Management Study

Completed by
Parul Verma
Spring 2010
 Contents
Management Study........................................................................................................................................................1

Completed by ................................................................................................................................................................1

Parul Verma...................................................................................................................................................................1

Spring 2010....................................................................................................................................................................1

Contents.........................................................................................................................................................................2

Title:............................................................................................................................................................................... 3

Background:................................................................................................................................................................... 3

Statement of the problem:.............................................................................................................................................4

Related research and How it is related to the Management concerns:..........................................................................4

Objectives: .................................................................................................................................................................... 6

Methodology:................................................................................................................................................................. 6

Limitations:.................................................................................................................................................................... 6

Findings:........................................................................................................................................................................ 7

Data Analysis – .......................................................................................................................................................... 7

Increasing trend in shift hours: ...............................................................................................................................7

Resource Availability............................................................................................................................................... 7

Survey Analysis........................................................................................................................................................... 8

Solution....................................................................................................................................................................... 8

Solution Approach 1: Utilize PRN staff for extra time...............................................................................................9

Solution Approach 2: Utilize PRN with guaranteed minimum shift hours.................................................................9

Solution Approach 3: Transfer patients to even shifts of other departments with regular staff or share resources
if possible................................................................................................................................................................. 9

Solution Approach 4: Alter Fridays shift timings......................................................................................................9

Conclusion:.................................................................................................................................................................. 10

Recommendations:...................................................................................................................................................... 11

References:.................................................................................................................................................................. 12

Assumptions................................................................................................................................................................. 13

APPENDIX A – Data & Analysis..................................................................................................................................... 14

Title:
The purpose of this management study is to help the management of the Medical College of Georgia (MCG) to

assess the requests of an Admission-Discharge-Transfer unit, of Medical College of Georgia and on the basis of the

assessment to add more human resources to the nursing unit, due to increased workload on Fridays as the floor had

been opening past closing times recurrently since the past one year. The nurse manager and staff feel that there

should be additional resources to meet the increasing demands and to maintain employee satisfaction.

Background:
This study is conducted for the eighth Admission-Discharge-Transfer Unit (hereinafterthe 8th ADT Unit) of the Medical

College of Georgia (MCG). The Hospital was founded in 1828 and includes has an adult medical centre (which is a

540-bedded facility), athe cChildren’s mMedical cCenter, a student center, a wellness center, an outstanding

medical education library, numerous extensive outpatient clinics, and residence halls, a student center, a wellness

center and an outstanding medical education library. MCG is considered as one of the largest employer in Augusta

area, with With approximately 5,000 faculty, staff, and residents., MCG is considered as one of the largest

employers in the Augusta area. The 8th ADT floor was opened in 2007 with an objective to be a release valve for the

bottlenecking of patients at the hospital’s entry points. As originally designed, the unit’s mission was to take direct

patient admissions from the Emergency department, clinics, hospital lobby and the minor surgeries of post

anesthesia care unit (PACU) as well as patient transfers out of an ICU until their permanent floor bed was available.

It was also designed to take patients discharged from the inpatient units who were waiting for transport, a test result

or last dose of antibiotics, etc. Hours of operation when the 8ADT was started were 7AM to 7PM Monday to Friday

and the floor was opened with a capacity of 18 beds.

Since past one year, as per the manager of 8 ADT there has been difficulty in placing patients to other unit due to

full capacity of all inpatient units, usually on Fridays. The 8th ADT normally opens for 24 hours for 4 weekdays from

Monday through Thursday and is supposed to close at 7 PM on Fridays. So for the past one year, the 8th ADT had to

open after normal closing timings due to the patients awaiting transfer to the inpatient units.. Shift supervisors have

to make several phone calls to schedule staff to do overtime for Friday evenings extending till late nights and the

unit even had to open all weekend on some occasions. Float nurses are called for working Friday nights or Saturday

which affects the budget due to their higher per hour wages as compared to regular RNs. When no staff is arranged

the staffs from 7 AM shifts have to stay till they are relieved or till there is a place to transfer the patients. On

occasion the Clerks and or PCTs leave the floor on Friday evenings at 7 PM, the nurses are left to do all the non

nursing tasks like answering phone calls, attending to patient call lights etc. This has a potential for causing a chaos

and it can be difficult for nurses to handle all the tasks and could impact patient care and safety.

Management is also concerned of the frustration among the nurses and other staff due to Friday shifts as nobody

wanted to work Fridays because of this problem . The problem also branches out to the possibility of high nursing

turnover and errors associated with overworked employees that may impact quality of patient care.

The issue here is a comprehensive one but the main areas of concern to the manager of 8ADT unit are problems

related to nursing dissatisfaction due to overwork which can also lead to poor quality patient care and possibly high

employee turnover. The 8 ADT had about 3 nurses leaving the floor in past 2 years and the current staff allocate

that to forced overtime they had to do on Fridays.

At MCG, the nursing units do face the problems related to understaffing which can consequently impact patient care

and patient satisfaction. Rigorous teachings and incentives are utilized to keep the employee morale high and

patient safety is emphasized for keeping the Quality of patient care at the best level. All Hospitals in general face

the problems of low staffing at some point during the current situation of nursing shortage, prospective payment

systems and the DRG as the basis of Medicare reimbursements. Hospitals try to operate in full capacity relative to

the staffing levels in order to deliver low cost; efficient but effective healthcare.

Statement of the problem:

The study addresses a management concern of weather adding more human resources is required

and/or helpful to the 8ADT unit which had been opening till late evenings on Fridays. This also finds out

about the staff dissatisfaction related to late stays and how it impacts patient safety.

The safety and quality of patient care can be affected by high probability of errors in taking care of patients by the

nursing staff when they work more than 12 hr shifts in a day. Low employee morale may lead to tensions at

workplace, inability to relate to coworkers, lack of efficient team work and potential of high employee turnover.

After interviewing the manager it was found out that there is a constant juggle about this issue and if the hospital

census remained the same way it is possible that they might have to open the floor to Friday nights and also

Saturdays so that the patients needing overnight observations could be discharged on the Saturdays and the floor

could be closed on Saturday after all discharges, due to no elective surgeries being performed on the weekends and

therefore no admissions from the PACU. The 8th ADT unit does not takes any discharge patients as they had too

many criterion for taking a discharge patient until they walk out of the hospital and most patients awaiting

discharge on the Inpatient units did not come under those criterion. The floor takes only the admissions and

transfers from PACU, ED or clinics and either discharges the patients the same day after surgery or transfers them

out to an inpatient unit. So with the capacity of 18 beds it may be transformed into a 24/7 Inpatient unit if the

demand for beds continued to increase but this is something that the management has to still explore and consider

reviewing on the basis of cost vs profit.

Related research and How it is related to the Management concerns:

As per Joint commission standards the healthcare organizations have to identify conditions and practices that

contributes to healthcare worker fatigue and the processes should be implemented that identifies fatigue that poses

a threat to patient safety. The healthcare organizations should also take action to mitigate the safety of patients

first. That is where the management of 8ADT is concerned and requires a solution to the springing issue which may

pose threats to patient safety if the issue remains as it is.

A report by press ganey in 2008, Employee and Nurse Perspectives on American Health Care Organizations

examines the viewpoints of about 200,000 employees among which 45,000 are nurses from 423 organizations. This

report presents employees’ and nurses’ greatest concerns with their organizations and identifies improvement

opportunities. Along with the appreciation the nurses have for the profession this report captures the frustration of

some nurses and their concerns about the profession. An interview with nurse mentions, the follows, “senior

leadership needs to get realistic about their expectations for nurses. We are overwhelmed by all the work we are

expected to accomplish with no ancillary support, along with outdated and antiquated equipment and systems.” The

above quote somewhat indicates that the reason for frustration is not being able to communicate the experience to
the management and being overwhelmed by the amount of work assigned to them. The study also mentions about

the high turnover of nurses and its poor impact to the organization. This relates to the issue of late stays on the 8

ADT as currently this is tiring out the nursing workers but consequently as the manager is concerned ,it may turn

out to be a weak morale of working on this unit and nurses looking forward to more rewarding and consistent

opportunities elsewhere.

A study published on-line by the journal Health Affairs indicates that hospital nurses working shifts of 12.5 hours or

more are three times more likely to make an error than nurses working shorter shifts. The study is based on data

from 393 members of the American Nurses Association who kept a log of their hours worked, overtime, days off, and

sleeping patterns for 28 days. The researchers found that in 39% of the 5,317 total shifts worked, the nurses worked

at least 12.5 consecutive hours, but only 7% involved mandatory overtime. And 14% of the respondents reported

working 16 or more consecutive hours at least once during the four-week period. Average, participants worked 55

minutes longer per day than scheduled and 40.2 hours per week. They reported making a total of 199 errors and

213 near errors during the period. About half the errors involved medication administration, while others involved

procedural, charting, and transcription errors. This study did not have any access to data related to any errors but

the long working hours at 8ADT place the nurses at risk of fatigue related errors compromising the goal of safety

first.

An article published in February 2004 - Volume 42 - Issue 2 - pp II-57-II-66 on Nurse Burnout and Patient

Satisfaction by Vahey, Doris C. PhD, RN; Aiken, Linda H. PhD, RN; Sloane, Douglas M. PhD; Clarke, Sean P. PhD, RN;

Vargas, Delfino PhD explains that Research on job-related burnout among human service workers, nurses in

particular, suggests that organizational stressors in the work environment are important determinants of burnout

and subsequent voluntary turnover.

Australian Resource Center for Healthcare Innovations (ARCHI) describes the short stay units to provide

short-term (<24 hours) assessment and/or therapy for select conditions in order to streamline the episode of care.

SSU front load resources to provide an intensive period of evaluation, treatment and supervision. The emphasis is

on enhancing patient flow through ED by allowing for early transfer out and improving ED bed access (Cooke:

Higgins & Kidd 2003: Hassan 2003: American College of Emergency Physicians 1994). Strong management and

policing of operational policies is vital. In particular, procedures for transfer out after 24 hours must be adhered to.

The 8 ADT unit takes admissions and discharges from different floors and it is modified to meet the OR demand

instead of ED. The elective minor surgeries are recovered here but it might take more than 24 hours for some

patients to get transferred or discharged. Technically, it does not meet this requirement of transferring out the

patient or discharging within 24hrs. Attempts are made especially on Fridays to transfer all patients to different

floors as per availability of patient beds which as per the data available from 8ADT was not possible during all the

Fridays the past year.

Another article from the medical Journal of Australia, by Sue Daly, Donald A Campbell and Peter A Cameron

examines how the short stay units affect the efficiency of healthcare delivery and quality of services provided. Their

research study concludes that the short stay units are effective in reducing costs, reducing length of stay, patient

satisfaction and improve efficiency of Emergence departments. The 8ADT does corresponds to some aspects of their

study by improving efficiency of emergency departments by accommodating short stay medical and surgical

patients and freeing the general medical surgical floors of beds for more complicated cases requiring clinical

intensive care. This study addresses staff satisfaction which is directly related to patient safety and satisfaction

which can be compromised if the staff is overworked or dissatisfied with their work.
Objectives:
1) To find best fit solution for 8ADT by meeting management needs of cost effective solution and
meeting employee satisfaction
2) To analyze root cause for employee dissatisfaction and recommend solution to improve/maintain
employee satisfaction
3) To develop an effective solution to decrease/eliminate 8ADT nurse manager’s concern of resource
planning
4) To develop a solution to minimize overtime costs and use of float pool nurses
5) To develop solutions to have right resources at right time

Methodology:
A two step analysis approach was taken to analyze the problem. In the first step, initial meetings were setup with

the nurse manager to understand her concerns and operations of the department. The nurse manager provided the

shift hours for each Friday evening for last one year. The data shows rooster of resources (PCT, R N, Clerks) and the

shfit closing time. This data is used to analyze capacity and costing scenarios. In the second step, in order to find

root cause for nurse dissatisfaction, a small survey was conducted on the employees of this department. A

questionnaire was prepared and distributed to the employees for their feedback and this information was used to

identify the dissatisfaction reason.

The collection of data for the purpose of this study was done by interviewing the manager of 8ADT floor. The

population under consideration is the staff of the 8ADT floor. The main subjects of this study are the staff nurses,

clerk and PCTs (Patient Care technicians) who were given a survey questionnaire and were also interviewed

randomly. The survey questionnaire had seven questions (Appendix B) that could be returned within 5 minutes by all

staff. The interview questions were consistent and were asked to each subject individually taking 10 minutes of their

shift time. As the study is to assess the satisfaction related to working long/late hours by the staff, one to one

interaction interview helped to reveal each staff member’s perspective on the issue.

Limitations:
The data received for shift hours did not have patient volume information, so staff volume is used to
estimate staffing requirements. Data for delay in transferring/discharging patient was not taken in scope
for the analysis. Data for patient satisfaction level and staff errors was also not taken in scope. Although
above data points were critical for analysis but were either not available or permission was not granted to
collect the data.

The survey for nurse dissatisfaction was conducted on a small group and hence may not be a true
representative of the actual population. Staff completed the survey during their working hours and were
interrupted during the process breaking their thought chain which could impact the quality of response.
Survey responses can be subjective and may bias the final results
The limitations of this study are that the survey and interviewing techniques use the subjective data and

perspectives of different subjects. The Assumptions are not based on facts collected from a large population but are

based on the views of the staff working on the 8ADT.

The study was done by interviewing the staff on their shift timings. In case of immediate need of patients or

physicians the interviews had to be interrupted to provide patient care (direct and indirect).The interviewing

technique could assess the relationship between the core issue of late stays and staff dissatisfaction but could not

entirely separate the staff dissatisfaction from other reasons for it.

Findings:

Data Analysis –

Increasing trend in shift hours:

The data for Friday shift hours for past 1 year is shown in the Appendix A. The unit was originally
scheduled to close by 7pm latest every Friday. However due to increase in patient intake and delay in
transferring patients, the shift close time for past few months is going beyond planned time causing
disruption in floor planning and employee dissatisfaction. Figure 1 and Figure 2 (without outlier) shows
variation in closing times.

Outlier

Rcd Id

Figure 1

Data shows a trend of

increase in shift hours

Figure 2

Resource Availability
Availability of right resource at right time is a major concern for planning resources in this department. It is
quite evident from figure 3 that a right resource mix (RN, PCT, Clerks) is not available every time. Example
PCTs were only present 26% percent of the time and unit clerks were present for on 56% of the time. This
increases the work load on the RNs and to substitute for the absent resources, float pool nurses (present
44% of the shifts) are scheduled costing more money.
 Figure 3

A closer look to the data shows the evidence for RNs dissatisfaction. Figure 4 shows that 37% of the time neither of the PCT and clerk
were available on the floor and thus their work was either performed by RNs of Float Pool nurses. Only 20% of the time both PCT and
clerks were available

Figure 3

Survey Analysis
A survey was conducted on the staff of the 8ADT unit to understand reason for employee absence and their dissatisfaction. A
questionnaire was developed and handed over to employees for their feedback. The survey showed that most of the employees were
not willing to work late on Friday nights. Married/Employees with kids were totally against working late on Fridays.
Unmarried/young people were indifferent to late timing shifts.
PCTs and clerks were not motivated enough to work late on Fridays so they normally leave early on Fridays. Their absence was a
major concern for nurses as they do not like to their jobs such as attending calls or unskilled tasks. As a result few of the nurses have
left the department in last few months and some are still complaining to the management.
Working long hours on Friday was also one of the major issues with the interviewees.

Solution
To solve the problem, different solution approaches were analyzed and the best approach will be recommended to the management
The analysis of the after shift hours shows that 81% of the time overtime was less than or equal to 3 hrs as shown in figure 5.

Figure 5
A baseline cost was calculated for the amount of overtime paid and it shows that management paid approximately $9922.0 as overtime
for this group for past one year. Management is expecting this number to rise this year due to indication of increase in workload in this
group.

Solution Approach 1: Utilize PRN staff for extra time

To avoid overtime and PRN staff can be planned to take over the charge from 7pm onwards every Friday till shift is closed.
This approach will eliminated overtime cost and PRNs will be paid based on shift closing times. Cost for this solution will be
$6,218.00 (see scenario 1 costing in Appendix A for details. Though this is the cheapest solution, it would be very hard to get
someone to work for only 1 hour at times and we may soon see the problem for PRNs not willing to come for 1 or 2 hrs

Solution Approach 2: Utilize PRN with guaranteed minimum shift hours

Most of the staff members are not willing to work 12+ hours’ shifts and as per data 81% of time shift goes up to 3 hrs. Also increasing
shift hours increases cost because of overtime.
To avoid frequent extra time by employees, a PRN staff can be hired for to work from 7pm to 10pm each Friday. This solution will
eliminate dissatisfaction of long working hours for employees and will assist nursing manager to plan resources and shifts well in
time. A minimum of 3 hrs shift for PRNs will cost approximately $7,225.0 (see scenario 2 costing in Appendix A for details)

Solution Approach 3: Transfer patients to even shifts of other departments with regular
staff or share resources if possible
In the interview the manager told that they tried to do this approach in the past and met with high resistance so it
was not further analyzed in this study.

Solution Approach 4: Alter Fridays shift timings

In order to fulfill 15-16hr shifts on Friday, the current morning shift of 7am to 7pm can be changed to 7am to 3pm and a second shift
can be introduced from 3pm to 10pm.
There will be no impact to overtime cost with this approach and 7 hrs on second shift will give enough motivation to employees to
pick shifts. The cost for scenario will also be same as approach 2 i.e. $7,225.0 (see scenario 2 costing in Appendix A for details).
However that major difference is that unlike only 3 hrs guaranteed in approach 2, this gives 7 guaranteed hours to the employees
which is quite right sized workload for a person.
Conclusion:
After analyzing data and reviewing various approaches, solution 4 seems to be the best fit to resolve
the problem. This solution will also help in improving employee job satisfaction. A comparative analysis
for all approaches is shown in figure 6. Even though cost for solution 4 is slightly higher than solution
1, its chances of success far out-weighs other solutions and thus makes it the best solution.

Very High Solution 4

Chances of Success

High Solution 2

Low Solution 1

Negative Solution 3

Cost  TBD 6k 7k

Figure 6

As per the survey, interviews and the data available from the 8 ADT unit , staff had to do recurrent overtime by
staying late till past closing times on Fridays in the last one year ( Shown in Appendix A). The survey and interviews
also tell us about the dissatisfaction of staff working on the floor due to the problem of staying till late evenings on
Friday. The staff is concerned of patient safety when they work overtime especially after 12 hour shifts. Nurses
often, on Friday evenings have to work in the absence of either PCTs or Unit Clerks and sometimes both. As per the
findings the problem of late stays need to be resolved to maintain the staff satisfaction for efficient and effective
patient care.
Recommendations:
The following recommendations can be helpful to the management in terms of cost, employee satisfaction and
patient safety.

1) To hire prn staff for a minimum of 3 hours. If a nurse ,PCT and a clerk is hired on a prn basis for three hours
for Friday evenings it will solve the problem of staff working day shift on Friday and they will be able to leave
at the end of their shift. Appendix C calculates the regular pay for all the 3 workers (Nurse, Clerk and PCT) and
if paid on a regular time basis, the cost to the unit will be less than the overtime payed currently to the staff.
Observing the past data, 81% of the overtime was upto 3 hours and the prn staff could be given regular pay
for the hours they work. If the unit opens for less than 3 hours they still should be getting pay for 3 hours. If
the unit opens for more than 3 hours they can get regular time pay (and not overtime) for the hours worked.
This way there is an incentive to come and work for some hours for people who work on different units and
want additional working hours. As most of the hospital workers work 3 or 4 days a week it is easy to find such
prn workers who can commit 3 hours a week (Friday only) on 8 ADT unit. These staff can come at 7 PM on
Fridays to relieve all the 12 hour shift employees from the Day shift so they can leave on time.

2) Another recommendation that will be helpful in solving this issue is to change the shift timings from 12 hours
to 8 hours shift on Fridays. Morning shifts starting from 7 AM to 3 PM and Evening shift starting from 3 PM to
11 PM can be implemented. This is suggested because it will help staff coverage to be scheduled till 11 PM on
Fridays which is usually the time by which there is patient placement available on other floors of the hospital
and patients can be transferred to close the unit on time that will be 11 PM after implementing this new
schedule.

3) Conducting a feasibility study on whether the unit could be opened for another day (Saturday) will be helpful.
To support the decision a full cost volume profit of hiring more human resources and increasing the cost of
opening the unit relative to patient volume can be explored further.
References:
• 2004 American Health Consultants, Inc. HEALTHCARE BENCHMARKS AND QUALITY IMPROVEMENTS. Sept
2004

• http://www.pressganey.com/galleries/default-file/Employee_Nurse_Check-Up_10-08-08.pdf

• February 2004 - Volume 42 - Issue 2 - pp II-57-II-66, Original Article: Nurse Burnout and Patient Satisfaction
,Vahey, Doris C. PhD, RN; Aiken, Linda H. PhD, RN; Sloane, Douglas M. PhD; Clarke, Sean P. PhD, RN; Vargas,
Delfino PhD

• http://www.archi.net.au/e-library/moc/emergency-moc/aboutssu

• http://www.mja.com.au/public/issues/178_11_020603/dal10608_fm.html
Assumptions

1. A nurse can handle 4 patients

2. A PCT can handle 10 patients

3. A Clerk can handle 15 patients

4. Salary for RN = $25/hr

5. Salary for Float Pool nurse = $30/hr

6. Salary for Clerk = $14/hr

7. Salary for PCT = $14/hr

8. Number of nurses present on a shift is used to estimate the number of patients

9. Overtime is paid at 1.5 times the normal hour salary

APPENDIX A – Data & Analysis