PENROSE-ST - Centura Health



|POLICY TITLE: SCHEDULING/STAFFING GUIDELINES |

|Department: Nursing Services | |

|History of Review/Revision Dates: |Effective Date: |

|Est. 7/90, 11/00, 7/04, 6/12 |8/30/2012 |

SCOPE: All nursing units in Penrose St Francis Health System.

PURPOSE: To outline the staffing and scheduling rules and the use of Atstaff .

STATEMENT OF POLICY: Practices will be in place to facilitate adequate staffing.

PROCEDURE: Master nursing schedules are legal records that will be maintained in the server for the Computer Scheduling System ( CSS) for the time allotted. All nursing units must keep for a minimum of 3 years with the exception of OB, which includes Birth Center, Nursery, and NICU, must keep for 25 years.

Schedule Preparation

A. Each unit will develop / revise a Provision of Care Plan to include a staffing matrix yearly, and when changes are made.

a. The matrix will be entered into the CSS

b. All units will establish core staffing guidelines that reflect established practices for staffing per shift.

c. These core guidelines will be entered into the CSS. Skill mix is determined at the discretion of the manager.

d. All units will establish staff size guidelines that reflect maximum levels of staffing which reflect established practices. These staff size guidelines will be entered into the CSS.

B. Each unit's schedule will be prepared for a minimum of 4 weeks.

C. For units staffed by the staffing office: 11, 9, 8, 7, 5, 4, CVU, ICU, PBBU, SFMC: Peds, NICU, Labor and Delivery, Mom/Baby, 5North, 5 South and CCU.

a. All units will use the web-based employee request component of the CSS, AtStaff Web. Associates may not sign up for more than 12hrs /day and no more than 4 shifts in a row as long as it does not involve overtime.. Managers may request staff to work overtime shifts if needed.

b. The nursing schedules will be entered into the CSS by the nursing units.

c. The, final complete schedules are due in the system by midnight on the Tuesday prior to the effective Sunday of the schedule.

D. For units not staffed by the staffing office:

a. All units will use the web-based employee request component to the CSS, AtStaff Web.

b. The nursing schedules will be entered into the CSS by the nursing units.

E. Unit based staff will be used to cover the master staffing plan. The Clinical Managers are expected to submit a balanced schedule meeting their core staffing requirements.

a. When the core staffing plan cannot be met, the manager will:

➢ Contact on-call per diem staff to see if they can cover.

➢ Contact regular staff to schedule extra time, or change scheduled days, and/or shifts as needed or when the schedule is staffed heavier.

➢ All extra shifts will be clearly marked as extra in the CSS.

➢ Encourage any current staff working to extend shift length. (Example: have a 7a-3p associate stay until 7p, and have an 11p-7a associate come in at 7p.) Staff may not work more than 16 hrs in a row except for disaster situations or by exception approved by the Director only.

➢ Inform staffing office to allow for planning of float staff and/or agency personnel.

E. The Staffing Office Manager/ Director of Professional Services will review the final schedule to ensure the schedules are balanced for each shift as much as possible and the units core staffing needs are met. If there are incomplete or unbalanced schedules they will be returned to the Manager for completion.

G Managers schedules will be entered into the CSS and reflect time off.

2 Schedule Maintenance:

A. Schedule changes will be approved by the Clinical Manager/designee only. Emergency changes will be made as soon as possible to insure enough time to find adequate coverage.

B. There will be no schedule changes, excluding illness, within 24 hours of the date the associate is scheduled to work unless the associate can find coverage for herself/himself.

C. No requests will be granted after the schedule is final and has been printed unless there is a replacement except for emergency leave of absence.

D. All schedule changes must be entered into the CSS prior to the change date, to be kept as the legal document.

a. Units staffed by the staffing office will send all changes to the staffing office via e-mail prior to the change date.

b. Units not staffed by the staffing office will enter changes directly into the CSS.

E. Scheduled PTO should be scheduled around the associate's required weekend off whenever possible. If this becomes an issue, the Clinical Manager/designee will decide whether or not the associate must switch weekends to maintain coverage for the unit. The Clinical Manager will approve all vacations and determine the number of associates that can be on vacation at one time based on number of staff and unit needs. Generally only one person per category of staff should be off at one time.

F. If an associate requests a vacation greater than 2 weeks at a time Clinical Manager approval is required.

G. All associates are required to work a minimum of every other weekend or as designated by the Clinical Manager.

III. Unscheduled Absences:

A. In case of illness or other absence, associates must notify their unit ASAP, but not less than 2 hours prior to their scheduled shift. Example: Day shift (7a-3p) will be at least 2 hours in advance, or by 5:00am.

B. All unscheduled changes must be entered into the CSS to be kept as the legal document.

a. Units staffed by the staffing office will send all unscheduled absences, including reasons, to the staffing office via e-mail. Changes will also be reported on the voice mail staffing line.

b. Units not staffed by the staffing office will enter changes directly into the CSS

C. The reported absences and tardiness of all associates will be entered into the CSS in order to implement equitable corrective action of excessive occurrences. Attendance records can be generated from the CSS on the units or as requested from the staffing office.

1 Holiday/Weekend Staffing

A. Holidays and weekends will be staffed according to each unit's core staffing. Each unit will use a call off and float rotation system to determine who may need to float or be called off.

B. Nursing staff is not expected to float on the six paid holidays from their home unit unless they choose to float.

C. During a temporary or permanent closure of a unit (holiday, low volume) a global call off and float guideline may be initiated to equitabley float and call off the associates affected by the closure.

Extra Shifts

A. When extra personnel are needed, this information is sent to the staffing office by using e-mail or phone call.

B. All extra shifts will be marked as extra in the CSS.

C. Scheduled work shifts over and above the budgeted FTE will be canceled according to the unit’s call-off system. Required weekends may not be designated as extra shifts.

D. Associates scheduled for extra shifts during a low census period will be given the choice to float. If there is no unit needing the extra associate, the extra shift will be canceled, An associate is not required to float if extra, . However another unit employee may be asked to float while the extra associate stays on their home unit. These situations will always be a Clinical Manager/designee decision.

E. At the Clinical Manager’s/Administrative Supervisor's or designee's discretion, a nurse may be rescheduled during the current schedule to meet the unit's patient care needs. A nurse may be canceled if there are FTE nurses needing to float from other units.

3 Canceling and On Call Status

A. An associate may be canceled if the census on the unit drops or if another level of skill is required for patient care. The call-off will occur a minimum of one hour before the shift starts; the associate still needs to remain available up to the start of his/her shift in case the census changes and will be paid one hour on call pay.

B. Associates scheduled for a 12 hr shift can be called off for 8 (7a-3p) or 4 hrs (7P- 11P) and must be available for the rest of the shift if needed ( e.g. 3P-7P or 11P- 7A). Failure to come in when called will result in an unscheduled absence and notification of the associates manager.

C. Associates placed on call are expected to answer the call within 15 min and arrive on their units within 60 minutes of being called back.

D. If the census increases prior to the start of the shift, the associate will be notified to come to work for his/her regular shift. If the associate has been placed on call and the census increases after the start of the shift , the associate will be notified to come to work.

E. If there is no need to float, the associate may:

a. take the day off without pay, or

b. take PAL/PTO time.

F. Separate lists of call off and float hours will be kept on each unit to assure fairness and consistency of float and canceled work days. These hours will be given to the staffing office along with the associate’s name when requested. The associate with the least amount of hours will be the first in line to be called off or floated. If there is a tie in hours, please refer to the last call-off/float date.. Associates on LOA and extended sick time will have their hours adjusted to one hour less than the associate on their shift with the least amount of hours when they return. If an associate has overtime in the current pay period, the Clinical Manager or Administrative Supervisor may cancel this associate when census is down.

G. An associate who requests a low census day or to float out of turn will not have those hours counted as call off or float hours.

H. The order of personnel to be canceled follows:

1. Agency staff

2. Traveler staff (May cancel up to 36 hours assignment.)

3. Regional Float Pool Staff

4. Associates working extra or overtime

5. On call and on call perdiem float pool associates

6. Associates who are on an “On call shift”

7. Unit based on call and on call perdiem associates

8. Regularly scheduled unit associates/Budgeted float pool associates

***In cases of needed continuity of patient care or specific clinical competence

requirements, the Clinical Manager or Administrative Manager will determine who to use.

I. On-call and on-call per diem associates are included in the Float Policy. They will be expected to work shifts that have been scheduled for more than 24 hours.

J. Before any staff are sent home prior to the end of a shift, the unit must call the staffing office or Administrative Manager to check if other units may be in need at that time. These hours are also included on the call off list.

K. Before placing personnel on-call, the staffing needs of the system must be met.

4 Floating

Definitions: Floating is required of all med/surg nursing staff. The RN floating from his/her home unit to another unit will not be expected to be the only licensed person on the unit or to take Charge. Floating is encouraged between the med/surg units at PH and SFMC. In general, the RN working in the Float Pool will not be expected to be the only licensed person on the unit or to handle the duties of Charge Nurse unless discussed with the float pool staff member prior to the start of the shift.

A. Nursing personnel will float to selected units where additional staff members are needed to carry out patient care requirements.

a. Notification of the units will be made by the staffing office personnel at least one hour prior to assigned shift for 7-1500 and 1500-1900, and 1900 -2300 shifts. Nursing personnel will be notified upon arrival to work of need to float.

Each unit will utilize an equitable process to determine canceling extra shifts and float rotation. Each unit will track call-off/float time by actual hours on an annual basis beginning with zero each July 1st

b. The readiness of graduate nurses and new hires to float will be determined by the Clinical Manager and the individual. Their hours are adjusted to one hour less than the next person with the least amount of hours on their shift The Clinical Manager/designee may submit names for floating or call-off to the staffing office out of order at his/her discretion.

c. In a 12-hour period, a staff member will not be required to work on more than two different units, (“home unit” and the receiving unit). Exception; float pool staff will be expected to go to different units in a 12-hour period if needed. An associate will not be required to float to a different campus for 4 hours. If a nurse does travel between campuses, the travel time will be charged to the receiving unit 8 or 4 hours at a time.

d. Associates may be placed on call or asked to come in at a later time i.e., 1100 or 1500.

B. Nursing personnel will provide competent care to the patients on the selected units:

a. Refer to Staff Competency Interdisciplinary Practice C-02-a.

b. For floating staff, an orientation will be provided at the beginning of the shift and a float orientation checklist will be completed at this time. This orientation check list will be kept on file on the receiving unit, not the floating person’s home unit. A float associate will only be expected to complete checklist the first time he/she floats to that unit, and yearly thereafter.

c. The person making assignments will make appropriate assignments based on the floating associate’s skills, and the patient’s needs.

d. Each nursing unit will provide a resource person for the floating/float pool personnel.

e. A Float Comment Card will be available on each unit and completed by the person floating as an option to provide feedback about their float experience. These cards will be given to the Clinical Manager of the receiving unit.

f. Float/Agency/float pool competency evaluation will be assessed as follows:

➢ Internally Floated Staff: The Performance Evaluation, Float or Agency Employee form will be completed at the end of the shift by the resource person for internally floated staff BY EXCEPTION only. This evaluation will be given to the Clinical Manager of the receiving unit. A copy of the evaluation will be forwarded within 24 hours to the associate’s Clinical Manager.

➢ Float pool: The EST Peer Evaluation of Competency form will be completed at the end of the shift by the resource person upon the REQUEST of the float pool associate or BY EXCEPTION. This evaluation will be forwarded to the float pool Clinical Manager.

C. The resource person will welcome the float staff member to the unit, give a brief tour, and answer unit-specific questions. The resource person will give the float staff member a packet of unit-specific information

D. Refusal to float: All med/surg nursing personnel will be required to float. Refusal to float will be addressed by staff member’s Clinical Manager resulting in possible corrective action.

IX. STAFFING PROCESS: Staffing Office available: 0445 - 1930 M-F and 0445 to 1745 S, S, and holidays.

A. In the absence of staffing personnel, the administrative manager will be the contact for staffing to include assuring the agency files are accurate and current. SFMC administrative manager will confer with PH Administrative Manager to verify agency files.

B. Process for staffing on the 07-15 shift (7 days a week):

1. Voice mail messages will be left on the voicemail staffing line (776-STAF/776-7823 before 0430).

2. Staffing personnel evaluates unit needs and who is called off or floated (determined by on call-off/float hours sent by each unit).

3. Staffing personnel will inform the units where their personnel will float or inform those not needed.

4. Staffing personnel will inform the float pool staff as to where they will float and when called off.

5. Staffing personnel will call all units with float/float pool person's name, after staffing is complete.

6. Staffing personnel will call units to let them know who went where and who was not needed, after staffing is complete.

7. If staffing is short in the system and no unit has personnel being called off, the unit staff and staffing personnel will collaborate in obtaining additional staff.

8. If any unit is successful in obtaining staff, the charge nurse will notify the staffing office so no one is double booked,. Staffing and the nursing unit will communicate with each other if there has been no success.

9. The staffing office will contact the Administrative Managers in the AM at both sites with the staffing information once all assignments have been made, and the nursing units have been contacted.

C. Process for staffing on the 15 – 19, and 19-23 shift daily:

1. Voice mail messages will be left on the voicemail staffing line (776-STAF/776-7823) before 1130.

2. Follow staffing process procdures above.

D. Process for staffing on 23 - 07 shift daily:

1. Administrative Managers will collect staffing information while making rounds on the nursing units.

2. Admin Managers at PH and SFMC will collaborate on staffing decisions,

3. Admin Managers will inform units about float and call off needs.

4. The PH Administrative Manager contacts 23-07 float pool staff with their unit assignments or call off information,

5. Nursing units will contact their own staff with call off information.

E. Summary of times that the staffing voice mail messages will be left on the voicemail staffing line (776-STAF/776-7823) are due in the Staffing office:

Time Day of Week Shift Being Staffed 0430 7 days/week 07-15 and 07-19

1130 7 days/week 15-23 and 19-07

1730 7 days/week 23-07

Private Duty PERSONNEL

A. A staff RN is always assigned to the patient. The assigned staff nurse is a resource for the private duty nurse.

B. A private duty nurse must be a Registered Nurse, Licensed Practical Nurse, CNA, sitter, or personal attendant requested by the patient's physician or family and employed by the patient or patient's family. The family will be asked if they have an agency preference, if no preference the family will be given direction as to where to locate contract labor agencies in the telephone directory.

C. The private duty personnel will be required to show proof of Colorado licensure and a current CPR card to the unit's Charge Nurse. A photocopy of these documents will be kept on file in the staffing office.

D. The private duty personnel will be required to abide by all PSFHS guidelines and procedures, as well as the Colorado Nurse Practice Act.

E. Orientation will include patient's room, safety/emergency procedures, and unit layout. (see float/agency nurse orientation form). A full report of the patient's needs and plan of care will be given. A copy of the orientation form will be kept in staffing office.

F. The private duty personnel may perform any duties for which she/he is licensed and qualified, except for administration of medications and performance of complex procedures that require certification or a special hospital training program.

G. The private duty personnel will coordinate meals and break with the patient/family and the assigned unit RN when leaving the nursing unit.

H. The unit RN will make periodic checks of the patient and private duty nurse to assure that patient needs are being met.

6 CONTRACT LABOR STAFF (agency, traveler, regional float pool staff)

A. The only agency and traveling companies to be used are those with approved contracts/agreements.

B. All contract labor (agency / traveler)_ has to be approved by the CNO.

C. The choice of which company(s) to use will be determined by a random selection of those that are approved for use. As noted in the Centura Health Professional Supplemental Staffing Services Agreement, no contract labor company will be given preferred provider status.

D. Staffing and scheduling of contract labor will be in accordance with the Centura Health Professional Supplemental Staffing Services Agreement.

E. All contract labor personnel will have to go through a formal approval and orientation process by the manager of the staffing office prior to be able work at PSFHS

F. Contract labor personnel will be entered into the CSS and floated to their assigned unit.

G. The first and last names and title of all scheduled contract labor staff will be entered on the unit schedule and assignment sheet.

H. Nursing Unit Personnel Responsibilities:

1. Contact internal per diem employees or other staff who want to work extra to offer work assignments before agency employees are requested. Communications with staff will be made in collaboration with the staffing office.

2. Assign a resource person during shifts worked by an agency employee. The resource person will provide unit-based orientation, which includes items on the attached form "Float and Agency Nurse Orientation Record" or "Float and Agency CNA Orientation Record". The completed form will be sent to the staffing office and kept in the emplyees file.

3. Agency: The Non-Facility Clinical Personnel Evaluation form will be completed at the end of the shift by the resource person EVERY TIME contract labor person works within PSFHS. This evaluation will sent to the staffing office immediately after the shift.

4. Immediately upon recognition, any performance concern serious enough to result in the contract labor person being evaluated to be placed on the Do Not Use list, will be reported directly/verbally to the staffing office personnel during staffing personnel normal hours and to the Administrative Manager at other times. The concern will be documented on the evaluation form, which will be sent to the staffing office immediately. When the concern originates from a site other than PH, these evaluation forms will be faxed immediately to 776-2532, and the original will be placed in interoffice mail.

G. Staffing Office Personnel Responsibilities:

1. Check all contract labor personnel files for current compliance documentation prior to scheduling them.

2. Schedule/assign contract labor employees who are on a long-term contract without specific unit assignment.

3. Cancel a contract labor employee 2 hours before the scheduled shift begins. If late cancellation occurs and the contract labor employee shows for his/her shift, PSFHS will be billed for 2 hours as noted in the Centura Health Professional Supplemental Staffing Services Agreement.

4. Maintain orientation/evaluation forms for each contract labor employee. Each contract labor employee will be evaluated for each shift he/she worked. RN’s who are on 13-week traveler contracts will be evaluated after one month and at the end of their contract. The unit staff will send the completed eval forms to the staffing office within 24 hours after the contract labor employee works on the unit (exception: 13 week traveler assigned staff). Any issue with the performance of a contract labor employee will be put in writing and sent to the staffing office. If the problem is severe enough that the clinical manager does not want to use the contract labor employee again, that will be submitting in writing to the staffing office. Staffing office will then place the contract labor employee on the “Do not use” list for that unit and inform the contract labor company. The manager of the staffing office will review all complaints from the nursing units and will make a decision regarding use on other nursing units. If the manager of the staffing office feels the problem was severe enough that the contract labor employee should not be used at any facility again, he/she will then notify the contract labor company and unit of his/her decision. At that point the contract labor employee will then be placed on the “Do not Use list” for Centura.

5. Send an updated “Do not use list” to all administrative managers and designated Human Resources personnel when additions or changes are made.

6. Assure that associates who leave PSFHS in bad standing are not eligible to work in the system through any contract labor company.

7. Assure that employees who leave PSFHS in good standing are eligible to work in the system through an agency one year after their voluntary termination.

8. Reconcile all contract labor hours with the CSS

2 Administrative Manager Responsibilities

1. PH and SFMC administrative managers will confer and collaborate on staffing decisions during their shift.

2. . Accurately document all staffing changes on the daily CSS staffing sheets.

3. Make decisions related to where unit staff, float pool personnel and contract labor personnel needs to be assigned in relation to patient needs for the 23-07 shift.

4. Maintains accurate and legible record of all staffing decisions.

5. When contract labor staff is used, the administrative managers will review contract labor personnel files kept in the staffing office at SFMC to determine presence of compliance documentation. Contract labor personnel will not be used if compliance documentation is not present. SFMC Administrative Manager will be called by PH Administrative Manager to review contract labor files, which are located at SFMC.

I. The external contract labor company responsibilities:

1. Submit information packets for each agency employee who works in PSFHS. The information will include items required by the Centura Health Professional Supplemental Staffing Services Agreement including license, current certifications, and profile sheets including information regarding skills lists, current BLS certification, results of medication and competency tests, etc.

2. Submit the above packets before the contract labor employee starts employment at PSFHS.

POLICY VIOLATION

Any Centura associate who fails to abide by this policy may be subject to disciplinary action, including termination.

|Approval Body: Nurse Practice Council | |

|Secondary Approval Body: |Signature/Date: |

| | |

| |Katherine D McCord, RN, CNO |

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