- Email: [email protected]
A buyer's guide to effective management of external staffing companies
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A Buyer’s Guide to Effective Management of External Staffing Companies Franklin A. Shaffer, RN, EdD, FAAN As one travels the country, it is hard to determine which is the greater problem for hospital chief nursing officers: the shortage of nurses or the cost of staffing. In any case, any effective solution involves vendor management. One of many problems is that the hospital (or health system) is trying to solve staffing issues with a “just-in-time” approach involving many vendors, many units, and even many disciplines. In addition to this, the financial and accounting process has been mainly manual, with each staffing company having distinct invoicing process, timesheets, and other forms for running the program. The sheer time, money, and effort it takes to manage multiple contracts adds significantly to the time/money burden and rarely helps ensure safe staffing in the facilities. The purpose of this article is to explore the many opportunities and pitfalls of developing a strategic partnership with your vendor of choice. PART OF THE PROBLEM Many hospitals today deal with multiple staffing companies (as many as 20 or 30 daily or travel vendors). The administrative responsibilities involve investigating potential vendors, negotiating the contract and then the ongoing management of that contract, interviewing the travel nurses, and conducting an annual audit of the vendor’s credentialing and competency files—all this times 20 or 30! 36 Nurse Leader
In addition, the hospital’s staffing office has to call all daily vendors for staffing needs, maintain daily credentialing and competency files, and review and verify vendorgenerated invoices—all this times 15 or 20! Moreover, unit management must interview all travelers, communicate orientation and start dates, and provide on-unit (and sometimes even a mini-whole hospital) orientation—all this times 12 to 26 times each year! April 2007
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Now if you are thinking that this is the end of the process, you are incorrect; we need to have staffing and scheduling managed on a 24/7 basis. Much of the nitty gritty has to be done on the off-shifts, as well. Then the work still is not completed: there is reconciliation of the invoices based on reconciliation of time and attendance. Talk about eating up time and money—all this is in addition to paying the invoices!
PART OF THE SOLUTION What might a vendor management program offer? When you find a vendor that consistently provides qualified, fully screened, highly competent, and experienced personnel; is large enough to consistently fill the majority of your staffing needs on all shifts; is consistently flexible (ie, can provide dailies and travel, specialty nurses and medical-surgical nurses); and is certified by the Joint Commission on Accreditation of Healthcare Organizations, consider making this vendor your exclusive vendor partner. Please note that the essential characteristics here are consistency and quality. Price you can negotiate. Let’s not get the cart before the horse. If you want a successful program (one that works for you), you must be crystal clear about your goals. Once you have selected a vendor management partner, the hospital or health system provides a list and contact information for all of their preferred vendors, stops answering calls from vendors, and refers all callers to the partner’s dedicated contact specialists. Meanwhile, the vendor partner assigns its vendor management team (which parallels the facility’s team that manages the hospital’s own staff), meets with department managers to discuss needs and develop interview management profiles, and works with existing preferred vendors to subcontract. In case you haven’t caught the drift yet, a vendor management partner is not a sole vendor, although you can and should expect one-stop shopping. You also should expect the vendor management partner to establish standard contracts and rates with all vendors, increase the efficiency and consistency of interview and hiring practices, improve the efficacy of all contract nurses’ orientation, and increase the fill rate for requests. By improving internal efficiency, your vendor management partner saves time, money, and aggravation while improving traveler/agency nurse satisfaction and performance. A major aspect for any successful vendor management system (VMS) requires that the facility identifies and appoints an internal champion. This highly respected and committed person understands and supports the VMS philosophy and rationale for the facility undertaking this strategic initiative; is prepared to defend the goals; and ensures that the process is timely, efficient, and on target. Another necessary part of the VMS is to ensure a clearly defined conflict-resolution or problem-solving process (within the hospital and staffing firm). The appropriate people with the authority, responsibility, and accountability for resolving any problems must be understood by both parties. Certainly the relationship between the facility and the April 2007
staffing company is on a much different plane than before committing to the new staffing methodology. A real strategic partnership is evolving, and over time this partnership identifies ways in which both partners can collaborate and collectively achieve new initiatives that succeed for both parties. Again, the process in most hospitals is by and large manual. Recently some technology companies have begun offering a platform that includes a VMS application. One company began its work specifically to enhance the staffing systems in hospitals by offering a Web-based or Internet process. That platform is being offered by the leading health care staffing firm in its VMS applications. For the first time, technology and all aspects of staffing are integrated and available on the Internet on a 24/7 basis. Today’s medical centers have a wonderful opportunity to embrace VMS with such technology integration, capture the efficiencies and economies encompassed within the two, and remove the labor intensiveness of staffing while ultimately improving morale.
CASE STUDY: THE JOHN MUIR HEALTH SYSTEM How does the contract really work? There is nothing like learning from actual experience. The John Muir Health System of Walnut Creek, California, consists of the John Muir Medical Center (JMMC), the Mt. Diablo Medical Center (MDMC), and the Mt. Diablo Medical Pavilion (acute psychiatry).
John Muir Medical Center (JMMC) JMMC is a 322-bed tertiary care facility (nonunion) with an average daily census of 270 (with a 300+ census on Wednesdays, Thursdays, and Fridays). Admissions, discharges, and transfers had increased by 25 compared to the same time 6 months earlier. Moreover, as a Level II trauma center for two counties, JMMC averages 24 emergency department admissions and 15 to 20 scheduled surgeries daily. John Muir also delivers about 300 babies monthly and has an 18-bed neonatal intensive care unit. JMMC had an all-RN staff augmented by the use of nursing assistants. Their nursing hours of care per patient per day were at or above national standards, and 41% of their RNs had worked there for more than 5 years. With staff turnover at 10.8%, the hospital had committed to a 7-week new graduate internship program. In 2003, JMMC started a drive to meet California’s 2004 nurse staffing ratios through the development of a successful recruitment program (augmented by the internship), the strategic use of travelers to fill anticipated staffing needs, and the use of a daily registry to fill staffing needs for nursing assistants. JMMC used a mixed approach to staffing, relying on a central office for inpatient units, using unit-based scheduling, and conducting monthly “staffing summits” to address issues and problems.
Mt. Diablo Medical Center (MDMC) MDMC is a 254-bed acute care facility (union) with an average daily census of 140, but the facility experienced
Nurse Leader 37
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wide fluctuations in census (100 to165). Mt. Diablo offers tertiary cardiac services for two counties and averages 18 emergency room admissions and 13 scheduled inpatient surgeries daily. By and large, MDMC used a mixed approach to staffing that was similar to JMMC’s model. They had a central staffing office for impatient care (except for surgical services) and practiced unit-based scheduling. MDMC recently introduced an operations resource manager to help them deal with their past crisis-mentality approach to staff shortages. To meet 2004 nurse staffing ratios, MDMC hired 111 RNs in 2003. Like JMMC, they also used travelers to meet anticipated RN staffing needs and a daily registry to meet needs for additional nursing assistants. In June 2003, John Muir Health System decided to assess their staffing model and make some changes. They were using 13 daily and 14 travel nurse staffing companies, and with the exception of a few specialty contracts, all the contracts were system-wide. Both staffing offices were calling vendors daily to meet staffing needs and were keeping credentialing/competency files on each person assigned to any of their units. Staffing office personnel also were reviewing and verifying all the invoices from the various staffing companies. The unit managers were interviewing all travelers, providing on-unit orientation for them, and communicating with their own travelers such things as start dates for orientation and for work. Meanwhile, administration investigated each potential vendor, negotiated and managed the contracts, interviewed each individual traveler, and conducted an annual audit of each vendor’s credential/competency files. Clearly there were points of confusion and numerous overlaps and disconnects! Communication with that many companies from that many hospital units about so many nurses and so many things was bound to lead to miscommunication and inefficiencies. Department desperation led to rapid signing of multiple contracts with different variables per contract. And all these multiples led to constant attempts to renegotiate existing contracts, a lot of variability among the huge number of invoices, some real cost overruns, and a colossal use of administrative time. It was time to take action, and the health system did. They decided to explore vendor management as an alternative. This is not to say that something was not going right. Managers had developed good working relationships with various staffing companies and made suggestions to leadership about which ones were consistently providing adequate quality services. The health system narrowed their selection down to two, and in June 2003, John Muir Health System contracted with one to be their vendor management partner.
(or vendor manager) was settled into an office at the hospital, the work began in earnest. Administration supplied the clinical liaison with a list of their preferred vendors, and the clinical liaison met with department heads to develop interview profiles. She also began an “issues list” and built an implementation team to address these problems and others that were anticipated (or, as the case may be, unanticipated) during the implementation process. One of the first issues to deal with was the vendor manager’s relationship with the existing vendors. First and foremost the unit managers needed to talk with the people with whom they had developed relationships prior to June 2003 to tell them what was going on, ask for their cooperation, and introduce the primary vendor’s clinical liaison (vendor manager) and let them know that she would be talking to them in the future and that everyone hoped to continue to work with them. Then it was important that unit personnel stopped taking calls from vendors. To help accomplish the vendors’ transition to “subcontractors,” the vendor manager, working in close cooperation with the transition team, worked to clarify expectations with vendors and help develop workable, consistent time sheets. Many changes were made over a relatively short period: 1. The contracts were standardized to include clearly defined responsibilities for credentialing/competency files, including monthly reports of each nurses’ work expiration dates, and the hospital reserved the right to review each traveler’s credentialing/competency files prior to his start date. 2. A central approval process was developed for postings and extensions of assignments. 3. It was decided that the evaluation process used for travelers should mirror the existing employee process. 4. At JMMC, the transition began with a “Staffing Summit” to determine overall staffing/scheduling needs. This was followed by a change from shift-based to a unitbased model of scheduling. Travelers, who also were unit based, were expanded to serve in the float pool, too. At MDMC, the transition began with projections of daily need from 1 week to 1 month in advance. Unitbased schedules were completed, and travelers were balanced to meet unit needs. Travel needs and requests were coordinated through a central contact. The most difficult issues in these transitions involved the availability of RNs in general; we began moving from crisis management to strategic planning. To deal with the lack of availability of RNs on a daily basis, we hired more travelers into the float pools and explored interhospital float travelers. We also streamlined the orientation process for travelers so that content could be covered an in 8-hour session, and we included point of care, equipment training, and fit testing.
MAKING THE TRANSITION While all this may sound well and good, actually implementing the change required a good deal of planning and even more work. As soon as the vendor management partner was selected and an on-site manager of vendor staffing 38 Nurse Leader
WHAT DID WE ACCOMPLISH, AND WHAT DID WE LEARN? We were able to reduce fees for hiring both travelers (RNs) and daily personnel (NAs). We also succeeded in April 2007
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Figure 1. John Muir Medical Center’s Agency Use—2003 National Database of Nursing Quality Indicators (NDNQI)
G
B
%Improved over First Half
Figure 2. Mt. Diablo Medical Center’s Agency Use—2003 National Database of Nursing Quality Indicators (NDNQI)
%Improved over First Half
April 2007
%Improved over First Half
Nurse Leader 39
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establishing one contact point (the vendor manager) for all vendor issues and problems and requests. We reduced both the number of subcontractors (from 27 to 16) and the number of calls from outside agencies. We developed a more consistent interview and entry-into-the-system process. And we developed a whole picture of traveler status contracts and provided weekly reports to administration. Most importantly, we actually did dramatically cut overall use of staffing companies (Figures 1 and 2) while significantly reducing the time burdens for administration and management. Now, on to what we learned. We learned that we needed better metrics from the beginning to measure our success. And we learned a lot about invoices. Perhaps the most important thing we learned about them is that they take organization oversight and cannot be delegated to a vendor. But there were other things, too. We learned that expectations must be firmly and clearly stated upfront and that one of those clear expectations must be vendor accuracy. Errors not only delay processing, they also require huge amounts of time to correct, and backlogs quickly pile up. We also learned that invoices should be submitted by pay period and reviewed carefully by the vendor manager who can run interference with subcontractors with the billing errors (and carefully review the corrections for more inaccuracies), as well as other problems and issues. Now we are looking at ways to improve the vendor management relationship: • We are considering putting one of our own employees in as vendor manager. • We are considering online shift auctioning as an option. • We are looking at the possibility of self-invoicing with automated payroll. • We are keeping the implementation team alive and well to help us deal quickly and consistently with any issues that may arise. Our vendor management solution worked, but we intend it to work better in the future. Franklin A. Shaffer, RN, EdD, FAAN, is the vice president and chief nursing officer of Cross Country Health Care, Inc., and executive vice president/CNO for Cross Country Staffing in Florida. He can be reached at [email protected]. 1541-4612/2007/ $ See front matter Copyright 2007 by Mosby Inc. All rights reserved. doi:10.1016/j.mnl.2007.01.005
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A Buyer’s Guide to Effective Management of External Staffing Companies Franklin A. Shaffer, RN, EdD, FAAN As one travels the country, it is hard to determine which is the greater problem for hospital chief nursing officers: the shortage of nurses or the cost of staffing. In any case, any effective solution involves vendor management. One of many problems is that the hospital (or health system) is trying to solve staffing issues with a “just-in-time” approach involving many vendors, many units, and even many disciplines. In addition to this, the financial and accounting process has been mainly manual, with each staffing company having distinct invoicing process, timesheets, and other forms for running the program. The sheer time, money, and effort it takes to manage multiple contracts adds significantly to the time/money burden and rarely helps ensure safe staffing in the facilities. The purpose of this article is to explore the many opportunities and pitfalls of developing a strategic partnership with your vendor of choice. PART OF THE PROBLEM Many hospitals today deal with multiple staffing companies (as many as 20 or 30 daily or travel vendors). The administrative responsibilities involve investigating potential vendors, negotiating the contract and then the ongoing management of that contract, interviewing the travel nurses, and conducting an annual audit of the vendor’s credentialing and competency files—all this times 20 or 30! 36 Nurse Leader
In addition, the hospital’s staffing office has to call all daily vendors for staffing needs, maintain daily credentialing and competency files, and review and verify vendorgenerated invoices—all this times 15 or 20! Moreover, unit management must interview all travelers, communicate orientation and start dates, and provide on-unit (and sometimes even a mini-whole hospital) orientation—all this times 12 to 26 times each year! April 2007
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Now if you are thinking that this is the end of the process, you are incorrect; we need to have staffing and scheduling managed on a 24/7 basis. Much of the nitty gritty has to be done on the off-shifts, as well. Then the work still is not completed: there is reconciliation of the invoices based on reconciliation of time and attendance. Talk about eating up time and money—all this is in addition to paying the invoices!
PART OF THE SOLUTION What might a vendor management program offer? When you find a vendor that consistently provides qualified, fully screened, highly competent, and experienced personnel; is large enough to consistently fill the majority of your staffing needs on all shifts; is consistently flexible (ie, can provide dailies and travel, specialty nurses and medical-surgical nurses); and is certified by the Joint Commission on Accreditation of Healthcare Organizations, consider making this vendor your exclusive vendor partner. Please note that the essential characteristics here are consistency and quality. Price you can negotiate. Let’s not get the cart before the horse. If you want a successful program (one that works for you), you must be crystal clear about your goals. Once you have selected a vendor management partner, the hospital or health system provides a list and contact information for all of their preferred vendors, stops answering calls from vendors, and refers all callers to the partner’s dedicated contact specialists. Meanwhile, the vendor partner assigns its vendor management team (which parallels the facility’s team that manages the hospital’s own staff), meets with department managers to discuss needs and develop interview management profiles, and works with existing preferred vendors to subcontract. In case you haven’t caught the drift yet, a vendor management partner is not a sole vendor, although you can and should expect one-stop shopping. You also should expect the vendor management partner to establish standard contracts and rates with all vendors, increase the efficiency and consistency of interview and hiring practices, improve the efficacy of all contract nurses’ orientation, and increase the fill rate for requests. By improving internal efficiency, your vendor management partner saves time, money, and aggravation while improving traveler/agency nurse satisfaction and performance. A major aspect for any successful vendor management system (VMS) requires that the facility identifies and appoints an internal champion. This highly respected and committed person understands and supports the VMS philosophy and rationale for the facility undertaking this strategic initiative; is prepared to defend the goals; and ensures that the process is timely, efficient, and on target. Another necessary part of the VMS is to ensure a clearly defined conflict-resolution or problem-solving process (within the hospital and staffing firm). The appropriate people with the authority, responsibility, and accountability for resolving any problems must be understood by both parties. Certainly the relationship between the facility and the April 2007
staffing company is on a much different plane than before committing to the new staffing methodology. A real strategic partnership is evolving, and over time this partnership identifies ways in which both partners can collaborate and collectively achieve new initiatives that succeed for both parties. Again, the process in most hospitals is by and large manual. Recently some technology companies have begun offering a platform that includes a VMS application. One company began its work specifically to enhance the staffing systems in hospitals by offering a Web-based or Internet process. That platform is being offered by the leading health care staffing firm in its VMS applications. For the first time, technology and all aspects of staffing are integrated and available on the Internet on a 24/7 basis. Today’s medical centers have a wonderful opportunity to embrace VMS with such technology integration, capture the efficiencies and economies encompassed within the two, and remove the labor intensiveness of staffing while ultimately improving morale.
CASE STUDY: THE JOHN MUIR HEALTH SYSTEM How does the contract really work? There is nothing like learning from actual experience. The John Muir Health System of Walnut Creek, California, consists of the John Muir Medical Center (JMMC), the Mt. Diablo Medical Center (MDMC), and the Mt. Diablo Medical Pavilion (acute psychiatry).
John Muir Medical Center (JMMC) JMMC is a 322-bed tertiary care facility (nonunion) with an average daily census of 270 (with a 300+ census on Wednesdays, Thursdays, and Fridays). Admissions, discharges, and transfers had increased by 25 compared to the same time 6 months earlier. Moreover, as a Level II trauma center for two counties, JMMC averages 24 emergency department admissions and 15 to 20 scheduled surgeries daily. John Muir also delivers about 300 babies monthly and has an 18-bed neonatal intensive care unit. JMMC had an all-RN staff augmented by the use of nursing assistants. Their nursing hours of care per patient per day were at or above national standards, and 41% of their RNs had worked there for more than 5 years. With staff turnover at 10.8%, the hospital had committed to a 7-week new graduate internship program. In 2003, JMMC started a drive to meet California’s 2004 nurse staffing ratios through the development of a successful recruitment program (augmented by the internship), the strategic use of travelers to fill anticipated staffing needs, and the use of a daily registry to fill staffing needs for nursing assistants. JMMC used a mixed approach to staffing, relying on a central office for inpatient units, using unit-based scheduling, and conducting monthly “staffing summits” to address issues and problems.
Mt. Diablo Medical Center (MDMC) MDMC is a 254-bed acute care facility (union) with an average daily census of 140, but the facility experienced
Nurse Leader 37
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wide fluctuations in census (100 to165). Mt. Diablo offers tertiary cardiac services for two counties and averages 18 emergency room admissions and 13 scheduled inpatient surgeries daily. By and large, MDMC used a mixed approach to staffing that was similar to JMMC’s model. They had a central staffing office for impatient care (except for surgical services) and practiced unit-based scheduling. MDMC recently introduced an operations resource manager to help them deal with their past crisis-mentality approach to staff shortages. To meet 2004 nurse staffing ratios, MDMC hired 111 RNs in 2003. Like JMMC, they also used travelers to meet anticipated RN staffing needs and a daily registry to meet needs for additional nursing assistants. In June 2003, John Muir Health System decided to assess their staffing model and make some changes. They were using 13 daily and 14 travel nurse staffing companies, and with the exception of a few specialty contracts, all the contracts were system-wide. Both staffing offices were calling vendors daily to meet staffing needs and were keeping credentialing/competency files on each person assigned to any of their units. Staffing office personnel also were reviewing and verifying all the invoices from the various staffing companies. The unit managers were interviewing all travelers, providing on-unit orientation for them, and communicating with their own travelers such things as start dates for orientation and for work. Meanwhile, administration investigated each potential vendor, negotiated and managed the contracts, interviewed each individual traveler, and conducted an annual audit of each vendor’s credential/competency files. Clearly there were points of confusion and numerous overlaps and disconnects! Communication with that many companies from that many hospital units about so many nurses and so many things was bound to lead to miscommunication and inefficiencies. Department desperation led to rapid signing of multiple contracts with different variables per contract. And all these multiples led to constant attempts to renegotiate existing contracts, a lot of variability among the huge number of invoices, some real cost overruns, and a colossal use of administrative time. It was time to take action, and the health system did. They decided to explore vendor management as an alternative. This is not to say that something was not going right. Managers had developed good working relationships with various staffing companies and made suggestions to leadership about which ones were consistently providing adequate quality services. The health system narrowed their selection down to two, and in June 2003, John Muir Health System contracted with one to be their vendor management partner.
(or vendor manager) was settled into an office at the hospital, the work began in earnest. Administration supplied the clinical liaison with a list of their preferred vendors, and the clinical liaison met with department heads to develop interview profiles. She also began an “issues list” and built an implementation team to address these problems and others that were anticipated (or, as the case may be, unanticipated) during the implementation process. One of the first issues to deal with was the vendor manager’s relationship with the existing vendors. First and foremost the unit managers needed to talk with the people with whom they had developed relationships prior to June 2003 to tell them what was going on, ask for their cooperation, and introduce the primary vendor’s clinical liaison (vendor manager) and let them know that she would be talking to them in the future and that everyone hoped to continue to work with them. Then it was important that unit personnel stopped taking calls from vendors. To help accomplish the vendors’ transition to “subcontractors,” the vendor manager, working in close cooperation with the transition team, worked to clarify expectations with vendors and help develop workable, consistent time sheets. Many changes were made over a relatively short period: 1. The contracts were standardized to include clearly defined responsibilities for credentialing/competency files, including monthly reports of each nurses’ work expiration dates, and the hospital reserved the right to review each traveler’s credentialing/competency files prior to his start date. 2. A central approval process was developed for postings and extensions of assignments. 3. It was decided that the evaluation process used for travelers should mirror the existing employee process. 4. At JMMC, the transition began with a “Staffing Summit” to determine overall staffing/scheduling needs. This was followed by a change from shift-based to a unitbased model of scheduling. Travelers, who also were unit based, were expanded to serve in the float pool, too. At MDMC, the transition began with projections of daily need from 1 week to 1 month in advance. Unitbased schedules were completed, and travelers were balanced to meet unit needs. Travel needs and requests were coordinated through a central contact. The most difficult issues in these transitions involved the availability of RNs in general; we began moving from crisis management to strategic planning. To deal with the lack of availability of RNs on a daily basis, we hired more travelers into the float pools and explored interhospital float travelers. We also streamlined the orientation process for travelers so that content could be covered an in 8-hour session, and we included point of care, equipment training, and fit testing.
MAKING THE TRANSITION While all this may sound well and good, actually implementing the change required a good deal of planning and even more work. As soon as the vendor management partner was selected and an on-site manager of vendor staffing 38 Nurse Leader
WHAT DID WE ACCOMPLISH, AND WHAT DID WE LEARN? We were able to reduce fees for hiring both travelers (RNs) and daily personnel (NAs). We also succeeded in April 2007
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Figure 1. John Muir Medical Center’s Agency Use—2003 National Database of Nursing Quality Indicators (NDNQI)
G
B
%Improved over First Half
Figure 2. Mt. Diablo Medical Center’s Agency Use—2003 National Database of Nursing Quality Indicators (NDNQI)
%Improved over First Half
April 2007
%Improved over First Half
Nurse Leader 39
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establishing one contact point (the vendor manager) for all vendor issues and problems and requests. We reduced both the number of subcontractors (from 27 to 16) and the number of calls from outside agencies. We developed a more consistent interview and entry-into-the-system process. And we developed a whole picture of traveler status contracts and provided weekly reports to administration. Most importantly, we actually did dramatically cut overall use of staffing companies (Figures 1 and 2) while significantly reducing the time burdens for administration and management. Now, on to what we learned. We learned that we needed better metrics from the beginning to measure our success. And we learned a lot about invoices. Perhaps the most important thing we learned about them is that they take organization oversight and cannot be delegated to a vendor. But there were other things, too. We learned that expectations must be firmly and clearly stated upfront and that one of those clear expectations must be vendor accuracy. Errors not only delay processing, they also require huge amounts of time to correct, and backlogs quickly pile up. We also learned that invoices should be submitted by pay period and reviewed carefully by the vendor manager who can run interference with subcontractors with the billing errors (and carefully review the corrections for more inaccuracies), as well as other problems and issues. Now we are looking at ways to improve the vendor management relationship: • We are considering putting one of our own employees in as vendor manager. • We are considering online shift auctioning as an option. • We are looking at the possibility of self-invoicing with automated payroll. • We are keeping the implementation team alive and well to help us deal quickly and consistently with any issues that may arise. Our vendor management solution worked, but we intend it to work better in the future. Franklin A. Shaffer, RN, EdD, FAAN, is the vice president and chief nursing officer of Cross Country Health Care, Inc., and executive vice president/CNO for Cross Country Staffing in Florida. He can be reached at [email protected]. 1541-4612/2007/ $ See front matter Copyright 2007 by Mosby Inc. All rights reserved. doi:10.1016/j.mnl.2007.01.005
40 Nurse Leader
April 2007