By Cara Cook
While we all agree that departmental productivity depends on having the appropriate number of staff deployed at the right place, at the right time, and at the right price, we also probably agree that it is easier said than done. Many healthcare leaders leverage float pools to address staffing needs, only to find new problems developing after their establishment.
Organizations with multiple facilities providing similar services in the same geographic area often leverage their scale by employing float pools to provide staffing relief, using non-premium pay options. Float pools help us diversify the risk of overstaffing departments within a facility or between facilities and present an opportunity for experienced staff members to receive greater pay for their flexibility. They are a great tool for filling daily staffing gaps while maintaining consistent quality care and operational efficiency.
However, without targeted strategies for each staffing challenge, float pools tend to be improperly utilized. Ineffective float pools have wide-reaching impact. They give leaders a false security about the number of available staff, which perpetuates uneven patient loads and contributes to lower patient satisfaction and quality of care. It can also impact overall resource availability and lead to an overreliance on premium pay and bonuses.
Three Common Staffing Challenges
The three most common hospital staffing challenges include: coverage for nurses calling in sick, seasonal fluctuation in census, and backfilling vacant positions. Resource needs for each of the three should be uniquely scoped (in FTEs by month) and staffed with permanent or temporary nurses, as appropriate. When resources in a float pool that is sized only to relieve unscheduled absences are instead used to backfill vacancies, problems arise.
1) Covering Nurses Calling in Sick
Permanent or ongoing needs, like nurses calling to cancel their shift, provide the opportunity for leaders to address them using permanent staff. Because employees are the most cost-effective labor option, a best practice is to permanently hire staff into float pools to cover nurse call-ins.
Right-sizing the float pool requires identifying which departments the float pool will support—keeping in mind the differing skill sets needed. Next, for these supported departments, quantify open shifts due to FMLA and call-ins, by skill mix. Once this is completed, hiring the correct number of FTEs for each skill type immediately reduces open shifts. If open shifts are currently covered with overtime or agency workers, leaders should expect this avoidable expense to decrease as well.
2) Addressing Seasonal Census Surges
The first threat to the success of your right-sized float pool is a seasonal census surge. It’s important to remember that, while permanent needs should be addressed with permanent staff, temporary needs should be addressed with temporary staff. While you can still use your float pool to operationally distribute staff to support these temporary needs, doing so will reduce the number of staff available to cover the permanent needs, as designed. Staffing needs created by seasonal fluctuations should be estimated separately and covered by overtime, contract labor, or other temporary labor solutions.
It is important to note that right-sizing anticipated seasonal needs should consider the department’s historical use of overtime. Calculating and publicizing the hourly rate of pay by resource type, as seen in the corresponding graphic, supports managers to more accurately estimate how much assistance they will require beyond their employed department resources.
3) Backfilling Chronic Vacancies
Don’t be too hard on yourself; chronic vacancies regularly occur in departments of even the most elite healthcare organizations. Whether due to a pay increase at a neighboring facility or a department leader vacancy, when turnover reaches around 20 percent, the department is stretched thin, which drives even more turnover. Once departments are in this bind, it is very difficult to course correct.
Chronic vacancies are best addressed by creating a hire-ahead strategy that is enabled by registered nurse (RN) pipeline development. Also, because vacancies are temporary in nature, the open shifts they create should be filled with temporary labor options. While it’s the most expensive, contract labor still can be the best option, as the utilization of emergency shift bonuses for over 12 months can inadvertently adapt staff to an increased rate of pay that is difficult to eliminate.
Perils of Bonus Abuse
When we use bonuses to incentivize fulfillment of long-term needs, we run the risk of “baking in” premium pay. Worse still, staff members can become accustomed to bonus payments, disabling the organization from making better choices in the long term.
One organization I worked with had executed such frequent premium bonuses over many years that staff members had fully adapted to the increased income level. When the organization was forced to remove the bonuses to support its financial viability, some staff members lost their homes. It is a heartbreaking scenario.
Better Staffing Outcomes
Once the scope of seasonal volume fluctuations and under-hired nursing units is understood and addressed with separate strategies, your appropriately sized float pool of permanent staff will be enabled to effectively address the challenge of nurses calling in with little advance notice, preventing employee reliance on premium pay.
Cara Cook is an industry-leading expert in optimizing complex healthcare operations. As CEO of Cara Cook Consulting, she brings extensive experience in labor management, ER and OR throughput, length of stay management, patient flow, clinical process improvement, and margin improvement work. Ms. Cook and her team of industrial engineers work closely with hospitals, large academic medical centers, and healthcare systems, assessing current state operations to develop and execute customized solutions designed to improve margin while simultaneously making a positive impact on patient and provider experience.