Strategic ED Staffing Plans

Very few Emergency departments and ancillary support interfaces adjust their staffing patterns to have more resources or most efficient members working the days of the week the ED is expected to have more demand. In addition, all departments have what is known as “fatal staff combinations” that should never be allowed to form. For example…having your slowest ED Physicians, your most inexperienced midlevel providers, your less effective charge nurse, your most novice ED techs and the least efficient X-ray Techs all working together a Monday afternoon is hardly a sound strategic choice. Unfortunately, these fatal combinations are allowed to form often and repeatedly in most Emergency Departments.

One reason most Emergency Department Managers cite for not approaching their schedule strategically is because of a shortage of staff members or too much variability in staff skill sets and capabilities. Although these reasons are valid sometimes, in most instances they just represent a “cop-out” for having to actually deal with the backlash that will inevitably ensue when the staffing preferences of some staff members are changed or from having to explain to some staff members why they cannot work on certain days or in certain areas of the ED.

Another barrier is that it takes a lot of time and effort for an ED Manager to create a strategic schedule that takes into account the whole department rather than just a particular group of people. For example, having a true strategic schedule would require that the person in charge of the nursing and Tech schedule and the person involved in the Physician and midlevel provider schedule both coordinate their staffing efforts to prevent fatal staff combinations from happening. The larger the Emergency Department, the more difficult implementing a strategic schedule becomes.

Nevertheless, the fruits of this endeavor can be very beneficial to the ED system and even the ED staff due to smoother system workloads and functional operations. All efficient enterprises adjust their staffing to cover more effectively their busier or seasonal demand days and try to prevent inefficient employees or managers from being scheduled together as much as possible. This is just common-sense.

Another reason strategic scheduling is so rare in Emergency Departments is that, in the typical overcrowded ED, the inefficiencies of some staff members are less visible amidst the chaos and idle time these departments must endure. Nevertheless, as a Department revamps operations and becomes more efficient, the effect that these fatal combinations and ad-hoc staffing approach has on the system become immediately visible. As such, Emergency Departments working on an operationally efficient model can identify these issues more easily and address them conclusively to reach the full performance potential the new operational model is designed to achieve…

Now...this is what must be done step by step...

1. Identify the busiest days and shifts and the lowest demand days and shifts of the ED based on historical data.

2. Adjust the staffing ratios so that you take some resources from the slowest days and transfer them to the busier days in a budget neutral way.

3. Classify all staff members (doctors, midlevel providers, nurses, techs, nursing assistants, X-ray techs, phlebotomists…etc…) as either A, B, C, or D players in the system based on their historical performance and capabilities.

4. Eliminate the D players as soon as possible (they shouldn’t be working in the system any way).

5. Make the schedule by taking your busiest days first and loading them mostly with A and B player across the boards. Afterwards, fill the rest of the schedule by keeping an almost equal proportion of A, B, and C players except in those areas that require a higher level of efficiency. If, due to staffing constraints, you must have a higher proportion of C players scheduled, try to only do this on the historical slowest days and shifts.

As a rule of thumb, never put two C players together if it can be avoided for obvious reasons. Also try to not put A with C players together but rather combine As with Bs and Bs with Cs. The reason for this is as follows:
When you put an A player together with a C player the C player knows he can’t keep up no matter what he does and will not attempt to make any adjustments in their performance. Meanwhile, the A player will tend to adjust his or her performance down partly due in reaction to the C players lack of productivity…Even worse, when you frequently combine A players with C players you will soon demoralize the A players and reduce their performance even more.

Now…when you combine As and Bs the dynamic changes as B players tend to adjust their performance up to more closely mirror that of the A player. When you combine a B player with a C player the dynamic is also different as the C players don’t usually see the performance of the B player as being out of reach and will thus adjust performance to more closely mirror that of the B player.

What I just discussed is based on numerous business productivity studies and is also very evident in sports performance. We all probably have witnessed this dynamic in action with major sport upsets in which a more gifted athlete is beaten by someone considered to be inferior. The usual reason for these upsets is that the gifted athlete adjusted his performance down and this allowed the inferior athlete to be more competitive.