[color=#336699]health leaders speak out
karen williams fraser: a schedule that nurses like
by kara olsen, for healthleaders news, feb. 2, 2004
roper st. francis healthcare in charleston, s.c., is a nonprofit system including 384-bed roper hospital and 141-bed bon secours st. francis hospital. since september 2003, both hospitals' staff of 600 inpatient rns have been working under a newly created scheduling system that aims at improving employee satisfaction by giving them predictability in their schedule.
the system has done away with mandatory weekends and shift rotations, and nursing leadership no longer must spend as much valuable time preparing schedules. the system has already experienced a drop in vacancy rates and may be nearing a time when there are more people applying for positions than there are positions available.
chief nursing executive karen williams fraser, r.n., b.s.n., discusses the results:
when did your system first begin to feel the effects of the nursing shortage?
since the nursing shortage has been projected, we've been monitoring rn vacancy rates as well as turnover rates and the average age of our workforce system-wide. in 2002, rn vacancy rates were from 18-20 percent. turnover rates were as high as 20-22 percent at one point in 2000. those indicators began a long study and look at what initiatives we could use to turn things around.
what initiatives did you study?
we asked our nurses specifically what drove their satisfaction at our institution, and it really was the quality of life issues that impacted them most with respect to scheduling. the no. 1 dissatisfier was mandatory weekends. second was mandatory shift rotation. they also noted the lack of recurring predictability because schedules were usually completed in a just-in-time basis. and they felt that nursing leadership was spending all of their time on scheduling. in our market area, many nurses had moved into premium pay nursing positions, where they were paid more to fill-in when holes occurred in hospital scheduling. high vacancy rates allowed them to dictate back to the marketplace when they would work and they still were paid more. our core nurses felt the premium pay nurses were given preference regarding shifts. we wanted to address those issues.
how does your scheduling system work to address those issues?
our dreamschedule system eliminates mandatory weekends and mandatory shift rotations, and it establishes long-term recurring schedules on our computerized system. our nursing managers were given the authority and responsibility to develop schedules that would meet the nurses' needs as well as cover the needs of the unit. they met with our core nurses and our premium pay nurses and asked what kind of long-term schedule would fit their lifestyle needs. once they chose when they wanted to work, the schedule was set on a two-week cycle.
we had a lot of people who had moved into premium pay positions coming back into our core because it was really the predictability they were after. we flipped a model that had been turned upside down. we now use our internal pool only to fill in the holes when someone calls in sick. it's no longer just-in-time scheduling, so nurses know when they're going to be at work.
how to you ensure proper staffing and experience levels?
there is a misperception among us in hospital administration that if you were to give nurses their choice of schedules openly and plainly, they would all pick monday thru friday days. so, no one ever attempted it. but the reality is that lifestyles are so varied, when asked what their ideal schedule was, the answers were all over the board. between 80 and 90 percent of our nurses got exactly what they wanted in terms of their ideal schedule.
we've had a patient acuity system in place for many years, so we had a great idea of our demand for inpatient nurse staffing in order to care for the patients on any given unit prior to the development of dreamschedule. all of those staffing rules were taken into account when it was we created. now that we are close to a zero vacancy rate system-wide, we plan to reevaluate our rn mix and staffing ratios to look for any additional opportunities for improvement.
can nurses alter their shifts?
even though they didn't all get their number one choice, the primary rules were that no one had to rotate weekends or shifts. so, it was still a huge improvement for them. and based on performance and longevity on a particular unit, nurses can certainly work their way into a schedule they prefer. they can trade schedules with someone else on their unit if another shift is more desirable to them. and when someone leaves the system or retires, that particular schedule also becomes available.
how do you cover weekend shifts?
for some, working weekends is their dream schedule, and we certainly didn't want to discourage that. so we funded additional 'work only weekends,' or wow, positions in order to attract people to fill those vacancies that our choices created within our own system to meet the core demand for the patients, and that has worked very well.
what technology and other expenses are required?
we were able to use our existing computer scheduling system and made it fit the program. but there is expense involved up front to make sure you're not going to leave any holes in the schedule. once the schedules are set, you have to commit to paying the premium in your internal pool for fill-ins.
which units use it?
we have 600-plus 'inpatient' rns who were part of the initial rollout. in the beginning some of our units that already did self-scheduling-- particularly labor and delivery and the ed-- decided not to participate. we allowed that because we weren't going to mandate it if the nurses didn't feel it was needed in their unit. but since then, our ed will be implementing it in march, and our labor and delivery nurses are contemplating it because they still have to work weekends. our surgeons and our medical executive committees have also asked if we can do this in the operating rooms. so the value of it has really been acknowledged and people are seeking the same sort of solution for other areas.
what other incentive programs do you have in place?
in conjunction with dreamschedule, we created an employee referral bonus. instead of rewarding new nurses coming on board, we wanted to reward our core employees. any employee in the system can recruit someone for us and bring to us a qualified nurse to fill an open position, and we will give them a referral bonus.the referral bonus is $2000 for each full time rn hired, and the amount is prorated for part-time employees.
how is your approach different from other solutions?
offering incentives like sign-on bonuses or premium pay positions are just throwing a compensation band-aid on the problem. they never get at the core issues. when we really listened to our nurses, compensation wasn't the issue. it was sort of like offering someone a bone if they'd work an undesirable shift. but the reality is that nurses want to work like everyone else and have a reliable schedule. our dreamschedule was more in line to improve the quality of employees' lives.
what results have you seen?
we're technically at 6-7 percent vacancy right now. st. francis saw its rn vacancy rates on inpatient units drop to zero within 120 days of implementation. they have increased their rn skill mix as well, and the cost per hour for nurses for 2003 is almost 12 percent below budget. we have 22 positions posted for inpatient rns and have asked the 23 students currently in our extern program to stay with us. potentially, we could have more people in the pipeline than positions available. we've also had to turn away nurses, so we're in a position to do selective hiring.
what feedback have you received from physicians and patients?
we get tremendous feedback from our physicians because, even on the weekends, they know who they're going to be working with when they come in. we've also received positive feedback from patients and have gotten top awards and scores for patient satisfaction in surveys.
what are the long-term plans for the program?
we really think dreamschedule will sustain itself, and we're relying on the nurses who use it to let us know if we can improve upon it. the benefit for us is that long-term, if you're in a market where you've reached low to zero vacancy rates, you can do more selective hiring and a lot of reinvesting in your nursing staff. you can build relationships with team members on the units and with physicians who are there to care for your patients so the quality of care is improved. then the patient satisfaction rate is improved, and employee satisfaction is improved. and all of those can be monitored to see the impact.
could this system work elsewhere?
doing something creative and innovative gives you a competitive edge within your market if you're first to market, but in any community there's still a limited number of nurses. i don't know if it would be as successful long term everywhere unless we can draw more people into nursing as a profession.
in what other ways has it benefited your system?
it has really set the tone for how we're going to take on other projects in the organization. it's been a true interdisciplinary approach and that has made a huge difference in breaking down perceived barriers. this was an effort where nursing partnered with human resources and finance. we've gotten diverse opinions to come up with a better solution that is more inclusive and comprehensive.