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“Failure is not an option. It comes bundled with the software.”

Jerry Krasner, PhD, MBA

For decades allocation of hours for emergency department (ED) nursing coverage has followed the inpatient model based on hours per patient day (HPPD), measured as hours per patient visit (HPPV) for the ED. That model continues to be applied widely and, as a result, ED Nurse Directors have to account for productivity that is measured using an insensitive and crude yardstick. This productivity measure has a low correlation with the hourly and daily ebb and flow of patient volumes, acuities, lengths of stay, and in short, the actual operational demands of providing care.

Using this volume-driven financial performance model, ED Nurse Directors stay out of fiscal hot water if their departments perform at or below allocated hours per patient visit. However, they must cope with daily stresses related to operating within strict staffing parameters. An “it-is-what-it-is” mindset leaves many departments operating chronically and hopelessly short staffed.

ED leaders are frequently reminded that human resources are the most expensive line items on any department's operating budget. There has been a tendency on the part of some hospital executives to approve requested nursing hours conditionally pending improvement of a certain metric, such as customer satisfaction scores or the percentage of patients who leave prior to medical screening examination. This is the theory:

“If you can get this boat to other side of the river, we'll give you the oars.”

Others have required demonstration that a new process or service can be successfully implemented prior to approving the resources required for successful implementation. The fault in this logic is readily apparent. “Prove it first” and “Let's make a deal” do not work because partial resources often fall short of what is needed to achieve the desired goals.

The Centers for Medicare and Medicaid Services (CMS) quality measures and value-based purchasing continue to elevate quality performance expectations for healthcare organizations. Simultaneously, economic conditions apply pressure on healthcare institutions to reduce the cost of providing services. Best practices such as parallel medical and nursing functions optimize ED throughput and better position EDs to perform well on metrics, such as

  • HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)
  • Quality measures for throughput segments

Because of different cycle times for medical providers and nurses, a ratio of 2 nurses to 1 medical provider is necessary to maintain uninterrupted patient movement through the ED. Ironically, in an attempt to create operational efficiency, ED fast tracks are commonly implemented with one medical provider and one nurse. The mistaken expectation is to provide expedited throughput times while understaffing the area with one nurse, whose standard work cycle time per patient is double that of the medical provider. It is also common for an ED with moderate volume to


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