If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
UCLA Health developed a system-wide in-house float team to meet organizational demands and strategic expansion, merging all facility float teams to create the nursing system float team (NSFT). The NSFT is designed as a centralized functional organizational structure that allows for systematic processes. In addition, the structure is designed to enable expansion into other areas with appropriate managerial oversight. As a result, contract labor dependence decreased by 45%, and self-reliance increased by 41%, providing a favorable operating margin. This article serves as a guide for external organizations to collaborate in developing a systematic approach for redeveloping staffing models.
Key Points
•
A centralized staffing model is essential to meet the current staffing demands for healthcare systems.
•
The financial benefits of using an in-house float team compared to contract labor show favorable margins.
•
Expanding the nursing in-house float team is necessary to meet organizational staffing.
UCLA Health developed a system-wide in-house float team to meet organizational demands and strategic expansion, merging all facility float teams to create the nursing system float team (NSFT). The NSFT is designed as a centralized functional organizational structure that allows for systematic processes. In addition, the structure is designed to enable expansion into other areas with appropriate managerial oversight. As a result, contract labor dependence decreased by 45%, and self-reliance increased by 41%, providing a favorable operating margin. This article serves as a guide for external organizations to collaborate in developing a systematic approach for redeveloping staffing models.
Purpose
UCLA Health aims to highlight the structure, efficiency, and results of its system-wide in-house float team for other organizations to work towards achieving resource independence by reducing dependency on contract labor in the current environment. The UCLA Health nursing system float team (NSFT) evolved since its early conception, merging 2 separate facility float pool teams into a centralized system float team, resulting in the NSFT workforce growing annually; as of fiscal year-end 2022, the total team size is 839 staff, which is a growth of 23% since the merger. Management coordination establishes oversight for specialty divisions to support a centralized structure and the team’s development. The functional organizational structure ensured adequate nurse staffing in times of uncertainty. UCLA Health has developed a systematic plan to establish and sustain strategies for a system float team. The design of the NSFT provides for expansion into other areas and recruits staff with the capability to deploy rapidly.
Background
During the past decade, nurse staffing in acute care hospitals has continually been evolving to meet the rapid changes in healthcare. As a result of these changes, health organizations across the country have responded by revising their operational model while facing increased fiscal obligations to provide safe patient care. Contract labor has financially impacted organizations by being a principal component in the staffing model. As of December 2021, US contract labor nurses earned as much as $8000 weekly,
which on average equates to a health system paying $24,000 per month to the traveler agency. Alternative approaches to staffing organizations adequately were considered by many health systems. Some have developed an in-house float team to combat staffing problems related to future emergencies or public health threats. Recent trends also show that contract labor staffing percentages have increased from making up 3% to 4% of nursing staff to 8% to 10%, driven by current demand.
In 2020, nursing faced the global COVID-19 pandemic, resulting in additional challenges across the nation related to the lack of nurses. The demand for temporary staffing will remain high as the nursing shortage has increased due to early exiting from the industry and increased patient populations as we see generational shifts.
UCLA Health made the strategic decision to increase the size of the NSFT to support adequate nursing staffing across the health system. The NSFT developed in phases, initially addressing the immediate staffing needs. As the plan evolved, the team grew and expanded into different areas (Figure 1). This placed the organization in a position of self-reliance. UCLA Health recruited highly trained RNs from other tertiary and quaternary facilities to join as per diem staff. To support the recruitment phase of the strategic plan and ensure sustainability, the per diem staff received multiple benefits, including flexible scheduling, competitive pay, growth opportunities, resources, and maintaining California-mandated staffing ratios. The fiscal outlook was beneficial in many ways, including decreased costs associated with benefits, onboarding of new staff, and reduced use of contract labor. Additionally, the organization experienced an unexpected phenomenon with more than 5% of the travelers joining the NSFT permanently because of the work environment and support they received during their temporary positions.
In 2018, UCLA Health merged all facility float teams to align with the organization’s strategic centralization plan. The merger phase allowed for the immediate expansion of resources through a centralized structure by systemizing processes. The design of the operation is to have one management team lead the merged NSFT. The standardized model decreased costs because of increased efficiency in support structures. UCLA Health reduced nursing department contract hours from 0.95% to 0.52% from 2020 to 2021.
During the same period, the median contract hours for the Vizient comprehensive academic medical center compare group increased from 0.87% to 1.53%, and the 75th percentile for that compared group increased from 2.52% to 4.28%.
Also, UCLA Health’s reduction in contract labor expense contributed to an overall improvement of 6% in the nursing services department wage index adjusted per equivalent patient-day.
Centralized Support Structures
Management Structure
The design of the management team is to model a functional organizational structure. The structure-organized divisions are grouped based on the various specialties, including critical care, medical-surgical telemetry, women and children’s, and certified nursing assistants (Figure 2). The administrative division includes a staffing office, payroll department, talent acquisition, and analytics analyst. Each division is led by an assistant director and supported by an administrative specialist. The benefits of this structure allow each division to provide specialty-specific leadership, including initial/ongoing education, administrative support, linear leadership relationships, and specialty-appropriate communication. A director and nurse manager provides oversight to the division leaders to ensure consistency and promote communication across all divisions. In addition, the structure allows for expansion through new divisions to support additional staff in both current and future campuses.
The NSFT is organized into specialty divisions to allocate staff based on their experience and competency. Each specialty division assistant director independently provides oversight of day-to-day operations, ensuring a balanced staff distribution and quality assurance. The NSFT staff are assigned to support individual departments based on the organization’s operational needs. The NSFT continues to expand departmental coverage by cross-training and developing the competence of current staff. For example, expanding the team’s clinical reach benefited the staff by increasing their knowledge and skill set, and expanding the organization’s capacity to more areas, including procedural areas, and across the ambulatory footprint. This model improved the operational goals, including throughput and patient access to care.
Short-Term Assignments
Short-term assignments (STA) support specific areas with operational vacancies to ensure continuity of staffing. Operational vacancies that are supported include leaves of absence, unfilled positions, new services, and fluctuations in acuity. The STA bridges the gap so the department can meet its staffing needs. STA is not a replacement for long-term support of unfilled positions. The STA is voluntary, and staff can choose the unit they would like to support based on the available opportunities in the department. Staff receive additional education and training for specific populations to improve care delivery for all patients. The STA is initially for 3 months and can be extended to 6 months if mutually agreed between the unit and staff. Per diem staff of 0.3 full-time equivalents (FTE) must commit to a minimum of 2 shifts (double their FTE) per week and preschedule their shifts with the area directly to meet the specific staffing needs. The STA feature allows the organization to try new programs to determine the feasibility for long-term planning. For example, 1 of the hospital’s chief nursing officers worked closely with the NSFT leadership team to establish a discharge lounge for patients awaiting transportation to assist with throughput.
Administrative Division
Centralized Staffing Office
Forming a centralized staffing office improves the day-to-day activities and maintains equitable resource utilization through a unified channel. In partnership with staffing coordinators, nursing supervisors, and nurse leaders from all facilities, the centralized staffing office coordinators maintain communication to ensure safe patient staffing with the appropriately qualified individual. By leveraging technology, the centralized staffing office streamlined the communication between individual units’ staffing requests. Furthermore, NSFT staff access their daily assignments via the NSFT’s online application, and staff report directly to the facility and the department they are assigned for the shift, dramatically improving staff satisfaction and punctuality.
Hiring And Onboarding
The NSFT systemized the hiring and onboarding process through collaboration with talent acquisition and float team leadership. The nurses seeking a position with NSFT are looking to expand their skill set and gain proficiency in multiple specialty nursing areas. In addition, the candidates look for scheduling flexibility through a 0.3 FTE per-diem position. NSFT follows the lead-the-market compensation strategy to set aggressive hourly rates above our competitors, to improve recruitment and retention. These candidates typically hold a primary job at another organization or are travelers that are seeking permanent employment. NSFT also offers fully benefitted career positions that are 0.9 FTE, which also include flexibility for those looking to transition to UCLA Health as their primary employment.
The hiring process establishes specific criteria to be eligible to apply, including a minimum of 3 years of recent experience within the specialty division. This supports the recruiting efforts in identifying candidates to interview who will likely have a greater probability of success with the NSFT. Furthermore, the interview process transitioned to virtual sessions to increase reliance and efficiency. The convenience of virtual interviews increased the number of qualified candidates readily available to interview and hire. Additionally, this shortened the interval between applying and the candidate’s start date by an average of 6 weeks. The process extends into onboarding, and once the candidate accepts the offer, the administrative specialist manages all pre-hire communication and requirements. The new hire attends a departmental orientation day to review and complete all regulatory requirements following 5 clinical orientation shifts specific to their hired division. Lastly, they complete a follow-up appointment with the assistant director and administrative specialist to ensure all onboarding requirements are met and to assess whether the employee is ready to function independently. New team members express satisfaction with the streamlined application and interview process and the onboarding journey.
Accountability And Sustainability
Implementing checks and balances across all divisions is necessary as the team expands. As a result, a weekly leadership team meeting occurs for all divisions to report their current state. This allows the group to identify gaps, evaluate progress and discuss expansion opportunities. In addition, this dialogue provides for the immediate identification of barriers, the evolvement of goals, and to make of just-in-time adjustments and decisions. This approach instills accountability vertically and horizontally across the NSFT and embeds the flexibility needed for sustainability.
Because the float team members do not have a permanent home nursing department, the importance of leadership visibility takes on an entirely new meaning. Daily purposeful leadership rounding (PLR) gives bidirectional information-sharing opportunities between leadership and staff to facilitate communication. The goal of PLR is to build relationships, establish rapport, and encourage staff feedback. Through PLR, we achieved positive results with nursing satisfaction, identified opportunities for coaching, and improved patient outcomes. Most importantly, the leadership visibility was impactful to both float staff and unit leadership, providing a sense of presence for the NSFT.
In collaboration with the leadership team, the NSFT Unit Practice Council created unit-specific digital tip sheets. The staff access the digital tip sheets through the organization’s intranet. The content of the tip sheets is a standardized template for all units across the organization, including unit-specific information, protocols, guidelines, and patient population-based care. The purpose is to offer readily available information for float staff as they support all the different specialty areas daily. The tip sheets are reviewed and updated annually through collaboration with professional governance and unit leadership.
Future Projections
UCLA Health’s mission is to deliver leading-edge patient care, research, and education.
As the organization expands and coverage demands increase, the NSFT enters a new phase of staff skill set development. The focus of this phase is to utilize existing staff and expand their areas of coverage beyond their core division into expansion departments. During this stage, the team can meet strategic expansion needs as the team continues to grow in both staff and areas covered. In addition, a centralized structure is in place to expand the team’s support, allowing for the immediate deployment of resources and providing rapid mobilization.
This phase has an external component through collaboration with other health care organizations. UCLA Health’s leadership has met with numerous organizations nationwide to bring awareness of the success of this model. During the interactions with other organizations, UCLA Health guided them through the model’s different phases. Current success has shown this model to be a best practice supporting the nursing profession shared among the industry.
Conclusion
The NSFT successfully ensures suitable staffing and continues to grow in coverage and workforce. Through strategic expansion and fiscal responsibility, the NSFT design is a functional organizational structure. A favorable operating margin is achieved by incorporating processes through centralizing support structures. Since the merger, the NSFT has grown in the workforce and increased the support to all departments, covering 41% more shifts. During the same period, UCLA Health’s contract labor utilization decreased by 45% as travel nursing demand increased nationwide. The NSFT continues to develop and implement processes to support the current market climate. UCLA Health continues to aim for self-reliance and collaborate with other organizations taking the same journey.
References
Tanzi A.
U.S. Travel Nurses Are Being Offered as Much as $8,000 a Week. Bloomberg. August 31, 2021.
Adam Fronczek, DNP, MBA, RN, ANP-BC is the Director, Sharon Doggett, MSN, RN, NEA-BC is the Nurse Manager, and Gilbert Barco, MSN, RN, CCRN is the Assistant Director of the UCLA Health Nursing System Float Team, in Los Angeles, California. Dr. Fronczek can be reached at [email protected]
00039-3&id=gr1.jpg){kind=link}
00039-3&id=gr2.jpg){kind=link}