Advice From Your Peers

We asked our current clients some questions regarding advice they had for soon-to-be Nash enthusiasts. Click each individual’s name to see their insightful advice regarding their experience with the Nash Methodology.

Charleen Scott - Southwest General: Middleburg Heights, Ohio

 What was one area that required the most attention while implementing the Nash methodology?

Ensuring the correct staffing grid was loaded into Nash Analytics. There were several versions for many floors so we had to keep validating the information.

How have you incorporated the Nash methodology into your daily operations at a unit and divisional level (Nash Analytics, patient placement, finances)?

I run many reports to provide information back to Nursing leadership. We have also created bi weekly staffing variance responses that incorporate the Nash methodology with our productivity system.

What, if any, operational changes were a result of the Nash methodology (staffing, patient placement)?

In the past, our departments were expected to manage to the same HPPD regardless of census. Nash allows them to adjust the HPPD based on the patients in the unit which is why it’s important to have the right number of patients in each unit to avoid incomplete care teams.

What qualities do you think a project leader should have to make the implementation successful?

The most important factor to make this process a success is the support of the executive team. We required a fair amount of new hires to have the right complement of staff. In addition, it’s important to have the physician leadership aware of the project and receive their buy in, which I’m not sure we did. As far as successful project leadership, you need to be assertive, organized and have a strong understanding of the process.

Sue Childers - ProMedica Toledo Hospital: Toledo, Ohio

 What was one area that required the most attention while implementing the Nash methodology?

I think the key item is frequent, consistent follow-up via daily monitoring of staffing variables and target census for the cost centers. After the initial education to Nash, making sure I was checking each cost center’s numbers daily was critical as I could quickly identify deviations and provide immediate re-education, etc.

How were you successfully able to communicate the expectations to your leaders?

Frequent meetings on Nash and then follow-up emails summarizing the meeting’s key points. Meetings were held both for all participants together and then by division which was more helpful looking at a unit’s specific needs in relation to their division. In addition, meeting 1:1 with each director/manager was essential to clarify information and allow opportunities for them to ask questions, etc. This was really an essential process as we discussed their cost center and looked at their deviations from Nash individually rather than in a general group meeting. I also met frequently with Bed Control to educate and re-educate on patient placement guidelines.

How have you incorporated the Nash methodology into your daily operations at a unit and divisional level (Nash Analytics&trade, patient placement, finances)?

Although I am only handling Toledo Children’s now, in the beginning I had Toledo and Wildwood. Directors/managers were integrating Nash into their daily operations via monitoring patient placement and staffing numbers. Directors/managers were responsible for looking at their Nash numbers every day and then educating their staff members as necessary. I met with the Administrative Supervisors several times to review Nash patient placement and staffing guidelines so they would be able to make better decisions based on Nash first to fill, etc.

How was the Nash methodology introduced to support areas (HR, admitting, physicians)?

During our general Nash meetings, I included bed control, finance, HR, etc. on the mailing list so that they were involved from the beginning. Additional staff members took the Nash Project to physician’s meetings.

What, if any, operational changes were a result of the Nash methodology (staffing, patient placement)?

The fill order was a significant change to operations. In the past, bed control filled a bed that had a patient discharged and divided up the admissions among various units. Also many times staff members were “held” with the presumption that they would eventually be needed for admissions. There was a major shift away from the “what ifs” type of thought.

What qualities do you think a project leader should have to make the implementation successful?

I think that a project leader must have the vision for the project and be engaged. It is critical to help establish direction and communicate information on the project including initial and ongoing education, updates, changes, etc. The project leader needs to be a problem solver by meeting with the stakeholders and fixing any issues that develop. As with any project, setting realistic and achievable goals is key. For instance, initially directors/managers needed to be looking at their staffing variance and target census every day and then we expanded from here. Individual targeted meetings with the directors/managers helped to deliver value to them with less waste and reduced time. A project leader has to be organized and keep track of what has to be done when and ensure follow-up on any problem areas.

Jean Doerge - Unity Point Health Trinity Rock Island: Rock Island, Illinois

What was one area that required the most attention while implementing the Nash methodology?

Nash methodology involves driving out variation in decision making about when to add another staff member  through establishing a plan. Plan the work and work the plan is the core principle of Nash;  nurse leaders developed their plan for staffing at the onset and the goal was to stick to what they had determined their unit needed.  There is a phrase associated with the Institute for Healthcare Improvement, “ nothing about me without me”.  Nurse managers and charge nurses were highly involved in the planning process and validation of their staffing plan to create ownership.  Engagement first, then consistent attention to how well we are doing  as a team compared to plan is the single most important area for focus in order to successfully implement and hardwire changes.

How were you successfully able to communicate the expectations to your leaders?

Expectations were communicated in three ways;  first the clear timeline and project plan associated with Nash implementation served as a roadmap with clear milestones for implementation.  Key activities were communicated during nursing management meetings, in one to one meetings between directors and managers, and also regular periodic communications to senior leadership and governance so that everyone understood the plan for moving forward.

For each major milestone, a performance target was established and communicated;  for example when we began to use the Nash Analytics and document every four hours, data was shared with each of the managers about their implementation of the project.

Finally expectations were hardwired into the performance evaluation process for all nursing leaders in the organization and during the annual goal setting process metrics were established related to where we were in the process of implementation.  For example for the first year of implementation the goal was established that all Nash units would be at the 85% threshold for reporting every four hours accurately on staffing in order to achieve

How have you incorporated the Nash methodology into your daily operations at a unit and divisional level (Nash Analytics, patient placement, finances)?

Several methods of integration have helped to build Nash into our culture of nursing operations. A rhythm of reports and review has been established that helps nursing and finance to work together. Every four hours of every day the nursing supervisor reviews and electronically reports to all nursing leadership actual staffing levels compared to census based on the Nash plan for staffing. Key variables that impact staffing as defined by nursing managers are included so we understand sitter use, pediatric patient volume, and suicide precautions as key variable that impact staffing on a real time basis.

Every two weeks productivity and wage reports are reviewed as a team with finance business leads, nursing directors and senior nursing leadership; this helps us to look at the overall picture together and understand where we are doing well and where we are experiencing higher than anticipated orientation, light duty assignments or even where our budget may need to be adjusted. Then each month finance conducts a Management Operating Review;  all variances over a certain threshold are reviewed by the manager and the manager, director and senior leader may be invited to attend a meeting with finance to further discuss the variance. Seeing it all on one page that has been very helpful to me as a senior nurse leader; our team developed a single one page report that puts together our budget productivity reports and the Nash Analytics reports into one spreadsheet so I can literally see the whole picture of performance at once.

Annually finance provides updated salary and staffing information to Nash and we review our plans for staffing.  Process controls are in place; no one can adjust their plan for staffing without review, discussion and projection of impact for the staffing change. Also, annual goals related to savings or adjustments in the Nash staffing plan are built into the budget. So if we achieve our budget we are achieving our Nash improvement targets.

How was the Nash methodology introduced to support areas (HR, admitting, physicians)?

HR has been an integral part of our Nash planning since the initiation of the program. An identified HR professional was involved in the training process for Nash so that they would understand impacts and also help us measure improvements. Organizational improvements related to Nash are ultimately measured in terms of actual salary dollars;  actual dollars spent reflect FTEs, average wage, skill mix and use of high cost variable labor. HR assists us with measuring how we are doing against our payroll targets.

Our goal was to make the Nash implementation seamless for physicians however we did have several opportunities identified by Nash work that required major change. An example was when we used the eco-sizing model to improve performance of our Transitional Care Unit that was struggling due to revenue changes.  Through reducing our daily census target and actually not filling the all beds on the unit, we were able to improve overall financial performance and stabilize the unit. For that change process, the medical director of the unit was involved early on and once he understood the WHY of the change he was able to help translate the change process and timeline to the medical staff. There is a principle of communicating changes seven times in seven ways when implementing a change. All communication channels were used including the Doctor Mailbox newsletter, established medical staff committees and most importantly one to one communication.

What, if any, operational changes were a result of the Nash methodology (staffing, patient placement)?

Another important area of focus Nash principles involve maximizing a unit and maximizing teams within the unit to help to take out pockets of inefficiency. Early on we realized that with three campuses we needed to centralize patient placement and ensure that whenever possible we were consistently filling units to the optimal plan as a key to success. Centralized placement was accomplished by setting up a bed hub staffed by RNs and aligned with house supervisors. This concept has really taken off under the leadership of the Director of Case Management. ONE CALL bed hub now provides one call access for physicians seeking to transfer patients into the hospital and that hub also conducts the appropriateness reviews on the front end for utilization.

What qualities do you think a project leader should have to make the implementation successful?

Nash project leadership requires two key qualities: the ability to motivate and keep a positive approach to change management;  second,  an understanding of nursing staffing and analytics. Rochelle Tinman, our Nash project champion exudes a “can –do” attitude. Often she is seen with a basket of goodies to share at key meetings and she is able to blend fun and focus to education and to our performance review meetings.  Ongoing communications and additional training are needed as new charge nurses and managers assume their roles and for some it takes additional time to understand how Nash plans can help them to be successful fiscal managers.  So patience and encouragement from the project lead also is a key ingredient for success. 

Chris Silka - ProMedica Flower Hospital: Sylvania, Ohio

What was one area that required the most attention while implementing the Nash methodology? 

Making sure that everyone attended every meeting. Following up with managers one on one and going over their data, looking at and giving suggestions of how to bring their staff into compliance and just being there as a support person for them. Cheering them on.
How were you successfully able to communicate the expectations to your leaders? 

I am fortunate at Flower that our Executive leaders have created a culture of expectation. I am fortunate to have a CNO who has sent the message that I was the leader of this project and the expectation was that everyone would be compliant.
How have you incorporated the Nash methodology into your daily operations at a unit and divisional level (Nash Analytics, patient placement, finances)? 

Yes, both at the unit and divisional levels. My next step is to get finance on board with reviewing the capabilities of this program to aid us in the budgeting process. My plan is to have a go to meeting with some finance people from Flower and St. Luke’s in the next two weeks. They seem very excited to learn about it.
How was the Nash methodology introduced to support areas (HR, admitting, physicians)? 

By myself through leadership meetings, one on ones, and through our Med Staff office. Taking it up with everyone who was interested in learning about it. The CNO weas another great advocate of this program and she brought it to the attention of others as well.
What, if any, operational changes were a result of the Nash methodology (staffing, patient placement)?

Our patient placement process has changed for the better and staff are very familiar with how and why patients are placed where they are. Everyone is on board with compliance to this methodology and those that drift are quickly addressed and brought back in compliance.
What qualities do you think a project leader should have to make the implementation successful? 

This person needs to be someone who has demonstrated the ability to be a great process leader who can lead a project through from beginning to end. They need good organizational and communicational skills. The must be able to send the message that adherence and compliance with implementation of this methodology is expected without exceptions. This person most of all needs to be someone who understands the program inside and out and able to speak with confidence when presenting to others. I jumped right into it and have continued to learn something all the time. It’s been exciting to be a part of this project because there have been great outcomes as a result of its implementation. Additionally; I have so appreciated the support I have received from Kerry and Shannon. They are awesome!!

Lori Cihon - Southwest General: Middleburg Heights, Ohio

What was one area that required the most attention while implementing the Nash methodology?

Grids were the biggest challenge with the changes that we made and really needed to explain the “whys” on the grids somewhere so that when we went back.. we could refer to the “why”.  The difficulty of not having private rooms lead to inability to get to target census so it helped when Shannon came and shadowed our Nursing Supervisors on patient placement.

How were you successfully able to communicate the expectations to your leaders?

We did meet and needed to meet multiple time to help them.. and frankly all of us.. understand the concept of ratios, care teams, target census, first to fill etc..

How have you incorporated the Nash methodology into your daily operations at a unit and divisional level (Nash Analytics, patient placement, finances)? 

We have our staffing coordinators send out the daily cost per unit. By 1pm each day, they all need to respond to a deviation of >  or < than $250 variance. That report is collated and send to our CNO and Nursing Directors. It allows us to assure each data entry point is completed.

How was the Nash methodology introduced to support areas (HR, admitting, physicians)? 

Human Resources has been heavily involved in the project and helped us hire the additional FTE/ Bodies needed to get us to our full care teams. Other groups have heard of the initiative on the periphery. HR participated in our project meetings.

What, if any, operational changes were a result of the Nash methodology (staffing, patient placement)?

AREAS that cannot get to their target census struggle with explaining budget variances every 2 weeks. Private rooms, level of care needs ie stepdown, medical tele and central monitoring capability of most patients this fall will assist in a better compliance.

What qualities do you think a project leader should have to make the implementation successful?

Internally Finance and Clinical Nursing lead this project which was a great mix in keeping the project on track and knowing resources were available to explain the “whys”. Char knew the numbers and I knew the operations which made a great mix. Externally- Having NASH team members understand circumstances that can be unique in hospital settings- private rooms, level of care issues- as above  Your team was  available at anytime we needed to get clarification or make any changes.

Rochelle Tinman - Unity Point Health Trinity Rock Island: Rock Island, Illinois

What was one area that required the most attention while implementing the Nash methodology?

The first hurdle we had to overcome was timely data entry into the Nash Analytics. While it didn’t take too long to completely master this issue, it is an important component to Nash methodology. The second hurdle was that of staffing compliance with the flex (of 2) for the appropriate units. Learning not to staff for the “what ifs…” is a very difficult concept to master for nurses as we prefer to be prepared for any and all issues that may develop.

How were you successfully able to communicate the expectations to your leaders?

Daily reports were run and were followed up by all levels of leadership. If leadership does not drive the results and stress the importance of compliance with Nash methodology on a daily basis, it will be deemed another “flavor of the month” tool that is expected to come and go.

I can honestly say that the most important thing you can do is to select an employee to be a Nash Champion. Having one person to learn the many components of Nash and become the internal “expert” will help drive the results. This person will also identify key stakeholders and form solid relationships with them (ie: HR, Finance, etc), and will offer ongoing education to all appropriate staff.

How have you incorporated the Nash methodology into your daily operations at a unit and divisional level (Nash Analytics, patient placement, finances)?

We realized the value of the Nash methodology very early in the game. At this time we use reports from the Nash Analytics tool as a staffing tool for the placement of CRT staff. We also created a patient admission/placement hub we call One Call. It is staffed with Case Management RNs whose sole job is to place patients using Nash placement rules and to ensure they are in the appropriate admission status, etc. Every patient placed in the hospital system goes through One Call to capitalize on an efficient admission/appropriate patient placement process which in turn has led to a new Case Management model (also developed from Nash).  On a more annual operative consideration (instead of daily) we utilize Nash data during our budgeting process.

How was the Nash methodology introduced to support areas (HR, admitting, physicians)?

Having a strong working relationship between nursing and HR was identified early. In order to maintain the efficiencies awarded by following Nash methodologies, we discovered that we needed a seamless process in which to replace staff as they transitioned off individual units (transferred to another department or left the organization).  Prior to Nash there was about a two week delay in replacing a position due to the internal approval process. We worked with HR and Administration to create a process for Nash units that allow Nursing Leadership to hire to Nash recommended FTEs without ascertaining any other approval. Nurse managers found that they could accept a letter of resignation and repost the position in the same day!

We asked Nash to work directly with our Finance folks so they could understand the data pertaining to finances. Each of the appropriate finance employees has access to Nash and are encouraged to use the data. Our internal Nash Champion continues to work with ongoing education to all appropriate parties.

What qualities do you think a project leader should have to make the implementation successful?

Must understand and embrace the methodology and be passionate about it! I believe this person must be able to form great relationships with all key stakeholders and possess credibility.

Greg Shock and LuAnne Christofaro - Reid Hospital: Richmond, Indiana

What was one area that required the most attention while implementing the Nash methodology?

We both believe that the most attention focuses around the timeline that is developed and making sure that the timeline is developed for the entire project so everyone on the team is aware of the due dates, next steps and other requirements that will be needed along the way.

How were you successfully able to communicate the expectations to your leaders?
  • We found that the on-site visits were very worthwhile. It might have been helpful to have had a meeting with the impacted units that talked through all the steps up front, the timeline and such for implementation as some of the information was only well known by the Greg, Debbie and LuAnne.
  • It was very helpful to have Kay, the CNO, involved in several of the key meetings.
  • I think it would have been a good idea to have included discussion or recommendations regarding how to roll-out the communication beyond the nurse managers to the charge nurses and nursing staff.  This was uncharted territory for us so we had to develop this communication and it has taken some time to accomplish.
How have you incorporated the Nash methodology into your daily operations at a unit and divisional level (Nash Analytics, patient placement, finances)?

We have not fully implemented the project so we’re not able to respond fully to this question.  However we have had a few meetings recently with our CFO as well as Accounting to talk about the impact to how we do things in our budget process as well as the monthly budget reports such as whether or not we will continue with hours of care/patient day or move to salary cost/patient day for our measurement.

How was the Nash methodology introduced to support areas (HR, admitting, physicians)?
  • LuAnne met with HR a couple of times to talk globally about the impact, especially with regards to the need to begin moving some positions around to create a balanced staffing plan, replacing full-time with more part-time positions, etc.
  • Admitting – our Patient Placement manager has been involved in a couple of meetings, but this will be a huge change in process for this department.  I think they need to have an overview of the project and then some tailored communications specifically to them.
  • Physicians – to this point in time, we have not done any specific communication with physicians, but before it is fully implemented, Greg and I were thinking it would be a good idea for Kay to present an overview to our highest physician committee, the Medical Executive Committee.  The chairs of each section serve on this committee so they are then responsible for rolling out the information to their individual physician sections.
What, if any, operational changes were a result of the Nash methodology (staffing, patient placement)?
  • Likely the most significant change for Reid is moving more of our full-time positions to part-time. We decided to do this through attrition rather than “right-sizing” our entire nursing department.
  • Patient Placement changes have not yet been implemented, but these changes will be very significant. Now we mostly assign patients to units in a rotating fashion.
What qualities do you think a project leader should have to make the implementation successful?
  • Understands the big picture of the project scope
  • Knows resources within the organization – where to get the information that will be needed
  • Excellent time management skills, especially with some of the information that has a short turnaround time
  • Good communication skills and excellent relationship with the nurse managers so they can be kept involved
  • Having a second person from nursing to help with the project was very helpful – our second person was a nurse manager

Beverly Schrickel - Firelands Regional Medical Center: Sandusky, Ohio

What was one area that required the most attention while implementing the Nash methodology?

The medical units were identified as most in need of establishing staffing standards and ratios. The staff was confused as to how assignments were made since it differed depending on who was in charge.

How were you successfully able to communicate the expectations to your leaders?

“Show and tell”. Improved staff satisfaction, consistency in staffing patterns, and a decrease in OT and mandated time. It also provides us with the data that is needed so as to compare quality to a productivity percentage.

How have you incorporated the Nash methodology into your daily operations at a unit and divisional level (Nash Analytics, patient placement, finances)?

Absolutely! It is taken very seriously at the staff level and has become a daily priority. Nash has proven to be an effective method to use for staffing, and because of the active participation by the staff, is has been positively accepted. I use the ratio compliance report to discuss with my CEO bi-monthly and the results are posted on the nursing units. The information has even been shared at the Board level. The name Nash is recognized throughout the organization by other clinical areas. Since nursing has done such a good job with their ability to do creative staffing we are often called upon to assist other areas.

How was the Nash methodology introduced to support areas (HR, admitting, physicians)?

There was never anything formal presented to other departments. They only realize that there is a methodology to admit patients but not the specific details. The physicians have no idea of what Nash is, but they do appreciate that they don’t hear the complaints about staffing like they did in the past. HR now has specific data that can be referenced when there are complaints about staffing ratios.

What, if any, operational changes were a result of the Nash methodology (staffing, patient placement)?

There has been control of staffing based on consistent guidelines. It is always better to have the support from the staff and Nash has provided them the opportunity to be the vital active participant.

What qualities do you think a project leader should have to make the implementation successful?

An open mind is number one. Never accept, “but we have always done it this way”. Be positive! Anything can be improved with the work of a dedicated team.

Wendy Prins - Unity Point Health St. Luke's Regional Medical Center: Sioux City, Iowa

What was one area that required the most attention while implementing the Nash methodology?

Labor/Delivery area: I believe our hospital might be a little unique compared to other organizations. We have two main OB physician groups in town and they do not provide NST’s, so all their patients come to the LD unit to have these performed. We have a rather large outpatient population that will take up and hour to a couple hours of time. I believe we are very close to capturing this data and should be able to get a true picture of the ADT activity in this area.

How were you successfully able to communicate the expectations to your leaders?

I have great support from our senior team, without this I don’t believe that you could be successful. The current nurse leaders in my organization already had some prior knowledge of these concepts so it was really just fine tuning some basic concepts. I have worked with the nurse leaders for a few years regarding labor management, staffing to productivity, balancing master schedules and core coverage.

How have you incorporated the Nash methodology into your daily operations at a unit and divisional level (Nash Analytics, patient placement, finances)?

We have a centralized staffing office, they report to myself. Again it was easier than expected in incorporate the methodology since it was not a foreign concept to them. This centralized office previously staffed all the inpatient nursing and inpatient maternal/child areas. We did keep the Nash Analytics centralized and they office staff work very closely with the lead nurses to ensure the right staffing mix and correct data for the Nash Analytics. We implemented 24/7 patient placement staff so all patients are filtered through on person. This person has the capability to see the big picture and is aware of the patient needs and how each area is staffed to ensure the best placement. We are still struggling a little with our fiscal department. We are slowly working towards hiring ahead and filling positions so this does not leave such a huge gap when an employee leaves the organization. We know have the support of our COO and are currently working with our CFO.

How was the Nash methodology introduced to support areas (HR, admitting, physicians)?

We have not implemented Nash outside of Inpatient nursing yet. Nash is currently working with our ER and Pharmacy.

What, if any, operational changes were a result of the Nash methodology (staffing, patient placement)?

Hiring ahead to fill the open positions, clearer communication between staffing and units, lead nurse/bed placement education regarding NASH methodology.

What qualities do you think a project leader should have to make the implementation successful?

  • Integrity
  • Enthusiasm
  • Commitment
  • Ability to Inspire others
  • Ability to see the “Big Picture”
  • Ability to delegate
  • Great working relationship with team members
  • Broad knowledge base-staffing, scheduling, productivity, budget
  • Communication, Communication, Communication

My words of wisdom “If at first you don’t succeed, try, try again”