Every year, like clockwork, facility leaders are called upon to create a budget that will fulfill the organizational goals for the following year. The nursing department typically consumes the largest percentage of a facility’s budget, and therefore the director of nursing services (DNS) plays a key role in determining the resources necessary to achieving quality resident care outcomes. Effective budgeting is not taught in nursing school, and the DNS’ task—advocating for staff and residents despite competing priorities—can seem daunting.
Here are three questions that will help the DNS accurately and efficiently budget for the nursing department and effectively present its needs to leadership.
  1. What staff education is needed to improve specific outcomes?
Effective staff education is directly correlated with successful resident outcomes. To make education a priority in the facility’s budget, this fact must be illustrated. Here’s how.

Clearly Show the Desired Outcome Improvement

The budget request must be as specific as possible, articulating both the necessary education and anticipated outcome. For example, if the facility has a high rate of infections, the DNS shouldn’t request funds for general education about infection prevention but rather should calculate specific educational needs. This can be done by using the facilitywide assessment to determine what types of infections are most prevalent on which units.

The findings might suggest conducting a limited number of unit-specific trainings or training the entire department on an error that’s most common in one unit. The request should specify the infection-control issues that staff need education on and the measures of care the education should improve, such as fewer urinary tract infections (UTIs).

Just as staff need to know why a specific topic is being in-serviced (it results from failure to perform a specific care need correctly), administrators need clarity about why requested in-servicing needs funding and how it will improve resident outcomes. Emphasize that improved outcomes will be reflected in improved Quality Measures (QMs), such as fewer UTIs, fewer rehospitalizations, or fewer antibiotics prescribed.

Articulate the Losses

In addition to articulating the goal for improvement, the request should outline the anticipated negative outcomes if education is not provided.

If a high infection rate continues, for example, the facility could be at risk for lost revenue related to the Skilled Nursing Facility Value-Based Purchasing program. This program uses comparative scores on a hospital readmission measure to determine which facilities will receive incentive payments for Medicare residents and which will not. The 40 percent lowest-scoring facilities receive less in Medicare payments. A lowered Medicare reimbursement for an entire year could be costlier than providing the education.

Keep a Track Record

The DNS should keep a running year-to-year list of the education provided and the benefit that it created for the facility. If facility leaders offered education on fall prevention and the number of falls declined over the following two quarters, that should be shared with administrators to demonstrate that education works.

2. Does the department have the necessary equipment to provide care in the most effective way?

The budget request must communicate, in the context of a long-range plan, what equipment is needed to effectively and efficiently deliver care to the resident population.

Know the Needs

Has there recently been an increase in rentals of specific equipment to meet the needs of new admissions? For example, maybe the facility has had a recent increase in the need for bariatric equipment or pressure-reducing mattresses to prevent or lessen the incidence or severity of pressure ulcers. The DNS should be in tune with residents’ needs as they change and ensure that equipment requests communicate the resident care need to administrators.

Have a long-range plan. It’s easier to buy a little at a time than a lot at once. Both immediate equipment needs and those anticipated for the next two years should be communicated to the administrator. This way, the administrator will not feel caught off guard by the need for a large purchase, and the DNS can avoid the stress of scrambling.

Keep in mind that unbudgeted urgent equipment needs tend to result from survey citations. To avoid these, have an ongoing process in place to both review current equipment and assess the need for additional equipment based on metrics such as acuity levels.

Spell out the numbers for how much it costs to rent versus buy. Depending on the equipment needs, a large purchase paid for over a period of time tends to be more cost-effective than daily rental fees. Have a process in place to review equipment rentals from the past year to determine whether there are any trends. If specific items have been routinely rented, consider purchasing those items.

Know All the Costs

New equipment can only be effective if it is functioning properly. For example, facility leaders may have decided to purchase new lifts but not enough batteries to keep them all operational. The purchase of big-ticket items will provide the most benefit when all the necessary costs are budgeted for and therefore purchased at the same time (as opposed to purchasing new equipment with insufficient batteries).

3. What staffing needs would most impact resident care?

The budget request should consider the type and cost of staff that would best help address specific issues, such as falls.

What’s needed may not be more nursing staff. The DNS should know what kind of staff are needed most and seek the most cost-effective ways of limiting risks.

For example, adding dietary staff to assist with dining room clean-up might help to free up certified nurse assistant (CNA) time, allowing them to be more prompt in addressing residents’ toileting needs following meals or to assist residents back to their rooms, reducing incontinence.

Likewise, is it possible that residents are falling after meals because they must sit and wait to be taken back to their rooms? If so, asking activities staff to provide entertaining activities during this time could keep residents safely occupied during the wait and prevent falls.

Estimate the Costs

A budget request for additional staff must estimate the benefits of the added efficiency.

For example, adding activities staff may be less of a cost to the budget than adding a CNA, and the benefit (fewer falls) can be tracked over time. The savings related to resident falls can be measured in a number of ways: fewer survey citations and civil money penalties; less nursing time spent filling out paperwork related to falls; better QMs (improving community perception of the facility); fewer opportunities for adverse litigation; and, most important, improved resident safety.

Get it Right

The DNS is responsible for the quality of the nursing department’s care delivery, which is closely tied to having the right staff with the right education able to use the right equipment. In order to ensure the department has the proper resources for success, the DNS must know what the facility’s specific needs are and be able to articulate both the needs and anticipated returns on investment in budget requests.

Although the idea of advocating for a budget need might initially feel overwhelming, doing the research to make the request as specific and clear as possible will alleviate stress and make requests more successful, ensuring that the nursing department has the necessary resources to provide the best care possible.
Amy Stewart, RN, DNS-MT, QCP-MT, RAC-MT, is curriculum development specialist with the American Association of Directors of Nursing Services. She can be reached at astewart@AADNS-ltc.org.