Exploring Methodology for Acuity-Based Staffing

By Doug Fullaway, President & COO, Vigilan

dougFullaway In a previous article, we explored the staffing in assisted living based on ratios versus staffing based on acuity. Ratios are the most commonly used, but it is also clear there is a tendency to overstaff and in all cases, ratios ignore the actual changes in acuity for an individual resident. Staffing based on acuity is preferred, but not widely used as it seems to be too difficult to implement. Let’s look at one method that can be used to develop an easy-to-use acuity staffing tool.


The first step is to build a spreadsheet with a column for each service you are offering and a row for each resident. For bathing you could look at your own assessment document and you might add the following columns: Independent, Provide Reminders Only, Partial Assistance, Full Assistance.

Enter a row just above all of the resident’s names that says, “Standard Time.” In that row enter a standard time. But where do you get that time? Start with an estimate. You know a great deal already and these times can be revised as you learn over time. And be consistent in the way you set the times. For example, hours per week or hours per month is a reasonably simple way to think about the services. Full bathing assistance might be 30 minutes per bath and delivered twice each week so one hour per week could be a good place to start with a standard time for bathing.

Now fill in the cells for each service that a resident receives services. Your spreadsheet is filled out and ready for some simple analysis.

Add totals at the end of each row and each column. You will see the acuity as measured in hours for each resident. Does this comparison across the residents seem reasonable? Does it seem correct that Martha takes twice the time as most other residents? Is John really only taking three hours a week for all of the services you provide? If not, perhaps you need to start adjusting the time for that resident. If the standard time for full bathing assistance is one hour per week and you know John is just difficult and requires more time, then perhaps the cell for his bathing needs to say 1.5 hours.


Now look at the totals for each column. You will likely see the amount of time for medication management for each resident is about six hours per month and is the largest single time for any service. If this is not the case, then perhaps you are doing some work that does not show up on the assessment. For example, does the nurse provide a monthly review of the medications? And does it take about 20 minutes for each resident? Time to add a column to reflect the time the nurse is actually putting into the work for that review.

Build a summary for each job skill of the total time for the period. Caregivers deliver the care for many of the columns.

You will probably end up with something that looks like this.


As residents move in, add a row. As they move out, remove a row. As you update an assessment for a resident, update the cells for that resident. You can gather the caregivers who take care of Mary Albright and have a discussion to see that all services being delivered are documented. You can also ask how long it takes to do the job for each service for Mary.

You can also make the standard times more accurate by actually measuring how long it’s taking for that service for about 30 observations and then take an average time. Adjust the time upward by 20% to allow for lunch breaks, taking time to talk with residents, filling out reports, etc.

You should see several benefits from your use of an acuity-based staffing approach. You will better understand where your staff time really goes. You will adjust your staffing based on changes in census AND based on the change in care you are delivering to each resident. (Ratios just don’t do this!) And our analysis shows you will have enough staff, but not too much, which should save you money.

About the Author:

Doug Fullaway is president and COO of Vigilan, a provider of software for senior living management, and has over 30 years of management experience. In 2002, Doug entered the senior market by joining the executive staff of Vigilan and is the proud owner of several senior communities.  Prior to Vigilan, Doug held positions in distribution, manufacturing, customer support, sales, and general management in the U.S., Europe and Asia.  Doug earned his undergraduate degree in industrial engineering from Oregon State University, served as an infantry officer in the US Marine Corps and graduated from the Harvard Business School.  In his spare time he loves to snow ski, fly a Cessna and go fly-fishing. He can be reached at [email protected].