It’s Time to Stop Dialysis Staffing by the Numbers
By Gale Golden Schulke
I have been thinking a lot about staffing ratios since the staffing bill hit the California legislature. (Although I am not the manager for an in-center program, I am still concerned about ratios in the dialysis clinics, including home clinics.) In the process I also gave a lot of thought to our social workers. I agree with the legislation that the ratios need to be addressed, but not in the way they are trying to address them.
In my home clinics, I have about 100 patients. I have had the nurses rate them on acuity 1-3 (1 being few or no issues and 3 being most acute). The idea originally was to distribute the patient load a little more evenly. I have found, however, that the acuity rating does more. It gives me a heads up as to who may be at the higher risk for dropping out of the program and who needs the most support, especially starting out in a home modality. If a nurse is given 10 patients rated at 3, his or her ability to take care of the remaining patients diminishes—and, before you know it, you have even more 3’s. These are the patients we need to address at our IDT meeting. They are also the patients that I, as a manager, should be assisting with. Clinic managers need to do more than sit behind a desk filling out paperwork. We need to be actively involved with patient care to understand the needs of our staff and of our patients. (This is also an argument for RNs as managers).
Acuity staffing also works very well to address in-center issues. For RNs, there could be a pod of higher acuity patients, or if the entire clinic is in an area where the acuity level is high, it makes sense to staff RNs at 1:8, and CCHTs at 1:3. It does not make sense in an area or at a clinic with an overall lower acuity to staff that way. I have always felt 1:13 is too intense anywhere. However, 1:11 or 1:10 allows the nurse to pre-assess fluidly. (With the overall lowering of the catheter rate in dialysis clinics, catheters are becoming less of an issue, and acuity is not as high as it once was with 10 catheters on a shift of 24 patients).
The acuity rating corresponds very closely with the amount of time the social worker is spending with a patient, as well. When dealing with the caseload of a social worker, numbers do not work. What matters is how “in need” are those patients. A ratio of 1:120 patients can look very different from clinic to clinic. In one clinic, that could be a very unrealistic patient load. If the SW is dealing with a large number of poor people requiring a lot of assistance with services, their ratio should be much lower than the ratio of a social worker in another clinic where the acuity is much lower with a relatively high number of self sufficient people. The availability of the Social Worker should be taken into consideration as well. If a clinic with the high acuity ratio only has a social worker available 3 days a week because of the numbers, and s/he is being asked to pick up a load somewhere else, that does not make any sense. That social worker may well need to be available at that high acuity clinic full-time, even if he/she has only 80 - 90 patients.
It is time for us to stop looking at our patients as merely numbers for staffing. We need to move into a model for registered nurses, certified hemodialysis technicians, social workers, and dietitians that looks more at the realistic needs of the patients. People are not numbers on a piece of paper. They are human beings who are looking to us to supply high quality care. We cannot do that as long as we are looking at a strictly numerical system of staffing our clinics. I really encourage the dialysis companies to develop staffing tools that are based upon acuity and need, not merely the number of people.