Shifting Priorities

A Georgia healthcare enterprise uses bid shifting technology to reduce agency labor costs and maximize nurse staffing efficiency.

Long-term solutions to the increasing nurse shortage certainly ends with bringing more qualified people into the field, but will likely begin with more effective utilization of the existing workforce. For Phoebe Putney Memorial Hospital, creating a comprehensive system that addresses staffing issues means a higher quality of care, lowered staffing costs and ultimately, a happier and highly effective workforce.

With 443 beds, 300 affiliated doctors and a staff of more than 3,400, Phoebe Putney Memorial Hospital (PPMH) has been serving the residents of southwest Georgia since 1911. As a regional center for cancer and cardiac medicine, a teaching hospital and a leading perinatal center in the state, PPMH sees more than 21,000 admissions and more than 53,000 yearly visits to its ED.

Boasting a nursing staff of more than 2,200, filling shifts throughout the hospital had become cumbersome, expensive and inefficient. Although the non-profit organization had a dedicated and skilled nursing staff, increasing their sense of professional and personal satisfaction, as well as quality of life would mean empowering them with greater flexibility and opportunity when it came to shift scheduling throughout the enterprise.

The Challenge
As AVP of medical services, Frances Marthone was tasked to find a permanent yet, flexible, solution to the issues of staffing and labor pool management at the hospital. The labor pool is the hospital’s internal pool of nurses that work out of the central staffing office and go to any unit in the building where a need has been identified. According to Marthone, the labor pool structure had morphed into one where each of those nurses ended up belonging to a particular floor instead of a central staffing office.

Although the change had been gradual and necessary at one point, PPMH realized that the system no longer worked and needed restructuring. “We gave the nurses the option to stay in positions on those units where they were currently working or come back to this new concept of centralized staffing with the labor pool, and of the 40 nurses, 12 returned and the rest took positions throughout the building, which was also a good thing,” says Marthone.

Compounding this problem, PPMH had a situation where every floor would call the staffing agency of their choice to fill their open shifts. This often resulted in having as many as nine managers calling different agencies trying to get staff to fill their needs. “We had lost control over that aspect of staffing, resulting in uncontrolled expenses for agency staffing, so we kind of blew the whole thing up and decided to start from scratch,” explains Marthone.

Under the hospital’s former system, if managers had a need, they would create their schedule with all of the available personnel. Then, for all of the vacant shifts, managers would write a list on a sheet of paper and post it by the nurses’ lounge, the elevators, the time clock, the restroom–anywhere the nurses could see it, thereby leaving it to random encounters that they would sign up for those needed shifts.

Unfortunately, this process usually resulted in the first pick of shifts going to those working on the day the list went up since it was essentially first come, first serve. “This meant that the other staff that might have been able to pick up some of those shifts could not because the remaining shifts conflicted with other plans or their schedule, effectively cutting the resource pool in half,” says Marthone.

Finding a Solution
In the first quarter of 2006, Marthone and director of applications specialist Kevin Ludwigsen began the search for a solution to the staffing challenges. As a member of the Georgia Hospital Association (GHA), PPMH was invited along with other member healthcare organizations to a scheduled demonstration and question period for one of their GHA-approved shift bidding vendors, BidShift Inc.

The event kicked off with BidShift showing attendees their product, followed by a comprehensive question and answer session. According to Ludwigsen, BidShift is a Web-based Application Server Provided solution, meaning that the company maintains the server at their location and the user goes to that Web site and logs in to view available shifts and then applies for that shift. “From a technical perspective, implementing this solution would be fairly simple for IT as it was a matter of putting a couple of hyperlinks into existing Web pages that we maintain, working through some security issues with the Web site and allowing access to that Web site,” says Ludwigsen.

According to Marthone, PPMH’s goals when first meeting with BidShift included creating a mechanism to communicate needs, keeping the staff working onsite rather than going to an agency for work elsewhere and finding a better way to manage the pro re nata (PRN) pool (as necessary or when circumstances require a pool). They also wanted to reduce if not eliminate routine agency use. Once Marthone and Ludwigsen were sold on BidShift, they made a list of the things they would need to validate and support the rollout.

Although the solution required very little IS support, Ludwigsen had questions about whether BidShift would integrate with their current staffing tool. “Our pre-existing staffing tool wanted to dictate to BidShift which shifts were open, and some scheduling systems have their own means of verifying or credentialing staff, so with help from BidShift, we were able to create the necessary interfaces to allow the two platforms to seamlessly communicate,” explains Ludwigsen.

The next step was bringing the vendor representative to PPMH to confer with the senior executive team and nursing leadership two weeks later. With their endorsement of the possible solution, the next step was to show the managers and directors, followed by a scheduled May 2006 implementation and rollout.

Rollout
Once Marthone became the official project manager, she enlisted PPMH’s staffing office clerk as a second system administrator. This was due to the clerk’s close working relationship with the staffing office and supporting the floors with general staffing and labor pool. The vendor and Marthone worked closely on the designated roles of who should be involved in the implementation process, such as an advisory committee that included all of the nursing leadership, HR, IS and Payroll.

Several other groups were also part of the process including the operations group, consisting of the staffing coordinator as well as nursing managers and directors that help write the guidelines and policies for use with BidShift. The marketing/communications group consisted of nursing leaders, marketing staff and HR, while the systems group reviewed existing processes and flow as well as exploring the new system’s capabilities, interfaces and effects on related systems.

Simultaneously, she began to tackle the all-important aspects of staff buy-in to the shift bidding system. “I stressed to the managers and directors the importance of telling their staff that we heard their issues and that a solution was coming, and to engage them in questions and get them excited about our new process,” says Marthone. “During this 3- to 6-week planning stage, I would send out informational flyers each week to all users so that everyone would know BidShift was coming, and then begin answering any questions.”

According to Marthone, PPMH’s goals when first meeting with BidShift included creating a mechanism to communicate needs, keeping the staff working onsite rather than going to an agency for work elsewhere and finding a better way to manage the pro re nata (PRN) pool.

Marketing was a big part of the implementation for PPMH, as they wanted to make sure that everyone felt and saw a sense of order, logic and ownership of the process. One of the tools that Marthone and the marketing department utilized was a slogan for the new concept of shift bidding and a graphic to accompany it and drive the concept home. The slogan became, “Make Hours Yours” integrated with the graphic of a clock face, which was sent out to the entire staff via e-mails and postings around the enterprise.

PPMH CNO Laura Cook simultaneously began the discussion process during her staff meetings with the nursing staff. Acknowledging the hospital’s existing fragmented staffing pattern, they discussed better ways to bring in staff, utilize agencies and how the new process would look.

While many on staff were very intrigued and happy about a pending solution that was past due, many in the labor pool had concerns how this would affect their working and private lives. The answer was to conduct specific meetings for the labor pool staff so that they could ask specific questions in a safe and open environment rather than a joint environment that could become adversarial. “The perception by many throughout the building was that labor pool staff were paid premium dollars and maintained full control of the shifts they worked under the former system,” explains Marthone. “This new process would allow all staff more equitable opportunities to see all available shifts, while giving the managers a way to show all of their staffing needs to the most staff.”

Templates and Profiles
At this stage, Marthone worked closely with managers to build the templates that would include all of the criteria for each level of nursing. Finished templates would only show staff those shifts that they can work based on the criteria and skills they already possess.

PPMH has a significant number of nurses throughout the hospital that are ACLS-certified due to their roles at the hospital, yet they don’t have the credentialing for critical care. When these nurses log onto the system, they are only shown those shifts for which they have the proper credentials and experience. According to Marthone, the template creation process itself took only minutes.

There were roughly 16 questions for the nurse profiles dealing with ACLS certification, psyche experience, charge experience, CNA, respiratory and unit secretary. Some additions were proprietary to PPMH, such as customization of the Emergency Center profile to ensure that those bidding for the trauma ward shifts had specific required certifications.

Profiles were then reviewed by managers for accuracy, approved and then released, allowing staff to begin the bidding process. Managers were also encouraged to call nurses individually when necessary and talk to them about their experiences in a one-on-one conversation. “If that conversation revealed that the staff person needed more experience on a particular unit, the manager could set up orientation days for the nurse before a scheduled shift, thereby giving the managers and bidding staff more comfort and confidence when they arrived on the unit for work,” says Marthone.

Pay and Staffing Patterns
Once the staff and managers were on board, the vendor uploaded the templates and showed managers what a typical shift would look like and what a nurse would see when they logged on. A primary decision for PPMH was deciding whether to set up the system in a reverse auction configuration or set specific prices that could include shift differential incentives.

The vendor’s strong recommendation was to attach dollar incentives to the shifts that are hardest to fill. Before BidShift, the hospital had implemented an additional shift differential for RNs, LPNs and respiratory therapists who picked up an extra shift. This overtime incentive produced good results that lowered the need for agency nurses. “We were very happy with our existing incentive plan and chose to stay with it,” explains Marthone.

Staffing patterns were changed so that PRN nurses could only pick up their shifts by going online to see what was available. This brought them in-line with the true intent of supplementals working when needed rather than when they wanted to work. A compromise with the labor pool staff brought them back to central staffing and allowed managerial staff to once again direct where they went on certain days that they were obligated to work in the labor pool. The compromise now allowed them to pick additional shifts online with BidShift beyond their obligation to the labor pool. “They ultimately felt that they had the best of both worlds,” says Marthone.

Another challenge of the old system for PPMH was that many of the staff had become entrenched in routine schedules that didn’t always put the best candidate in each shift and often resulted in overtime hours without necessity. “The focus had to be what was the best thing for the patient and organization, how we staff our floors and taking care of patients,” explains Marthone. “We tried to steer clear of the language of loss or changing the process, rather, that it is more effective and efficient.”

Training Stage
The training phase involved bringing in managers as well as a designated support person and showing them how to log on, post and create the different types of shifts. Marthone began sending out more detailed flyers by e-mail about BidShift that explained what it meant and who could use it.

In a training meeting just before go-live, the team brought 10 computers to a facility classroom along with food, refreshments and $100 door prizes that nurses could only win by attending. “For the next six weeks, if you went online to bid on a shift, you were enrolled in a raffle for that week where we would give away items like a camera, an iPod, gas cards, uniforms gift card and other desirable items to keep up the momentum of people getting online and using BidShift,” says Marthone.

The result was that the team saw more than 400 nurses register in the first 12 hours. During this period, nurses who attended the training spread the word upon returning to their floors. The next day, Marthone held a second planning meeting to catch the night crew and register the remaining nurses. Once the nurses were registered and logged, the next process was having the managers log in and approve the profiles with Marthone and the staffing office clerk monitoring the process, providing help when needed and reminding managers to complete the profile approval process.

On May 31, 2006, the team had the managers come in with their schedules for July, put in their core requirements and then bring their vacant shifts to the training session to learn how to post those shifts. “Once posted, they were real and live, but in a type of holding pattern until go-live just days later,” says Marthone.

Six Months Into BidShift
Just over six months into the new shift bidding system, Marthone conducted a staff satisfaction survey to gauge the success and comfort with BidShift. The response showed that 68 percent of the staff received fewer calls at home begging them to come in. Eighty-seven percent found the system easy to use and 75.5 percent saw it as a positive addition to the organization. According to Marthone, the belief is that nurses don’t like to float, so they asked the audience in the survey and found that 31 percent requested hours on another floor. “That change of attitude was fostered by personal control of when, where and how they floated, which made a big difference for our nurses,” says Marthone.

The implementation was a staff and financial success, reducing monthly agency staffing costs from $500,000 a year at its peak to slightly more than $200,000 by December of last year. According to Marthone, the success of the implementation was equally about finding the right platform as well as keeping everyone informed for a full staff-acceptance. “I truly feel that if you can empower people with knowledge and information, then they are going to be more willing to participate.”