Exploring the workload balance effects of including continuity-based factors in nurse-patient assignments

Workload balance in nurse-patient assignments is important for ensuring quality in patient care. Unbalanced workloads can lead to high levels of nursing stress, medical errors, lower-quality outcomes, and higher costs. Studies have pro-posed assignment strategies based on patient acuity, location, and characteristics of specialized units. These methods do not address the part of workload associated with continuity in care coordination, and the potential benefits associated with continuity-based assignments. We present the results of a pilot simulation study comparing an acuity-oriented method to a continuity-based approach, using acuity as a measure of workload. Our results suggest that a purely continuity-based approach can result in skewed workloads when measured by patient acuity. In future work, we plan to consider hybrid methods, which may be able to provide the benefits of both continuity and acuity based methods

Multiple Criteria Decision Models for Nurse-Patient Assignment: Balancing Workload and Continuity of Care

Continuity of care is critical for delivering high-quality care, yet has seldom been considered in models supporting nurse-patient assignment decisions within inpatient units. Research in the nursing literature suggests that assigning nurses to patients they have cared for previously can help reduce care-related error rates and increase patient satisfaction. However, it is also essential to ensure that patient workloads are allocated to nursing staff in a balanced manner to avoid overwork and burnout. This study investigates the tradeoffs associated with the assignment of patients to nurses in inpatient settings under the dual objective of maximizing continuity of care and minimizing workload imbalance. We develop a hybrid method that balances the need for fair workload distribution and continuity of care, and demonstrate the extent of the tradeoff between the level of continuity achieved and the associated cost in workload balance. To reduce the impact of this tradeoff, we relax the goal of maximizing continuity by introducing an acuity threshold. Here, patients with acuity values above the threshold vi are targeted for continuity-based assignment, and remaining patients are assigned to minimize workload imbalance. We evaluate the utility of introducing the threshold under a variety of hospital environmental conditions using a simulation model of the inpatient environment. Our findings show that it is possible to provide a substantial continuity assignment with a marginal impact on workload imbalance under the hybrid policy using the acuity threshold. In virtually all cases studied, the results show that it is possible to use the acuity threshold and gain the benefits of continuity of care, even under conditions of a strong preference for minimizing acuity imbalance

Effects of Incorporating Patient Acuity into the RN Assignment Process

As the largest sector of healthcare, nurses are the primary providers of patient care. By 2025, it is estimated that there will be a shortage of over 250,000 registered nurses (RNs) (American Association of Colleges of Nursing, 2011). Factors contributing to the nursing shortage include increased complexity of patients and decreased staffing that leads to decreased job satisfaction (Fox & Abrahamson, 2009). Over half of neonatal intensive care nurses reported missing at least one nursing task per shift when staffing was inadequate or patient acuity was high (TubbsCooley, Pickler, Younger, & Mark, 2015). The purpose of this evidence-based practice (EBP) project was to evaluate the effects of incorporating patient acuity into nursing assignments on nursing satisfaction and workload measures over a 3-month period. Kanter’s (1996) theory of structural empowerment and the Iowa model (2015) were used to guide the project on two medical units at a large pediatric hospital. Assignments for RNs were made by charge nurses who considered total patient acuity and each nurse’s proficiency level when making assignments. Nurses were surveyed using the Nurse Workload Satisfaction Questionnaire (NWSQ) pre- and post-implementation. In addition, two workload measures – pain reassessment within 30 minutes and medication given within 1 hour of scheduled time – were monitored throughout the study. Using paired t-tests, NWSQ scores showed a statistically significant increase in overall RN satisfaction. The mean pre-intervention NWSQ scores (M = 35.14, SD = 8.245) were compared to the mean post intervention NWSQ scores (M = 29.23, SD = 6.195, t = 2.833, p = .014). Other statistically significant improvements were found in the relational portion of the NWSQ, which gauges colleague relationships. There were no changes in the success rate of the two workload measures. Findings from this project support the incorporation of patient acuity into the nursing assignment process

Effects of Incorporating Patient Acuity into the RN Assignment Process

As the largest sector of healthcare, nurses are the primary providers of patient care. By 2025, it is estimated that there will be a shortage of over 250,000 registered nurses (RNs) (American Association of Colleges of Nursing, 2011). Factors contributing to the nursing shortage include increased complexity of patients and decreased staffing that leads to decreased job satisfaction (Fox & Abrahamson, 2009). Over half of neonatal intensive care nurses reported missing at least one nursing task per shift when staffing was inadequate or patient acuity was high (TubbsCooley, Pickler, Younger, & Mark, 2015). The purpose of this evidence-based practice (EBP) project was to evaluate the effects of incorporating patient acuity into nursing assignments on nursing satisfaction and workload measures over a 3-month period. Kanter’s (1996) theory of structural empowerment and the Iowa model (2015) were used to guide the project on two medical units at a large pediatric hospital. Assignments for RNs were made by charge nurses who considered total patient acuity and each nurse’s proficiency level when making assignments. Nurses were surveyed using the Nurse Workload Satisfaction Questionnaire (NWSQ) pre- and post-implementation. In addition, two workload measures – pain reassessment within 30 minutes and medication given within 1 hour of scheduled time – were monitored throughout the study. Using paired t-tests, NWSQ scores showed a statistically significant increase in overall RN satisfaction. The mean pre-intervention NWSQ scores (M = 35.14, SD = 8.245) were compared to the mean post intervention NWSQ scores (M = 29.23, SD = 6.195, t = 2.833, p = .014). Other statistically significant improvements were found in the relational portion of the NWSQ, which gauges colleague relationships. There were no changes in the success rate of the two workload measures. Findings from this project support the incorporation of patient acuity into the nursing assignment process

Nursing workload balancing: Lean healthcare, analytics and optimization in two Latin American University Hospitals

91 páginasIn most Latin American hospitals, the workload assignment of healthcare workers is a crucial process. These strategies seek to improve the level of patient care and safety while avoiding incurring unnecessary costs by hiring and maintaining excessive staff. The distribution of activities falls to the chief nurses in the hospital, taking as criteria for allocation the number of patients rather than the complexity of care that each individual carries. Specifically for the inpatient area and for nursing professionals, it is complex to determine an adequate distribution of human resources, considering the diagnosis of the patients and the number of tasks that a nursing professional must carry out throughout the day. Therefore, this work proposes the development of a strategy and a load-balancing model based on lean healthcare theory, analytics, and mathematical optimization, so that working hours do not result in the generation of stress and the presence of burnout in nurses. Likewise, mathematical modelling maximizes the use of the nursing staff’s capacity, generating awareness based on the integration of continuous improvement theories so that the clinics can be updated to technological trends. Finally, this project is part of a macro-project for the development of technologies that support hospital nursing processes, carried out by the Universidad de La Sabana Clinic in Colombia and the Universidad de los Andes Clinic in Chile, so the results of this project impact two clinics in Latin America.En la mayoría de los hospitales latinoamericanos, la asignación de carga laboral al personal de la salud es un proceso de vital importancia. Estas estrategias buscan mejorar el nivel de atención al paciente y la seguridad, sin tener que incurrir en gastos innecesarios por la contratación y manutención de un personal excesivo. Esto conlleva a la distribución de las actividades recae en los jefes de las áreas en el hospital, tomando como criterios de asignación la cantidad de pacientes y no la complejidad del cuidado que acarrea cada individuo. Específicamente para el área de hospitalización y para los profesionales de enfermería, resulta complejo determinar una distribución adecuada del recurso humano teniendo en cuenta el diagnóstico de los pacientes y la cantidad de tareas que debe realizar un profesional de enfermería a lo largo de su jornada. Por ello, este trabajo propone el desarrollo de una estrategia y un modelo de balanceo de carga a partir de la teoría lean healthcare, analítica y optimización matemática, de tal forma que las jornadas laborales no resulten en la generación de estrés y la presencia de burnout en los enfermeros. Así mismo, se logra maximizar el aprovechamiento de la capacidad del personal de enfermería, generando bases de concientización sobre la integración de teorías de mejora continua para que las clínicas puedan actualizarse a las tendencias tecnológicas. Por último, este proyecto se enmarcó en un macroproyecto para el desarrollo de tecnologías que soporten los procesos hospitalarios de enfermería, llevado a cabo por la Clínica Universidad de La Sabana en Colombia y la Clínica Universidad de los Andes en Chile, por lo que los resultados de este proyecto impactan dos clínicas en Latinoamérica.Maestría en Diseño y Gestión de ProcesosMagíster en Diseño y Gestión de Proceso

Improving Emergency Department Throughput: Using a Pull Method of Patient Flow

Practice Problem: Overcrowding in the emergency department (ED) has been shown to increase the length of hospital stay, adversely impact patient outcomes, and reduce patient satisfaction. Problems with overcrowding and throughput are often thought of as an ED-specific inefficiency; however, the issue is indicative of hospital-wide inefficiencies. PICOT: The PICOT question that guided this project was “For ED patients admitted to the medical-surgical unit at an acute medical center, will the implementation of a pull model for patient flow, when compared to the current push model, reduce admission delay and length of stay (LOS) within six weeks of implementation? Evidence: A total of 21 studies were identified in the literature that directly support the implementation of this project. Themes from the literature include delays adversely impact patients, ED throughput is directly affected by throughput of inpatient units, and bed ahead programs can improve throughput. Intervention: The primary intervention for this project was implementing a bed ahead process for the host facility. The nurse hand-off process was also altered to improve efficiency. Outcome: The project resulted in an improvement in the ED delay time. During the project, the mean admission delay time was reduced from 184 minutes to 112 minutes. Conclusion: Using a pull methodology effectively enhances ED throughput by reducing delays in the ED admission process

Improving Compliance with the SEP-1 Sepsis Management Bundle

Abstract Problem: Providing high quality sepsis care is an organizational priority, however this medical center has only met the target compliance goal for the Centers for Medicare & Medicaid Service (CMS) SEP-1 sepsis management bundle 50% of the time over the past year. Root cause analysis has revealed that 40% of the fallouts have been attributed to non-compliance with the intravenous fluid bundle element. Context: A microsystem analysis was completed on the quality department, a supporting microsystem to the larger mesosystem involved with providing acute sepsis care. A return-on-investment analysis demonstrated that efforts to improve sepsis care and reduce sepsis progression could have significant cost savings for each patient that has reduced morbidity or length of stay. Intervention: An online education module focused on weight-based intravenous fluid orders was developed and assigned to all emergency department and inpatient nurses. A sepsis bundle checklist tool was implemented, and huddle messages were also delivered at physician staff meetings. Measures: The outcome measure was the percent of adult patients with severe sepsis and/or septic shock that met all elements of the CMS SEP-1 sepsis management bundle. Process measures included compliance with the intravenous fluid bundle element as well as compliance with order set use. Results: The outcome measure of overall SEP-1 compliance post project implementation rose from 69.3% to 71.4%. Intravenous fluid bundle compliance rose from 81.6% to 100% for adult patients with septic shock and from 86% to 87% for adult patients with severe sepsis. Compliance with use of the septic shock order set rose from 45.6% to 77.6% post project implementation. Conclusions: In conclusion, the implications for practice based on this project are significant. While the specific project aim was not achieved, in the short span of 4 months substantial improvements were seen with intravenous fluid sepsis bundle element compliance as well as sepsis order set utilization. It is expected that these improvements will contribute to ongoing improved compliance with the CMS SEP-1 sepsis management bundle moving forward

Registered Nurse Satisfaction: The Impact of Organizational Communication on Satisfaction among Registered Nurses in the Acute Care/Hospital Setting

Organizational communication can impact the satisfaction of registered nurses in the acute care hospital setting. With the projected growth of the nursing profession, recruitment and retention of registered nurses is essential in building a highly engaged workforce. Literature review identified areas that impact nurse satisfaction including salary and benefits, nursing leadership, nursing engagement, and nursing workload and staffing. The researcher recognized a gap in the literature regarding the impact of organizational communication on satisfaction of registered nurses in the acute care hospital setting. This study evaluates the difference in the satisfaction of organizational communication among registered nurses who spend less than 50% of their time in direct patient care and registered nurses who spend 50% or more of their time in direct patient care in the acute care/hospital setting. The Job Satisfaction Survey tool by Paul E. Spector was disseminated to members of the Academy of Medical-Surgical Nurses via a Survey Monkey link to aid in the evaluation of perceived organizational communication between the two groups. The research study data found that registered nurses spending less than 50% of time in direct patient care were dissatisfied more than those spending 50% or more of time in direct patient care in the three of the four organizational communication categories: communications within the organization, knowing what is transpiring within the organization, and full explanation of work assignments. Research showed that both groups felt that they had a clear understanding of the goals within the organization. Implications for nursing practice include professional and career development of nurse leaders, improvement of communication tactics and techniques among the leadership team and organization, and validation of communication techniques

Leveraging the Granularity of Healthcare Data: Essays on Operating Room Scheduling for Productivity and Nurse Retention

The primary objective of this dissertation is to provide insights for healthcare practitioners to leverage the granularity of their healthcare data. In particular, leveraging the granularity of healthcare data using data analytics helps practitioners to manage operating room scheduling for productivity and nurse retention. This dissertation addresses the practical challenges of operating room (OR) scheduling by combining the existing insights from the prior literature through various tools in data analytics. In doing so, this dissertation consists of three chapters that operationally quantify the operational characteristics of the operating room and surgical team scheduling to improve operating room outcomes, including OR planning and OR nurse retention. This dissertation contributes to healthcare operations research and practice by emphasizing the importance of using granular information from hospitals’ electronic health records. While the prior research suggests that different team compositions affect OR productivity and OR time prediction, the empirical insights on how the team composition information can be utilized in practice are limited. We fill this gap by presenting data-driven approaches to use this information for OR time prediction and nurse retention. The first and third chapters deal with OR time prediction with the granular procedure, patient, and detailed team information to improve the OR scheduling. The second chapter deals with the OR nurse retention problem under OR nurses’ unique work scheduling environment. The first chapter, which is a joint work with Ahmet Colak, Lawrence Fredendall, and Robert Allen, examines drivers of OR time and their impact on OR time allocation mismatches (i.e., deviations of scheduled OR time from the realized OR time). Building on contemporary health care and empirical methodologies, the chapter identifies two mechanisms that spur scheduling mismatches: (i) OR time allocations that take place before team selections and (ii) OR time allocations that do not incorporate granular team and case data inputs. Using a two-stage estimation framework, the chapter shows how under- and over-allocation of OR times could be mitigated in a newsvendor ii setting using improved OR time predictions for the mean and variance estimates. The chapter’s empirical findings indicate that scheduling methods and the resulting scheduling mismatches have a significant impact on team performance, and deploying granular data inputs about teams—such as dyadic team experience, workload, and back-to-back case assignments—and updating OR times at the time of team selection improve OR time predictions significantly. In particular, the chapter estimates a 32% reduction in absolute mismatch times and a more than 20% reduction in OR costs. The second chapter, which is a joint work with Ahmet Colak and Lawrence Fredendall, addresses the turnover of OR nurses who work with various partners to perform various surgical procedures. Using an instrumental variable approach, the chapter identifies the causal relationship between OR nurses’ work scheduling and their turnover. To quantify the work scheduling characteristics—procedure, partner, and workload assignments, the chapter leverages the granularity of the OR nurse work scheduling data. Because unobserved personal reasons of OR nurses may lead to a potential endogeneity of schedule characteristics, the chapter instruments for the schedule characteristics using nurse peers’ average characteristics. The results suggest that there are significant connections between nurse departure probability and how procedures, partners, and workload are configured in nurses’ schedules. Nurses’ propensity to quit increases with high exposure and diversity to new procedures and partners and with high workload volatility while decreasing with the workload in their schedules. Furthermore, these effects are significantly moderated by the seniority of nurses in the hospital. The chapter also offers several explanations of what might drive these results. The chapter provides strategic reasoning for why hospitals must pay attention to designing the procedure, partner, and workload assignments in nurse scheduling to increase the retention rate in the ongoing nursing shortage and high nurse turnover in the U.S. The third chapter, which is a joint work with Ahmet Colak, Lawrence Fredendall, Babur De los Santos, and Benjamin Grant, systematically reviews the literature to gain more insights into addressing the challenges in OR scheduling to utilize granular team information for OR time prediction. Research in OR scheduling—allocating time to surgical procedures—is entering a new phase of research direction. Recent studies indicate that utilizing team information in OR scheduling can significantly improve the prediction accuracy of OR time, reducing the total cost of idle time and overtime. Despite the importance, utilizing granular team information is challenging due to the multiple decision-makers in surgical team scheduling and the presence of hierarchical structure in surgical teams. Some studies provide some insights on the relative influence of team members, which iii partly helps address these challenges, but there are still limited insights on which decision-maker has the greatest influence on OR time prediction and how hierarchy is aligned with the relative impact of surgical team members. In its findings, the chapter confirms that there are limited empirical insights in the existing literature. Based on the prior insights and the most recent development in this domain, this chapter proposes several empirical strategies that would help address these challenges and determine the key decision-makers to use granular team information of the most importance

A Systematic Review of Acuity-Based Staffing in Acute Healthcare Environments

Nursing leadership is responsible for considering the equity of patient care assignments when providing nursing care. Nursing leadership is responsible for assuring the delivery of patient care assignments with the intent to offer nurses an unbiased, evenly distributed patient load. Effective distribution of patient care assignments ensures patients receive the safest, most efficient, and highest quality of care. The purpose of this project was to provide nursing leadership with an executive summary of a systematic review of evidence-based research on the structure and process of making patient care assignments, and it provided evidence on how those patient care assignments affect the quality of care provided to patients. The researcher conducted a systematic review of the literature to inform stakeholders about best practices used for acuity- based staffing. The systematic review of the literature involved using the PRISMA model as a structured assessment to screen and eliminate articles during the article search. All data from the systematic review were synthesized to collectively determine each acuity-based tool’s effects on patient care assignments within the acute care settings. The review of articles found that the implementation of acuity-based staffing tools in an acute care setting is associated with outcomes that included self-efficacy or retention, patient and nurse satisfaction, quality of care, and other additional findings. This systematic review of literature provided information to healthcare professionals about literature and the influence of implementing acuity-based staffing tools for patient care assignments in acute care settings. The project also included an implication of analysis for leaders and recommendations for change and future research