VARIABLES THAT AFFECT STAFFING IN WOUND CARE

Patient variables

Caseload

• Caseload is the ideal starting point. In wound care, time is tissue - thus, staffing should aim at improving patient access to care, with the right number of team members (not too many, not too few). That means, if the number of patients fluctuate throughout the day, week or month, staff should be hired and scheduled based on those fluctuations. Part-time and per diem clinical staff members may be utilized, provided they have experience and certification in wound care. 

Case mix

• Types of conditions seen in the clinic have a direct impact on staffing. Appointments for some conditions will take longer than those for others. For instance, new patients with venous ulcers will need non-invasive vascular assessment prior to application of compression therapy, and the time needed for assessment and treatment should be factored in when scheduling appointments.  

Patient co-morbidities

• Patient mobility, altered cognitive status or with special needs, presence of fecal or urinary continence likely increase appointment length

Referral sources

• Are most cases of inpatient or outpatient origin? Inpatients need to be transported to the clinic and clinic staff’s help may be needed.

Staff members variables

Qualifications and scope of practice

• Wound care is a niche, specialized field in medicine. Experienced clinicians are in high demand, and recruitment focus should be on retention, in order to offer patients continuity in wound care
• A wound care program multidisciplinary team may include but are not limited to [4][5]:
• • Program/clinic director/manager: The program director, who may be a nurse or another qualified professional with or without wound care certification, oversees various aspects of the clinic's operations. These responsibilities include staffing, scheduling, materials management, staff training and education, regulatory compliance, and ensuring profitability. Regular and proactive interactions between the program director and the insurance, billing, and coding staff are crucial for the early detection of reimbursement or documentation issues, allowing for timely corrective actions. Additionally, the program director should actively engage in community education programs to establish connections with potential referral sources such as home health care agencies, nursing homes, physician offices, urgent care centers, and emergency rooms.
  • Medical director
  • Registered Nurses: nurses play a pivotal role in the functionality of the wound care clinic by managing patient flow and coordinating care. Their duties encompass patient check-in, conducting interviews, removing dressings, assessing wounds, and working alongside wound specialists and other team members to devise and execute care plans. A foundational understanding of physical and basic wound assessments is crucial for the nursing staff to perform effectively within the clinic.
  • Wound specialists: wound care certified professionals, typically nurses, physical therapists, nurse practitioners or physicians are integral to the treatment planning process. They bring a deep understanding of treatment modalities tailored to the patient's specific needs, leveraging insights from past treatment responses to shape future care strategies.
  • Providers: may be certified wound specialists. May have different backgrounds such as general surgery, emergency medicine, plastic surgery, infectious disease, vascular surgery, rheumatology, orthopedics, hyperbaric oxygen therapy (HBOT), podiatry, family medicine, etc. Besides providing direct care, physicians also supervise allied healthcare personnel so that procedures performed by the latter can be billed (e.g., application of negative pressure wound therapy) 
  • Physical therapists: may be certified wound specialists. Can apply biophysical technologies including use of therapeutic ultrasound, lymphedema management, sharp debridement, total contact casts, seating evaluations, etc
  • Insurance and Billing Coder: the expertise of insurance and billing coders is vital for achieving regulatory compliance and securing appropriate reimbursement. These professionals often work closely with the coding department and may also handle pre-approvals from insurance companies, playing a crucial role in the financial and operational aspects of the clinic.
  • Ancillary Staff: this group includes schedulers, medical assistants, and surgical assistants, who support the clinic by managing administrative tasks such as patient registration, appointment scheduling, and data entry for billing and supplies. Training ancillary staff to perform both clinical support within their scope and administrative duties enhances operational flexibility, allowing for adjustments in staffing based on clinic demand and staff availability.
  • Leveraging ancillary staff and carefully monitoring staffing ratios—such as nursing hours versus ancillary hours and total hours worked versus patient visits—helps in managing the efficiency of worked hours per patient visit. Keeping a close eye on these ratios can indicate when it may be necessary to hire additional staff as clinic visits grow, adjust staff hours on less busy days, and reallocate hours to accommodate peak periods.
• Consultants: available on site or on a referral basis, these professionals include general surgeons, vascular surgeons, orthopedic surgeons, dermatologists, plastic surgeons, podiatrist, infectious disease providers, geriatricians, occupational therapists, dietitians.
• For roles in hyperbaric centers see topic " Hyperbaric Medicine - Job Descriptions & Training Guidelines". In hyperbaric centers, it is important that all wound care personnel be cross trained for HBOT and that the HBOT is cross trained for wound care. In that way, when scheduling at the HBOT unit allows, the hyperbaric technician can help out in the wound clinic, or when the hyperbaric technician is on vacation, wound nurses can provide coverage for HBOT services.

Experience and/or certification in wound care and/or hyperbaric oxygen therapy 

• As in the wound care field much is learned through experience, certification in wound care is beneficial so that team members can share the same basic knowledge of wound care and HBOT. See topic "Choosing a wound certification that is right for you".

Staff mix

• It is important to consider questions such as “How can the right mix of clinical professionals be hired so that optimum services can be delivered without wasted resources?”
• • For instance, medical assistants can manage rooming and patient flow, provide clinical support and patient care, and help complete documentation on the EMR, while wound-certified nurses provide wound-care specific interventions
  • In centers where nurses are responsible for insurance verification, authorizations and database entry, fewer nurse-hours will be spent on direct care and more nurses may be needed to cover patient demand.[6]  

Vacation policies

• Vacation policies have a direct influence on staffing and are predictable

Clinical operations/ workflows

Protocols and processes

• Development of established protocols and processes (both clinical and business-related practices) to help streamline patient care and analyze revenue cycles from admissions through discharge.[4]
• • When staff members are overwhelmed, it is very common to think that the addition of extra staff members is the best solution. However, this solution may be short-sighted and collaborate to hide inefficiencies in workflows and processes. Establishment of lean protocols and workflows with identification and elimination of wasted time, resources and bottlenecks will help clarify the real need to add extra staff members. As a result, staff members’ time, productivity and satisfaction will be optimized.
• We suggest development of lean workflows that leverage technology (e.g., telehealth) to save staff’s time and improve patients’ satisfaction. (see tool "TeleVisit Tool 2.0")

Patient scheduling

Table 1 shows scheduling templates commonly used in outpatient settings. There are no definitive guidelines or best practices for determining the length of patient appointments, and variation in scheduling templates is both expected and beneficial across diverse settings, populations, and care delivery models.[7]

Table 1. Commonly-used Scheduling Templates [7]

TIPS ON LEAN STAFFING 

• For determination of number of full-time employees, centers can use acuity and productivity tools.
• • Benchmarking tools may help understand staffing needs for each center. The staffing tool created by Larson-Lohr for wound care and hyperbaric medicine centers incorporates elements of both patient acuity and staff productivity and provides suggestions on number of full-time employees (FTEs), more specifically nurses, to cover patient demand in a wound and hyperbaric center.[6] These tools are not meant for daily use, but rather to establish a benchmark for the center. 
• To improve motivation and retention, suggestions below can be employed [8]
• • Hire responsibly: hiring people with the right fit is important for a cohesive team and retention of high quality staff. Expectations should be clear. For instance, if work hours change with case load, it is important that the policy be clear to all staff members
  • Share financial information such as profit/loss variables portion of financial reports. Transparency is important to bring everyone onboard
  • Turn to staff members for solutions. Typically the best solutions come from people who live the problem.