Exemplary Professional Practice: Staffing Scheduling and Budgeting Processes EP9 Nurses are involved in staffing and scheduling based on established guidelines, such as ANA’s Principles for Nurse Staffing, to ensure that RN assignment meet the needs of the patient population. EP9b: Provide a description, with supporting evidence, when input from clinical nurses was used to modify RN staffing assignments and/or adjust the schedule to compensate for a change in patient acuity, patient population, resource or redesign of care. Introduction Electroconvulsive therapy (ECT) is a medical treatment used for patients with certain mental illnesses, including severe depression or bipolar disorder, which may not have responded to other medical treatments. ECT involves a brief electrical stimulation applied to the brain while the patient is under general anesthesia. In a typical course of treatment, a patient will receive two to three ECT treatments a week for several weeks. At Massachusetts General Hospital (MGH), ECT has been performed in the Post Anesthesia Care Units (Ellison 3, Lunder 2,3,4), specifically, the White 3 Post Anesthesia Care Unit (White 3 PACU), because of the clinical expertise of the Registered Nurse (RN) staff in treating patients under anesthesia. ECT procedures are performed both on an inpatient and outpatient basis, and MGH treats approximately 16 patients daily.

The White 3 PACU is one of five individual PACU locations spanning three buildings and three floors: White 3, Ellison 3, Lunder 2, Lunder 3, and Lunder 4. Across these critical care areas, both adult and pediatric patients are cared for preceding and immediately following surgery and/or procedures requiring anesthesia. As such, the clinical nurses in these areas have the critical care skills necessary to treat patients under anesthesia. While clinical nurses are hired under one PACU nursing leadership team and work across the different PACU locations, they may possess skills for certain specialties and are scheduled accordingly (e.g., the Lunder 2 Operating Rooms (OR) perform predominantly orthopedic surgeries and as such, the Lunder 2 PACU clinical nurses are skilled with the orthopedic patient population). In the White 3 PACU, there was a group of clinical nurses who specialized in the care of ECT patients.

The Center for Perioperative Care (Wang 3), or CPC, is a 33-bed unit for admitting and preparing patients for both surgical and interventional procedures. Patients arrive in the CPC, undergo preoperative assessments, and then proceed to the OR or other procedural area. After initial recovery in one of the PACU locations immediately post-operatively, patients undergoing ambulatory procedures return to the CPC for “phase 2 recovery” and then are discharged. The CPC is open from 5:30am-9:30pm, Monday through Friday for full services, and on Saturdays from 7:00am-3:00pm for preoperative preparation of patients only, when there is a more limited OR schedule.

Historically, from a patient flow perspective, outpatient ECT patients arrived in the CPC for initial nursing assessment and then were transported to the White 3 PACU. In the White 3 PACU, procedure preparatory work was performed followed by the procedure itself and then recovery from anesthesia. The patient was then transported back to the CPC for final assessment and discharge. Inpatients receiving ECT treatments were brought to the White 3 PACU directly for preoperative assessment, procedure and recovery, before being transferred back to their inpatient rooms. The total average length of stay for this patient population from arrival to discharge was approximately three hours.

In 2015, the MGH Perioperative Services Department launched a 10-year Operating Room Renovation Project with the goal of upgrading various perioperative spaces, increasing capacity, improving operational efficiency and enhancing the patient experience. As the first phase of the 10-year project, the White 3 PACU was scheduled to close at the end of 2015 whereby the unit was to be repurposed into two spaces:

1. One of eight new, state-of-the-art operating rooms, and 2. Perioperative “bays” where all aspects of perioperative care could be performed.

Among other operational changes, the closure of the White 3 PACU would require a relocation and operational redesign of the ECT program. In preparation for the redesign of the ECT program, volume and patient flow analyses along with a clinical pilot were conducted during the summer of 2015 to identify a new model that could accommodate the program safely and effectively. The following narrative is an example of how clinical nurses from the CPC were involved in the redesign of the ECT program as it transitioned from the CPC and the subsequent modification of RN assignments and staff schedules to accommodate this new patient population. Clinical Nurse Participation in ECT Program Relocation During a staff meeting in April 2015, CPC Nursing Director Caroline Horgan, RN, MSN, announced that the White 3 PACU was scheduled to close for renovations by the end of 2015. Two units were identified as possible relocation areas: Ellison 3 PACU and the CPC. To assess redesign options for the ECT program and determine the best location for these patients, clinical nurses from the CPC volunteered to evaluate these two models during the summer of 2015. Given their expertise with the ECT patient population, White 3 PACU clinical nurses would be exploring these models together with the CPC clinical nurses. The possible relocation options are summarized below:

1) Move the ECT program to the Ellison 3 PACU as a direct substitute of the White 3 PACU. This relocation would have limited impact on the CPC.

2) Move the entire ECT program to the CPC to allow complete patient care from preparation through procedure, recovery, and discharge. This relocation option would have significant impact on the CPC as CPC clinical nurses would be

caring for patients under general anesthesia and inpatients would now be cared for in the CPC while undergoing ECT.

As part of the evaluation, clinical nurses Nancy Dibona, RN, Eleanora Ditocco, RN, BSN, and Joan Tafe, RN, took the lead from the CPC. They went to the Ellison 3 PACU to observe the clinical care that the White 3 PACU clinical nurses provided to ECT patients during procedure preparatory work, the procedure, and recovery from anesthesia. As identified in the September 3, 2015 staff meeting minutes (attachment EP9b.a), Dibona and Ditocco observed that, given the general anesthesia component of the ECT treatments, RN assignments for the ECT patient population would be two patients as was done in the White 3 PACU; this two-patient assignment would be different from the typical three-patient assignment currently in the CPC.

Concurrent with the ECT evaluation in the Ellison 3 PACU, an analysis of patient volume identified that the significant OR volume coming through the Ellison 3 PACU would cause a backlog of ECT patients, if the program was relocated there. An operational feasibility analysis also showed that the CPC could accommodate the ECT patient population. Given these results, a collective decision was made within Perioperative Services to move the entire program to the CPC to allow for greater continuity of a one-stop model of care for all ECT patients. A change in the timeline for the renovation project in the White 3 PACU led to the relocation of the ECT patients to the CPC sooner than expected, on October 5, 2015. In order to support the ECT program in the CPC, three RN Full Time Equivalents (FTEs) were transferred from the White 3 PACU budget to the CPC budget.

Clinical Nurse Input into RN Assignments

Between October and December 2015, the transition of the ECT program was supported by White 3 PACU clinical nurses partnering with CPC clinical nurses. Given their expertise, the White 3 PACU clinical nurses oriented the CPC clinical nurses in all phases of ECT care: preparatory procedure work, the procedure under anesthesia, recovery from anesthesia, and discharge. Considering that the length of stay for the ECT patient was, on average, only three hours – a relatively short time frame from admission, procedure with anesthesia, and discharge – it was paramount that the redesign of care met the needs of both the patient population and the CPC nursing staff. Part of the program transition included the translation of Dibona’s and Ditocco’s input from the evaluation period that the RN assignments would have to change to two patients. Attachment EP9b.b shows the CPC budget staffing model before the ECT program moved (with RNs having a three-patient assignment as depicted by the highlighted 0.34) and after it moved (with RNs having a two-patient assignment as depicted by the highlighted 0.5).

Clinical Nurse Input into Lead ECT RN Role

In the White 3 PACU, a clinical nurse functioned as a Lead ECT Resource Nurse. This role was responsible for managing patient flow, supporting other staff with the more

acute patients, and directing support staff for treatment area and equipment readiness. Over the course of the October – December 2015 transition period, CPC clinical nurses identified that a Lead ECT role, similar to what existed in the White 3 PACU, would help support the ECT program. Tafe also recognized the need to have a Lead ECT RN role in the CPC in order to accommodate this redesign of care. Tafe had previously been a clinical nurse in the White 3 PACU and had clinical experience in caring for ECT patients. As such, Tafe volunteered to assume the Lead ECT RN role during the transition and to develop guidelines for this new role in the CPC.

Prior to the ECT program transitioning to the CPC, Tafe had traditionally worked 10-hour shifts, four days per week. As Lead ECT RN and to maximize her impact on the unit for this new patient population, Tafe recognized that she would need to be on-site five days a week and that her shifts should overlap with the ECT procedures which occurred first thing in the morning. As such, Tafe adjusted her schedule to work eight-hour shifts (6:30am-3:00pm), five days a week to coincide with the arrivals of the first ECT patients and the subsequent completion of all the ECT treatments. Tafe’s assumption of this new role and this change in schedule were communicated with the CPC staff at the December 30, 2015 staff meeting (attachment EP9b.c) and is evidenced in her schedule change in attachment EP9b.d. Upon arrival, Tafe would assess the ECT schedule for the day, assign patients and clinical staff to the six designated ECT bays, and participate in the 7:00am patient huddle. During the course of ECT treatments, Tafe managed patient flow, provided support to clinical staff as necessary for more acute patients, and called on additional resources within the CPC to assist if needed with discharges. Per the December 30, 2015 staff meeting minutes (attachment EP9b.c), all CPC staff would rotate through the Lead ECT RN role to gain expertise. To support this new responsibility for CPC clinical nurses, Tafe developed guidelines and responsibilities for Lead ECT Resource Nurse in CPC and shared them with Horgan via email on January 21, 2016 (attachment EP9b.e).

Clinical nurses were involved in the redesign of the ECT program as it transitioned from the White 3 PACU to the CPC. Clinical nurse Tafe’s input into the development of the Lead ECT RN role and the adjustment of her schedule was paramount to the accommodation of this new patient population in the CPC. Furthermore, CPC clinical nurses had input into modification of the RN assignments for these patients who were undergoing a procedure under anesthesia.

CPC Staff Meeting September 3, 2015

10-11PM

Presiding: Caroline Horgan

Attendance: Diane Scott, Kathy McKinney, Melissa Garvin, Eleanora DiTocco, Lisa DeAngelis Justine King, Eileen Picazio, Diane Beurmann, Joan Tafe, Linda Younker

Topic Discussion Follow-Up Lumbar

Laminectomy and

Decompression Patients

Dr. Jenis, Dr. Schwab and Dr. Cha will be sending their lumbar microdiscectomy and unilateral laminotomy patients home the day of surgery.

• Patient instructions will be located on the CPCSharePoint site

• Dr. Jenis will be doing an in service for us inthe near future on these surgeries

ECT Trial We had our second ECT trial in Ellison.

• Eleanora Ditocco and Nancy Dibona went toEllison 3 PACU and observed RNs coveringtwo ECT patients; while one patient waspreop’d the other had the treatment done

• Most patients were recovered and dischargedin about 20 minutes

• There were 13 patients that day

It was discussed that the RN process needs to be better defined.

? trial of ECT in CPC next

Epic The following staff have volunteered to be CPC super users: Eleanora, Bernie, Maureen Laughlin and Melissa Garvin.

There will be 6 new RN graduates joining us mid September to help with EPIC training.

• They will be oriented to the preop process• Lucy will be looking into Metavision training

for them• They will be on the unit for two days, Sept 14

Please contact Caroline if you are interested in becoming a super user.

Topic Discussion Follow-Up and 15, and return to hospital orientation for another week. They will be observing the flow of the unit.

• If you are interested in precepting please let Lucy know.

• Once the new graduates are feeling comfortable in the preop area then staff who are interested in working in the PATA Phone Program can train. Those who train in the Phone Program will cover those RNs while they learn EPIC.

If you are interested in precepting please let Lucy know. If you are interested in learning the phone program please let Caroline know.

New Traveler

We have a new traveler, Maggie Harrity joining us on September 22nd. She will be here for 13 weeks.

Phone Program Offices

The old Phone Program offices will be used for interview rooms through June 2016. We will look into the configuration of the rooms and equipment.

RN Market Adjustment

RNs will see a market adjustment in the September 10th paycheck. If you would like to know your specific adjustment amount please see Caroline.

CPC budget staffing as of Fiscal Year 2015 before ECT Program moved to CPC

CPC budget staffing as of Fiscal Year 2016 after ECT Program moved to CPC

SLOT TOTAL RN STAFF RN STAFF DIRECT PCA PCA DIRECTDAY TIME HOURS SLOTS HOURS DAYS HOURS / HOUR HOURS RN FTEs / HOUR HOURS PCA FTEs

MTWF 5A-6A 1 28 28 199 5,572 0.34 1,894 0.9 0.10 557 0.3MTWF 6A-7A 1 30 30 199 5,970 0.34 2,030 1.0 0.17 1015 0.5MTWF 7A-1:00P 6 33 198 199 39,402 0.34 13,397 6.4 0.17 6567 3.2MTWF 1P-2:00P 1 33 33 199 6,567 0.34 2,233 1.1 0.10 657 0.3MTWF 2P-4:00P 2 33 66 199 13,134 0.34 4,466 2.1 0.10 1313 0.6MTWF 4:00 - 7P 3 20 60 199 11,940 0.34 4,060 2.0 0.10 1194 0.6MTWF 7 - 9:30P 2.5 10 25 199 4,975 0.34 1,692 0.8 0.10 498 0.2

TH 6A-7A 1 28 28 52 1,456 0.34 495 0.2 0.10 146 0.1TH 7A-8A 1 30 30 52 1,560 0.34 530 0.3 0.17 260 0.1TH 8A-1P 5 33 165 52 8,580 0.34 2,917 1.4 0.17 1430 0.7TH 1P-2:00P 1 33 33 52 1,716 0.34 583 0.3 0.10 172 0.1TH 2P-4:00P 2 33 66 199 13,134 0.34 4,466 2.1 0.10 1313 0.6TH 4:00 - 7P 3 20 60 52 3,120 0.34 1,061 0.5 0.10 312 0.2TH 7 - 9:30P 2.5 10 25 52 1,300 0.34 442 0.2 0.10 130 0.1

SAT 6A-2:30A 8.5 8 68 52 3,536 0.25 884 0.4 0.00 0 0.0

SUBTOTAL 915 19.8 7.5

SLOT TOTAL RN STAFF RN STAFF DIRECT PCA PCA DIRECTDAY TIME HOURS SLOTS HOURS DAYS HOURS / HOUR HOURS RN FTEs / HOUR HOURS PCA FTEs

MTWF 5A-6A 1 26 26 199 5,174 0.34 1,759 0.8 0.10 517 0.2MTWF 6A-7A 1 26 26 199 5,174 0.34 1,759 0.8 0.17 880 0.4MTWF 7A-1:00P 4 26 104 199 20,696 0.50 10,348 5.0 0.17 3449 1.7MTWF 11A-1:00P 2 33 66 199 13,134 0.50 6,567 3.2 0.17 2189 1.1MTWF 1P-2:00P 1 33 33 199 6,567 0.50 3,284 1.6 0.17 1095 0.5MTWF 2P-4:00P 2 33 66 199 13,134 0.50 6,567 3.2 0.10 1313 0.6MTWF 4:00 - 7P 3 20 60 199 11,940 0.34 4,060 2.0 0.10 1194 0.6MTWF 7 - 9:30P 2.5 10 25 199 4,975 0.34 1,692 0.8 0.10 498 0.2

TH 6A-7A 1 26 26 52 1,352 0.34 460 0.2 0.10 135 0.1TH 7A-8A 1 26 26 52 1,352 0.34 460 0.2 0.17 225 0.1TH 8A-11A 3 26 78 52 4,056 0.50 2,028 1.0 0.17 676 0.3TH 11A-1P 2 33 66 52 3,432 0.50 1,716 0.8 0.17 572 0.3TH 1P-2:00P 1 33 33 52 1,716 0.50 858 0.4 0.17 286 0.1TH 2P-4:00P 2 33 66 199 13,134 0.50 6,567 3.2 0.10 1313 0.6TH 4:00 - 7P 3 20 60 52 3,120 0.34 1,061 0.5 0.10 312 0.2TH 7 - 9:30P 2.5 10 25 52 1,300 0.34 442 0.2 0.10 130 0.1

SAT 6A-2:30A 8.5 8 68 52 3,536 0.34 1,202 0.6 0.00 0 0.0

SUBTOTAL 854 24.4 7.1

From: Horgan, Caroline,R.N. Sent: Monday, January 25, 2016 2:28 PM To: MGH CPC All Staff Subject: 12.30.15 Staff Meeting Minutes

CPC Staff Meeting December 30, 2015 10-11am and 1-2pm

Presiding: Caroline Horgan

Attendance: 10AM –Lisa DeAngelis Stf Assist, Bernie Warren RN, Monique Goguen RN, Maddie Boyington RN, Brian Gambon OM, Sarah Mauzy RN, Kathy McKinney RN, Chris Irving RN, Erik Schmidt OA, Erin Yarde-Mason PCA, Kathy Farrell-Alexander RN, Diane Scott OA, Lucy Milton NPS, Nancy DiBona RN

1PM – Vi Limon RN, Nancy DiBona RN, Lisa DeAngelis Stf Assist, Pat Kane RN, Liz Hurson RN, Linda Younker RN, Eleanora DiTocco RN, Janice Carey RN, Brian Gambon OM, Cheryl Gomes RN, Suebeth Brown RN, Michaela Alexander OA, Stephanie Bardzilowski RN, Joan Tafe RN, Anne Gavigan RN, Sarah Buckley RN, Justin Vanden Bosch RN, Krissy Svagdis RN, Kathy Mullen RN, Maureen Laughlin RN, Courtney Poirier RN

Topic Discussion Follow-Up Saturday Cases Currently there are 2 RNs for surgical cases and 3

PACU RNs for the ECT patients. Need to work as one team. RNs that work on Saturdays were in agreement that this is the current practice.

The PCAs have been transporting patients because There are no ORAs assigned.

Please call transport to bring ECT patients back to floor

ECT Program • Joan has volunteered to serve as Lead ECT RNand will adjust schedule to 5 days/week toaccommodate.

• Everyone will rotate through the Lead ECT RNrole. Joan will write down the role’sresponsibilities and it will be shared withstaff.

• The ECT Resource role will be assigned on thetime plan and the daily assignment sheets.

• All ECT guidelines, schedule grids andequipment location sheets can be accessedon the SharePoint site

• iCMP is an escort company provided by MassHealth. Currently, 4 patients are using the

Topic Discussion Follow-Up services. Ryan is noting on the MOSAIC schedule that the patient is part of iCMP and who the escort will be.

• Inside the patient’s green chart you will begin to see a communication page. This page can be used to document such things as, ‘use a 22 g IV’, patient prefers..... It is not a permanent part of the record but rather, a communication sheet for the various providers taking care of the patient.

Epic

• Epic classes have been scheduled through the end of this month

• The class schedule can be found in the time plan book

• Each class is 4 hours long and all RNs are required to take 5 classes

• Some classes may be scheduled outside of working hours. Everyone’s flexibility is greatly appreciated.

• You will have Epic access once you attend a class. This is a good time to go in and try to familiarize yourself with the program.

• We will be looking at the belongings process before the go live date`

Patient Belongings

Patients have been arriving with luggage, jewelry, electronics and cash.

• Ambulatory patients do not need valuables locked up unless, it is a large sum of money.

• We should remind patients that there is not a secure area and it would be in their best interest to have family members take their valuables.

• There is a hospital work group that is going to ask Risk Management to create a disclaimer form for the patient to sign regarding the securing of valuables.

Topic Discussion Follow-Up Staffing & Scheduling Committee

We would like to set up a scheduling and staffing committee to determine guidelines for requesting ET and defining prime time, etc.

Caroline will send out an email requesting volunteers.

NPS = Nursing Practice Specialist

OA = operations associate

OM = operations manager

PCA = Patient Care Associate

Stf Assist = Staff Assistant II

Tafe Schedule

Working four 10-hr day shifts prior to ECT relocation to CPC (June 28, 2015 – July 25 2015)

Working five 8-hr day shifts during transition of ECT program to CPC (December 13, 2015 – January 9, 2016)

Workshift Code Legend { = 5:30am – 4:00pm U = 8:00am – 8:30pm

C = 6:30am – 5:00pm v = scheduled earn time

K = 6:30am – 3:00pm

From: Tafe, Joan E., R.N. Sent: Thursday, January 21, 2016 12:01 PM To: Horgan, Caroline,R.N. Subject: FW: Guidelines for Lead ECT RN in CPC Attachments: Guidelines for Lead ECT RN in CPC.docx

Here is a draft of the guidelines. Joan

Guidelines for Lead ECT RN in CPC

1. Print Mosaic Schedule, check for inpatients and call Nursing Unit for report on these patients ( verify NPOstatus, If they have an IV, Diabetic status)

NOTE: the ECT office has been trying to put at least 1 or 2 of the in patients in wave 1 Do not hold patient on unit if no IV access; That will be done in the CPC

2. Have OA call Milton to bring in patients to CPC3. Set up paperwork at sink area across from ECT bays. This includes:

• Sign out sheets, extra consents, H & P, etc• Red, blue, and yellow laminated sheets to signify H&P, anesthesia, or procedure consent needed

NOTE: H & P valid for 30 days; Consents valid for 6 months

4. Assist OA in placing of patients in bays. Try to alternate bay placement i.e. 8/10/12; 7/9/11 so that the RNassigned to these bays will not have 2 patients in the Phase l Recovery stage

5. Help with the patient flow. This includes IV starts. If an RN does have his/her 2 patients treatedsimultaneously, start to recover the 2nd one until the RN can safely step away from her other patient andtake over

6. Communicate with ORA (Jay) and PCA (different assignment daily) about turning over bays once patient isdischarged.

7. Keep Mosaic work sheet up to date; This includes noting the follow up appointment on this work sheetfor the ECT office to be aware.

8. Keep in mind that Bay 13 may be available to use; Discuss with CPC Discharge Resource RN if needed. Youmay also pre-op 2nd wave patients in bay 13, and move them into the ECT bays when Wave 1 patients aredischarged to assist with the flow

9. Once ECT treatments complete; return above paperwork ( sign out sheets, etc); File Green chartsalphabetically in the File cabinet in Room 325

10. Jay ( ORA) replaces the sharps container in the ECT bays after all treatments are completed. Make surethis is done if Jay is off

1/15/16