Variable staffing models at work

Healthcare providers are facing a number of challenges in the wake of historic and rapid industry change, which shows no sign of letting up. That leaves providers with two choices: Focus on what can be controlled or react once the dust settles — if it ever does.

One area of control is how staff management views workforce planning and staffing models. Efficiencies in this area will position medical groups for long-term sustainability and success, regardless of what may come.

The term “staffing model” is used to represent different concepts. For this discussion, staffing model refers to the operational tool for day-to-day targets upon which clinical and office staff schedules are built. This is also referred to as a staffing grid, staffing plan or staffing matrix.

• Variable staffing model. This model matches an organization’s workforce to demand or volume versus physician schedules. For example, if Tuesdays and Thursdays are lighter days at a clinic, staffing levels would be lower compared with busier days, such as Monday. Analyzing historical data can provide insight into volume trends. Using this as a baseline will align resources to demand, increase staff satisfaction and influence quality of care.
• Enterprise approach. This concept applies to practices with multiple locations and extends beyond clinic walls to incorporate the idea of contingency float pools. This model creates layers of redundancy that allow an organization to flex to demand, contracting in times of low need and expanding in times of high volume. Contingency staff members also serve as the first line of defense to counter sick time and paid time off. Instead of scrambling to find help, practices have a flexible pool of resources. When a variable staffing model is combined with an enterprise approach to practice management, the team staffing concept is elevated beyond traditional physician and nurse teams.

While the fee-for-service model of reimbursement allowed staffing models to be centered on physician desires, the change to a value-based reimbursement structure challenges practice leaders to reconsider staffing for the following reasons:

• As reimbursement rates are tied to quality and more payers are moving to pay-for-performance models, increased collaboration with and among multiple provider organizations will be required to achieve higher standards.
• As more patients acquire insurance, medical practices must plan effectively to handle increased volumes.
• Tighter profit margins require more creative ways to identify areas of wasteful spending.

Building a business case

When proposing a variable staffing model, analyze these key elements to build a business case: 

• Defining work
• Time studies
• Physician scheduling
• Cost-effectiveness: Calculating the return on investment (ROI)

Defining work

Identify the work completed by your staff and the factors driving it. A physician walking through the door does not necessarily drive work for staff. While the needs of each clinic are unique, the majority of work is driven by patient visits. Receptionists are needed to greet, check in and update insurance and other filing tasks. Nurses or other staff are needed to room patients; take vitals and perform other preliminary tasks; and complete post-visit work, such as billing and collections, follow-up reminders, and nurse follow-up phone calls or case management.

Once the key drivers of work are understood, the next step to developing a variable staffing model is to define the number of staff needed to perform tasks. Ask staff to log time spent performing key activities. Then compare this information with patient volumes (assuming this is the driver of work derived from the previous step) to determine when additional staff members will be needed based on patient volumes.

For example, to simply open the clinic doors and see one patient, the minimum staffing needed may be a receptionist, biller and licensed practical nurse/registered nurse. This also pushes administrators to explore what cross-training or options might exist to leverage greater efficiencies. Could the nurse be cross-trained on basic billing and intake processes that would eliminate the need for some staff during extremely low patient volumes? Using data from time studies and applying it to patient scheduling practices (either wave, block or other type) will help determine what patient volume would prompt staffing changes.

Physician scheduling

Along with average patient visits and types of patients seen, the maximum capacities of the clinic can be understood relative to physical limits due to time and space constraints. Understanding that Dr. Jones has an average visit length of 15 minutes and Dr. Smith’s visit length is 30 minutes means that if they are operating at maximum capacity, Dr. Jones will see twice as many patients as Dr. Smith. This visit volume increase means that additional staff are needed to support Dr. Jones’ schedule. This sets the upper limits for staffing needs and provides guidance on the effects of changes to staffing during the cost-benefit analysis. Make sure you understand day-of-week variables and total volume trends by physician, and do not assume that physicians will always operate at peak levels.

In addition to the typical visit volume per physician and time trends, consider emergency patient needs that take them out of your clinic. You can also manage nonclinical drivers, such as holding physicians accountable to attendance expectations for other organizational leaders and staff.

Last-minute changes in physician schedules are frequently cited as pain points for medical groups. When a physician takes time off with little advance notice, there is a ripple effect with rescheduling patients and staff. Some sites allow employees to work the shift, which increases labor costs for the day while incurring a loss in revenue from fewer appointments; other sites require employees to take paid time off, which leads to disgruntled staff. Some organizations are implementing attendance policies and defining bonuses (or penalties) around attendance and the frequency of last-minute changes (within two to three days).

Cost-effectiveness and ROI

As you develop staffing grids and identify targets for each range, use Microsoft Excel to calculate and compare hours per visit and the cost effect of proposed changes. Take the number of staff hours needed for a session and divide by various visit bands to obtain the new hours per visit. The tables below illustrate the costs of a fixed model versus a variable model.

Table 1 demonstrates that the same staffing is applied and the cost per four-hour session (and day) remains constant regardless of expected volumes, assuming there is no change in physician schedules. Applying the data obtained from the time study, one additional medical office assistant (MOA) was needed for every increase in 10 visits.

Table 2 demonstrates how the cost per session and per day (applying two sessions per day) varies based on scheduled visits. This table also calculates the net change (labor savings or increase) from the fixed model at each visit band with the greatest savings during the days with the lowest visit volumes.

Adjustments are required to ensure that additional time paid to staff (independent of patient visit) are not captured in the grid, such as orientation, training, meetings or other activities.

Change-readiness culture

The data compiled in the previous steps is the first part of implementing a variable staffing model. The heavy lifting comes with preparing your organization for change, which requires change management protocols.

To effectively lead through change, we must align our thinking with the goals of our organization. Clarity is a critical component of implementing change. Drama and the lack of accountability come from ambiguity on goals and responsibilities. Leaders need to provide absolute clarity on goals, next steps and desired outcomes.

To start the process of implementing a new staffing model, consider these steps:

1. Involve the team. Reach out to the critics and pull them in. Connect with various stakeholders among your staff to ensure they get involved and get some skin in the game. For example:
   - If their name is on it, they are invested in its success.
   - If people become involved and help define the objectives, that creates ownership and leads to greater involvement in its success. (This is accomplished by developing cross-functional work groups and having meetings to gather information for design and ideas on implementing and planning for success.) 
2. Communicate. Make sure you deliver a clear, concise message. Transparency is key.
3. Plan properly. There are always multiple projects going on in medical groups, such as EHR installations and site- or unit-specific initiatives. Proper planning will reduce confusion around goals, timelines and responsibilities.
4. Don’t let up. When facing pushback, it’s easy to cave. But one exception will lead to more. Stay on course.