Episode 89: Staffing Standards and Delivering Quality Patient Care

March 15, 2023


Welcome to The Handoff presented by Trusted Health. I'm your host, Dr. Dani Bowie, Chief Nursing Officer for Trusted Health. This season we're doing a deep dive analysis regarding workforce flexibility, examining unique concepts such as staffing models, scheduling best practices, technology, and the latest research. Today I'm delighted to be joined by Brie Sandow, the Chief Operating Officer and Chief Nursing Officer at St. Luke's Meridian Medical Center. Brie has had an impactful nursing career for St. Luke's from leading patient care services to enterprise responsibilities for its staffing and scheduling for the entire system on a national level. Brie is a former ANA board member and the current president of the ANA, Idaho Board of Directors. Brie is passionate about solving their staffing at the local and national level, and is actively advancing the professional practice of nursing through evidence-based care, quality improvement and research. Let's dive in.

I'm so excited to have Brie Sandow today to talk more about the flexible workforce, workforce and staffing workforce and analytics. You name it, workforce. She's an expert. Brie, thank you for joining us today.


Thank you, Dani, for having me.


You know, I wanna dive right into the topic that I think everyone's been talking about for the last couple of years. But before we do, Brie, you have a really unique background. Can you tell us a bit more about your career journey and what you're currently doing for St. Luke's?


I came into nursing really as a second career. I graduated from high school and went to college. But the first time I double majored in psychology and child, family and consumer studies. Then I graduated and did not know really what I'm supposed to do with those two degrees, which to be fair, my dad brought up every day of undergrad what are you gonna do? How are you gonna make money? And I feel like I really just liked studying psychology and child family consumer studies and wasn't really worried about it. And so at that point I went to work for the YMCA, actually in their child development division, and then needed to make a plan on how I was going to really find a career. So that is when I decided on nursing. And so fortunately I got into Boise State University's bachelor's program on the first try which was very fortuitous I feel.

And then once I finished health assessment, was able to get my nurse apprentice letter and I had left the YMCA and gone to work at St. Luke's which is a health system in Idaho. And so I went to work at St. Luke's as a patient business associate. Like the person that checks you in has you sign your consents. But it was a good move because it got me back to St. Luke's, which I really loved. I was in Boise, Idaho, which is where I was born and raised. I was actually born in St. Luke's and it got me tuition reimbursement, which at that point for bachelor degree number three was going to be key. So I got my bachelor's degree in nursing worked full-time nights as a nurse apprentice the entire time. This program was unique in that when you finished the requirements for your associate's degree, you could apply for the degree even though you were in the bachelor's program and then you could license.

So I got to license as an RN when I finished the associate requirements. And then I was able to go to work. I went to work in labor and delivery as an RN and worked there full-time while I finished my bachelor's. So I finished my bachelor's in 2006 and kept working in L&D. And then I had been asked to be the representative of labor and delivery on the nursing practice council. So at that time, Joanne Clavell, who has published several articles about shared governance and professional governance was the CNO of my hospital. And we had a practice council at the system level or at the Treasure Valley level, which is like our region. We had a practice council, quality council, and an education council. So I was on the practice council and then had gotten nominated to be the co-chair, which was mind-blowing to me at the time.

So I was an L&D nurse and I was like, are you sure? But they were sure I got elected. And then the two co-chairs of each of those councils made up the coordinating council and Joanne chaired the coordinating council. So that was a really pivotal moment, I think for me in my career because I got a lot of exposure to the CNO. And then when supervisor position opened up in the float pool, she said, I think that you should do this. I think you have good leadership skills. I think that's what's important. And the beauty of the float pool is no leader has clinical expertise in every area that the float pool supports. So I did that. I was hired as the clinical supervisor, got my master's at Sacred Heart University in patient Care Services Administration, my MSN, and eventually over 10 years just had a lot of growth in leadership roles.

So I was the manager when I finished my master's degree, my leader, who was the director had gotten her DMP, so she moved on, I got to be the director. And then in 2019 we established the enterprise resource and staffing office, which was an operational center of excellence. And I became the senior director of that. And this was a pivotal moment for me in regards to my subject matter expertise on staffing and scheduling, because what I had been doing before always reported to the CNO, but there was a shift where with the enterprise resource and staffing office, it was gonna report to the vice president of operations who re reported to the Chief Operating Officer. And while nursing was going to be a component of this, which is why it was a good fit, that I was an rn, it was also intended to oversee and to help develop staffing and scheduling strategy for all volume driven areas regardless of what the volume metric was.

So whether it was E VS or whether it was lab, the volume metric didn't have to be patients. And so at that time, they centralized the health system had three slope pools, two regional acute care float pools, and then a shepherd float pull for ambulatory that rolled up under me. We also had a central staffing and scheduling office that had staffing and scheduling techs in the Treasure Valley, which is one region and in the Magic Valley, which is another region, but they were to the same leadership. So we had that involved, both staffing techs that run the central staffing office for inpatient nursing and ED, but also schedulers that were paired with specific departments and helped facilitate their scheduling and scheduling software. And then we also had oversight of IT, administrator of the productivity software and then was Strata, and then also the staffing and scheduling software, which is Taz, which is Symplr. Yeah. So that really made up that team. Go ahead. And so I ran that for 10 years. Well, it, I was in operations for 10 years and that kind of culminated, I ran the era, so for three years. And then at the end of that time had the opportunity to apply for the job that I'm in now, which is the chief operating officer, chief nursing officer for St. Luke's Meridian Hospital and our Eagle Medical Plaza.


Wow. You know, I, as I'm listening to your story, Bree, we actually have some parallel path. So when I first started my career, not necessarily my career, my, my academic journey, I was pre-dental, I was at a, at a <laugh> at a college that didn't have a nursing degree, nursing degree offering. Switched my major second year in, had to leave. I went to a community college, lived with my parents and worked at Quiznos for a year. And then finally got into nursing school and then pivoted and started, you know, the, the professional journey. But I love hearing how you are able to move your career along. You know, you started one way and what I hear in your story is a lot of tenacity, a lot of hard work, and a lot of people recognizing things in you and leadership capabilities and calling that out.

And you having the courage to get step up and, and take that. You know, I wanna talk a bit more about the, the workforce space a bit more and, and then we'll go back into the CNO and COO, which is a fantastic role and I love hearing, you know, nurses are in this space. But let's talk a bit more about what St. Luke's has, which is this really comprehensive resource center and management center. And I know that you've built in analytics. And so can you describe you, you describe some of it, but describe a bit more about the enterprise resource center that you led, the flexible workforce, how you brought it together and how you're using analytics to really drive decisions. Cause I'm sure our listeners are interested in, you know, how did you structure that and how are you, you operating today or where were you at past and where do you wanna go into the future?


Yeah, definitely. So I think like a lot of organizations, Dani, there were parts of the enterprise resource and staffing office that had started several years before and really had grown organically out of necessity. So the fall pool's a good example of that. When I first joined CSU, which is what we call our float pool, the Clinical Support Unit we had a small group of nurses and CNAs in the Treasure Valley, which is one region and IT service two hospitals, Boise and Meridian. And then we also had a small group in the east region, which was at Magic Valley, which is another hospital. And then Jerome, which was a neighboring hospital. But that was critical access. And then ambulatory had put together a small group. There actually weren't very many RNs and still aren't it, it's a lot of LPNs and CMAs because that is the primary workforce for us in ambulatory.

But those three flow pools at the time originally were not, were not connected because in our health system there's eight hospitals, but four critical access. And so critical access hospitals have very unique needs and need a very unique workforce to meet those needs versus some of your bigger hospitals where I feel like it could be a little more cut and dry. So at the time that the enterprise resource and staffing office was formed, the vision was that you would have a center of excellence that starts to, in a much more intentional and meaningful way, harness data and analytics to understand based on volumes, how many staff do you need scheduled every day, even at different times of the year. But then also as that FTE rolls up, how much worked or productive FTE do you need? What's the non-productive methodology and how does that differ for groups?

And then what's the total roster target by role that you need to be hired to, to be able to meet your staffing obligation, which is really your historical volumes. We all have an obligation as operators or nursing leaders to understand what are the volumes that we've historically had, what do we expect? And then what do we know based on clinical expertise and evidence-based best practice about the number of resources we'd need in each role to cover that. And that logic really applies to any, like I said before, any volume driven area. So as the ERSO was pulled together, so we have the flow pools initially, the flow pools continue to operate and we've had a central staffing office just and to, even today, the central staffing office is just overseeing inpatient and ED staff. So there's probably an opportunity there in the future.

There's no reason why they couldn't oversee RT or or, but we're not there yet. And so one of the most important or foundational projects that we took on in the ERSO was the development in partnership with our data and analytics team of what we called the enterprise demand-based staffing. We called it a logistics engine or just an engine. And so what we did is we met with data and analytics, several different members of their team because there's a lot of different aspects to data and analytics. And we worked within Empower BI and what we looked at is we took 36 months of historical volumes, which is really sort of the sweet spot. Three full calendar years is really sort of the sweet spot to understand what your trend is. And we know COVID has introduced a lot of variation in that, but in general, if you can look at three closed calendar years, and I'm really emphasizing that because I think a lot of software programs that are out there today that are, that are meant to inform staffing, utilize a rolling 12 months.

Yeah. And what's very hard about a rolling 12 months is that you don't patch your seasonality. So when you think about the fact that we know anecdotally that med surg tele critical care are gonna peak in the winter, we're gonna hit our highest volumes in the winter. And in general, women's services, labor and delivery are gonna hit their highest volumes in the summer. And then with peds, it's kind of a mixed bag because you have RSV season in the winter, but then you have, if you do any trauma, trauma tends to peak in the summer. But understanding that and being able to look at a whole calendar year to see your volume patterns is important. And so that was one of the foundational pieces. So we pulled together three closed calendar years, and then the engine captured volumes by department by day of the week and hour of the day. Oh wow. For all 365 days. So you, so if it looks different in July, then it looks in October, we were able to capture that.


So that is because I've spent my career looking at data analytics, predictive modeling for workforce. And the question I have, which is, this is phenomenal pulling 36 months, being able to see the seasonality as well as by day of week and timing, how many units was that? Do you know off the top of your head how many inpatient units you were able to pull to, to trend?


That we, that we pulled in, that we pulled in data for? Yeah. Yeah. I have not added them all up. I'd have to add them cuz we did it for the system. So it was all inpatient nursing departments and EDs in the system.




I do not know the total of that. Okay. And so, but I mean that, I'm


Sure it's it's a lot. I'm sure it's a lot.


It's a lot because it's eight hospitals, right? Yeah. And we did it for critical access and we did it for the big hospitals. Every hospital has a, has an E. So that was a, that was ADDs Yep. Right off the bat. And then all hospitals had had at least one med surg cell unit, but like our largest hospital in Boise has multiple Yeah. Med surge and tele units. And so it was a lot of units. It was, it was a lot of units.


How, one last other question, I'm sorry, I'm, I'm kind of, you knows fine nerding out on, on the data, but how did you get that information? Was it coming from your EMR? Was it coming from your scheduling solution where were, because that's one thing I've noticed with health systems as well is we do wanna make decisions with data, create the analytics to inform strategic plans how you wanna drive, you know, supply and demand. But what I've discovered is the ability to pull data is often lacking. It's either not clean, there isn't con a standard language or nomenclature to capture that. And so I'm just curious, where did you get your data from? Had you already set a standard nomenclature that you were looking for outside of seasonality and was there coding set up with like matching the nurses? I'm just a bit more curious about how you were able to do that, because I've often found that to be one of the barriers in moving into a more, you know, data driven and then informed space in healthcare.


Yeah, definitely. So what I'm gonna tell you, I'm gonna tell you from my nursing and operations brain, but what I can tell you about what I know about the front end. Yeah. Is that we have one EMR. So that's a good call out is because that was not always true. And so we had rolled out Epic to the entire system. And so the entire system, inpatient nursing departments, EDs, everyone is on Epic. So that was foundational. Prior to that we had double digit individual systems. And so this type of work would not have been able to occur if we didn't have a standard EMR because that is where we pulled the patient volume data. And our data and analytics team was phenomenal because what I think was unique about this is they came really with their data and analytics knowledge and their understanding of how they were gonna build it and code it and interface it.

And then myself and my team really just came with this nursing clinical and operational subject matter expertise. And so we met a lot in the beginning. We were meeting more than weekly. And what would happen is we would come in and we would say, okay, here is what the outcome data that we're looking for, here's the information that we like, like understanding. I had a very clear understanding at this point, having worked in the float pool and with the central staffing office for over 10 years, I had a very clear understanding. And also had other partners and leaders in the space at St. Luke's who had been contributing to this work. There was a very clear understanding of things like, we want 36 months. So if we're gonna look at July 5th, I wanna be able to see the average of the volume on July 5th by hour of the day for the last three years, the last three July 5th.

The intent of that is really to try to minimize that variation that you get from year to year. And so we had a very clear idea of the, of the fact that we didn't want it to be rolling, we wanted closed year, so we wanted to pull the data in and we had a very clear idea of the staffing standard that we wanted to apply to help drive the ideal schedules. And then what we wanted to do once we pulled in those patient volumes is we wanted to overlay the staffing standard based on skillset. And for us that was one to five med surg, one to four tele one to two critical care. Our L&D actually runs, we run with a one-to-one. So this is where I feel like ratios and staffing standards are very important and helpful. Yeah. Because what that does then is it takes the number of patients that you're anticipating, overlays the number of staff that you need to take care of those patients based on evidence-based best practice.

And then you can create a schedule and then from the schedule all those hours, then roll up into the productive FTE you need. And then you, we built in a non-productive methodology. And then that's how you achieve kind of your roster goal, right? Yeah. But one of the things that was trial and error as we were putting this together is originally we thought, okay, we want flexibility, right? Yep. And that's what we're here to talk about. Yeah. So we're like, we could have, let's say that we do an increments of four, so we could produce a four hour shift, an eight hour shift or a 12 hour shift, or I actually think at the first pass, cuz here's the beauty of it, right? You nobody's using it right now. So you're already, you're doing what you're already doing, you know, you know, that's not optimal, but you have the freedom to kind of say, well, what would it look like if we did this? What would it look like if we did that? We had a lot of shift options initially. So data analytics goes the way they build it. So what we call those variable constraints. So what is the shift time gonna look like? When can shift start and stop, et cetera, et cetera. And so what ended up happening initially with all those variable shift lengths is it produced like a million different shifts in the schedule, right.


Question did. So, which I, I agree. I love hearing the variable constraints and also the flexibility. And I love what you said too, where it was like, you are already doing what you're doing. Oftentimes I'd find people are just like, well, this is how I used to staff, right? Yeah. Like, it's always been built this way. So you're right. A starting point is like, it's probably not gonna hurt where you're going with tri trial error. Was this, did you have to manually put this into your schedule then to then say, this is our need? Or was it then feeding it back into your schedule? So then as you opened your schedule up for self-scheduling, you knew the number of nurses that need to be scheduled?


Yeah, so that's a great and timely question because as we were building the logistics engine the first thing that we saw, and I had all my, my entire leadership team participated in this because I had RNs that were leading the float pool, but then I had my leaders like my productivity software and my leaders of my scheduling software who are gonna look at things, everyone's coming from their own individual perspective, which was hugely important in this project because my nursing leaders that are running my float pools are not necessarily gonna see the barriers that my administrator of my scheduling software is gonna see. So, and her name was Brandy. So right away Brandy was like, there's no way <laugh>, I mean the, the nursing leader saw that too, right? There's like, this is chaos.

Like there'd be a million handoffs. There's just no way. Right? So, but that was important to recognize because they think when you're talking about flexibility, and even if we take a really broad stroke at that and say what flexibility means to each individual nurse, honestly, whatever they need to make their life work. But we understand we have to provide a certain number of resources, 24 7. We understand that continuity of care is important. We understand that minimizing handoffs is important. And then we also understand things like there are standard handoff times, right? So we don't want a nurse randomly coming in or in a lot of times going home at two in the morning because there's not a match to that shift or things like right now nurses get off work at 11, but really if you're here at 11:00 PM you're here till 7:00 AM we do what we can to not have people driving around on the roads.

Yeah. Between 11:00 PM and 7:00 AM as we kind of moved through, we really had to dial that back. And we also thought things like, we don't really want nurses scheduling in for four hours. By the time you get in and you get report and you give report, not to say that when we're short staffed, that we aren't willing to say, oh yeah, we'll take you for four hours because we are, but I think one of the key concepts that goes either missing or is misunderstood when we talk about staffing and scheduling is the logic and the methodology you need to build schedules is entirely different than staffing. Yeah. People convolute that all the time. People are always talking about staffing and scheduling, but they really are two totally separate functions that I would, that I always say are two sides of the same coin, right? They have to be married, but they're very different.

So what we're talking about right now is all of the logic that we were harnessing all of the data and all of our philosophy and principles from a practice and clinical standpoint about how we deliver the best care and what's appropriate. That was really being harnessed to build ideal schedules. Yeah. And really when you look at logic, what you're trying to do, what we all know is what happens on day of operation happens. And so it is very unlikely that you go into day of operation with exactly what you need in terms of the number of staff in terms of the skill mix. And so what you're really trying to do with the logic around scheduling is lower what I, this is how I think of it, that you're trying to lower the upper control limit and raise the lower control limit so that the span of variation around wherever you're gonna land on day of operation is smaller so that you're more, that you're closer to the goal more often. Yeah. Which means that you have to flex up less and you have to flex off less because those are both dissatisfiers. And so that was really what we were trying to achieve with the EDBS engine.


I really like what I'm hearing, and I think it's a good call out for our listeners and something that you do hear staffing and scheduling lump together all the time, and you're right. Building a schedule and ensuring that you're getting closer to what's gonna be projected for staffing, which essentially you're describing standard deviation, you're limiting the standard deviation between supplying and demand and need. Totally. That's exactly right. And then, and then allowing for the opportunity of, you know, less cancellations or less, you know, last minute recruitment opportunities, but recognizing there's still some need there. And what I love hearing too is the way that, you know, you put principles in place to also guide flexibility. So you said we started kind of fraud, realize that there may be some chaos involved, and how do you create that kind of compromise between flexibility but also ops that's 24 7 and very complex with patients.

And if there's more, you wanna talk about the, the ev you know, the evidence base and, and the data that's striving this. But you touched on staffing standards and how you overlaid that. Yes. And you mentioned it kinda like nursing ratios now that's a very controversial topic in the sense that you see a lot of headlines out there, safe staffing. There's obviously been legislation both at the state levels for different states as well as some talk even at the federal level of like setting safe standards for staffing. And oftentimes it's tagged its ratios or as you're saying, staffing standards. Can you, and you've had also, which we haven't talked about, but you have a history with ANA, like you've, you've served I believe in a position in the ANA. So you're just really well versed in this, but I would love to know more about staffing standards, your thoughts around that. It's very controversial and kind of where you see this fitting into the ecosystem of healthcare management, both, you know, whether it's legislative, whether it's operational at their practice level. Can you just talk a bit more about that?


Ratios, which today are more commonly referred to as staffing standards? Because I think the term ratio started to, to garner sort of a reputation and some controversy as you touched on, are an important component of the conversation around staffing and scheduling. I would say the majority of the controversy around ratios is whether or not the government needs to be involved in legislating those either at the federal level or the state level. And I, there's a lot of opinions in the space that that is beneficial, that there are people in states or at health systems who really are the nurses are being given unsafe assignments. And while I absolutely advocate for safe staffing standards, I do not personally believe that putting the government in charge of that is the solution. And what I think is when you look at the way that we deliver care, so the majority of the patients that come into your hospital come in either through surgical services, scheduled procedures, or they come in through the ED.

And in terms of the ED volume, it's unpredictable. And because of intola, we accept all of the patients that walk into the ED. And so I think when you look at legislating ratios and you look at the number of nurses that you have on any given day, even if you are in a health system like mine that's committed to safe staffing and you've built all these logic and tools and you have a robust float pool that comes in on day of operation and you have robust policies around incentive, and we do not have mandatory overtime. And I think I'm gonna go out on a limb and say, I think most nursing leaders would not advocate for mandatory overtime, but when you put all of those together operationally, it would, it's very easy to legislate yourself into a corner. Yeah. The patients come and they come, when they arrive at the ED, they come through surgical services.

Things happen on day of operation in terms of did you start with the right number of staff? How many sick calls have you had? What's your skill mix? What is the workload intensity of the patient? So we know the resources that we need are gonna be variable if you, and what we also know is nurses can choose to come to work or not come to work. And so even the best laid plans can go sideways on day of operation. And so I think when you look at, if you're required to have, let's say in a med surg unit, one nurse for every five patients, regardless of intensity, regardless of acuity, regardless of skill mix, one nurse for every five patients, but your ED is full and you're continuing to admit, and you, and you've called the nurses and no more nurses are coming and, and we're not forcing them to come.

Yeah. Then you're in a situation where something has to give. And I think what you see in states like California is they have mandated ratios, but there's a process when they're in this situation to write the explanation that says, I can't meet the ratio, which to me then feels like a lot of government oversight and involvement for a process that at the end of the day works the way it works regardless because there's no option. And so what I would like to see is that nursing as a profession continues to have more conversations like the conversation you and I are having on how do we harness the data? What's the right data, what do we know about evidence-based best practice and skill mix and what we need for nursing workload intensity, which is a variation on patient acuity. How do we harness that so that we are driving and governing our practice and not relying on the legislators or the government to control that for us.

But in terms of staffing standards and ratios, I think that there best utilized the way that I described, when you are building schedules, when you get down to what you need on day of operation, there is variability in the way that you build assignments based on the patient where they're at in, in their care, in the trajectory of their care for that episode. So do they have discharge orders and they're just waiting for a ride? Is it day one? Is it day two post-surgical, the amount of nursing workload intensity that, that requires each day? Varies, your skill mix varies. How many experienced nurses do you have? How many new grads do you have? Are you running a team nursing model? Are you running a primary care model? How many CNAs do you have? How many suicides do you have? Do you have the CNAs that you need for constant observation?

There's a million variables. And so I, I think on day of operation it's been, it's completely appropriate if you have it, an expert nurse that has, let's say you're on a med surg unit and they have five patients and they have three patients that are busy and two that have discharge orders that if you get an admit and two of those patients are on autopilot, that that experienced nurse might be the person to take the admit. And your new grad who just finished orientation last week, that has four patients, is not the right person based on that admin. The other thing that's variable is what are the support resources you have on your unit? Do you have a resource nurse? Do you have an ADT? Does your charge nurse have patients or don't they? Do you have an a and m on that day?

Do you have a crisis nurse that runs your, or an RNR T nurse? There's a thousand things that go into that that are not captured by every med surg nurse every time she should be in a one to five assignment. Now that being said, do I think nurses should be taking eight patients? Never. Yeah. Never do I think that's what should be happening. But I think we have to be in a position where nurses can lead that conversation and that, that are in an unsafe situation, feel empowered to say, this is not why I'm gonna work if organizations can't recruit and retain nurses because they're implementing unsafe staffing practices that something's gotta give. But I also think people like myself, Dani, and you, or people who have really leaned into the staffing and scheduling space and really want to come up with a solution, I'm also incredibly committed within my own organization of being able to translate what we need and what the return on investment is of all of this to operations and finance. And I think we all have to tell ourselves the hard truth, which is that operations and finance are never going to have the clinical expertise to make these decisions. But 1000% clinicians can develop the finance and operational acumen to speak clearly and with data about what we need and why we need it and what the return on investment is in terms of patient outcomes and recruitment and retention.


Yeah. You know, I, I love that you're, you're really kind of getting to the meat of this issue here. And you, you touched on some key elements that I think are important to call out. One, the state of California ratios were implemented, but also then assistive personnel, like there was a shift. So sure, we got your standards to a level that, as you mentioned, I do believe is meant to build a schedule but not operate day of staffing because of patient condition, nurse workload expertise involved. There's so many things that go into the nuancing of ensuring that you have the right nurse at the right place at the right time. But there's also then kind of that shift, sure, we'll, we'll get you safe standards, but then also the support staff, you know, we can reduce that and we know that we want our nurses working to the top of their licensure.

And so I, is that really the right model way to approach this? But you know, ultimately we all are on the same, you know, goal and team here of we want the right amount of nurses and the right amount of assisted, you know, personnel support staff to be caring for our patients to get the right outcome. But it's more complex than just a number and overlaying, you know, staffing standards and then creating the administrative burden that often comes with managing those ratios or those state staffing laws. And so really, like you said, having the conversations about how do we solve this how do we look at data? Is there new technology and analytics that can help support our decision making? And let's develop that business acumen to talk eloquently and intelligently around the solution and, and the ROI associated with some of the things we're talking about.

A couple more questions for you just to, you have, you have so much expertise here and so much passion and I, I love hearing your perspective around the workforce. We've touched a bit on this a bit more, but flexibility and, you know, you, you said at at St. Luke's, you guys were starting one way, it was chaos, you were readjusting, but kind of couple trends. What is it that you believe as a nurse leader and those that you are leading, you know, what does flexibility mean to you as a leader and how you lead, but also to the frontline you're serving? And and also are you seeing anything unique in regards to what the generations are looking for in regards to flexibility?


Yes, definitely. I think that as a nurse leader one of the things you have to be in tune to is the needs of your staff and, and at really at all levels. So I think this is true for your direct care staff. I think it's true for your supervisors, assistant nurse managers, managers, directors, all the way up. At the end of the day, a fundamental principle that I believe is that if your staff can't manage their lives at home, they will not be able to be exceptional at work. Right? At St. Luke's, we always say exceptional staff experiences create exceptional patient experiences. And the idea that you're able to separate your personal life from your work life and my opinion is not is not real. That's not a real thing. So I think the goal always you have to give the patient is the true north.

And I really emphasize that when you talk to staff about what we need, it always has to start and end with the patient. So when I was running the float pool, one of the things I would say because our float pool in our region grew exponentially as our health system grew over time. And so at the height we at 150 CNAs, a hundred RNs, I mean, we were one of the largest units in the hospital. And managing the float pool is really unique because you, they don't come to a physical space every day, right? I really emphasize rounding spending time and all the hospitals checking in with them. Cuz you really have to create to retain them. You really have to create this culture where your float pool has an identity and they're connected to it. But one of the things that I would always say to my leaders in the float pool, and then I say to the managers in my hospital now, is when staff come to you with any kind of a request for their schedule, I want you to start with yes in your mind.

And the only question I want you to ask yourself is what is the impact of patient care? And if the impact of patient care is positive or neutral, you say yes to whatever it is. Say yes. If the impact of patient care is negative, I need you to be able to articulate to the staff, I wanna be able to say yes to this request. Here's how it's gonna impact patient care, the schedule, whatever the thing is that's impacting patient care. And then work with the staff. If the staff has suggestions or ideas, how to mitigate that. If you can neutralize that, then say yes. Because at the end of the day, the idea that you're gonna collaborate with your staff and you're gonna support them a hundred percent of the time, as long as we can meet our obligation for patient care. I think even just the way that you frame that engages staff in a different way.

But I do think when you're looking at how you're building schedules and the options, it can be tricky. So when we first started building the EDBS engine there were a lot of leaders who were like, can we go to eight? Can we go to eight? And we all know, if you look at the evidence on shift work, oh, there's a lot of evidence to support the safety of eight hour shifts. And when you're looking at 24 hours, that aligns with that. You can have three eight hour shifts, you can have a day shift to swing shift and night shift. But the issue is, I'm telling you, young nurses don't wanna work five days a week. They don't wanna do that. They wanna work full-time in three days and they either wanna have four days off or they wanna be able to leverage the time they have off to pick up extra and incentive shifts and capitalize on their income.

And so it's tricky because a lot of nurses come into the, first of all, the vast majority of nurses are women, which it would be erroneous to to not recognize that because women over the course of their lives have different responsibilities often or different needs in terms of family. Now I do think my husband's a nurse, so I do think there's a lot of that that is shifting as we get more men in the workforce. And I think as more men over time engage in the same way as women do it in their home life, you see that. But over time, a a lot of nurses come into nursing right outta college. And so if you think about how long a nursing career lasts, people have seasons in their lives. So there may be a point in time where they're trying to save for a house and they're picking up, they're, they wanna work twelves and they're picking up extra incentive to beat the band.

And then there's a period of time where maybe they have kids and their kids are young, and so maybe they're coordinating a schedule with someone else. They're trying to minimize childcare, which is expensive and hard to come by. And then maybe you get to a place where your kids are school age or they're in high school and they have sports and you wanna be able to accommodate that. And so I think that generationally the flexibility, people need changes as their lives change. Yeah. And then even within that, when people say, I wanna work eight, I can tell you the majority of those people wanna work seven A to three p maybe three to 11. The majority of people who say they wanna work eight, are not trying to sign up for 11 p to seven, eight, they're not. And there are factors like night shift work is hard, it's hard to sleep appropriately, it's hard to be able to flip back to functioning on day shifts if that's what you have to do on your days off.

So when people talk about flexibility, it's a very complex problem. So what we try to do with the engine, with the EDBS engine is we have 12 hour shifts and we said when, when the engine evaluates volumes, we want it to default to the fewest number of, number of staff per shift that you would need. And in order to do that, it generates 12 hour shifts first because generating a 12 hour shift is gonna result in the lowest headcount. Because the other thing that we have to recognize is that we don't have the nurses that we need for the patients that we're taking care of today. And we don't anticipate having the nurses that will need to take care of the patients tomorrow. And so that conversation is a almost a whole separate conversation about how we're gonna maximize models and all of that on data operation.

But what we know is we can't be cavalier when we're looking at shift length and create a model that is gonna require many more nurses than what we know that we have. So it fundamentally at, at a foundational level started with 12 hour shifts. But then, so if you think about your volumes, let's just say for example that your volumes over the 24 hours in a day are in a bell curve. Right. And, and a lot of med surg units, they're not in a lot of places in the country. Med surg just matched out all the time. So it's like literally a flat line, but there's a lot of, but there, especially post covid, I feel like we're all just running at max capacity all the time. Yeah. So a lot of the variation's been removed, but there's a lot of departments like the ED where the volumes really are in a bell curve.

And so when you look at that, the base of that bell, the wide part, the mouth of the bell is where your 12 hours are. And then as you go up, you're really looking at, okay, there's shorter shifts here and then what does that look like? And so the engine was able to differentiate that and start and stop times. And so then you have to look in an ED, you can basically start someone and end someone whenever you want because there's not the same concept with continuity of care in a med surg tele critical care unit. You don't want people coming in for six hours in the middle of the day because all you're doing is generating hands handoffs. So we set variable constraints for when shifts would start and end, and we were able to do that for 12 hour shifts and we were able to do that for eight hour shifts.

Nice. So ultimately we ended up running with twelves and eights. And then to your point before your question, what actually happens is the EDBS engine and power BI generates a report. So my administrator of our Taz scheduling software worked with data and analytics to create a report. So we schedule in six week blocks. So every six weeks it generates the schedule targets for the individual units based on the days in that six weeks and it generates a report. And the scheduler that has oversight of that department in our scheduling software enters in the schedule targets. Got it. Based on those volumes. But then for flexibility, our nurses self-schedule, okay, so that really is today. And I know that's not a new concept. It really is one of the key concepts though for flexibility that they can pick when they wanna work. And the beauty of it is you can have some nurses templated if that's what you need to do.

You can have other nurses self-scheduling even over the template. And then for nurses, one concept that's key is nurses can't move in and out of from eighth to 12. So they know they either are a 12 hour day shift or a 12 hour night shift employee, or they know they're an eight hour employee. But I will say this was key because the eight hour blocks change. So what we said is if you're a 12 hour shift worker, you know, you'll work 12 hour days, seven eight to seven p 12 hour nights, seven P to seven A, right? That's a guarantee. If you want eight hours. And there's a limited number of people on every unit that can have eight hours. So we have a process where you say, I would like to go to eight hour shifts, you get on the list. But what we say to them is, we can commit to saying your eight hours on days or your eight hours on nights, if you're eight hours on days, your shift will start between seven a, it will start and end between seven A and seven p, but the exact hours will be based on what the engine produces.

So they had to know, is that the trade off that you want or not? I can guarantee you won't start before seven A and you will be off by seven P, but one day the engine may say that we need you to start at nine in work eight hours and one day it may say, we need you to start at 10 in work eight hours based on the historical volumes. Yeah. That's a negotiation with those staff that they agree to that to get eight hours. And so that is part of how we've moved forward.


I love it. I I really like, you know, hearing Well one, you, you're taking a multi-pronged approach and that's often the best approach. Flexible workforce requires flexible solutions and a variety of solutions. There isn't a magic bullet or a silver bullet that's gonna solve this all. And so being able to say self-scheduling, but maybe some pattern scheduling if that's what the nurse is looking for, but then also


And what the unit needs, right? And yeah, like if you're running a charge nurse 24 7, which we are, and only certain people can charge that their self-scheduling to their own charge nurse scheduling target, they're not scheduling in with the RN scheduling target. And the beauty of the software is not to look different on every unit also. So you might have a unit where the charge nurses want a template themselves. Yeah. And they, and they've agreed. And, and it doesn't even have to be by unit. We have some, sometimes it's by unit, by shift. Like you might have a unit whose day shift charges wanna work the same days. And if the other charges who are in that unit agree to that, oh, we push all that to share governance as well and professional governance, because the message I give my managers is this, you are accountable.

You're the CEO of your unit. I need you to understand the evidence-based practice staffing standards. I need you to know the number of nurses and CNAs that you need every day. Your obligation is to schedule to that number, how that goes down. Those decisions can be unique to your unit as long as you come in today of operation. And we utilize travelers and, and there's a whole list of reasons that managers would request travelers, seasonality, LOA vacancy and orientation are, we're always gonna utilize travelers to get to that roster target. They know that they're responsible for requesting those when they, when they need them and then putting them into the schedule. But ultimately that also helps create variability and it allows the nurses to govern their time by saying, on our unit, this is how we're gonna cover weekends and how many nurses you need on the weekend is different from unit to unit. So not all of our nurses have the same weekend requirement, because that's ridiculous. We don't all have the same number of patients. So it really is all about understanding the target and the data behind it, hitting the target, however your nurses on your unit wanna schedule to get to that target. And then on day of operation, the system supports with all the centralized resources for the higher volume, higher acuity or sick calls.


Absolutely. Yeah. There's, there's, I mean, again, this just kind of hit the nail on the head maybe why staffing standards just a generic statement isn't gonna solve what we're facing today because of the complexity that you just described. This has been really, really insightful, impactful, I loved hearing about your engine, the data you're using to drive decisions the way that St. Luke's is thinking about the workforce, the way that you've supported your workforce with all of these robust opportunities, programs, you know, not, and not requiring mandatory overtime, all these things. I mean, it sounds like a wonderful place to work. And I wanna, I wanna close it out. Typically we ask our, our guests, you know, what would you like to hand off to our listeners? This just a final piece of wisdom and you know, things to to, to cause our leaders to to think our listeners to think about anything. We've talked a lot about flexibility. You have a very unique background and your c o coo, you've been on the a a all these things. What's the final piece of advice or information you'd like to hand off to our listeners today?


If there was one thing that I really wanted to leave for nursing leaders to think about today is that you have the knowledge of practice, of nursing workload, of patient acuity, and of operations to figure out what is in the best interest of your staff and patients. And that, while I think in general, the nursing profession has a lot of published work and has been very vocal about our philosophy, I think we need to be pushing ourselves in a different direction to be able to harness everything that we know into a data-driven solution for staffing and scheduling that works in critical access hospitals, that works in the largest medical centers and that has the flexibility to meet both the patient and the staff needs. And what I'm describing is complex, but we are capable of establishing a complex system and working through it or multiple complex systems. I do think the solution lies with us and not with any external governing bodies outside of us. And so I do hope that as we continue, we can start having this conversation with a different, through a different lens, a lens of specificity around our ability to make data-driven decisions.


Powerful. The answer lies within the profession. We should be holding the conversations, leaning the decision. And Brie, you're such a strong and inspirational leader in this space, thank you for sharing the knowledge, the work that you've done for the profession and, you know, kind of poking us to think differently about the way that you've operated at St. Luke's, giving us some ideas there as well as looking at, you know, joining our professional organizations to help support the cause as well as thinking broader at our state or or federal level for this. So thank you for your time. Really appreciate it. I'm sure you're gonna have a lot of listeners reaching out and asking more about the engine that you created and how you've been using that at Saint Luke's. So thank you so much.


Thank you Dani.