Chapter 7.

Staffing

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 Outline
 Workload Management Overview
 The Establishment of Work Standards and
Their Influence on Staffing Levels
 Patient Acuity Systems
 Internal Work Standards
– Utilization of FTEs
– FTEs for Nurse Staffing
– Coverage Factor
– Reallocation-Daily Adjustments
 External Work Standards
 Productivity & Workload Management
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 Importance of Staffing Decisions
Human resources is the greatest expenditures of
many health care organizations.

In manufacturing, determination of skill-mix and

staffing levels is fairly straight forward.

In healthcare, uncertainty makes staffing

particularly difficult.

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 What would you do?
Staff for peak levels at all times?

Staff for minimum census and acuity levels?

Staff for minimum census and acuity levels and

hire part time agency nurses?

What are problems with each approach?

A solution-- flexible staffing!

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 Flexible Staffing

Setting a core level staff based on a

long term needs assessment which
is then augmented by short-term
(daily) adjustments using various
methods to match staffing levels
and patient needs.

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Figure 7.1 Workload Management

Workload Standards

Staffing Scheduling
Staff Utilization Patient Satisfaction

Reallocation

Costs Staff Satisfaction

Productivity

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Workload Management: the components

 Staffing-- determining the appropriate

number of full-time equivalents (FTEs) to be
hired in each skill class (RN, LPN, aides, MHA,
MBA, etc..)
 Scheduling-- who is on and off duty and
when; operational procedure
 Reallocation-- fine tunes the previous
decisions; daily if not shift by shift

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To staff efficiently we need a standard!

 Work standard-- a predetermined allocation of

time available for each unit of service
(presumably at the appropriate quality level)
– Acuity Adjusted-- patient days are adjusted
for the acuity level of the patients being served
 Example: Nursing hours per patient
day
– Procedural standard-- when the unit of service
is a procedure, such as a lab test or x-ray
 Example: Technicians per CT scan

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 Standard development

 Historically based solely on estimated average

census of the entire organization
What is a problem with this approach?
1) Doesn’t account for unit to unit variation.
2) Dependent upon a physician estimate of LOS.
 Today, precise estimates of LOS can be
determined from information systems.

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 An adequate staffing system
contains three components.
 Reliable patient classification and acuity
system that determines patient need for
services based on patient specific
characteristics.
 Development of time standards to reflect
the time needed to provide services based
on the patient classification system.
 A method of converting total service time
needed to FTEs
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The patient classification and acuity system

 Departmental acuity adjusted census is best for

determining workload standards
 Fewer staffing adjustments are necessary when
an admissions monitoring information system is
based on the unit’s patient care requirements
rather than unit census.
 An illustration: Who requires more

care, a patient in the ICU or one

recovering from minor surgery?

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 Before developing acuity
standards. . .
 A patient acuity system is necessary to
measure the amount of care required by
any given patient.
 Also called patient classification systems

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 Types of Acuity Systems
 Prototype systems
– Classify according to type of care needed
– Patients grouped into 3-10 categories based
on expected time commitments, diagnosis,
mobility, and education needed
– Highly subjective; easy to implement
 Factor-analytic systems
– Establishes classes by summing relative
values assigned to individual tasks or
indicators of patient needs (Example:
GRASP, MEDICUS)
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 Table 7.2 Daily Census, Required Labor Hours, and Acuity Level Statistics for a Medical/Surgical Floor.
If staffing was based on unadjusted census, inaccuracies would result. For instance, compare January 5 (Census = 9)
and January 7 (Census =12). Which day would require a greater number of FTEs?

Based on Patient
Classification--
Required Hours Number of Patients in
Census per Patient Day Acuity Level
Date Day of
Week
AM PM Night Total AM PM Night Total 1 2 3 4

01/02/05 SUN 12 13 12 12.3 2.3 1.4 0.8 4.5 6 7

01/03//05 MON 13 12 12 12.3 1.9 1.6 0.9 4.4 6 7

01/04/05 TUE 22 22 10 18.0 2.1 1.7 1.0 4.7 1 5 16

01/05/05 WED 9 9 9 9.0 2.1 1.7 1.0 4.8 2 7

01/06/05 THU 11 11 9 10.3 1.8 1.4 0.9 4.1 3 3 5

01/07/05 FRI 12 12 12 12.0 1.6 1.3 0.7 3.6 6 4 2

01/08/05 SAT 12 12 11 11.7 2.0 1.6 0.9 4.6 3 3 4 2

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 Table 7.2 Daily Census, Required Labor Hours, and Acuity Level Statistics for a Medical/Surgical Floor.
But, if we look at acuity levels, we observe that 80% of patients on January 5 are in categories 3 and 4, compared to only 17 percent
in these categories on Jan. 7. The greater acuity is reflected in the greater number of required hours.

Based on Patient
Classification--
Required Hours Number of Patients in
Census per Patient Day Acuity Level
Date Day of
Week
AM PM Night Total AM PM Night Total 1 2 3 4

01/02/05 SUN 12 13 12 12.3 2.3 1.4 0.8 4.5 6 7

01/03//05 MON 13 12 12 12.3 1.9 1.6 0.9 4.4 6 7

01/04/05 TUE 22 22 10 18.0 2.1 1.7 1.0 4.7 1 5 16

01/05/05 WED 9 9 9 9.0 2.1 1.7 1.0 4.8 2 7

01/06/05 THU 11 11 9 10.3 1.8 1.4 0.9 4.1 3 3 5

01/07/05 FRI 12 12 12 12.0 1.6 1.3 0.7 3.6 6 4 2

01/08/05 SAT 12 12 11 11.7 2.0 1.6 0.9 4.6 3 3 4 2

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 Table 7.3 Average Census, Required Labor Hours, and Acuity
Level Statistics for a Medical/Surgical Floor.

Average Census Based on Patient Classification-- Percent of Patients in Acuity

Avg. Required Hours Level
per Patient Day

Year Month AM PM Night Total AM PM Night Total 1 2 3 4

2003 January 14.1 13.8 13.8 13.9 1.8 1.5 0.9 4.1 26.3 26.9 45.0 1.7

February 14.9 14.3 14.1 14.4 1.8 1.5 0.9 4.1 26.2 31.8 38.6 3.3

March 15.3 14.9 14.6 14.9 1.9 1.5 0.9 4.3 19.7 27.5 48.8 3.5

April 18.7 18.4 18.2 18.4 1.8 1.4 0.8 4.1 27.3 26.4 44.3 2.0

May 19.8 19.5 19.3 19.5 2.0 1.6 0.9 4.4 21.7 21.0 52.7 4.3

June 19.2 18.5 18.3 18.7 1.8 1.5 0.9 4.2 23.8 24.9 50.2 1.1

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 Table 7.3 Average Census, Required Labor Hours, and Acuity
Level Statistics for a Medical/Surgical Floor (Cont.)
July 8.7 8.2 7.5 8.1 1.7 1.4 0.8 4.0 18.0 43.4 38.1 0.6

August 8.0 7.5 6.7 7.4 1.6 1.4 0.8 3.7 23.1 44.8 32.1

September 7.4 6.9 6.5 6.9 1.8 1.4 0.8 4.0 15.4 44.6 38.2 1.7

October 6.4 6.1 5.3 5.9 1.8 1.5 0.9 4.1 13.0 39.7 47.3

November 13.5 13.2 12.7 13.1 1.8 1.4 0.8 4.1 28.7 30.4 38.3 2.6

2004 December 13.3 12.6 11.2 12.4 1.6 1.3 0.7 3.7 30.3 43.6 25.7 0.4

2005 January 11.3 11.2 10.1 10.9 1.9 1.5 0.9 4.2 18.9 32.7 45.9 2.5

Statistics

Mean 14.4 13.9 13.4 14.0 1.8 1.5 0.8 4.1 23.3 32.0 42.1 2.4

Minimum 4.5 4.4 4.1 4.3 1.6 1.3 0.7 3.7 12.2 21.0 25.7 0.0

Maximum 22.8 22.2 21.9 22.3 2.0 1.6 0.9 4.5 38.0 44.8 53.7 5.2

St. Deviation 5.3 5.1 5.2 5.2 0.1 0.1 0.0 0.2 6.7 6.7 6.8 1.5

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 Standard Development
 Standards can be internal or external --
choice of standards used depends on cost and
accuracy targets
 Internal standards are often more accurate
– The first step in standard development is
identifying and documenting the activities
performed on the unit/department being
examined
– What tools might you use to identify
these activities?

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 Fixed or Variable?
 All activities identified should be classified as
fixed or variable
– Fixed -- do not vary by volume
– Variable -- fluctuate with services offered
 Classification by direct or indirect care should
also be made
– Direct -- centered around the patient
– Indirect -- Patient care support services

Can you think of examples of each?

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 Determining Activity Times

 Often no need to analyze all activities on the unit,

but the activities chosen should be representative
of all department activities
 For some departments, it is better to analyze all
activities, especially if service mix and complexity
differs greatly
What are some tools we can use to determine
activity times?

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 We should remember these!

 Work sampling
– often done by outside source
 Time and motion studies
– expensive and time consuming; not
common in healthcare
 Estimation- low cost and minimal time
 Historical averaging- easiest and least $$
 Logging- excellent, low cost method

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To determine work standards. . .
Divide the total estimate of hours required
for a given activity by the total volume to
determine the workload standard.

If Radiology works 1500 hours to produce 3000

x-rays, the work standard would be:
1500 hrs. = 30 minutes per x-ray
3000 x-rays
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 But can we expect 100% from anyone?
 Many factors prevent 100% staff utilization
– Controllable-- staff scheduling, avoidable
delays, scheduling of vacations,
– Uncontrollable-- physician ordering
patterns (and golf tournaments!), sick
leave, market constraints of labor force
 Estimating Utilization

– Review historical levels and agree to a

target
– Quantify delays and downtime and allow for
acceptable levels
– Calculate a weighted average utilization
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Table 7.4 Weighted Average Utilization for a
Laboratory Based on Workload Fluctuations by Shift

Shift Percent of Expected Weighted

Work Load Utilization Utilization
(A) (Percent) (B) (A*B)
Morning 45 95 .428
Afternoon 35 85 .298
Evening 7 90 .063
Night 13 85 .111
Total 100 0.900

Weighted Average Utilization Target = 90 %.

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 Example 7.1
A teaching hospital’s laboratory routinely performs nine
microscopic procedures. Average monthly volume of each
procedure has been determined from the historical data. An
earlier time study also revealed the workload standard for each
procedure, as shown in Table 7.5.
Table 7.5 Workload Standards for Microscopic Procedures in Laboratory
Variable Volume Workload Standard Hours
Activities (# of procedures per 30- Standard (hours for 30-day period
day period) per procedure)
Procedure 1 350 .12 42.00
Procedure 2 222 .30 66.60
Procedure 3 185 .45 83.25
Procedure 4 462 .26 120.12
Procedure 5 33 .84 27.72
Procedure 6 12 .88 10.56
Procedure 7 96 .362 34.75
Procedure 8 892 .46 410.32
Procedure 9 26 1.9 49.4
TOTALS 2278 844.72

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 Solution:

The first step in setting staff levels for a procedure

is to discover the number of procedures to be
performed (A).

By multiplying the volume for each procedure by

the workload standard, a time estimate for each
activity is made.

The sum of the standard hours represents the total

time needed to perform the procedures (B).

Because this total represents only the direct

procedure hours of the technicians, it must be
augmented by the indirect (support) hours, which
in this example are estimated at 0.21 hours per
procedure. Table 7.4 depicts these calculations.
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Table 7.6 Calculation of Staffing Requirements for Microscopic Procedures

Total volume of activities (tests) (A) 2278

Total direct procedure hours (B) 844.72
Indirect support hours (C) = .21 x (A) 478.38
(assume 0.21 hours per procedure)
Subtotal variable hours required (D) = (B) + (C) 1323.10
Department utilization target (E) [from above] 90.00%
Total variable hours required (normalized) (F) = (D)/(E) 1470.11
Constant hours (G) (30 days at 12.28 hours per calendar day in this example) 368.40

Total target worked hours required (H) = (F) + (G) 1838.51

Total target FTEs required (I) = (H) divided by 173.33 (hours per FTE per 10.61 FTEs
month-- (40 hrs./wk. x 52 wks)/12 months)
Vacation/holiday/sick FTE allowance (J) = (I) x 9.8% (percentage varies by 1.04 FTEs
hospital department)
Total Required Paid FTEs (K) = (I) + (J) 11.65 FTEs

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 Determination of FTEs for Nurse Staffing.

Determination of the FTEs required to staff a

nursing unit requires several steps. First, the
minutes of required care is determined using the
following formula:
Minutes of Care Required = (Average Census)*(Average Required Minutes per Patient)

This equation then should be divided by the number of

minutes available to work per nurse per day (equals 8
hours/day * 60 minutes/hour, or 480 minutes available) to
determine the number of unadjusted FTEs. Thus, in second
step, unadjusted FTEs are calculated using the next
formula:

Total Minutes of Care Required

Unadjusted FTEs 
Minutes Available to Work per Nurse per Day
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 Determination of FTEs for Nurse Staffing.
However, this method of calculation assumes 100
percent utilization of the staff, an assumption that is
clearly unrealistic for the reasons mentioned earlier.
Suppose that the administration has established a
utilization standard of 0.75; that is, 75 percent of each
employee’s time will be spent in unproductive activities,
or activities unrelated to direct patient care. The
number of minutes available to work per nurse per day
(example, 480 minutes) must be adjusted by the
utilization standard; hence in the third step, core level
FTEs is determined with this formula:

( Average Re quired Minutes per Patient ) * ( Average Census )

Core Level FTEs 
(Utilizatio n S tan dard ) * ( Available Work Minutes )

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Example 7.2:

The nursing manger would like to determine the number of

nursing staff needed for the medical/surgical unit. Table 7.2
and Table 7.3 provide census and acuity information for a
medical/surgical floor.

Solution:
Table 7.2 provides information on the daily census
for January, 2005. Table 7.3 aggregates the monthly data
to provide the average census over a 25-month period.
Notice that the mean values presented in Table 7.2, are the
same as those found in the January, 2005 row in Table 7.3.
It is important to realize that the core staffing levels in this
example are found through a retrospective analysis of
average monthly census and required hours per patient day.

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 Table 7.3 Average Census, Required Labor Hours, and
Acuity Level Statistics for a Medical/Surgical Floor.

Average Census Based on Patient Classification-- Percent of Patients in Acuity

Avg. Required Hours Level
per Patient Day

AM PM Night Total AM PM Night Total 1 2 3 4

Mean 14.4 13.9 13.4 14.0 1.8 1.5 0.8 4.1 23.3 32.0 42.1 2.4

Minimum 4.5 4.4 4.1 4.3 1.6 1.3 0.7 3.7 12.2 21.0 25.7 0.0

Maximum 22.8 22.2 21.9 22.3 2.0 1.6 0.9 4.5 38.0 44.8 53.7 5.2

Std. Deviation 5.3 5.1 5.2 5.2 0.1 0.1 0.0 0.2 6.7 6.7 6.8 1.5

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Solution:

The first step of the staffing calculation is to find the total

number of minutes of care required, using formula:

Minutes of Care Required = (Average Census)*(Average Required Minutes per Patient).

Minutes of Care Required = (14 * 4.1)*60 minutes = 3444 minutes.

The second step uses next formula to divide the number of

minutes available to work per nurse per day (480 minutes) to
determine the number of unadjusted FTEs required.
14 * 4.1
UnadjustedFTEs   7.0
480

The third step determines the core level FTEs, using formula:

14 * 4.1
Core Level FTEs   9.6
Chapter 7: Quantitatve 0.75 * 480
Methods in Health Care
Management Yasar A. Ozcan 32
 Determination of FTEs for Nurse Staffing.
Coverage Factor.

One other adjustment must be made to make sure that the core
staffing levels are as accurate as possible. The above calculation
assumes that employees will be available to work 365 days per
year, without vacations, sick days, or holidays. To adjust for these
factors, we must calculate a coverage factor.

An example of the coverage factor adjustment is found in Table

7.5. The first step in its determination is subtracting weekend days
per year and benefit days from the required coverage days per
year (365 in most any health care organization), to arrive at a total
of available days per FTE (line 5).

By dividing the total number of required days per year by the total
available days, we obtain a coverage factor. This coverage factor is
then multiplied by the unit FTE requirements to calculate the total
unit FTE requirements.
Chapter 7: Quantitatve
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Table 7.7 The Effect of Shift Alternatives on Staffing – The Coverage Factor

Assumptions 5/40 or 4/40 or 4/36 Plans

2/12 & 2/8 Plans

(1) Required Coverage Days per Year 365 365

(2) Weekend Days per Year 104 156

(3) Benefit Days 10 10

*Vacation 7 7
*Sick Days 7 7
*Holidays 1 1
*Other

(4) Total Allowance Days of FTE (2) + (3) 129 181

(5) Total Available Days of FTE (1) - (4) 236 184

(6) Coverage Factor (1)÷(5) 1.55 1.98

Shift Alternatives Unit FTE Requirement Coverage Factor Total Unit FTE Requirements

5/40 9.6 1.55 15

4/40 9.6 1.98 19

4/36 9.6 1.98 19

2/12 & 2/8 9.6 1.55 15

Chapter 7: Quantitatve
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Management Yasar A. Ozcan 34
Figure 7.2 Distribution of Daily Workload on a Nursing Unit

Elasticity Limits
Middle Zone

+ \ - 10%

Can the core level staff

handle the unit’s
activities?
Lower Zone Upper Zone

Float Staff
Low Census-- Necessary
Days Off (HCI = 16%)
(LCI = 16%)

WSI = 68%

27 30 33
Lower Mean Upper
Limit s.d = 3 Limit

Chapter 7: Quantitatve
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Management Yasar A. Ozcan 35
 External Work Standards

 Two Types:
– Industry Standards
– Professional Standards
 Must be careful to adjust these factors for case-
mix and skill-mix
 Per se standards have been argued to lead to
staffing standards that are inaccurate

Chapter 7: Quantitatve
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Management Yasar A. Ozcan 36
Exhibit 7.6 Factors to be Considered in Deciding on Staffing Levels

Size and design of facility

Average length of stay
Non-nursing responsibilities
Nursing responsibilities
Intensity/acuity levels of patients
Reliability of patient classification system
Clinical expertise of available staff
Organized system of patient education
Staff mix
Research and data management responsibilities
Patient transport responsibilities
Physician practice patterns
Facility census patterns
Chapter 7: Quantitatve
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 External Work Standards
It is important to recognize that no standard is absolute. Some room
must be left for flexibility in staffing. Figure 7.3 demonstrates how
statistical analysis can reveal whether the staff is meeting the
standards. Figure 7.3: Workload Standard Tolerance Ranges

Time

U
Workload Standard Tolerance
S Limits
L

n Tests

Unit: ________ Acuity Level: _________

Chapter 7: Quantitatve
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Management Yasar A. Ozcan 38
 Staffing and productivity
Departmental productivity (the ratio of
required hours to number of hours actually
worked) is a measure of staff utilization

Appropriateness of employee skills

Matching of skills to job descriptions
Worker satisfaction and work organization,
retention, recruitment, and transfers also
impact productivity

Chapter 7: Quantitatve
Methods in Health Care
Management Yasar A. Ozcan 39
 Staffing problems impacting
productivity of workforce
Work load volume fluctuations--MD
vacations impact ER staff productivity

Work load scheduling--should

eliminate fluctuations as much as
possible

Skill Mix--does it match work needs?

Staffing patterns-- can staff meet

demand fluctuations?

Chapter 7: Quantitatve
Methods in Health Care
Management Yasar A. Ozcan 40
 The End

Chapter 7: Quantitatve
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Management Yasar A. Ozcan 41