The County of Santa Clara
California

Personnel Recommendation
90346

Authorize extension of extra-help hours beyond the 1,040-hours limitation for the remainder of Fiscal Year 2018 for 199 per diem and extra-help registered nurses in the Santa Clara Valley Medical Center and Custody Health Services.

Information

Department:Hospital Administration (Santa Clara Valley Medical Center)Sponsors:
Category:Personnel

Body

FISCAL IMPLICATIONS

Approval of the recommended action would not require modification to the current Board-approved budget for Santa Clara Valley Medical Center (SCVMC) at this time.  The recommended action would eliminate the need to recruit, on-board and train additional per diem and extra help nursing staff as current per diem and extra help nurses reach maximum hours.  This recommended action would not increase extra help hours expenditure.

REASONS FOR RECOMMENDATION

Pursuant to Merit System Rule A25-188(e), no person may receive pay in an extra help capacity in the same classification in the same department for more than 1,040 hours in any fiscal year, unless otherwise approved by the Board of Supervisors.  On December 12, 2017, the Board of Supervisors approved a recommendation that authorized Santa Clara Valley Health and Hospital System (SCVHHS) to continue to utilize 216 per diem and extra help nurses through March 2018. At the time, the Registered Nurses Professional Association (RNPA) had responded that they concurred with the recommendation, but only supported the extension of extra help hours through March 31, 2018.  Therefore, SCVMC is now requesting authorization from the Board of Supervisors to continue utilizing the per diem and extra help nurses listed in Attachment B through June 30, 2018.

Per diem and extra help nurses are a reliable source for providing registered nurses for variable staffing needs throughout SCVHHS.  Budgeted staffing levels are based on the budgeted average daily census (ADC) or visit volume for a cost center.  Utilization of per diem and extra help nurses at times of increased demand above budgeted ADC allows SCVHHS to adjust staffing when demand exceeds budgeted staffing.  While the SCVMC inpatient ADC for the fiscal year-to-date (YTD) through January 31, 2018 was 333.15, 4.1 percent below budget, ADC is higher than budget in the adult intensive care units and in the adult medical-surgical units.

However, even in areas where the actual ADC does not exceed budget, there is still a need for supplemental staff to meet daily or periodic census fluctuations above the planned operational census, such as in the Maternal and Children Health nursing units, where census fluctuations are common. When current staffing cannot meet the demand, the use of per diem or extra help is utilized. During the first six months of the fiscal year, there was an increased need for the use of per diem and extra help nurses to backfill for nurses completing training for the move to the Sobrato Pavilion. With the addition of four Medical Intensive Care Unit (MICU) beds at Sobrato Pavilion, new coded positions were added in January 2018, but until these positions are filled, per diem and extra help nurses will be utilized to provide additional staffing when census exceeds the currently budgeted census for MICU.  

Per diem and extra help nurses also provide staffing coverage while departments are recruiting to fill vacancies, while nurses are completing critical care training programs, for extended sick time, and for unplanned leaves of absence of coded staff. As of February 12, 2018, there were 132 Clinical Nurse positions vacant (95.5 FTEs), three Assistant Nurse Manager positions vacant (3.0 FTEs), and four Clinical Nurse Specialist and/or Nurse Coordinator positions vacant (3.8 FTEs) throughout SCVMC inpatient nursing. Of the 132 Clinical Nurse positions vacant, 47 positions (33.4 FTEs) were just added to the Medical Intensive Care Unit, Emergency Department and the Ambulatory Surgery Post-Anesthesia Unit effective January 15, 2018.  SCVMC inpatient nursing also had 47 Clinical Nurses (34.6 FTEs) and three Assistant Nurse Managers (3.0 FTEs) out on extended leaves of absence as of February 12, 2018.  

Current SCVMC vacancies are in active recruitment for all vacant clinical and psychiatric nurse positions, and management is meeting regularly with Human Resources to track the current status of vacancies and recruitments.  To help fill critical care nurse vacancies, 44 nurses completed the clinical portion of their critical care training program in December 2017. A total of 52 nurses are beginning a new critical care training program that starts on March 20, 2018.

In Inpatient Nursing, the availability of per diem and extra help nurses is essential to ensure patient access and timely inpatient admissions, especially during the flu season each year. In addition to offering extra hours to part-time coded staff, use of per diem and extra help nurses is a cost-effective method for responding to daily fluctuations in staffing requirements due to volume and acuity that exceed budgeted staffing based on the budgeted patient volume (ADC or visits).  During a 24-hour period, SCVMC can see fluctuations in inpatient census of up to 35 patients. For medical-surgical/telemetry, the ADC for fiscal YTD through October is 2% above budget. The ADC for fiscal YTD in adult critical care is 4% greater than budget.  The utilization of supplemental staff in critical care units is needed to support patient census continuing at near 100% capacity while new nurses complete critical care training programs. 

In the departments of Primary Care and Community Health Services and Specialty Health Services, extra help nurses address fluctuating staffing demands. The extension of hours for extra help nurses is needed to ensure adequate staff to backfill vacancies during recruitment and onboarding, and to provide staffing coverage for unplanned absences, extended leaves, and patient visit fluctuations in key areas of primary and specialty care.

In Custody Health, extra help nurses are regularly used to backfill vacancies, sick leaves and other leaves of absence.  Per Diem and extra help nurses are also being used to backfill staff who are completing newly developed assessments for suicide risk for all inmates at the time of booking.  An increase in the number of inmates needing mental health care has also caused a need to hire more per diem and extra help nurses. For these reasons, an extension of extra help for registered nurses is requested.  Recruitment and retention data is reported to the Health and Hospital Committee bi-monthly.  Vacancy reports are reviewed with RNPA upon request at standing meetings with the SCVMC Chief Nursing Officer and other Executive Nurse Managers.

This agenda item was provided to the President of RNPA, for RNPA review, including the comparison by clinical setting of this request and the request approved last year. A meeting with RNPA to discuss the recommendation was held on March 2, 2018.

RNPA presented the County a proposal on March 2, 2018 in exchange for the union’s concurrence on the extension of extra help hours beyond the 1,040 limit as recommended in this agenda item.  There are no provisions in the proposal to which the County can agree, and, as a result, RNPA has not concurred to extend hours as requested.  SCVMC Nursing Administration will work to expedite filling existing RNPA vacancies as needed and commits to continue to work collaboratively with RNPA to review utilization of per diem and extra help nurses. 

CHILD IMPACT

The recommended action will have a positive impact on children as it affects the Routine Access to Healthcare indicator by ensuring appropriate nurse staffing levels for inpatient nursing units and clinics providing pediatric care throughout SCVHHS and supports the SCVHHS vision of “Better Health for All.”

SENIOR IMPACT

The recommended action will have a positive impact on seniors as it helps to ensure appropriate nurse staffing levels for nursing units and clinics providing adult and senior care throughout SCVHHS and supports the SCVHHS vision of “Better Health for All.”

SUSTAINABILITY IMPLICATIONS

The recommended action will have no/neutral sustainability implications.

BACKGROUND

SCVHHS continually monitors the usage of extra help hours. Extensions of the annual 1,040 hours limitation for registered nurses is needed in order to provide a flexible staffing model to ensure safe and appropriate staffing to meet variations in census and staff availability. 

Hiring is in progress for all areas with vacancies. The supplemental nurse staffing pool creates a continuous flow of staff to hire into coded positions.  Of the 185 per diem and extra help nurses who were approved for 1,040 hours extensions in FY 2017, 62 (34%) were hired into coded positions last year (see Attachment A, Table III). Of the 216 per diem and extra help nurses who were approved for FY 2018 1,040 hours extensions on December 12, 2017, ten nurses have been hired into coded positions. Nurse Managers have also identified 18 per diem and extra help nurses who will be hired into coded positions during March 2018. Additionally, 10-20 more extra help nurses are expected to be hired into coded positions once a new certified eligible list is referred from Human Resources. Even when there are no vacancies, there is always a need for supplemental staffing in order to meet peak workload, such as increases in census, sick leave and other unexpected leaves of absence.

The total number of requests for extensions by division and the position vacancies by division are provided in Attachment A, Tables I & IV. This request is for 199 extensions, compared to the 216 extensions approved on December 12, 2017. See Attachment A, Table II for a table that compares the number of extension requests that were approved from FY 2012 to FY 2018, with this second request for FY 2018.

The number of staff submitted for extensions exceeds the number of position vacancies, as per diem or extra help nurses do not usually work to a full FTE.  For example, of the 185 extra help nurses who were approved for 1,040 hours extensions last fiscal year, only 99 (54%) actually worked more than 1,040 hours (see Attachment A, Table III). We anticipate similar utilization patterns this fiscal year; however, this request reflects the desire to more efficiently identify and retain these current per diem and extra help nurses who are oriented, trained and fully functioning in their departments, should the need arise, rather than hire and train new extra help or per diem nurses who would need to be oriented and trained in their departments.  

For Primary Care and Community Health Services, as the number of SCVMC paneled lives continues to grow, increasing demand for services is seen in both primary care and specialty care areas. These services require seamless coordination throughout the care delivery system. Nurses serve an increasing role in the patient care team that includes proactive care management and outreach.  Although there are ongoing efforts to make improvements in the recruitment and hiring processes for coded positions, it takes several months to hire, orient, and train the appropriate level of nurses. There is also an increase in clinic activity during the winter months related to influenza-like illness, resulting in the need for additional nurse staffing.  Per diem and extra help nurses are also utilized by Employee Health to assist with influenza vaccination administration offered at multiple sites for all County employees. 

Custody Health Nursing is a specialized area requiring related competencies, and utilization of extra help nurses is imperative to ensure staffing levels to maintain patient access to care. Custody Health is currently actively recruiting to fill all vacant RN positions and needs extra help nurses to help backfill vacancies while recruiting.    

SCVMC continuously monitors staffing compliance with Title 22 requirements to ensure nurse staffing is adjusted for census and acuity.  While temporary situations may require adjustments, these situations are reviewed regularly with RNPA, and SCVMC has remained in compliance with nurse staffing requirements.  Nursing recently filled a new Medical-Surgical Nurse Manager position and a new Assistant Nurse Manager position for Interventional Radiology. Nursing has also recently hired a new wound/ostomy clinical nurse to assist with the large number of patients requiring skin care throughout SCVMC.  These positions will provide support, guidance and training to our new and existing staff in the affected units.

Having the flexibility to meet the varying demand of admissions and discharges contributes to improved patient access to care and increased revenue generation for SCVMC, when operating above budgeted visit and/or patient volume in the Emergency Department, Emergency Psychiatric Services, Labor & Delivery, Mother Infant Care Center, Renal Care Center, Primary Care and Community Health Services, Specialty Health Services, and in Custody Health Services.

CONSEQUENCES OF NEGATIVE ACTION

Failure to approve the recommended action would make it more difficult to provide flexible nurse staffing to support patient care during periods of increased activity. This could negatively impact patient access to care and revenue generation if staffing is not sufficient to admit patients from the Emergency Department, or for repatriation.  It also could negatively impact the ability to schedule patients in Primary Care and Community Health Services, and Specialty Health Services.

STEPS FOLLOWING APPROVAL

The Clerk of the Board of Supervisors will notify Michael Perry in SCVMC Nursing Administration when an approved copy of this legislative file is available.

Meeting History

Mar 20, 2018 9:30 AM Video Board of Supervisors Regular Meeting

At the request of Supervisor Yeager, the Board directed Administration to report to the Board through the Health and Hospital Committee no later than May 2018 relating to a review of efforts to hire and retain experienced nurses, particularly Clinical Nurse II and III positions; and, to include an analysis of the number of nurses who have resigned for reasons other than retirement and the level of positions that are impacted.

At the request of Vice President Chavez, the Board directed Administration to include in the report a plan to address the nurse hiring issue and include information regarding the cost per trainee and turnover relative to that cost.

RESULT:APPROVED [UNANIMOUS]
MOVER:Ken Yeager, Supervisor
SECONDER:Mike Wasserman, Supervisor
AYES:Mike Wasserman, Cindy Chavez, Dave Cortese, Ken Yeager, S. Joseph Simitian