cutting-edge discussions of management, policy, and program issues in emergency care
TRANSCRIPT
CUTTING-EDGE DISCUSSIONS OF MANAGEMENT,POLICY, AND PROGRAM ISSUES IN
EMERGENCY CARE
Authors: Jeff Solheim, RN, CEN, and AnnMarie Papa, MSN, RN, CEN, CNA, FAEN
COLLECTION OF COPAYMENTS
When do you ask for a copayment, and what are the
strategies you use to accomplish this?
Answer 1:Our emergency department has recently begun collectingcopayments at patient discharge. For this strategy to work,all patients need to be seen in the discharge booth (staffedby our admitting department) before leaving the emer-gency department. We have had some difficulty in gainingcompliance from the nursing staff in making sure all pa-tients are seen in the discharge booth. In the month ofJanuary, only 20% of our patients were seen in the dis-charge booth. We challenged our nursing staff to having50% of our patients seen in the discharge booth in themonth of February; if they achieved this goal, all staffwould receive a $25 gift certificate. In February, 58% ofour patients were seen, which greatly increased the amountof collections. We then challenged the staff for 75% duringthe month of March. Our total for the month of Marchwas 68%. Although we did not reach our goal for March,we are well on our way to reaching 75% for the month ofApril.—Todd Luther, RN, CEN, Interim Emergency Depart-ment Director, Mercy Medical Center, Roseburg, Ore; E-mail:[email protected]
Answer 2:We request copayments at the end of the visit. The regis-tration staff put a sticker on the patient’s face sheet thatindicates a copay is due and the amount, if known. Afterthe visit, patients with stickers are directed by the nursingstaff to stop at the cashier’s office, where the copay willthen be collected.—Tracy Richmond, RN, BSN, Associate
Director of Nursing, Coshcoton Hospital, Coshcoton, Ohio;E-mail: [email protected]
MANDATORY OVERTIME
Do you use mandatory overtime in your department?
If so, how does this work?
Answer 1:We only use mandatory overtime if all other avenues havebeen exhausted. All nurses are given pagers so that thenurse can page out for staffing vacancies and rescue help.Call pay is given for staff answering pages. We ask for vol-unteers to stay past their regularly scheduled end of shiftbefore looking to mandate overtime. A “red X” is placedby a staff member’s name so that they know the days theyare on call for mandatory overtime, allowing that personto plan their day accordingly. Full-time staff will have a“red X” by their name an average of 1 day per week.—Laurie Wehner-Evans, RN, MSN, Director of EmergencyServices, Porter-Valparaiso Hospital Campus, Valparaiso, Ind;E-mail: Laurie.wehner-evans@ porterhealth.com
Answer 2:We do not use mandatory overtime in our emergency de-partment. In an effort to handle volume surges and possibleunexpected shortages due to staff illness or family emer-gencies on the weekends, each RN or licensed vocationalnurse is required to do 60 hours of call a year. The call startsat 7 PM on Friday and ends at 7 AM on Monday. We alsooffer a bonus or adjunct pay when we are short.—JeffCarico, RN, Clinical Manager, Memorial Hermann HealthCenter Southwest, Houston, Tex; E-mail: [email protected]
Answer 3:We have the ability to use mandatory overtime but rarely,if ever, does this happen. We have a house float from9 AM to 9 PM who can be utilized in the emergency depart-ment during busy times. We also have on-call nurses whoare willing to come when needed. Part-time staff are calledduring busy times and frequently respond. Many of our
The opinions expressed are those of the respondents and should not be con-strued as the official position of the institution, ENA, or the Journal.
J Emerg Nurs 2008;34:478-81.
Available online 29 July 2008.
0099-1767/$34.00
Copyright © 2008 by the Emergency Nurses Association.
doi: 10.1016/j.jen.2008.06.013
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hospital staff are cross trained to the emergency departmentand are floated into our department or will come in fromhome if they are called.—Tracy Richmond, RN, BSN, As-sociate Director of Nursing, Coshcoton Hospital, Coshcoton,Ohio; E-mail: [email protected]
SELF-SCHEDULING
Do you use self-scheduling in your department? If so,
what is your process?
Answer 1:We having been using the self-scheduling approach for manyyears and have found many benefits as well as some hurdlesin this process. First, we have developed a series of guidelinesthat allow the staff members to complete self-schedulingwhile still ensuring that there is adequate staff coverage ona daily basis, especially on weekends and holidays. Eachemployee is required to work every third weekend, andthe weekend staffing is automatically entered into eachmaster schedule before it is available for self-scheduling.Management is willing to cover the employee for oneweekend off per calendar year and the employee is respon-sible to find coverage for any additional weekends theywish to have off. In addition to every third weekend, theemployee is responsible for working a total of 5 Mondaysand Fridays in any combination in a master schedule,which is defined as 6 weeks in duration. Recently, we havefound that there have been issues with staff members pick-ing up Fridays; hence we have decided to change the policythat each employee must pick up their required Mondaysand Fridays, which must include at least 2 Fridays. Eachfull-time and part-time employee is responsible to cover2 summer and 2 winter holidays as well as covering Thanks-giving biannually. This is achieved by posting past holidayschedules so that employees can see when they worked lastyear and can plan their holidays appropriately. If needed,leadership will step in and assign holidays for any employeewho is not meeting the requirements. Vacations are grantedbased on years of service, and no more than 2 employees aregranted vacation time on the same day. An employee mustplace his or her vacation requests before the opening of self-scheduling; the employee is then notified of the request ap-proval/denial, and it is placed onto the master schedule. Inaddition to vacation time, each staff member is able to place5 “X’s” on a master schedule, which prevent them frombeing scheduled on a particular day and their schedule isworked around those “off requests.” Because we have manynurses who are continuing their education as well as manyancillary staff going into nursing and allied health programs,
we give anyone who is going to school priority schedulingbased on their school schedules; this also stands for anyonewho is attending an educational program or certificationcourses. Unfortunately, we are unable to accommodate sched-ules based on child care or personal issues; however, we tryto work with the employee as much as possible.
Recently, many changes in the size and function of theemergency department have taken place, causing a signifi-cant increase in the number of staff in the department andconsequently causing more strict adherence to schedulingguidelines. Currently, the health system is in the processof converting to an online scheduling system allowing em-ployees to enter schedules from any computer that has Inter-net access. This also is beneficial from a management pointof view because it has the ability to set parameters on howmany staff of each position (RN, ED technician, and so on)can sign up for a particular day, and when that day is full, itis “locked out.” The system also allows employees to placevacation time and holiday/personal time as well as bid forany open overtime shifts. One of the major issues that weface until this system is fully in place is the fact that manydays become overstaffed and moves need to be made.Moves are made based on a rotational and seniority system.Employees now also have the ability to work a set scheduleif they wish. Another issue with this system is that staffmembers will switch with each other before the final sched-ule has been posted, causing a decrease in the ability to movestaff around on the schedule as needed. Moves are made toensure that each day/shift is adequately staffed and also bylevels of experience. The downside to self-scheduling is thatthe staff members cannot count on the schedule they madeuntil the final schedule is posted in casemoves had to bemade.
The advice we have for any facility that is consideringgoing to self-scheduling is as follows:
• The greater the number of employees the facility has,the stricter the guidelines need to be.
• Clearly define scheduling procedures and ensure thatstaff understands the “rules.”
• Self-scheduling, which allows employees to pick theirown schedules, cuts down on staff calling out and in-creases staff satisfaction.—Anthony M. Angelow, BSN,RN, Staff Nurse, and Denise L. Meyers, BSN, RN, CEN,Clinical Manager, AtlantaCare Regional Medical Cen-ter, Pamona, NJ; E-mail: [email protected] and [email protected]
Answer 2:We have been using self-scheduling in our department forapproximately 15 years. Full-time employees and thosewho job share are placed in groups. Each scheduling cycle,a different group is allowed to choose their shifts first;
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then a different group picks their shifts next and so on.These groups rotate so that all employees have a chanceto choose their shifts first on a rotational basis. Once thefull-time and job-share employees have picked their re-quired time, the part-time staff can choose their time. Ourpart-time employees are also placed in groups and pick theirtime in a rotation similar to the full-time staff. All shiftsthat remain after this process are made available to the ca-sual staff.
When choosing shifts, each pay period must have anequal number of shifts (75 hours in 2 weeks at our facility).Staff are required to work 2 of 4 weekends, and 50% ofthe shifts must be night shifts. (We use 12-hour shifts.)Vacation is handled in such a way that 33.75 hours mustbe used to get a week off; staff cannot block more than aweek of time off without the use of vacation time. We havefound that this has worked well consistently.—DaveneKorince, RN, BScN, Regional Emergency Educator, NiagaraHealth System, St Catharines, Ontario, Canada
Answer 3:Six to ten weeks ahead of time, we put out a six-week,blank schedule sheet (so, for instance, the schedule for allof May and the first part of June would be put out blankaround the first of March). Each person then pencils intheir “dream schedules.” This schedule also has (in perma-nent ink) each staff member's requested days off that havebeen approved. Over the course of the following 4 weeks,people are expected to change their own schedule aroundto help out with the needs of every day. They are asked toconsider factors such as understaffing or overstaffing on anygiven day and the balance of experienced with less expe-rienced nurses. Approximately 4 weeks ahead of time, I“close” the self-scheduling, and I take a few days to “bal-ance out and finalize” the schedule. My goal is to make thefewest number of changes possible to each staff member’srequested schedule. There are always some changes that aremade, and they expect this. Requested days off that havebeen approved are not taken away, and late requests are of-ten accommodated. If I foresee needing to make a hugechange in any given person’s schedule, I run it by that per-son before finalizing, to make sure that it will work out,and I also want that person to know that I am not disre-garding the importance of his or her personal needs. I alsouse this finalization stage to “make deals” with staff. Forinstance, if I need a more experienced nurse to work anoff shift to “balance” a less experienced staff, I will try tohelp them out with a week that they need to work onlyspecific shifts or let them have a last-minute request.
Our full-time staff (36 hours a week) generally work4 to 6 weekend shifts out of 12, but we do not work a
set “every other” weekend rule. We also have a 3-holidaygroup plan, and this allows for every person to do just 1 ma-jor holiday and 2 minor holidays per year. I let people signup for these at the beginning of the year and have some sayin which ones they will work.
Suggestions I would make to departments consideringself-scheduling are as follows:
• Have specific guidelines so that all staff will interpretthe self-scheduling process the same way.
• Keep track of weekends worked.• Keep track of who generally will make switches to helpout with the general good of the schedule and who willnot move themselves. This helps justify whose dreamschedule you have to make changes to.
• If someone inadvertently gets a schedule much differ-ent from what they asked for, remember them on thenext schedule and try to help them out!
• Most importantly, have staff be a part of the planningprocess before you implement self-scheduling.
• Always try to put the finalized 6-week schedule outabout 4 weeks before the start date on that schedule.Staff members really appreciate knowing what theycan plan on.
I am proud of how our staff works so well togetherto make the schedule work. There are very few complaintsabout the process, and when we hire new staff, they are quickto revel in how nice our self-scheduling process is!—BarbaraGreen, MS, RN, CEN, Resource Nurse, Emergent Care, YorkHospital, York, Maine; E-mail: [email protected]
Answer 4:We have a book that has an empty schedule in it withnames and dates but no assigned shifts. Staff go throughand assign themselves shifts. At the completion of this pro-cess, if a day is off balance with skill mix or certification mix,staff are asked to switch a day, and most of the time, theycomply.—Rebekah Child, RN, MSN, CEN, Clinical Edu-cator, Cedars-Sinai Medical Center, Los Angeles, California
Answer 5:Self-scheduling is handled by one of the nurses in the de-partment. The manager has to have very little involvement.The schedule is available in pencil for several months (al-most a year) before the schedule is due. This gives themplenty of time to review and discuss among themselves im-portant days they want off. The nurses are able to frontload and back load their schedules so that they get longstretches off. As long as it does not create overtime andthe schedule is put out without any vacancies, I am happy.The ED nurse scheduler has access to the PRN nurses’ con-tact numbers so he can fill in any holes by calling them. In
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the case of vacations, I will approve only 1 nurse per shift tobe off at a time, with the caveat that if the scheduler canmake it work, it is all right. He is usually able to accommo-date all requests. The main thing is good communication be-tween the scheduler and the staff, as well as the staff amongthemselves. They are a close-knit group, so they try veryhard to help each other get the schedule they want. Theywork 12-hour shifts with every third weekend and everythird holiday off. We see 18,000 visits per year and have12 full-time RNs and 9 part-time RNs.—Tracy Richmond,RN, BSN, Associate Director of Nursing, Coshcoton Hospital,Coshcoton, Ohio; E-mail: [email protected]
EMPLOYEE SATISFACTION
What have you done as a nursing leader to improve
employee satisfaction?
Answer 1:We held a few different staff meetings and asked the staff toanswer one question: If you were to stand up at the ENALeadership Conference and declare our emergency depart-ment as “the best emergency department in the country,”how would you quantify it? We gave them 4 different areasto address: growth, quality, operational excellence, and pa-tient satisfaction. The staff then voted on the top 5 initia-tives under each area and told us what needed to be done toaccomplish the initiative.
After a few months, we went back and reviewed withthem what they had selected. Of 20 initiatives, 18 were at-tempted, and on the basis of those initiatives, some processeswere changed. The changes were a direct effect of what thestaff told us they wanted us as leaders to focus on.—JeffCarico, RN, Clinical Manager, Memorial Hermann HealthCenter Southwest, Houston, Tex; E-mail: [email protected]
Answer 2:I believe that employee satisfaction is rooted in a person’spride in his or her job, and that pride begins with holdingeach person accountable for his or her responsibilities and,in turn, giving that person the positive feedback and fre-quent affirmation that he or she is a valued member of theteam. Nurses cannot hear enough that what they have to sayis important and what they do is even more important!
1. I try to invite staff to give their ideas and feedback to me atevery turn. Even when I get a “crazy” suggestion, I try tostop and say, “Now really, could this possibly work? Howcan I at least give it a try?” When I am wrong, I admit it.When an old policy or procedure is just not working forthe staff, I try to get them to help me make the change sothat it does. I send out employee surveys (just in our de-partment) at least once, and sometimes twice, a year. Imake the questions current and pertinent, and I try alwaysto include the following: “Your suggestions on anythingwe do here are always welcome, please!”
2. I set high expectations for education and competency. Ionly set goals for individuals and the entire departmentthat I know can be met. People take pride in learning ontheir own and in groups. I try to make educational eventschallenging and fun. As a result, the majority of the nursescome in on their own time to take part.
3. I never question why a nurse has to call out for a shift.We donot have a problem with excessive call outs, and the messagethat I try to send back to any staff member is that they do nothave to feel badly about calling out, as I know it is beingdone for an important reason. I trust them to make fairand right decisions for themselves and for the department.
4. I also try to send the message, on a frequent basis, that thestaff is our most important and valuable resource. When youthink this way, it makes all of the other important goals andobjectives so much easier to accomplish!—Barbara Green,MS, RN, CEN, Resource Nurse, Emergent Care, York Hospi-tal, York, Maine; E-mail: [email protected]
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