Acuity-based scheduling: A promising strategy for optimizing patient care

Nurse staffing levels impact patient and nurse workforce outcomes

There are multiple variables to balance when constructing shift schedules for healthcare staff. One key factor for hospital managers to consider is patient acuity, and yet there is much discussion about how to consider it when making staffing decisions.

“There's essentially a tug-of-war in the practice of measuring patient acuity between the desire to objectively determine required nursing work and the need to rely on the professional judgment of nurses to know which patients need more or less of their time,” wrote Rebecca A. Paulsen, MS, RN, CPN, Senior Director, Medical/Surgical Services at Children’s Mercy Hospital in Kansas City, MO, in a 2018 paper.

Upon her review of the literature, Paulsen concluded that even though it is not perfect, factoring patient acuity into staffing decisions is a better approach than relying solely on nurse-patient ratios or financial targets to determine unit-level nurse staffing needs.

Relying on nurse-to-patient ratios as a way to shape healthcare staff schedules is a major topic within the industry. Some are in favor of mandating nurse-to-patient ratios, believing that it promotes patient safety. Meanwhile, some who oppose the ratios say that the approach is a one-size-fits-all model and it does not consider patient acuity.

“Ratios are a static and ineffective tool that cannot guarantee a safe healthcare environment,” Mary Ann Fuchs, DNP, RN, former president of the American Organization for Nursing Leadership, an affiliate of the American Hospital Association, said in a 2021blog post. “Care is team-based, and a lack of flexibility to provide staffing based on the acuity of the individual patient needs jeopardizes safe patient care.”

Everyone does acknowledge that staff scheduling in a nursing work environment is complex. The link between staffing and patient health as well as nurses’ health has been studied by numerous researchers. “The strong and consistent association between nurse staffing and patient outcomes cannot be ignored,” said Christopher R. Friese, Ph.D., RN, AOCN, a professor at the University of Michigan School of Nursing and School of Public Health, in a U of M article.

A recent study, funded in part by the National Institute of Nursing Research, described the importance of improving hospital nurse staffing. They examined the variation in patient-to-nurse staffing in New York hospitals and its association with adverse outcomes (i.e., mortality and avoidable costs). Their findings revealed that nurse staffing varied across hospitals ranging from having 4.3 to 10.5 patients per nurse. Notably, each additional patient per nurse increased the likelihood of patient death, length of hospital stays, and chances of being readmitted to the hospital within 30 days.

“Our estimates of potential lives and costs saved substantially underestimate potential benefits of improved hospital nurse staffing,” concluded the authors, who published their data in May 2021.

In a separate analysis, researchers said, “The nurse-patient ratio is a direct determinate of the effects of psychological, mental, emotional health and nurse productivity in the workplace, which also determines the patients’ overall health.”

The rise in patient acuity will shape healthcare’s future

The length of hospital stay for adult inpatients is expected to rise by 8% over the next decade, due to increased chronic conditions. Hospital patients are sicker and more medically complex than they were before the COVID-19 pandemic, driving up hospital costs for labor, drugs and supplies, according to a recent AHA report.

Hospital patient acuity as measured by average length of stay (ALOS) rose almost 10% between 2019 and 2021, including a 6% increase for non-COVID-19 Medicare patients as the pandemic contributed to delayed and avoided care, the report further noted.

This rise in patient acuity will likely exacerbate capacity constraints that hospitals and healthcare organizations are already experiencing.

Nurse staffing mandates being weighed in state legislatures

To address some of the challenges facing the healthcare system, states are adding new requirements for hospitals and healthcare facilities to better support staff and ensure adequate patient care. State lawmakers continue to deliberate about how to address hospital staffing plans, with numerous states already mandating staff ratios while other states push to include such legislation (API Healthcare, 2014).

The new staffing laws can be categorized into one of three approaches: 

1. Require hospitals to have a nurse-driven staffing committee that creates staffing plans that reflect the needs of the patient population, paired with the skills and experience of staff.
2. Require legislators to mandate specific nurse-to-patient ratios.
3. Require facilities to disclose staffing levels to the public and potentially a regulatory body.

“Healthcare organizations will likely need to reevaluate their service distribution and service line prioritization given the rapidly increasing complexity of patients, increased inpatient volume, and increased length of stay,” said Gia Milo-Slagle, Senior Director of Product at HealthStream. “The mix of patients is different at each hospital but the healthcare landscape is evolving for everyone.”

Patient acuity is an important component of nurse staffing

Acuity-based scheduling has been studied as an approach to nurse staffing. Some health systems actually already rely on patient acuity systems. Research supports that it should be considered as part of a multifaceted solution to healthcare workforce challenges and poor patient outcomes.

“Acuity is a way of viewing the whole picture with the inclusion of the nurse, the patient, and the actual nursing environment. Not all locations or types of patients are the same, so having a tool that can adjust and assist in mapping out the right assignments could be the intervention that can boost satisfaction, promote safety, and enhance the quality of care within a healthcare organization (Acar & Butt, 2016),” wrote Demitria Idella Stafford of Abilene Christian University in a doctoral project that involved a systematic review of acuity-based staffing in acute healthcare environments. “The use of acuity in patient care assignments can be critical to the safety and quality of care that patients receive, which influences nursing satisfaction (Acar & Butt, 2016).”

A 2018 pilot study found that an objective patient acuity tool used for a medical-surgical floor could increase nurse assignment equality, improve nurse satisfaction, and improve nurses’ perception of patient safety.

Scheduling to acuity with HealthStream

To help facilitate effective and efficient healthcare scheduling, managers need the right technology as it can make or break a shift.

In a webinar on scheduling solutions, Sloane Johnson, RN, Solution Executive for HealthStream, said, “Complicated features and functionality are a requirement today, but not at the expense of ease of use. For example, rules-based guidance and intuitive navigation help managers make informed decisions.”Having a scheduling solution that leverages your facility’s data, including patient forecasting, acuity, and staff credentials, and is easy to use takes the stress out of acuity-based scheduling while streamlining communication and lessening workloads.

HealthStream offers leading technology solutions, such as ShiftWizard and Acuity and Assignment Manager, that provide real-time, acuity-based scheduling as well as tools to help streamline staff communications and increase productivity. ShiftWizard, a fully customizable scheduling solution, includes rules-based scheduling options, third-party integration capabilities, 24/7 calendar access, and AI-based analytics and forecasting.