Here’s how Children’s Hospital of Philadelphia (CHOP) creates staffing efficiency in the emergency department with data, role clarification and flexibility.
The PROSPECT data program helps hospitals develop appropriate staffing standards, reduce costs and maintain viability in the marketplace. Data supports peer benchmarking and the discovery of improved performance practices.
For more information, contact Carla Hronek.
CHA members: Access recorded webinar and presentation slides here.
Emergency department (ED) managers face staffing challenges due to the nature of the department—people usually don’t plan a trip to the ED. Since most patients arrive in the ED unexpectedly, it may appear as though managers have to plan staffing without insight into patient volume variation.
ED managers often wish they had a crystal ball to make predictions. At Children’s Hospital of Philadelphia (CHOP) a team has found the next best thing, using data to uncover trends in care, predict when to expect variation in volume and determine how to staff for volume change. The team can see how patient volume may rise and fall months at a time or on a seasonal basis. Volume on each day of the week can have a pattern too.
To help hospitals uncover trends in data, CHA’s PROSPECT program captures a vast library of operational metrics. To see how CHOP performed, CHA analysts compared four staffing criteria from PROSPECT to identify high-performing pediatric EDs, and CHOP emerged as one of the top four hospitals.
Here’s how CHOP performed in four areas ranked through PROSPECT data:
Emergency Department Team Structure
Staff cover a range of 88 to 120 beds based on the season with an additional three rooms reserved for resuscitation. The physical layout of the ED at CHOP is structured for the eight focused teams. Here’s how the teams are assigned.
Teams 1 and 2
- 32 beds
- Available 24 hours a day
Teams 3 and 4
- 27 beds
- Open 16 hours
- During low season, team 4 is used for fast tracking low acuity patients.
- Team 3 can also flex open overnight for high-occupancy in patient holds
- 14 beds, including four safe rooms
- Observation and extended care
- Up to 24 beds, borrowing space from the cardiology clinic
- Activated during moderate to high census season
- Six rooms
- Start care when appropriate
- Four beds
- Behavioral health patients
Successful Staffing Strategies
CHOP begins the staffing planning process by establishing a budget that matches projected volumes. The planners consider what is needed for the coming year based on data that reveals three variable seasons and the days of the week that influence volumes.
“Managers pay close attention to nursing productivity so they can schedule the right type of care based on patients’ needs,” says Jackie Noll, RN, senior director of Emergency Nursing at CHOP. “Deciding on staffing levels is a collaborative process that includes nursing, medicine and finance.”
CHOP maximizes efficiency by clarifying roles and giving staff flexibility. While RNs make up of most of the ED staff, CHOP hired two LPNs with previous experience in the hospital to work as ED LPNs with vital roles in the Team 5 observational area. The hospital merged the original two ED tech roles into one to eliminate confusion about what skills the techs could perform.
Charge nurses, team leaders and patient flow coordinators have additional roles, which vary based on time of day and season. The team tries to carve out roles that may not have direct patient contact but are important to managing ED activities.
“We use PROSPECT data to help compare worked hours per unit of service (WHPUOS) for primary staff who provide direct patient care and secondary staff who are more management or leadership,” says Stewart. Leaders incorporate PROSPECT data into a biweekly analysis to determine if WHPUOS should increase or decrease based on volume. The key to success is staffing volume, not to the room.
Some organizations rely on agency staff to supplement department needs, but CHOP does not use agency staff as a solution to meet high volumes. “Using agency staff is not philosophically supported by leadership,” says Noll. “We like to have staff who are really part of our team, culture and engaged with the hospital.”
When nurses leave the organization or take extended leave, it’s important that the ED has enough staff to cover high volumes. But if the ED experiences a dip in available staff, managers know they can’t ask to fill positions when the unit is missing its productivity mark. Everyone in the unit is up to date on the latest financials. Knowledge about where the unit stands on productivity and staffing helps everyone be on the same page to deliver financial savings for the organization ensuring the hospital can offer competitive pay.
The need for additional staff fluctuates so the ED team builds a staffing pipeline to keep the organization stable. Experience showed if a team is not fully hired it can produce more turnover because it’s hard for people delivering pediatric care to maintain resilience over time.
“The ED volume for FY 2019 was an all-time record high. Our our worked hour per unit of service was favorable by 3.7% over the prior year.”
—Tim Stewart, senior operations manager, Surgical Services and Clinical Operations
Using Data to Get Results
The hospital celebrated a record high volume in fiscal year 2019 with over 100,000 visits. Even with higher volume, full time equivalents (FTEs) came in under budget. “We staff to the volume, which really reflects the true measure of value as far as cost and trying to make things as productive as possible,” says Stewart. “The ED FY 2019 volume was an all time record hight. Our worked hour per unit of service was favorable by 3.7% over the prior year."
PROSPECT helped CHOP’s leaders find trends to support the need for variances in staffing throughout the year. In addition, staff and providers receive a data report to stay up to date on the latest census trends. If events, such as the flu, produce a volume spike, leaders develop strategies to prepare to treat more patients.
As part of a quality improvement project exploring how to better match physician schedules with ED schedules, CHOP added Kronos data to its analysis process to manage shift structure and staff to volume.
The hospital offers seven different:
- 12-hour shifts
- Eight-hour shifts
Staffing managers planned on providing a choice of several shift options but hit a roadblock when the Kronos program didn’t work with the wide variety of shift data. To overcome the technical problem, the team eliminated four-hour shifts that started on even hour shifts, e.g., 10 a.m. - 6 p.m., 6 p.m. - 2 a.m. Managers created some overlap in shifts to allow for meals or participation in projects and meetings.
The staffing model is flexible to respond to increases or decreases in volumes daily. The charge nurses huddle with the physician leaders to decide whether to close the team early or to send staff home or assist in other areas with needs. “It’s a true partnership,” says Jane Lavelle, M.D., associate director of the Emergency Department. “To add a physician to the mix without adding a nurse partner doesn’t help.”
Typically, staff is supportive of working overtime, and requests are strategically managed to decrease overtime needs in low volume to have the budget to support overtime in higher volumes. Teams open based on volume, so during the summer low census period, staff can volunteer to fill needs in other areas of the hospital. Nurses select areas where they can gain new skills and experience. “We ensure nurses are practicing at the highest scope,” says Lavelle. “We support a culture of lifelong learning, and it’s important nurses embrace the opportunity. I rely on their knowledge because every day they direct me to the patient I need to see next.”
Continue Progress in Behavioral Health Care and Discharge
Many pediatric hospitals report difficulty planning for staff to treat the rise in these children who often present in the ED. The closure of a local pediatric crisis center created additional need for urgent mental health care at CHOP. Beds or areas for treatment in CHOPS’s ED are limited and don’t support the long-term stay usually necessary for these patients.
To address the challenge of more children seeking mental health care, CHOP assigned social workers and the psychiatry team to manage LOS in the ED. The hospital also added electronic tools to reduce the duplication of documentation. These changes produced positive outcomes. While the volume doubled, the teams reduced LOS.
In addition, the Quality Improvement (QI) team addressed the need for efficiency in ED discharge time with a QI project to streamline the process for lower acuity cases. The new process focuses on discharging patients who don’t need to be admitted. The strategy encourages ED physicians and advanced practice providers to treat and discharge Emergency Severity Index (ESI) 4 and 5 patients more quickly, which creates more room for the higher acuity ESI 1 and 2 patients.
“The collaborative effort between the physician group and the nursing group is so strong,” says Debra Potts, RN, nurse manager, ED. “That’s what really makes the operation of our ED a grand slam.”