Ambulatory Care Quarterly: Find optimal staffing for outpatient surgery
By Stephen W. Earnhart, MS
President and CEO
Earnhart & Associates, Dallas
If there is anything constant in this business, it is the inconsistency we have in our staffing levels. So, what’s the deal here? The American Society of PeriAnesthesia Nurses in Cherry Hill, NJ, and the Association of periOperative Registered Nurses in Denver have staffing ratios.
The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, is concerned that we don’t have enough nurses to staff our hospitals. Our staff tell us it isn’t in their job description, and the administrator is saying we have too many people. The sky is falling; it hit me on the head!
No one can tell you what is "optimal," but you sure can tell when you have too many or not enough staff. In our industry, the tendency is to overstaff — it’s human nature. In accordance, rare is the facility we visit that is understaffed. But the consistent problem is overstaffing in all the wrong areas and for the wrong reasons.
I know that cross-training is a "no-no" to many nurses, but it is time to wake up and see what is happening.
There are 200 surgery centers being built this year, according to SMG Marketing Group in Chicago, and I estimate that the full-time equivalents (FTEs) for an "average" outpatient surgery program is 22. Do the math: That is another 4,400 experienced staff required.
Unless you believe in the "spontaneous generation" theory, they have to come from somewhere. Chances are high that they are coming from one hospital or surgery center to another — maybe yours, maybe mine.
So it might be time to figure out if we are at risk. This exercise is more difficult for hospital folks because often the postoperative ambulatory care unit (PACU) does not come under the operating room (OR) budget, but you still can work it.
We have to assume that your staff are cross-trained; otherwise you will be completely overstaffed from day one. We assume you are doing 6,000 cases per year (approximately 1,200 cases per OR per year). Start with the number of ORs, and you can adjust up or down depending upon your situation. Just as revenue is the driver for your budgets, the number of ORs is the driver for staffing.
Starting with the basic needs
Start with the basics. You need one RN for each OR. Five ORs then equal five RNs. You now need one tech (or another RN) per OR for a scrub. You now have 10 FTEs for a normal eight-hour day. (Normal?) That is your core staffing. Now you need to front fill and backload your support staff.
No one better take offense at being considered a "support staff." I am the support staff to my company, and we all should be considered the support staff to the surgeons.
Assuming you do your own registration, you need to add in the front-desk personnel. On average, your staff should require no more than 15 minutes to register a patient on the day of surgery. You have five ORs, and you have your patients come in about 60 minutes before surgery, so ideally you need two FTEs to handle the registration, schedule cases, and answer the phone. Once they have finished the morning rush of patients, they can assist in the billing and correspondence work that never goes away.
Overseeing all of this is the business office manager. That is your front desk, scheduling, accounts/payable, and accounts/receivable. You can embellish it the way you want to. I only can guarantee that you will add staff to it because you will not believe you can do it with only three staff members. You can, but it’s your call.
Obviously, we need to take the patients to change clothes, have their pre-op interview, and be prepped for the OR. Anesthesia should be checking to make sure lab results are there, etc.
Two RNs can handle that caseload in the morning rush if your patients have been properly screened, anesthesia is doing their job, and the pre-op phone call was made giving them your instructions, etc.
Air traffic control
The OR is covered, and now they leave there and go to PACU. You have to do your planning here. I like to use the analogy of a busy airport and the role of the "air-traffic controller" for PACU.
A good anesthesia department, working with the administrator or PACU charge nurse, can make a real difference in keeping your PACU from becoming overwhelmed with incoming patients and the resulting tendency to overstaff.
You can control the number of patients coming into PACU by working with the circulating nurse in each OR and releasing those OR cases in an orderly fashion. Don’t allow yourself to get backed up by not controlling the situation.
You need to exercise good judgment here in the sense that you don’t want to "hold" patients in the OR because of staff coffee breaks or because your weren’t staying on top of the situation.
Control the flow for the right reasons. Avoid holding up a room when you know the surgeon has three more cases to follow in the same room. Instead, hold up the case when the next patient coming into that OR isn’t scheduled for another 45 minutes.
Pick your "holding pattern" well. Your criteria should change case by case and situation by situation, not by some silly blanket policy. If you can control that flow and maximize your pre-op nurses, you can run those cases on three RNs. Yeah, I know. You don’t agree.
Instrument prep and inventory/materials management is the role of the surgical techs whose cases are starting to wind down after lunch. Depending upon your specialties, you might be able to justify a full-time instrument tech. Put one in there, but assume you can cross-train that position.
That gives us a total of 19 FTEs. Now add your administrator and nurse manager, and you are up to 21 FTEs.
Due to the nature of the business, add another 40 hours per week to fill in gaps with a "float." You now have 22 FTEs for your department.
Now, that does not mean 22 bodies. Oh, no — that could mean 45 people. The shortage of nurses is in the full-time block. You want to recruit the part-time "I only want to work 15 hours a week" people. And yes, they are out there. You are going to need more staffing than we described above on certain days and less on others.
The key of a good administrator is to work that staffing level based upon projected need and not the budget. Through attrition, try to slowly reduce your staffing levels to a basic function and then adjust on a PRN basis. I think you will find that less is more.
(Editor’s note: Earnhart & Associates is an ambulatory surgery consulting firm specializing in all aspects of surgery center development and management. Earnhart can be reached at 5905 Tree Shadow Place, Suite 1200, Dallas, TX 75252. E-mail: searnhart.com. Web site: www.earnhart.com.)
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