Evaluation of a Staffing to Workload Tool in a Multispeciality Clinic Setting

Abstract

Increasing pressure to manage the cost of healthcare has resulted in shifting care towards ambulatory settings and is driving a focus on cost transparency. There are few nurse staffing to workload models developed for ambulatory settings, less for multi-specialty clinics. Of the existing models, few have been evaluated against outcomes to understand any impact. This evaluation took place after the AWARD model for nurse staffing to workload was implemented in a multi-specialty clinic at a regional healthcare system in the Midwest. The multi-specialty clinic houses 26 medical and surgical specialty practices. The AWARD model was implemented in two specialty practices in October 2020. Donabedian’s Structure-Process-Outcome (SPO) model was used to evaluate outcomes based on changes to the structure and processes of care provided. The AWARD model defined and quantified the processes, recommended changes in the structure of day-to-day nurse staffing. Cost of care per patient visit, total visits, total nurse performed visits used as structural and process measures, influencing the outcomes of cost of care and access to care. Independent t-tests were used to compare the difference in variables pre- and post-implementation. The SPO model was useful as an evaluation tool, providing a simple framework that is understood by a diverse care team. No statistically significant changes in cost of care, total visits, or nurse visits were observed, though isolating the effect of the model was impossible given the circumstances. Two weeks into the post-implementation period, the multi-specialty clinic paused all non-critical patient visits due to a second surge of the COVID-19 pandemic. Clinic nursing staff was re-allocated to support the inpatient areas. This negatively impacted the ability of the Nurse Manager to fully utilize the AWARD model to plan daily staffing. The SPO framework could be used for on-going assessment of nurse staffing performance. Additional variables could be measured giving a more complete picture of the impact of nurse staffing. Going forward there must be continued focus on the outcomes of care and the value of nursing.