After an uptick in COVID-19 hospitalizations began in June, local hospital systems have closed or kept closed off-campus locations, halted elective surgeries and Hail Mary’d people to get the vaccine. 

“All COVID-19 related care must take place in real time while hospitals also handle their core functions,” John Hawkins, the senior vice president of government relations at the Texas Hospital Association, wrote in a September letter to the Texas Legislature. 

He went on to list those core functions: planned care, like cancer surgeries and knee replacements, urgent care and “the special care given by hospitals at the beginning and end of life.”

Hawkins was urging the legislature to extend state funding for thousands of out-of-state medical personnel past September. They did. As of Monday, more than 1,800 of those personnel were working in counties across north Texas, according to the Texas Department of State Health Services

Despite this aid from the state, and despite a decline in hospitalizations since early September, staffing at hospital systems in north Texas continues to be “very tight,” according to Stephen Love, president and CEO of the Dallas-Fort Worth Hospital Council

But what does hospital “staffing” mean? Here’s what we know about hospital employees, and where hospitals turn if they’re understaffed. 

What is hospital staffing? 

“Staffing is actually quite difficult,” said Dr. Amy Faith Ho, a clinical informaticist and physician at John Peter Smith Hospital in Fort Worth. 

Ho originally worked in hospital administration. She served as an assistant medical director and associate medical director at the hospital’s emergency department and currently teaches at the TCU and UNTHSC School of Medicine

“For hospitals, the clients are patients, and the product is the assessment, intervention and care you give to those patients, which we term ‘healthcare.’ But it’s anything from medications, to diagnosis, to counseling, to procedures, etc.,” Ho said. “The people that make those products, give those products, deliver those products are a suite of people”

“You can clump all of those humans (within that suite) and call it staffing,” she said.

Whom do hospitals employ? 

Hospitals are like “mini cities,” said Larry Ashlock, a bioethicist who’s been on various hospital ethics committees throughout Tarrant County. “They have so many people who move in and out and through them,” he said. 

That foot traffic includes administrative and organizational staff like people who work in human resources, public relations, billing and risk management. It also includes a myriad patient-facing roles from physicians and nurses to allied health professionals like physical therapists, physician assistants and imaging specialists, as well as people who serve patients behind-the-scenes. 

For example, a single inpatient floor may include technicians who help with feeding, bathing and changing bed linens; administrative clerks who schedule appointments and manage paperwork; dietary aides who provide meals to patients; and clergy who provide pastoral care to patients and providers.

Not every person who works at a hospital is an employee of the hospital, however. For example, a patient’s physician may or may not be an employee of the hospital where the patient is admitted. 

Although some hospitals employ all of their physicians, others have adopted a “hybrid model,” according to Valentina Gokenbach, a professor at the TCU and UNTHSC School of Medicine. Gokenbach has nearly 50 years of experience as a hospital administrator; most recently, she served as the chief nursing officer at Baylor Scott & White All Saints Medical Center in Fort Worth. 

A hybrid model means some physicians with staff privileges at a hospital aren’t hospital employees — they run their own private practice but come to the hospital to visit their patients and provide oversight for their care. 

Hospitals also contract with nearby universities so health care workers-in-training like nursing or pharmacy students can practice on site, Gokenbach said. 

How do hospitals determine how many staff members they need? 

When a hospital is understaffed, “it can mean a number of things,” Love, with the Dallas-Fort Worth Hospital Council, said. “But overall, what it means is they could use additional appropriate staffing in certain levels of care.” 

Units, or departments, within hospitals may use a variety of methods to calculate their staffing needs according to the ebb and flow of patients and their specific roles in patient care, Ho, with John Peter Smith Hospital, said. 

One staffing method is called patient-per-hour, which considers how many patients a physician can see in one hour. If each physician can see four patients per hour for 10 hours a day, and, for example, a clinic plans to see 120 patients per day, that clinic needs to staff three physicians. 

Departments that don’t rely on scheduled appointments may combine the patient-per-hour method with a staffing-by-arrival method, Ho said. In the latter model, she said, “you look at the time of the arrival of the patient, you figure out the human resources that are needed to accommodate those patients, and then you back-calculate from there.”

Because more people may come to the emergency room at different times of day, an emergency room might also use a graded staffing model, with more providers during the busy hours and fewer during the slower hours.

These models are imperfect, Ho said, because surges happen — say, in a mass casualty event or a prolonged mass casualty event like a pandemic. 

“​​And then it gets increasingly complicated when you look at how the departments interact with each other,” she said.

Inpatient floors that receive patients coming from the emergency room need to time their staff by patient admissions, or the time the patient is admitted to stay in the hospital, rather than arrivals, the time the patient sets foot in the emergency room. 

The level of care a patient requires on these floors determines the number of bedside staff, like nurses, needed. Sicker patients require more “hours per patient day,” Gokenbach, with the TCU and UNTHSC School of Medicine, said. 

For example, some COVID-19 patients might require 24 hours of care each day, she said, whereas other, less sick patients, might require only five or six hours per patient day. The number of hours each patient requires determines the number of nurses needed on the floor. In the intensive care unit, for example, especially sick patients require a 1:1 or 2:1 ratio of patients to nurses, she said. 

So if a hospital is reaching capacity, it’s not necessarily related to the number of physical beds available at the hospital, Ho said — it’s related to “staffed beds.” 

“That means it’s not a physical space issue, like you need to build more buildings,” she said. “That means it’s a labor market issue, and labor markets take a lot longer to fix.”

Where do hospitals turn for more staffing? 

Hospitals typically maintain their own staffing reserves to help fill in understaffed areas. 

“We call it a nursing staff pool,” Gokenbach said. Staff pools work in different ways based on the hospital, but typically comprise nurses who float between hospitals in one region or departments in one hospital. Hospitals also have physicians and other providers on reserve.

“Most (hospitals) have contingency plans, but it obviously requires all these people to be waiting in the wings,” Ho said. “They need to already be credentialed, they need to be skilled, they need to be onboarded.”

When demand exceeds even the supply in the staff pool, hospitals turn to outside staffing agencies to provide temporary health care workers from out of town or state. 

Turning to those agencies isn’t ideal, Gokenbach said. They can be more expensive, and the providers who come aren’t as familiar with the hospital.

“They don’t know all the ins and outs,” she said. “So, in my mind, quality and safety goes up with the elimination of agency. The only reason that hospitals use agency is there’s no alternative.”

Looking beyond a hospital’s own people can also be incredibly time-consuming. Hiring almost any patient-facing role could require three months of onboarding: credentialing, licensing and training, Ho said. 

“Which is why in the COVID situation, we identify a surge, but by the time we notice the surge, we’re already behind,” she said. “If you start recruiting right then, by the time you actually have new staff ready to work, it could be months later and by then the original surge is over. So that’s why staffing is so complicated.”

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Alexis Allison is the health reporter at the Fort Worth Report. Her position is supported by a grant from Texas Health Resources. Contact her by email or via Twitter. At the Fort Worth Report, news decisions are made independently of our board members and financial supporters. Read more about our editorial independence policy here

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