Staff scheduling for skilled nursing facilities (SNF) is more of an art than a science. How should providers staff their buildings? There are numerous scenarios that arise when attempting this task: Set schedules, weekday and weekend staffing and creating a schedule every month based on employee-requested days off are just a few examples of the many options available to providers. No matter how your department-specific schedules are written, the one key factor in producing a fiscally responsible schedule is requiring all departments to adhere to a schedule based on hours per patient day (HPPD). State and national data is available that illustrates the lower, median and upper quartiles of HPPD for most departments. This data can be used as a starting point to develop a specific departmental budget, with the target HPPD varying based on the provider’s financial health and current patient acuity levels.
SNFs often assume additional staff are needed when there are issues with quality of care or survey results. However, in reality, there often is a disconnect between the number of staff members scheduled and quality of care provided; having more staff scheduled doesn’t automatically produce higher quality care. Having an adequate number of staff members is important, but having staff members who understand their job requirements and are committed to providing quality care is more important. In the SNF industry, recruiting, training and maintaining employees capable of providing consistent quality care continues to be a challenge.
How does a SNF determine the number of staff members needed to care for its resident population? The national and state HPPD benchmarks by department may be a good starting point if a facility doesn’t already have a budget based on HPPD. Selecting the appropriate benchmark from this data, i.e., upper, lower or median, will depend on the SNF’s patient acuity. As of November 28, 2017, all SNFs are required to conduct at least an annual facility assessment according to the revised Requirements of Participation. Once the facility assessment is completed, using the information gathered regarding Diseases and Conditions, Physical Function and Care Needs and Physical Disabilities, a combined patient acuity level should be provided. This information can be obtained from either software-generated reports from the Multiple Data Set software system or from the Centers for Medicare & Medicaid Services Census and Condition (CMS-672) and Roster Matrix (CMS-802) forms. Using the patient acuity information, as well as the facility layout information, will allow facility management to determine the appropriate level of staff for each department. Providers must be mindful of any segregated areas (locked units) of the facility, as staffing levels may need to be higher due to these segregated areas—this should be accounted for in the total HPPD numbers.
A tool can be used to allow facility management to calculate the number of hours allowed for each department based on management’s budgeted HPPD and the current daily patient census. Upon transitioning to this tool and staffing based on HPPD, facilities may want to implement some, or all, of the following:
- There may be times when staffing according to HPPD leads to a department that has too many scheduled hours due to a lower-than-budgeted census. To accommodate changes necessary during these times, it’s recommended all SNFs have a low census policy. This policy should include how hours will be adjusted daily when the current census isn’t at budget.
- To attain the best possible results when staffing according to HPPD, each supervisor should be held responsible for adhering to the budgeted HPPD in his or her department. To enforce these responsibilities, it’s recommended that management implements a process requiring each department supervisor to document an explanation when the hours in his or her department are over budget.
- Daily monitoring of staffing HPPD is recommended to allow facility management to make minor adjustments on a consistent basis. If providers take this daily approach to staffing, there shouldn’t be any overages when the monthly financial information is reviewed.
Scheduling that allows consistent staffing and quality care is a key metric to SNF success. SNFs that add staff without determining how it affects their financial health may find it difficult to operate profitably in the future. Scheduling daily based on HPPD can provide confidence the facility budget is being monitored and followed by all departments in the SNF. Daily adjustments to the schedule and staffing hours can prevent budget shortfalls in monthly financial reporting.
For additional information about SNF staffing and scheduling, contact Sherri or your trusted BKD advisor.