We’ve created a truly inclusive culture,” observed Fochesto. “At the daily huddles, all departments are on deck. When a need arises — such as not enough transporters scheduled — there isn’t any finger pointing. Instead, the focus is on how we can fix the problem.”
- Established interdependent team culture that eliminates traditional department silos and competitiveness, and encourages collaborative problem solving and new relationships
- Motivated managers to consider the financial implications of initiatives
- Boosted employee satisfaction by engaging and empowering employees
Savings and efficiencies
Using a daily census is helping Newton to staff appropriately without sacrificing care quality. At the same time, cultural changes enabled the staff on hand at any given shift to work more productively as a team.
- Saved $2.9 million in expenses
- Implemented dynamic predictive demand curve analytics to staff appropriately
- Adjusted nurse staffing to align with demand curve and reduce ED costs
- Created Nursing Resource Center with nurse and nursing assistant floaters who can supplement staffing as needed
- Increased efficiency and productivity by replacing staffing approaches for three separate units with a single and global staffing model
- Reconfigured and customized shifts to reflect unique department needs
Lowering the LOS leads to improved patient satisfaction
Implementing new, streamlined processes allowed for better patient throughput that lowered the average LOS by 0.8 days and the average LOS in the ED by more than two hours. This generated positive patient experience. Staffing was then aligned to support the new processes.
- Increased emergency department throughput
- Positioned departments for more savings from better labor utilization
- Improved competitive positioning by adding more private rooms without remodeling existing space
While new tools and processes play integral roles in these results, DiPaolo credits his hospital’s staff as being the biggest force for positive change. “Once you create a situation where people feel empowered to bring attention to problems, you create an environment where patients truly come first,” concluded DiPaolo.