Anyone who thinks clinical staffing isn't a big challenge must live in a world of stable OR caseloads and employees who don't call in sick or take vacation. For the rest of us, maintaining an efficient staffing pattern is an ongoing juggling act, a daily exercise in checking your staffing pattern against the surgery schedule and striving to achieve that perfect blend of nurses and techs to ORs and procedure rooms.

Assumptions we can make
Let's look at some universal truths as they affect your staffing patterns. We all know that

• there should be one RN for every patient in the OR/procedure room;
• only RNs can do patient assessment and discharge instructions;
• an ACLS-trained nurse will be in the surgery center whenever a patient is present;
• if your facility administers IV conscious sedation, an RN will be designated to monitor the patient - not monitor and circulate; and
• you'll staff your facility with a combination of full-time, part-time and PRN staff.

Given all that, you might think that identifying a facility's core staffing requirements would be easy. But there's no simple formula for calculating how many people you'll need from one day to the next. Do you have a combined pre-op and PACU area? Do you need separate coverage in step-down (Phase 2 PACU)? Can cross-trained staff float to the decontamination and sterilization area as needed, or does an instrument tech need to be there at all times?

What about the number of rooms per day you'll run? Many factors influence this, including your facility's physical layout, days and hours of operation and method of scheduling cases (block or modified-block scheduling). Ownership models can also affect staffing patterns. Many single-specialty facilities are owned by a single physician. When the doc is off, the center is closed, or the center may be open only one day a week. On the other hand, a six-OR multispecialty center will be open from 6 a.m. to 6 p.m., five days per week. It will use all rooms every day. Cases are varied, may last longer than scheduled and cause overtime for staff.

Staffing solutions
Let's look at a couple of examples that illustrate the inexact science of staffing.

• Single-specialty center. Patients usually go straight to step-down, making PACU and step-down interchangeable. Such a center will require three RNs or two RNs and one LPN if only one OR/procedure room will be used. An RN must supervise an LPN as well as perform the assessment and teaching.

Depending on expected patient numbers per day, you may need to assign two people to pre-op and PACU. If the areas are physically separated, you'll need to assign an RN to each area. A clinical director will actively care for patients, so this becomes one of the nurse positions. Don't forget that someone needs to make pre-op instruction phone calls as well as post-op calls.

You'll need an RN and a surgical tech for each room, and a surgical tech for each room to set up and/or scrub the cases. Many times the surgeon will bring an employee to first assist, so the scrub is free to set up cases and process instruments. If the scrub will work alone, you might need an additional person to process instruments and keep the schedule moving. And depending on volume, you might need an instrument tech.

Since many single-specialty centers are only open one or two days a week, these employees will all be part-time or PRN. Most will work in other facilities and supplement their income by working in an ASC.

• Multispecialty center. Pre-op may require an RN and LPN or two RNs, depending on patient load. You'll need an RN and a surgical tech for each OR/procedure room. When there are more than three rooms, an instrument tech is invaluable. PACU will require two RNs in most cases.

I'd suggest two cost-effective CNAs for such a busy ASC. They can take vital signs, transport patients, restock areas, escort families and unload supplies at a fraction of the cost of an RN. I'd also suggest an inventory manager/orderly who splits his time, helping turn over rooms and transporting patients in the morning or during peak hours and ordering and unpacking inventory when things get quiet.

Despite working five days per week, I still prefer to hire as many part-time staff as possible. You can flex part-time staff so that you use fewer staff on slow days and more than usual on busier days. They get no benefits, although they're often paid a higher salary, and they may accrue paid time off.

The clinical director in a busy multi-specialty center usually won't have time to carry a regular assignment. This person should be available to help wherever needed, thus reducing the need to call in staff who are off, if help is needed.

Scheduling in advance
Ideally, facilities should set a one-month advance staff schedule. This is achievable in hospitals, but much more difficult in ASCs. Every facility I've ever worked with must check the staffing against the surgery schedule every day. Even so, it's advisable to strive for a minimum two-week schedule, posted early enough to allow staff time to plan appointments and other commitments. Here's a tip: Make a staff nurse responsible for managing the extended staff schedule.

Finally, employees should request time off in a timely manner. I believe that once the time is posted, it becomes the employee's responsibility to switch with another employee to accommodate changes she needs - this is not the scheduler's responsibility.