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How to Cut Overreliance on Contract Nurses

 |  By Alexandra Wilson Pecci  
   July 01, 2014

Realigning leadership, beefing up in-house resources, and centralizing nurse staffing helped one Iowa hospital save money and decrease turnover.

Alegent Creighton Health Mercy Hospital in Council Bluffs, IA had a staffing problem.

It had a lean staffing model—so lean, in fact, that the hospital was relying more and more heavily on an outside nurse staffing pool called Noll Pool that's meant to fill emergency, same-day absences at the hospitals in the Omaha-based Alegent Creighton Health system.

When Denise McNitt, MS, RN, NEA-BC, started as chief nurse at Mercy in January 2012, the hospital's nurse staffing problem was about to hit its tipping point.

"We really hit an unsustainable number of contract hours," says McNitt, who is now vice president of patient care services. Although Mercy Hospital isn't the largest hospital in the Alegent Creighton Health system, it was using a much bigger percentage of Noll resources than other hospitals.

And because Mercy Hospital was dipping into the emergency pool so much, it was getting harder to staff the rest of the system, too. "My problem at Mercy was starting to affect all the other hospitals," McNitt says.

Mercy Hospital was also experiencing a significant amount of turnover among its core nursing staff. McNitt says the hospital was itself continually taking people off of some shifts to cover others, and directors were competing with each other for core staff, in addition to being overreliant on the Noll Pool.

"We were in a reactive mode," she says. "We were robbing Peter to pay Paul."

Analytics showed that the units were actually overstaffed, but the hospital's own, in-house float pool was down to just six people; in other words, nearly nonexistent. Managers were staffing their own units, and there was no central person responsible for overseeing hospital-wide staffing (a "quarterback," as McNitt calls it).

"It got worse and worse as the summer months went by," McNitt says. "We knew we had to do something."

So she pulled together her team of directors; ran staffing analytics with Avantas; and conducted surveys at the unit and house levels to find out what staff believed to be the No. 1 issues for the hospital.

The surveys showed that the lack of an in-house float pool was a huge problem, as was the very high incidence floating that staff nurses did outside of their own units. This was all exacerbated by the lack of a "quarterback." In addition, there wasn't 24/7 team lead coverage.

"We were setting [ourselves] up for competition among our own units," McNitt says. "We put together a plan to work on each of those gaps."

The Solution
The first step, she says, was to hire a daytime house supervisor to take the staffing pressure off of the unit directors. They also hired round-the-clock team lead positions, increasing the number from one per floor to three or four per department.

Next, they realigned the leadership of the units so the critical care and post-critical care units were under one director and the medical-surgical and orthopedic medical-surgical units were under another. These units were made partner units.

"The goal was to align the competencies of the nurses," McNitt says.

Realigning the units also helped realign staff. No one wanted to "float." Instead, nurses were cross-trained for both of the partner units. In addition, all new hires come onboard with the understanding that they'll be trained for and work on both partner units.

"[It is] expected that they will go equally to both units," McNitt says, which eliminates the "floating" mentality.

Another way that the floating mentality has been changed is through the name itself. Mercy Hospital not only substantially beefed up its float pool—from six to 60 nurses—but has also renamed it the "resource team." The hospital recruits to fill the resource team specifically, and has even hired some nurses from within the hospital's core staff.

"I've really gotten away from using the word 'float' because it has such a negative connotation," McNitt says. "It really isn't a float pool; it's a resource team."

Now the mentality of being part of the resource team has truly changed.

"They're not floating. That's just what they were hired to do," she says. "We were very intentional about who we hired, we were very picky about who we hired."

So far, the changes have yielded positive results. According to McNitt, the hospital has reduced floating among its core staff from 4.6 FTE-equivalent per pay period in FY2012 down to 1.5 FTE-equivalent per pay period as of the second quarter of FY 2014.

Float Reduction

FY2014

FY2012

1.5 FTE-equivalent

4.6 FTE-equivalent

In addition, the turnover rate fell from 15.3% in FY 2012, to about 10% in FY 2014. The hospital also saved $600,000 between FYs 2012 and 2013.

Turnover Rates

FY2014

FY2013

FY2012

10%

12%

15.3%

Nurses are happy with the changes, too.

"There's been a lot of very positive feedback from the nurses," McNitt says. "It's rare that I hear anyone complain about staffing."

In fact, there's been a complete reversal from January 2012. McNitt believes that Mercy Hospital's contract usage is now among the lowest in their healthcare system. And now that staffing isn't an issue anymore, the directors can put more of their energy toward patient care.

"They've got other things to worry about on a daily basis," McNitt says. "But staffing's not one of them."

Alexandra Wilson Pecci is an editor for HealthLeaders.

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