STAFFING EFFECTIVENESS
PLAN
FOR CARDIOPULMONARY
DEPARTMENT
MANUAL
SECTION
Respiratory
Administration
POLICY CODE
and NUMBER
PURPOSE:
The purpose of this policy is to provide an approach and guideline that utilizes screening indicators for the
staffing effectiveness of the Cardiopulmonary Department, and to provide for adjusting staffing based on
census and workloads.
POLICY:
The department of Cardiopulmonary shall be staffed, with a sufficient number of qualified personnel, to
provide the range of services described within the scope and function. Staffing will be determined using a
budgeted standard which is based on historical data, patient acuity, and census. Cardiopulmonary services
will be provided 24 hours a day, seven days a week. The Cardiopulmonary Department actively maintains
on-going processes to assure that only qualified and competent staff provides care or support services.
EMPLOYMENT:
The department of Cardiopulmonary shall employ qualified/competent respiratory care practitioners who
have established themselves in one of the following employment categories:
Registered Respiratory Therapist (RRT) – Graduate of an AMA approved respiratory therapy
program. Registered by the National Board for Respiratory Care. Current BCLS certification,
ACLS certification preferred. Completion of identified competencies and equipment skills.
Certified Respiratory Technician (CRT) – Graduate of an AMA approved respiratory therapy
technician program and certified by the National Board for Respiratory Care. Current BCLS
certification, ACLS certification preferred. Completion of identified competencies and equipment
skills.
Each employee performs his duties according to a criteria based job description that reflects patient and
population, specific needs, and defines re-qualifications and competency standards. A performance
appraisal is conducted for each employee upon completion of probation period and annually thereafter.
Clinicians are also required to complete a competency/proficiency annually in the selected area to assure
that on-going competency requirements are met.
STAFFING EFFECTIVENESS
PLAN
FOR CARDIOPULMONARY
DEPARTMENT
STAFFING PLAN:
I.
All staffing will be evaluated on a daily basis and adjusted accordingly. Staffing is based on
patient census, acuity, and the amount of time required completing the procedures requested by the
ordering physician. Subsequently, staffing is flexed based on procedural demands of each shift.
There are 1.5 hours per patient budgeted to cover 24 hours per day, seven days per week (which
equates from the number of worked hours/census).
Number of Hours Worked
72
68
64
56
Hospital Patient Census
45
40
37
32
Staffing Needs/24 hours
6
5.6
5.3
4.6
a.
Total therapy units reflect all therapy given per shift, with ultimate goal between 44 to 48
units of therapy per shift per therapist average.
b.
Increased staffing needs are met through use of prn staff and/or overtime. Decreasing
staffing needs are met by utilizing paid time off (PTO), vacation time, and /or request of
that therapist at the discretion of the department director. Skill level of providers is as
follows, total employees 23, 10-FTE (~12.8 FTE), 13-PRN, with 11-RRT and 12-CRTT.
A per-diem pool of employees will be maintained in order to allow for an upswing in the
volume of therapy to be rendered. It will be at the discretion of the department director to
request additional staffing levels based on volume data.
II.
Department Director will be scheduled Monday – Friday, and will be on call if needed.
III.
Each shift will be allowed a number of staff positions with varying skill mixes, working under the
direct supervision of the director. The director has the authority to adjust staffing levels as
deemed appropriate. If staff needs to be added, per-diem pool staff should be first utilized, and
overtime secondarily.
IV.
Patient Volume Adjustments – depending on the volume of the patient population, it will be
necessary to adjust staffing levels. Acuity level assessment will be the responsibility of the senior
staff member.
V.
Staff coverage – Day shift - 2/3 RCPs, Night shift - 2/3 RCPs
VI.
Respiratory Care Staffing Variance Report will be completed daily with written weekly report
forwarded to COO or designee. This information will be utilized to evaluate staffing on a
budgetary/operational level.
STAFFING EFFECTIVENESS
PLAN
FOR CARDIOPULMONARY
DEPARTMENT
STAFFING EFFECTIVENESS:
I.
Monitoring and evaluation of the effectiveness of patient care and support services are maintained
on an on-going basis through a well-defined program for improving organizational performance.
II.
The program emphasizes the analysis of the appropriateness of care, evaluation of problems and
concerns identified, as well as opportunities for improvement of services and patient care. These
activities provide mechanism to effectively assure a comparable level of care for all patients.
III.
This plan for provision of patient care is reviewed and revised as necessary. The following
elements are taken into consideration in conducting the annual review:
The facility’s mission;
Strategic and budget planning process;
Findings from performance improvement, risk management, utilization review and other
evaluation activities;
Changes in patient care needs;
Patient requirements and implications for staffing;
Relevant information from staffing variance reports;
Adequacy of staff recruitment and development activities;
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IV.
The staffing indicators are approved and trended data will be reported to the Performance
Improvement Committee, Quality Council, Medical Executive Committee and Governing Board.
V.
Clinincal Indicators for the Cardiopulmonary Department include but are not limited to respiratory
treatment rate and ventilator pneumonia rate. As indicated we will participate in organization
wide clinincal indicators when applicable.
VI.
Human Resource indicators for the Cardiopulmonary Department include but are not limited to
employee/staff injuries rate
The COO, DQM and Cardiopulmonary Director and/or designees collaborate with various senior
leadership, medical staff and department representatives to plan, implement and evaluate performance
improvement activities and report the results of these activities, including performance improvement team
outcomes, cost/quality and human resource outcomes to the Performance Improvement Committee.
Cardiopulmonary personnel are encouraged to participate in performance improvement identification,
implementation and evaluation. Feedback is provided through various means including but not limited to
employee meetings, individual recognition and routine postings.
The Cardiopulmonary Director and/or designees communicate with other departmental representatives on a
regular basis to plan, implement and evaluate activities that support the cardiopulmonary care delivery
services.
STAFFING EFFECTIVENESS
PLAN
FOR CARDIOPULMONARY
DEPARTMENT
INDICATORS FOR 2003
Indicators
Selection
Rationale
Formula
Goal
Monitoring
Frequency
Related to the
Six C’s
Monthly
C3, C5, C6
Monthly
C1, C3, C6
Monthly
C2, C3, C6
Monthly
C2, C3, C6
HR
Respiratory
Hours per Patient
Day (RT-HPPD)
Measure overall
productivity of care
providers. HPPD was in
2002 is 1.64. Skill-Mix
100% of direct care
providers.
Total worked hours in day
Total patients in day
1.64
(2002)
YTD
average
1.46
(2003)
HR
Staff Injury
C/S
Vent Pneumonia
Rate
To measure the number
of staff injuries compared
with plan and provision
of care.
To measure patients on
ventilator with newly
diagnosed nosocomial
pneumonia
Total Departmental Staff Injury
Number of patients on MV
with new
nosocomial pneumonia
X 1000
Total vent days
<12
YTD
3.00
YTD
Rate
C/S
Delivered
Treatment Rate
To measure the number
of respiratory treatments
compared to overall
treatments
Number of treatments
delivered
X 100
Number of treatments
99.8%
(2002)
YTD
Rate
References:
JC-HAS:
OTHER:
Original Date
Review/Revision Date
 Supersedes all Previous
07/17/97
04/28/03
Approved: _____________________
Date 06/11/03