University of Michiganioe481/ioe481_past_reports/19W05.docx · Web viewThe Nursing Supervisor of Scheduling informed the team that schedulers use seniority rankings to provide nurses

Nurse Staffing Model for Von Voigtlander Women's Hospital Birth Center

Final Report

To:Missy Knudsen, Senior Nursing Director, VVWH, [email protected]

CC:Zac Costello, Continuous Improvement Specialist, MM, [email protected] Duck, Admin Manager Sr Healthcare and Lecturer, MM, [email protected] Mukavitz, Continuous Improvement Specialist, MM, [email protected]

From:IOE 481 Project Team 5:Colby Hanley, [email protected] Hebard, [email protected] McKeown, [email protected] Moran, [email protected]

Date:April 23, 2019

Subject:Final Report on Nurse Staffing Project for Von Voigtlander Women's Hospital Birth Center

IOE481/19W5-final

TABLE OF CONTENTS

Executive Summary…………………………………………………………………………….. 3Introduction…………………………………………………………………………………....... 6Background & Key Issues……………………………………………………………………… 6Goals, Objectives, and Expected Impact……………………………………………………… 7Project Scope……………………………………………………………………………………. 7Design Process…………………………………………………………………………………... 8

Engineering Challenges……………………………………………………………….... 8Design Constraints…………………………………………………………………….... 8Design Standards……………………………………………………………………….. 8Design Requirements………………………………………………………………….... 9Literature Search……………………………………………………………………… ..9Deliverables & Design Tasks………………………………………………………….. 10

Alternatives Considered………………………………………………………………………. 10Criteria for Evaluation & Pugh Matrix…………..………………………………….. 10

Data Collection Methods, Analysis, and Findings…………………………………………... 12Observations………………………………………………………………………….... 12Interviews………………………………………………………………………………. 14Surveys…………………………………………………………………………………. 15Historical Data Sets……………………………………………………………………. 20

Conclusions…………………………………………………………………………………….. 26Observations…………………………………………………………………………… 26Interviews………………………………………………………………………………. 27Surveys…………………………………………………………………………………. 28Historical Data Sets……………………………………………………………………. 28

Recommendations……………………………………………………………………………... 28Nurse Specialization…………………………………………………………………… 28Electronic Daily Staff Assignment……………………………………………………. 30Orientation Restructuring....………………………………………………………….. 30

References…………………………………………………………………………………….... 31Appendix……………………………………………………………………………………….. 32

Appendix A: Overview of Interviews and Observations……………………………..32Appendix B: Nurse Survey Comments on Nurse Specialization…………………….36Appendix C: Charge Nurse Assignment Sheet Examples…………………………....37Appendix D: Enlarged Version of Figure 13………………………….........................38

LIST OF FIGURES & TABLES

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Table 1: Constraints and Standards Matrix……………………………………………………….9

Table 2: Pugh Matrix of alternatives for future steps in the nurse staffing project……………...12

Table 3: Procedure distributions…………………………………………………………………23

Figure 1: Nurse competency and comfort levels in each work area…………………………….16

Figure 2: Nurse preferences on specialized work areas………………………………………....17

Figure 3: First choice work area preferences……………………………………………………17

Figure 4: Additional work area preferences of nurses with first choice labor/delivery………...18

Figure 5: Additional work area preferences of nurses with first choice high risk……………....18

Figure 6: Additional work area preferences of nurses with first choice OR/PACU…………….19

Figure 7: Additional work area preferences of nurses with first choice postpartum……………19

Figure 8: Additional work area preferences of nurses with first choice triage………………….20

Figure 9: Top 3 Birth Procedures in Von Voigtlander by Volume……………..…………...….22

Figure 10: Percentage of nurses participating in less than X number of births per month……...22

Figure 11: Percentage of nurses participating in less than X number of births in FY18……......23

Figure 12: Distribution of cases in the OR by scheduled start hour for each weekday…..……..24

Figure 13: Average number of patients in each wing by hour for each weekday…...………….25

Figure 14: Percentage of census records by level for each wing………………..………………26

EXECUTIVE SUMMARYThe University of Michigan Von Voigtlander Women’s Birth Center is facing concerns with regards to their nurse staffing. The Women’s hospital is currently training and staffing their

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nurses in all areas of the birth center. Nurses state they have difficulties in being prepared for all work areas, as they may rotate to some of them too infrequently to feel confident and competent. Due to this, there is nurse dissatisfaction with the staffing model. This motivated the birth center management team to request a University of Michigan student team from IOE 481 to analyze the current state of their nurse staffing model and to provide recommendations for future steps. Through evaluating the current practices and opinions of various nursing staff, the team developed a comprehensive current state analysis and specific recommendations for next steps.

Background & Key IssuesThe birth center currently has 234 nurses that work across the five work areas. The work areas include labor and delivery, operating room, postpartum care, high risk, and triage. Newly hired nurses are oriented and trained to all work areas and then scheduled according to seniority and daily availability into one of the work areas. The birth center generally operates at or approaching capacity and has an increasingly high risk patient base. Nursing management has identified issues in the current staffing model that involve lack of nurse comfortability and competency in certain work areas leading to possible patient risk and work process inefficiency.

The key issues that have contributed to the need for a current state analysis and future recommendations for an improved nurse staffing model are the following: a lack of quantitative knowledge regarding current staffing strategy, stressful conditions resulting from insufficient nurse knowledge base, and divided opinions regarding specialization.

MethodsThe team performed several tasks to analyze the current state of the birth center staffing model and to give future state recommendations.

● Performed literature search: This literature search included information on different hospital operations and how communication occurs in the Operating Room.

● Interviews: The team met with the Nursing Supervisor of Scheduling and the Educational Nurse Coordinator as well as multiple OR nursing staff members.

● Observations: The team observed the Charge Nurse change of shift and a c-section in the operating room.

● Staffing preferences surveys: Data from two previous nurse surveys created to gauge nurse opinions on staffing was analyzed to determine nurse preference frequencies across all work areas.

● Collected historical data: 1-3 years of census data, OR data, charge nurse sheets and labor and delivery data provided by nurse management was analyzed to find trends.

FindingsThe team discovered four types of findings based on tasks performed which formulated the current state analysis and recommendations for future state steps.

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● Observation & Interview Findings: The Nursing Supervisor of Scheduling informed the team that schedulers use seniority rankings to provide nurses with shift preferences. The team found that the Charge Nurse assigns work areas based off of need on that day. The Educational Nurse Coordinator detailed how the orientation process works. The team found that new nurses are all oriented the same. The Nurse Coordinator discussed how this, along with changing the module requirements, could provide an opportunity to significantly reduce orientation time. Nurse opinion on working in the OR is split.

● Survey Data Findings: A higher percentage of nurses considered themselves competent as opposed to comfortable in a work area whereas in triage it was the opposite. 79% of nurses prefer to work in multiple work areas while 21% would like to specialize in only one work area. Out of all work areas, the lowest percentage of nurses chose OR/PACU and triage as their first choice. Nurses whose first choice is postpartum would typically like to specialize.

● Census Data Findings: Weekdays are typically busier than Saturday and Sunday by about 100%. Thursday generally has the most cases compared to other weekdays by about 33%. 10AM has the highest number of patients and 4PM the lowest. The number of patients in each wing is roughly a normal distribution.

● Historical Data Findings: 54% of nurses that performed birthing procedures had performed under 3 per month, 42% less than 2 per month, 22% less than 1 per month, and 11% less than 0.5 per month. 43% of procedures performed by a nurse were performed by a nurse who had participated in a statistically significant amount less than normal. 3 birthing procedures made up over 95% of all procedures.

ConclusionsBased on the findings from the various methods of data collection, the team was able to makeseveral conclusions.

● Observation Conclusions: From observing the charge nurse, the team concluded that there is no standard surrounding where nurses are placed day to day and that charge nurses sometimes choose not to update assignment sheets if nurses move work areas.

● Interview Conclusions: Better understanding of why nurses are staffed in the way they are is needed. The Coordinator saw wasted time during on unit training for nurses who already knew how to perform the tasks. The primary reason why nurses do not want to work in the OR due to heavier workload than other work areas. Partial nurse specialization staffing model could be beneficial in an area such as the OR.

● Survey Data Conclusions: There are at least 10% of nurses in each work area who do not consider themselves experienced enough in the area. Out of all work areas, OR/PACU were chosen least as nurses’ first choice. In a partially specialized staffing model, nurses should be given the option to work only in postpartum as postpartum had the highest rate of nurses desiring to work there and also to specialize in one specific work area.

● Delivery Data Conclusions: There are many births staffed with nurses who may not be fully comfortable with the procedure.

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Recommendations for Future StepsThe team has formed one recommendation based on conclusions from data analysis and two future steps for the nurse staffing project outside of the team’s scope

● Nurse Staff Specialization: Nurse management should further analyze the potential of partially specializing nurses. This could be a portion of the nurse population trained for 1-2 specific work areas and the other portion of nurses being trained in all areas still. The team also determined that efforts should be made to have nurses staffed on births who are experienced in those procedures. A future project should determine how this would take place.

● Future Project Steps: To further the current state analysis and nurse staffing project, the team recommends a change to nurse staffing sheets and orientation layout.

○ Electronic Daily Staff Assignment: The team recommends implementing a staff assignment application to be used on an electric tablet. This would assist in retrieving data as to daily staffing numbers and staffing changes throughout a day.

○ Orientation Time Reduction: The team recommends a reevaluation of the orientation process. A potential change on separating the orientation requirements for experienced new hires versus inexperienced new hires whereas experienced hires can pass a module and eliminate the need for on work area training. Additionally, the team recommends additional preceptor training so as to enhance on work area training for new inexperienced hires.

INTRODUCTIONThe University of Michigan Von Voigtlander Women’s Birth Center is a top-ranked, state-of-the-art Birth Center that is facing concerns with regards to their nurse staffing. They currently follow a model wherein their nurses are trained and oriented in all 5 treatment areas of the birth center: labor and delivery, operating room (OR), postpartum, high-risk antepartum, and triage. A

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nurse may be moved to multiple work areas during a work day but Birth Center nurses cite difficulties in being prepared in all areas and patient safety is questioned when a nurse is less equipped to provide care in a specific unit. The difficulty and dissatisfaction voiced by some nurses motivated the Birth Center nurse management team to ask a University of Michigan student team to analyze the current state of their nurse staffing model. The team will thus provide recommendations for future steps to be taken by nurse management in re-envisioning their current nurse staffing. The team has performed data collection and analysis, interviews, and observations of nurses in the Birth Center. These methods were performed to ensure that the current state analysis and future recommendations delivered by the team are quantitatively accurate based on surgical caseload and patient data as well as incorporates the experiences and opinions of nurses. The purpose of this report is to present all methodologies, findings, and recommendations for nurse staffing in the University of Michigan Von Voigtlander Women’s Birth Center by a University of Michigan student team. BACKGROUND & KEY ISSUESThe University of Michigan Von Voigtlander Women’s Birth Center currently has 234 nurses on staff. They currently experience a patient volume of approximately 4,700 patients per year and their units of care include labor and delivery, operating room (OR), postpartum care, high risk, and triage. Their current nurse staffing model follows Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) guidelines. The staffing model begins with nurses training in low-risk areas such as labor and delivery and continuing on to higher risk areas such as the OR. Once nurses are trained, they are scheduled according to seniority and daily availability into one of the multiple work areas and then assigned to a patient within that work area.

The current nurse staffing model used by the Birth Center has resulted in issues for the nurses and managers. One such issue is lack of competency for primary care nurses in the operating room leading to potential patient risks and uncertainty. Such a nurse may not be fully proficient in operating room procedures due to not being staffed in the OR for a long period of time. The nurse may be forced to work in the OR because of a possible shortage of OR-preferred nurses or a switch in nurse work area assignment. This OR scenario can create uncertainty if a nurse does not recall equipment, patient, or surgical procedures because of unfamiliarity with the OR. Given this example of a scenario not suited well by the current nurse staffing model, the following is a list of key issues which have contributed to the need for an improved current state analysis and future recommendations:

● Lack of quantitative and organized knowledge base for nurses and managers regarding current staffing strategy, leading to disorganization and confusion

● Potentially hazardous and stressful conditions resulting from insufficient nurse knowledge base in all work areas

● Divided opinions: some nurses desire to work across all work areas and others prefer to be specialized to one or two work areas

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GOALS, OBJECTIVES, AND EXPECTED IMPACTThere were four goals and four objectives that were considered for this project. The goals were to:

● Better meet the needs of the patients of the Birth Center in the Von Voigtlander Women’s hospital

● Improve patient outcomes● Improve nurse satisfaction and engagement● Contribute to a staffing model with increased efficiency for nurse orientation and

competency maintenance

The objectives of the project were to:● Identify and analyze the current state of the nurse staffing model in the Birth Center● Interview nurses and understand employee engagement and satisfaction● Determine the viability of future staffing recommendations● Provide the nursing leadership with a deliverable that assists in their understanding of the

current state, as well as gives our recommendation as to future steps

The expected impact is to transfer meaningful knowledge to nursing leadership to allow them to make a more informed decision in the future for their staffing model, and to offer recommendations for future steps relating to a possible new staffing model. Meeting these goals will generate a future state of nurse staffing that makes it easier for the nurse schedulers to schedule and allows for an easier training and onboarding process for new nurses. The team expects the work in understanding the current state will offer guidance for a fully functioning staffing model to be implemented by another project at a future date.

PROJECT SCOPEThis project scope includes a comprehensive current state analysis of nurse staffing in the Birth Center and recommendations for future steps in the nurse staffing project. Discussions with the client and team coordinators determined that the entire scope for a re-strategizing of the Birth Center nurses scheduling would require extensive work. Thus, an analytical staffing alternative for the entirety of nurses on the floor is not possible within the scope of Team 5’s project work, but may be pursued in the future by the nurse management team at the Birth Center.

DESIGN PROCESS The following information describes the design process the team took to outline the current state analysis and to give recommendations for the future state nurse staffing model. This section outlines the engineering challenges, design constraints, design standards, design requirements, literature search, deliverables and design tasks.

Engineering Challenges

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There are two main challenges at hand, the first being the unknown current state of nurses scheduling in the birth center and how to best optimize and improve the scheduling. The second challenge at hand is allocating cohorts of nurses to specific work areas based off of patient demand and nurse competency. This issue arises due to unknown patient demand and daily fluctuations in patient cases across the floor. The team focused on a few specific engineering principles in order to address the nurse allocation and staffing issue. When analyzing the current state, the team utilized data and statistical analysis to identify current pain points and scheduling inefficiencies and then subsequently discovered metrics by which improvements in performance could be measured. Design ConstraintsThree design constraints have been identified that limited the project during the analysis of current state. These constraints were used when presenting quantities of surgeries, types of surgeries, distribution of nurses across units, and others. The number of nurses is constrained to 234 and there are approximately 25 nurses who specifically work in the OR and do not float to other work areas. Another constraint is limited availability of data which the team overcame by requesting relevant data and meeting with additional nurse management faculty. These constraints were taken into account when understanding the current state and the optimal recommendations for future state analyses.

Design StandardsThe team will abide by two main design standards. Specifically, the team abided by HIPAA standards throughout the project. Patient data was needed for current state analysis and in order to protect patient confidentiality and abide by HIPAA standards, the information used was de-identified and stored in a secure MBox document storage folder. Additionally, the Birth Center abides by the AWHONN professional staffing model standards which inform obstetrics units on how to properly staff nurses to ensure safe and effective perinatal care. While this standard does not directly affect the team’s work, it is important to the future progress of this project beyond the team’s scope to ensure that perinatal care is not affected by nurse staffing changes. These constraints and standards are classified in Table 1.

Table 1: Constraints and Standards Matrix

Organizational Ethical Health & Safety

Constraints

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Number of Available Nurses

x

Number of Operating Rooms

x

Number of Specifically Trained Nurses

x

HIPAA x

Data Availability x

Standards

HIPAA x

AWHONN x

Design RequirementsThe current state analysis and future recommendations for the nurse staffing project are designed under four main requirements. The current state analysis accounted for nurse training across work areas in order to classify nurses based off of their competencies for various procedures. Additionally, the analysis took into account nurse surveys that were given to the team which gave information regarding nurse preferences for work areas and potential specialization. These surveys were used to gain a qualitative understanding of the views and concerns of the nursing staff. Also, the seasonal influx of patients based off of data analysis was accounted for in order to understand patient flow and nurse demand. Finally, the analysis accounts for the number of available nurses for each unit at any given time and staffing patterns across work areas.

Literature SearchThe team performed a literature search of one peer reviewed article and a previous IOE 481 project regarding analyses of nurses, scheduling, and staffing. The first article, “The operating charge nurse: coordinator and communicator” [1] discusses the role of communication in the operating room and how communication can be improved across faculty that are involved in the operating room. This is useful for this project because it gave a reference point for the Operating Room observations. With this paper in mind, the observations were done taking into account how to document different types of communication such as doctor to nurse interactions or nurse to nurse interactions. This paper also gave the team information on analyzing frequency of communication and methods of communication such as phone calls or reference board documentations. This was beneficial when analyzing the efficiency of the operating room

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because the team was able to take their knowledge from this paper and investigate the way in which Birth Center OR nurses have found most effective to communicate.

The IOE 481 project reviewed was, “Final Report for Evaluating Nurse Staffing Practices in C.S. Mott Children’s Hospital General Care Units” [2] that was finalized on December 15, 2015. This project focused on evaluating the effectiveness of a nurse staffing model based off of various types of patients in different areas of Mott Children’s Hospital. This is useful for this project because of the similar variations in training requirements across the work areas, and the need for standardization of care- even though the type of care is different from the children's hospital and the women’s hospital. This similarity allows this past 481 project to be a good reference for types of observations to be made and ways to analyze them, such as types of care in different areas and nurse satisfaction.

Deliverables and Design TasksThe team’s main deliverable provides an analysis of the current state of staffing to nursing leadership and gives recommendations for next steps regarding the potential next steps. The deliverables do not include creating a staffing model for the future state of staffing in the Birth Center. The team analyzed the current state qualitatively and quantitatively and will transfer this knowledge. This analysis is a statistical analysis on data provided by the Birth Center. The description of the current state is in the form of anecdotal descriptions of the floor’s current sentiments about staffing, as well as in-depth description of nurse sentiments regarding staffing. It also includes statistics surrounding the current state of staffing.

ALTERNATIVES CONSIDEREDThe team decided to evaluate alternatives for the potential specialization of nurses in the Birth Center. This decision came as the team analyzed the possibility of specializing nurses in the Birth Center, which is not currently in place. This specialization could happen in multiple ways, two of which are evaluated below: 50% specialization wherein half of the nurse population is trained to specifically work in one work area and 100% specialization wherein the full nurse population is trained to work in one area. These two options have benefits and disadvantages and the most important criteria decided by the team are used for evaluation of the two specialization methods.

Criteria for Evaluation & Pugh MatrixWhen analyzing recommendation options for future steps in the staffing project for Birth Center management, the team created 5 main criteria by which the recommendation options could be compared. The first of these is nurse satisfaction and engagement. This criterion is important to the team as they create recommendations since any staffing change made directly affects the nurses. They do not want any change to negatively affect how the nurses engage in their work and with patients and thus gave this criterion a weight of 3 out of 5, showing that it is considered more important than some other criteria.

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The second and third criteria are patient satisfaction and outcomes. These are important because changes in operations, no matter what they are, at the hospital should not negatively impact patients and their sentiments about how they were treated by nurses during their hospital stay. The outcomes portion is important specifically, and was given the highest rating of 5 out of 5, because healthy and safe patient outcomes are always the ultimate priority in healthcare settings, including the Birth Center while the satisfaction portion was weighted 2 out of 5 as it holds importance but not as much as medical outcomes. Changes to staffing in the Birth Center should in no way affect healthy and safe procedures and births.

Scheduling ease is the next criterion evaluated for alternatives. This is evaluated because any changes made to scheduling should hopefully have a net zero or net positive effect on how easy it is for nurse schedulers to form daily schedules. Any new changes should not be burdensome for nurse schedulers in comparison to their current state. When considering the 100% specialization alternative, scheduling can be greatly hindered as the schedule becomes much more complex when only able to put a nurse into one single work area depending on their specialization. This criterion was given a weight of 2 out of 5 as it is important and ideally would not be negatively impacted by new changes to staffing, but realistically may be impacted slightly.

The final criterion used for analysis is cost, given a weight of 2 out of 5. This is relevant since budgeting is a concern when any operational changes are made in the Birth Center and in any hospital unit. Thus, the team compared the potential financial burden of different recommendation options for the Birth Center. This criterion is considered when looking at the 100% specialization option because when all nurses are specialized in a single area, you lose the ability to have nurses float between work areas. This inability to float means that even if enough nurses are present to fulfill the numbers needed in each work area, nurses would have to be mandated on to ensure that all areas are sufficiently full. This increases cost as the nurses staff population becomes larger and more nurses need to be paid for their work time. Cost is also considered as a drawback for electronic daily nurse assignment. Any implementation of a digital charge nurse sheet whether on a tablet or other device has costs of at least device purchase, programming, and data integration. Thus, this option has a higher cost component.

Table 2: Pugh Matrix of alternatives for future steps in the nurse staffing project

Weighting Current State

50% Nurse Specialization

100% Nurse Specialization

Electronic Daily

Orientation Time

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Staffing Assignment

Reduction

CriteriaNurse

Satisfaction and

Engagement

3 0 1 0 1 1

Patient Satisfaction

2 0 1 0 0 0

Patient Outcomes

5 0 1 0 0 0

Scheduling Ease

2 0 -1 -1 1 1

Cost 2 0 0 0 -1 1TOTAL 0 8 -2 3 7

DATA COLLECTION METHODS, ANALYSIS AND FINDINGSThis section of the report describes the data collection and analysis methods used, including:

● Interviews with nursing staff administrators● Observations of charge nurse shifts● Observations of operating room procedures● Analysis of historical data● Analysis of surveys of the nursing staff

In order to produce a comprehensive overview of the current state of the Von Voigtlander Birth Center nurse staffing model. A summary table of the key details, obstacles, tasks completed, tasks in progress, and remaining tasks is located in Appendix 3.

ObservationsTo understand the current state and develop a comprehensive overview, the team performed two sets of observations within the Von Voigtlander Birth Center. Findings from these observations were used to develop the qualitative analysis of the current state of the nurse staffing model at the Von Voigtlander Birth Center.

Charge NurseOn March 1, 2019, the team observed a charge nurse shift, including the turnover between shifts. Two members of the team observed the shift for a total of five hours. During the observation the team members spent time with the charge nurse while reviewing staffing, attending several floor

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huddle meetings, and visiting various work areas on the floor. The team members also observed the charge nurse in her daily responsibilities, and asked questions about her role. Team members noted observations throughout by hand. At the end of the observation, team members discussed their notes to ensure the procedures followed by the charge nurses were clearly understood.

OR/PACUThe team observed the workflow in the PACU and OR area on March 15, 2019; during this time the team also observed a cesarean section performed in the OR. Two members of the team were present for this observation for 4 hours. This observation enabled the team to understand the number of nurses and the competencies required of the nursing staff when working in the OR, as well as nurse opinions about the OR.

Findings from Birth Center ObservationsAt the end of a shift, the charge nurse creates the scheduling plan for the incoming charge nurse and staff nurses on the upcoming shift. In creating the scheduling plan for the next shift, the charge nurse was required to know the situation of every patient on the floor, the care that they required, and the preferences and skill sets of the incoming nurses. Based on the needs of patients, the numbers of nurses coming in, or other extraneous circumstances such as an incoming nurse giving late notice that they will be absent, the charge nurse will call in on-call nurses or mandate nurses to work extended shifts. When the charge nurses turnover between shifts, the outgoing charge nurse will run through the list of patients and nurse assignments and make sure the incoming charge nurse is well informed on the status of the floor. During the shift, the charge nurse performed tasks that included walking to talk with nurses face to face in their work areas, using the telephone, and sending and responding to pages in order to ensure adequate nurse staffing of all work areas. Additionally, these trips around the floor allowed the charge nurse to maintain a working knowledge of all patients. Detailed findings from the charge nurse observation are located in Appendix A.

For any procedure within the OR, there is 1 nurse assigned to the patient, 1 attending anesthesiologist who leaves at the beginning of the procedure, 1 resident anesthesiologist who stays for the entire procedure, 1 attending surgeon, and 1 resident surgeon. There is 1 nurse assigned to the baby being delivered for applicable procedures. The OR also staffs 10-20 nurses on a highly regular basis who have become the OR “core team” because of high preference for working in this work area. OR nurses self-assign to patients once they have been given their work area assignment by the charge nurse and will prep a patient for the OR approximately 45 minutes before a procedure. Detailed findings from the OR/PACU observation are located in Appendix A.

Interviews

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To gain a qualitative understanding of the current state of the nurse staffing model in the Von Voigtlander Birth Center, the team interviewed administrators and nurses on the floor. These interviews were held over the course of one month and two team members were present for all interviews. Team members discussed with both the client and coordinators in order to determine which interviews would be most relevant. The results of the interviews are detailed below.

Nursing Supervisor of SchedulingTwo team members met with the supervisor of scheduling on February 22, 2019, who discussed how the Birth Center schedulers determine who will be scheduled on which days during which shift times. The supervisor of scheduling also distributed documents to the team members which provided samples of previous schedules, breakdowns of the shift times and their correlating abbreviations, and a list of nurse seniority.

Educational Nurse CoordinatorTwo team members met with the educational nurse coordinator, on February 19, 2019. The team discussed the orientation process with her and she provided documentation of skills assessed by the unit and time required for orientation of new nurses.

OR Nursing StaffTwo team members met with four members of the nursing staff in the OR work area on March 15, 2019. One of the nurses was the OR team leader and the other three were Registered Nurses (RN’s) working in the OR for their shift. The two team members held discussions with them regarding specialized work areas and work area preferences while the nurses had downtime. This interview was held directly preceding the OR C-Section observation in the Birth Center.

Findings from Nurse InterviewsUpon speaking with the Nursing Supervisor of Scheduling, the team learned how the schedulers utilize seniority rankings to provide nurses with their preference of shift: preference given first to the most senior nurses and last to the least senior. She also provided details about how the schedulers collect nurse availabilities in order to schedule accordingly as they schedule nurses for one month blocks of time. Schedules are created one month in advance. Scheduling from her perspective is only a high level view of which nurses are scheduled on a day, it does not include which area of care they are assigned to. Therefore, the team members took this information and proceeded to interview a Birth Center charge nurse to gain more information on how nurses are placed into work areas on a day-to-day basis.

When meeting with the Educational Nurse Coordinator, the coordinator communicated that she felt that orientation time was longer than needed. When nurses join the hospital, they start at the beginning of the orientation process regardless of their experience. Addressing this level of experience discrepancy could provide an opportunity to significantly reduce orientation time for nurses joining the nursing team with prior experience in high risk hospital environments. The

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coordinator also felt that many of the orientation processes could be completed through online modules for experienced hires rather than direct instruction.

The four nurses with whom team members spoke in the OR and PACU area provided more personal and specific details about nurse dynamics in the work area. The team discovered through these interviews that some nurses dislike working in the OR because they perceive the OR area to be busier and more stressful than other work areas. The nurses also explained that there is a group of nurses who prefer working in the OR over work areas and have a high level of experience in the area and thus work in the OR most often as the “core team” in that work area. They went on to explain that when a nurse who has little experience or comfortability in the OR and requires help with a task, a “core team” member will aid the nurse to ensure proper patient care.

SurveysThe Von Voigtlander Birth Center nursing administrators provided the team with two nursing staff surveys they had previously conducted in January and October of 2018. Both surveys included free response feedback from the nurses, which is used in conjunction with the quantitative survey data to gauge nurse opinions on a staffing model with specialized work areas. Using the nurse survey data, the team created several histograms and pie charts to use for data visualization. These aids provide a visual interpretation of the breakdown of nurse opinions regarding specialized work areas and the distribution of experience by work area for the nursing staff, which will be used by administrators to better understand the attitude towards the current state of the nurse staffing model. After grouping nurses by their first choice work areas, the team produced histograms for each work area which illustrates nurse interest levels in all of the other work areas, along with the percentage of nurses who are not interested in any other work areas. The team also produced a pie chart which shows the percentage of nurses who desire specialized work areas compared to those who do not.

January 2018 SurveyThe first survey was conducted in January 2018. This survey collected self-ranked levels of competency and comfort in each work area along with an ordered ranking of each work area and comments from each nurse. A sample size of 104 nurses participated in this survey.

October 2018 SurveyThe second survey was conducted in October 2018. This survey collected the first choice work area, whether or not nurses were interested in working in multiple work areas, and the work areas those nurses are interested in where applicable. The team utilized these surveys to develop recommendations for the nurse staffing model at the Von Voigtlander Birth Center. A sample size of 149 nurses participated in this survey.

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Findings from Nurse Opinion SurveysFigure 1 depicts the percentage of nurses who consider themselves to be competent and the percentage of nurses who consider themselves comfortable in each of the five work areas from the survey data. The team found that a higher percentage of nurses considered themselves as competent in a work area compared to being comfortable in the same work area; however, in triage, a higher percentage of nurses considered themselves comfortable than competent. As indicated in Figure 2, 79% of nurses prefer to work in multiple work areas while 21% would like to specialize in only one work area. The team analyzed the first choice work areas and found that the OR/PACU and triage were chosen as first choice the least which can be observed in Figure 3, which shows the percentage of nurses that prefer each work area as their first choice. Among the nurses who selected a specific work area as their first choice, Figures 4-8 display the percentage of nurses who are interested in each of the other work areas; which led to the finding from Figure 7 that nurses whose first choice is postpartum, would typically like to specialize. Appendix B can be referenced for the personal comments provided by nurses in the October 2018 survey.

Figure 1: Nurse competency and comfort levels in each work areaSample size: 104; Source: January 2018 Survey

Figure 1 demonstrates that a higher percentage of nurses consider themselves to be competent compared to the percentage who consider themselves to be comfortable in every work area except for triage. Another important finding from Figure 1 was that less than 90% of nurses consider themselves to be comfortable in any of the five work areas.

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Figure 2: Nurse preferences on specialized work areasSample size: 149; Source: October 2018 Survey

Figure 2 shows that the majority of nurses would prefer to continue working in multiple work areas while 21% of nurses would like to specialize in only one work area.

Figure 3: First choice work area preferencesSample size: 149; Source: October 2018 Survey

Figure 3 shows that it can be observed that the OR/PACU was the least popular work area when nurses ranked their first choice work areas. The most popular work area was high risk.

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Figure 4: Additional work area preferences of nurses with first choice labor/deliverySample size: 149; Source: October 2018 Survey

Figure 4 shows that it can be observed that high risk antepartum was the most desired additional work area among nurses whose first choice work area was labor/delivery. Additionally, about half of these nurses also expressed a desire to work in postpartum.

Figure 5: Additional work area preferences of nurses with first choice high riskSample size: 149; Source: October 2018 Survey

Figure 5 shows that labor/delivery, triage, and OR/PACU were the most desired additional work areas among nurses whose first choice work area was high risk antepartum.

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Figure 6: Additional work area preferences of nurses with first choice OR/PACUSample size: 149; Source: October 2018 Survey

Figure 6 shows that labor/delivery was the most desired additional work area among nurses whose first choice work area was OR/PACU.

Figure 7: Additional work area preferences of nurses with first choice postpartumSample size: 149; Source: October 2018 Survey

Figure 7 shows that among nurses whose first choice work area was postpartum, the majority of these nurses did not want to work in any other work areas. This finding indicates that many of these nurses would like to specialize in postpartum.

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Figure 8: Additional work area preferences of nurses with first choice triageSample size: 149; Source: October 2018 Survey

Figure 8 shows that labor/delivery and high risk were desired additional work areas among the majority of nurses whose first choice work area was triage. This finding indicates that theses nurses may benefit from a sub specialization group consisting of triage, labor/delivery, and high risk.

Historical Data SetsThe team received several data sets from the business analyst of the Birth Center. The team analyzed each data set and determined its usefulness in contributing to an understanding of the current state.

Labor and Delivery DataThe Fiscal Year 2018 (FY18) Labor and Delivery data set includes data for all births that occurred during the year. The data included the date, the type of birth, and the personnel staffed on that birth. The team used the information from the Labor and Delivery data set to summarize the nurse participation in births during a year. Additionally, the team analyzed the frequency of different types of births in the Birth Center and created a visual representation of the data. Next, distributions were extracted from the data for each type of birth and calculated how often each nurse participated in each type of birth in order to compare them.

Charge Nurse SheetsThe team has also acquired nurse staffing charts by work area, recorded by the charge nurse for each shift. These sheets had information on all nurses that were staffed during a shift, and where they were assigned throughout da shift.

FY18 OR DataThe team obtained data that included all procedures performed in the OR for FY18; the data set included 2,398 records. Analysis of this data was performed in Tableau Desktop 2019.1 to gain an understanding of case demand by day and determine the peak hours for cases to begin the OR.

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Census DataThe team obtained data that gave the number of mother and baby patients in each wing of the hospital, every hour of the day for January 2015 through March 2019; the data set included 74,448 records. Analysis of this data was performed in Tableau Desktop 2019.1 to understand patient demand in the East and West wings of the floor on an hourly basis. Distributions of the size of hourly census records for each wing were also produced to determine if one wing consistently experienced higher demand than the other.

Findings from Historical Data SetsFrom the Delivery Nurse assist data, the team discovered that there were 272 nurses that participated in birthing procedures in FY18. There was a broad range of different procedures that included the following in order of decreasing frequency:

● Vaginal, Spontaneous● C-Section, Low Trans● VBAC, Spontaneous● Vaginal, Vacuum (Extractor)● C-Section, Class● Vaginal, Forceps● C-Section Low Vert● Medical Termination● VBAC, Vacuum● Spontaneous Loss● VBAC, FRCPS● Inpatient Induction of Labor

The three most common procedures (Vaginal, Spontaneous, C-Section, Low Trans, and VBAC, Spontaneous) made up over 95% of all births. Percentages for each of these three can be seen below in Figure 9.

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Figure 9: Top 3 Birth Procedures in Von Voigtlander by VolumeSample size: 10,032; Source: FY18 Delivery Data

From the Delivery Nurse assist data the team discovered that of the 272 nurses that participated in birthing procedures in FY18, 54% of them participated in under 3 per month, 42% in less than 2 per month, 22% in less than 1 per month, and 11% in less than 0.5 per month. In these percentages, the 54% includes the 42% with less than 2 per month, the 42% includes the 22%, and the 22% includes the 11%. This can be seen in Figure 10.

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Figure 10: Percentage of nurses participating in less than X number of births per monthSample size: 272; Source: FY18 Delivery Data

In addition to the data collected in Figure 10, the team developed a histogram of number of births performed by nurses, regardless of procedure type. This is seen in Figure 11. A bucket size of 5 births was used for the chart. Important percentage numbers of nurses are called out on the cumulative line. The distribution is very right skewed, meaning that high numbers of nurses performed lower numbers of births, and low numbers of nurses performed high numbers of births.

Figure 11: Percentage of nurses participating in less than X number of births in FY18Sample size: 272; Source: FY18 Delivery Data

The team also extracted distribution data for the number of times a nurse participated in a specific type of birth, shown in Table 3.

Table 3: Per Nurse Statistics by Procedure TypeSample size: 272; Source: FY18 Delivery Data

Using these distributions, the team compared the number of times each individual nurse was involved in a type of procedure, and compared it to the distribution to test if it was significantly different. This was tested by comparing the nurses personal total for a

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procedure to the 90% confidence interval for the procedure. 43% of procedures were performed by a nurse who had participated in less than the average number of procedures.

From the OR data, the team found that weekdays are typically much busier than Saturday and Sunday; this can be observed in Figure 12, which depicts the number of cases that began at each hour on each weekday throughout FY18. Figure 13 depicts the average census at each hour on each weekday compared to the weekday average for the East and West wings of the Birth Center. This figure shows that although the weekday distributions were all quite similar, there was a noticeable peak in cases found on Thursdays. The team discovered that there is typically an increasing number of patients during the week starting with the lowest amount on Monday. It was also discovered that for every day of the week, the count of patients in the hospital appears to cycle with peak demand occurring around 10AM and the lowest demand occurring around 5PM. The team discovered roughly normal distributions for the number of patients in each wing for the Birth Center from the census data; this can be seen in Figure 14, which shows the distribution of census records by size of census for the East and West wings of the Birth Center.

Figure 12: Distribution of cases in the OR by scheduled start hour for each weekdaySample size: 2398; Source: FY18 OR Data

Figure 12 shows that the OR deals with significantly less cases on Saturdays and Sundays compared to weekdays. Figure 12 also indicates that the majority of cases in the OR begin between 7AM and noon.

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Figure 13: Average number of patients in each wing by hour for each weekdaySample size: 74448; Source: Census Data

Figure 13 shows that the patient demand for rooms in the East and West wings of the floor fluctuate throughout each day of the week with peaks in demand occurring around 10AM and demand bottoming out around 5PM. Figure 13 also indicates that the East wing typically has around five more patients than the West wing.

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Figure 14: Percentage of census records by level for each wingSample size: 74448; Source: Census Data

Figure 14 shows that the distribution of patient demand follows a roughly normal distribution in the East wing; however, the distribution of the West wing is skewed to the left which supports previous findings that the West wing is typically occupied by fewer patients than the East wing.

CONCLUSIONSAfter analyzing the quantitative and qualitative data gathered, the team has created conclusions concerning their observations, interviews, surveys, and historical datasets. These conclusions aided the team in making recommendations relating to the nurse staffing in the Birth Center.

OR/PACU & Charge Nurse Observations From observing the charge nurse the team can conclude several things. Firstly, there is no standard for where nurses are assigned day to day. The decision is up to the individual charge nurse who is free to base their decision on any factors that they deem appropriate, besides the consideration of seniority, which must always be considered when scheduling and calling off nurses. Some charge nurses, for example, will try to take nurses work area preferences into account while others will not.

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Nurse Management Interviews Meeting with the Nurse Supervisor of Scheduling produced the conclusion that an interview and observation of the charge nurse needed to be scheduled because this interview had not provided evidence or discussion concerning daily nurse placement into work areas. The Nurse Supervisor of Scheduling had provided quality explanation and evidence of monthly nurse scheduling according to seniority, availability, and skillset but was unable to provide work area assignments because that assignment is done by only the charge nurse and on a day to day basis. The information provided by the Nurse Supervisor of Scheduling was relevant background information for the team to fully understand the entire scheduling process, but it was concluded that further information was needed in order to have a full, analytical understanding of the nurse scheduling and assignment process. In addition, it provided information that upper level nursing management are unaware of where specific nurses are staffed day to day.

After meeting with the Educational Nurse Coordinator (ENC), the team made two conclusions. Firstly, that the orientation should be separated for new nurses versus experienced nurses. This was concluded because the ENC saw wasted time during on unit training for nurses who already knew how to perform the tasks in low risk, postpartum, and high risk. Nurses spend 12-13 weeks training in low risk labor followed by 6 months of working solely in this work area. Next, nurses begin training in postpartum care 72 hours followed by 1 month working only in the postpartum work area. Finally, nurses undergo training modules for high risk care, followed by 72 hours of training in the unit; after training, nurses spend 1 month working in high risk. After theses three segments of training, nurses are finished with the orientation procedures. In addition, the second conclusion was the staff should focus on changing the orientation fetal monitoring training. There are 12 hours of training designated to fetal monitoring which can be streamlined through training preceptors to then train nurses, which will be detailed in the recommendations section.

Team members came to two conclusions after speaking with the nurse staff in the OR of the Birth Center. The first is that, from the words of the nurses, a competency problem is not the primary reason why nurses do not want to work in the OR, but instead that they do not want to work there because of the increased complexity and time-intensive nature of OR work. This detail was a new finding for the team and helped draw the conclusion that across different work areas, their intensity and complexity of work can act as an additional factor regarding nurse desire to be placed in an area. The team also concluded that the core group of 10-20 nurses who prefer to always work in the OR and the 10-20 who would like to work in the OR once a month demonstrates that a partial nurse specialization staffing model could be beneficial in an area such as the OR. This positive feedback from the OR nurse team lead contributed greatly to recommendations.

Nurse Opinions Surveys

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Although the majority of nurses are both competent and comfortable in all work areas, there are still at least 10% of nurses in each work area who do not consider themselves competent. Given the high stakes of properly caring for patients, nurses should be more strategically rotated through work areas in order to ensure proper experience or nurses should become specialized into the work areas in which they can confidently provide the best care possible for patients. The OR/PACU were the least desired first choice work area; this was also supported by the interviews with nursing staff discussed previously. Additionally, from Figure 8, the team determined that a potential grouping of high risk antepartum, triage, and labor/delivery would be desirable as 80% or more of nurses with first choice triage also indicated a desire to work in high risk antepartum and labor/delivery. Finally, the team found that nurses who most prefer working in postpartum also most prefer the option to specialize in one work area.

Historical Data SetsBased on analysis of the historical data set, the team was able to create multiple conclusions. Over 95% of births come from three types of procedures. The team also determined that 54% of nurses that performed birthing procedures had performed under 3 per month, 42% less than 2 per month, 22% less than 1 per month, and 11% less than 0.5 per month. Using the distributions for each procedure, the team determined that 43% of procedures performed by a nurse were performed by a nurse who had participated in a statistically significant amount less than normal. Due to these numbers, the team can conclude that there are many births staffed with nurses who may not be fully comfortable with the procedure because of lack of regular experience. This coupled with the fact that such a small number of procedures make of the majority of the volume provide possible room for specialization.

RECOMMENDATIONSThe team has created one recommendation for modification of the Von Voigtlander Women’s Hospital Birth Center nurse staffing model project based on conclusions from data analysis and two steps for furthering the current state analysis.

Nurse Staff SpecializationThe team recommends the Birth Center nurse management to further analyze the potential of partially specializing nurses. This nurse specialization would entail a portion of the nurse population at the Birth Center being trained for 1-2 specific work areas and the other portion of nurses being trained in all areas.

Based on the results of the analysis of the historical data, the team determined that the nurse staffing structure should be modified to have nurses staffed on specific birth procedure types who are experienced in those procedures. A future project should determine how this would take place. A possible solution could be with nurse specialization. With specialization, the number of different types of procedures expected of an individual nurse would be lowered. As a result of limiting the number of procedures for a nurse, job engagement and satisfaction may increase due

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to better understanding and confidence in a more limited number of work areas and less unexpectedness in work procedures. In addition, a more experienced nurse in a procedure is more likely to provide excellent care to a patient. This could improve patient satisfaction as well as patient outcomes. The number of births that were staffed by nurses who had not performed the hospital average number of that type of birth was about 40%. In addition, 17% of nurses participated in less than 0 births a year. These numbers would suggest that nurses are staffed on birthing procedures with which they are not familiar. With all of this information holding true, there is still a divide in Birth Center nurses about whether or not they would like to specialize or not, so the future of this project would need to determine whether fully specializing all nurses is best or if specialization of a portion of the nurse population would be better for nurse satisfaction.

Nurses currently are divided on whether or not they would like to work in one or multiple work areas, according to the two nurse surveys distributed in 2018: 79% of nurses want to work in multiple areas and 21% want to work in one area. This data is supported by nurse comments in the surveys detailing how some believe strongly in working in multiple areas and would strongly dislike being forced to work in only one, while others disagreed and said it would be easier and better to be placed in one or two specific areas instead of all. This divide in nurse opinion provided evidence to the team to recommend that a partial specialization in work areas for nurses would best suit the needs and preferences of nurses and should be investigated further.

While spending time in the OR, the team learned that 10-20 nurses prefer to only work in the OR and another 10-20 prefer to work there regularly but not singularly. This testimony combined with the complexity of OR work showed that specialization of nurses and specific placement of some nurses in work areas such as the OR could improve staff performance in this area and others and improve patient care.

The team also decided to recommend the investigation of nurse specialization because of its impacts on Birth Center efficiency. By specializing a portion of the nurse staff, management would be able to decrease amount of time spent on orientation for some nurses and also minimize some concerns about nurse comfortability in areas requiring more intense training or with reportedly lower rates of nurse comfortability. The team is recommending that this nurse specialization be analyzed and investigated further because nurse staffing standards, the Nurses’ Union, and scheduling restrictions would need to be explored, which were all outside of the scope of this project.

Future Step of Current State Analysis: Electronic Daily Staff Assignment Based on the observation of the charge nurse, the team recommends the implementation of a staff assignment application to be used on an electronic tablet. The team found four primary reasons an application would assist the charge nurse compared to the daily staffing sheets currently being used. First, the charge nurse would benefit from being able to sort all nurses

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currently on duty in seniority order for the purpose of mandating nurses to stay on duty or to mandate nurses off of a shift when patient demand is low. Second, the application would also allow the charge nurse to sort nurses by work area and visualize each nurses’ first choice work area. By looking at work area preferences while making daily assignments, the charge nurse would be become more capable of increasing nurse satisfaction within their day to day work. Third, the process of nurse shift swaps could be streamlined through the use of an electronic submission system. This system would notify the charge nurse on duty of requests, and give the charge nurse the option to approve or deny those requests.

Finally, the implementation of an electronic nurse staffing assignment application would result in daily schedules being recorded into a database for future analysis. This standardization of daily staff assignments through an electronic process is critical for the progress of understanding the current state in extensions of the nurse staffing model project. This data tracking would allow nursing administrators to better track how staff nurses are being utilized and where changes to the staffing model could be made on a periodic basis, which is necessary information for understanding the current state.

Future Step of Current State Analysis: Orientation RestructuringBased on the team’s meeting with the Educational Nurse Coordinator, the team recommends changing the orientation process to shorten the time nurses spend in orientation. Shortening this process would help to eliminate cases where incoming experienced nurses are not able to work independently, which would minimize cases of the charge nurse needing to mandate extended shifts due to a shortage of available staff to call in. Specifically, the orientation process should be different for experienced nurses versus inexperienced nurses. Having experienced nurses complete 12-13 weeks in low risk followed by 72 hours in postpartum and 72 hours in High Risk on the floor with a preceptor to prove their competency reduces the time they could be acting as a nurse on the floor on their own. To separate the two groups, experienced nurses should have the option of taking the module pre-test, and opting out of the orientation portion if they score perfectly on it. Additionally, to shorten orientation time, the team recommends the Nursing Management team looks into training preceptors to teach new nurses in the work areas instead of the nurses participating in lengthy modules. If preceptors were able to teach the new nurses, this would reduce orientation time because the nurses would not need to participate in as many 4 hour modules.

REFERENCES

[1] J. Moss, “The Operating Room Charge Nurse: Coordinator and Communicator,” Journal of the

American Medical Informatics Association, vol. 9, no. 90061, 2002.

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[2] M. Guzman, B. Lopez, A. Zimmerman, “Final Report for Evaluating Nurse Staffing Practices

in Mott Children’s Hospital General Care Units,” Ann Arbor, MI, USA, December 15, 2015.

APPENDIX

Appendix A: Overview of Interviews and Observations

Charge Nurse Observation

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Turnover:● Night shift charge nurse reviews list of all patients currently in the floor as well as the list

of all incoming nursing staff● She will make calls or walk around the floor to learn more information if necessary● She is kept up to date if a patient is moved to the OR or PACU or another room for any

reason● She is also kept up to date on the status of laboring mothers● Depending on the needs of patients, the numbers of nurses coming in, or other extraneous

circumstances (such as an incoming nurse calling off late), the charge nurse will call in on-call nurses or mandate night shift nurses over

● When the day shift charge nurse arrives, the night shift charge nurse will run through the list of patients and nurse assignments and make sure that the day shift nurse is caught up on everything

● Then the night shift charge nurse will leave and the day shift charge nurse will take over● The charge nurses responsibilities consist of monitoring the needs of patients and the

availability and positions of nurses, and shifting nurses around as needed● 7:40AM: charge nurse discusses patients with nursing team● 7:45AM charge nurse sends out a page to try and get more nurses in for the 11AM shift

○ Anyone with pager turned on will receive this, regardless of f they are at the hospital

○ In cases where a shift is ending and the on call nurses have been called in, charge nurse can mandate other nurses to work an extended shift

○ Planned to do another page at 11AM● 7:56AM: charge nurse is informed in person of a shift swap for the 7PM shift

○ Makes changes to staffing plan by hand on paper○ Typically nurses should give more advanced notice for a swap, but this is not

strictly enforced● 8AM: huddle meeting for high-risk patients with attendings in the team room

○ This meeting was cancelled● 9AM: huddle with management, team leads, doctors, social work, etc (representatives

from each work area basically) in hallway○ This hallway was used for this, had whiteboard with lots of floor information

● 9:10AM: huddle with nurses in a team room● Working as the charge nurse is more stressful than working as a staff nurse; the two

charge nurses the team talked to prefer to be a staff nurse● The charge nurse is responsible for all nurses and patients on the floor throughout their

shift● Charge nurse shifts are 12 hours long (7AM-7PM and 7PM-7AM)● Staff nurse shifts are also 12 hours and run from 11AM-11PM, 11PM-11AM, 3PM-3AM,

3AM-3PM, 7AM-7PM, and 7PM-7AM● Charge nurse will also jump in to help with patients if necessary

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● Those who work as charge nurse are typically assigned to 3 charge nurse shifts per month

OR Nurse Interview/Observation● Core group of 20-40 nurses enjoy working in the OR

○ Roughly 10-20 want to work in the OR for 1 week per month○ Roughly 10-20 nurses only want to work in the OR

● 8-10 nurses in PACU before any of the procedures begin in the OR● There were 4 procedures on the schedule for the day

○ So far, one of these came from triage● Nurses assign themselves to patients on the list which is prepared by the team leader● OR typically staffed by:

○ 3 residents○ 1 fellow○ 2 attending physicians○ 3 scrub techs○ 1 scrub tech runner○ There will be 1 nurse per patient (mother+baby count as 1)○ 1 team leader nurse○ 1 floater nurse

■ For example, 4 patients would mean 6 nurses in OR● Staffing Coordinator suggested that nurses just come into OR near the time of the

procedure they will be working● C-sections, terminations, etc occur in the OR

○ C-sections take 1-1.5 hours typically● Roughly 45% of cases in the OR are unscheduled● 3 types of doctors in PACU/OR

○ Family medicine○ OB○ Midwife Service

● 4 OR’s○ Always want to keep at least 1 of the OR available

● Reason for nurses disliking OR○ They are less certain that they will get their hourly breaks and lunchtime○ Less free time

● For observed case there was:○ 1 floating nurse○ 1 surgical tech○ 1 resident○ 1 attending anesthesiologist at the beginning○ 1 resident anesthesiologist throughout○ 1 nurse practitioner and one PEDS doctor came to assist with baby

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■ Typically only 1 RN for baby■ Extra help came because of unusual delivery (head came out after body)

○ 1 nurse who is assigned to the procedure

Nurse Supervisor of Scheduling Interview● Nurses provide availability in 1-month increments● Schedules are created for 1-month blocks of time● 6 shifts of 4 hours in 24-hour time period● Scheduling is done by seniority

○ Most senior nurses get shift preferences first○ Least senior nurses get shift preferences last

● Nurse schedulers do not handle day-by-day work area assignments, that is all left up to the charge nurse

● Supervisor hands out documents including schedule examples and definitions of shift names

● Nurse scheduling restricted by hospital and industry standards including nurses’ union

Appendix B: Nurse Survey Comments on Nurse Specialization

separate units. Patients want a nurse that is happy in her role taking care of her and her family. If this is where she excels at that makes sense. Patient satisfaction

Split the unit. We operate on the LDRP model. We have never been an LDRP. The reason why it has never worked is that we never plan for enough rooms. In an LDRP all rooms must be

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able to recusitate mom and baby. We move pts after delivery because of this , therefore never have been a true LDRP. Split like this:Postpartum, Labor / High risk, OR team, with charge and triage nurses on each team/ area.

Separate OR completely

I believe Post-Partum should be a seperate area, like many hospitals already are. If this means we need to sacrifice senority then I am willing to do so. I have been here 14 years and prefer post-partum. This is an area I feel comfortable with and thrive. I feel very knowledgeable and and asset to pt. and families. Especially when I have a child with special needs. I have more insight how to educate families/pt. with a new dx, especially with Down Syndrome. I have walked these shoes and and feel this is where my strengths and empathy can shine. After working in all department (minus charge/triage) I feel I have "earned" the right to be where I feel I would thrive and be a resource for my patients. This is my niche and I know this is where I belong. I feel post-partum would also allow me to keep up on my high risk skills. As we all know pt.'s are sicker and therefore we are seeing a lot of magnesium/blood transfusions on our floor. Having a post-partum pt. on Mag is seen a lot on this unit. I would like to see high risk and post-partum units combined if we can't keep post-partum a seperate unit itself.

Remove OR from the rotation, keep nurses competent in the areas they are most comfortable (as we currently do) and labor nurses hand off pts to OR team, then she becomes a float NOT 2nd nurse in OR, that just defeats the purpose of having staff feeling uncomfortable and incompetent in the OR when we all know that the "baby nurse" would most likely be doing more than just baby things.

High Risk/Antepartums/Triage togetherMother/Baby togetherOR/PACU alone. Dedicated circulators to take patient when she goes to OR (Labor nurse to 2nd)

Is there a way to allow nurses to work in their preference area and fill gaps with nurses who want to work all areas? Specialize the OR, triage and high risk.

Depending on what you find out at Northwestern, I feel that the OR (pre-op, intra-op (including 2nd RN) and post-op, should be completely separate from the rest of the unit. That way staff on days and nights can function like a well oiled machine.

I think postpartum should be a separate area of care. Nurses should have the ability to do just Postpartum.

I see the biggest issue being that people prefer PP only. I do not see how keeping labor and PP together will solve any issues. I do agree the OR should be its own place.I also believe triage and charge should stay its own group. Triage has a different environment

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in terms of nurse/provider relationships and level of proficiency in that specific area, especially when it comes to phone calls. It’s not a place people can work here and there.

I like the idea of having low-risk and high-risk labor grouped together, as well as low-risk and high-risk postpartum grouped together. OR/PACU/triage could be another category. I think this would make a lot of labor nurses happy since so many also like to do high-risk, and I don't feel like it would take much training for postpartum nurses to perform high-risk tasks (mag, insulin gtt, etc.).

I believe most nurses prefer to be in the area that they feel most confident and excel in, this helps with nursing moral and nursing retention.

Appendix C: Charge Nurse Assignment Sheet Examples

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Appendix D: Enlarged Version of Figure 13

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Figure 13: Average number of patients in each wing by hour for each weekdaySample size: 74448; Source: Census Data

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