D580 Task 1 Capstone Project Proposal Example

Our Own Nurses on Call: A Capstone Proposal for a System-Wide Internal Float Pool to Cut Contract Labor Spending at a Composite Three-Hospital System

Student Name

Leavitt School of Health, Western Governors University

D580: Healthcare Administration Capstone, Task 1

Course Instructor

Month Day, Year

Our Own Nurses on Call: A Capstone Proposal for a System-Wide Internal Float Pool to Cut Contract Labor Spending at a Composite Three-Hospital System

The Problem

Tri-County Health, a composite nonprofit system with three hospitals and 780 staffed beds, spent $41.6 million on contract nursing labor in the last fiscal year, compared with about $9 million five years earlier. At the peak of the pandemic the system relied on more than 200 travel registered nurses at once; it still uses about 96 on an average day, most on medical-surgical, telemetry and step-down units. Contract nurses cost the system an illustrative average of $118 per hour, compared with about $68 per hour for an employed nurse including benefits. The spending is the largest single reason the system's operating margin fell from 2.9% to 0.4% over three years.

The problem is not only financial. Nurse managers report that frequent turnover of contract staff weakens unit routines, increases orientation workload for employed nurses and creates resentment over pay differences. Employed nurses' own turnover reached 19% last year. The system needs a way to cover vacancies, leave and census swings that is cheaper and more stable than contract labor without harming quality.

Causes

Three causes stand out in the system's staffing data. First, vacancy: the system has 142 open registered nurse positions, concentrated on the same units that use the most contract staff. Second, variability: census on medical and telemetry units swings by as much as 20% from week to week, and each hospital staffs to its own needs without sharing nurses across sites, so one hospital hires contract nurses while another sends its own staff home. Third, structure: the system has no internal pool of nurses employed to float; managers rely on overtime, agency staff and contract nurses because no alternative exists. The first cause will take years to solve through recruitment and retention. The second and third can be addressed now.

Stakeholders

Sponsorship sits with the chief nursing officer, while the chief financial officer shares accountability for the savings. Nurse managers and directors would give up some control over their own staffing in exchange for reliable coverage. Employed staff nurses would work alongside float nurses and could apply to join the pool. The central staffing office would schedule the pool. Human resources would design pay and recruit, and the nurses' shared governance council would review policies on floating and competencies. Patients are affected through continuity and quality of care.

Proposed Solution

The project proposes a system-wide internal float pool of 80 registered nurses, employed by Tri-County Health and deployed across all three hospitals through a central staffing office. Pool nurses would be cross-trained and competency-validated on two unit types, such as medical-surgical and telemetry, receive a pay premium of 15% over base rate in exchange for flexibility across sites, and choose their shifts four weeks in advance through self-scheduling. The central staffing office would use census forecasts to place pool nurses where the next week's needs are greatest, and contract nurses would be used only when the pool and overtime are exhausted.

Evidence supports each part of the design. A study of supplemental nurse staffing in a large medical center found that modest use of supplemental nurses was cost-efficient, but heavy reliance on them was not (Xue et al., 2015), which describes Tri-County's current position. A national study found that hospital use of agency nurses was not itself associated with higher patient mortality (Aiken et al., 2013), so the case for the pool rests mainly on cost and continuity rather than on a safety crisis. Most encouraging, a recent cross-sectional study found that dedicated float pool nurses, as distinct from unit nurses floated off their home units, were associated with lower risk of pressure injuries and central line-associated bloodstream infections (Stephens et al., 2026), suggesting that a trained, dedicated pool can support quality.

Alternatives Considered

Three alternatives were considered before the float pool was chosen. The first was to negotiate lower rates with staffing agencies. Rates have eased since the pandemic peak, and the system should continue to negotiate, but lower rates would still leave it dependent on outside staff for a large share of its care. The second was to rely more heavily on overtime among employed nurses. Overtime is already high, and extending it further would add to fatigue and to the turnover the system is trying to reduce. The third was an aggressive recruitment campaign to fill all 142 vacancies. Recruitment must continue in any case, but it addresses only the first cause of the problem; even a fully staffed system would still need a way to absorb census swings and leave.

The float pool addresses the second and third causes directly and supports the first, because a flexible, well-paid float role is itself a recruiting and retention tool for experienced nurses who want more control over their schedules. For that reason it is the option recommended here.

Scope and Goals

The project covers registered nurses on medical-surgical, telemetry and step-down units at the three hospitals. Intensive care, emergency, perioperative and women's services are out of scope for the first phase because their competency requirements are more specialized. The table sets the project's goals.

Resources and Feasibility

The pool requires a recruitment campaign, a system float coordinator, two staffing office schedulers, cross-training for pool nurses, a scheduling software module and the pay premium. The illustrative first-year cost of these additions, above the base wages the pool nurses replace, is about $2.9 million. If the pool replaces 60% of contract hours on in-scope units at the difference between contract and employed cost, the gross annual saving is well over $7 million, so the project is financially feasible even with slower hiring than planned. The main feasibility risks are recruiting 80 experienced nurses in a tight market, resistance from managers used to controlling their own staffing and nurses' reluctance to travel between sites. These are addressed in the implementation plan through internal recruitment of experienced nurses who want flexible schedules, a manager advisory group and mileage reimbursement with site assignments grouped by week.

Request for Approval

This proposal asks the chief nursing officer and chief financial officer to approve the internal float pool as the capstone project, with the scope and goals above. If approved, the next two stages of the capstone will produce an executive summary for the system's senior leadership and a detailed implementation plan covering recruitment, training, scheduling, communication, budget and evaluation.

References

Aiken, L. H., Shang, J., Xue, Y., & Sloane, D. M. (2013). Hospital use of agency-employed supplemental nurses and patient mortality and failure to rescue. Health Services Research, 48(3), 931-948. https://doi.org/10.1111/1475-6773.12018

Stephens, C. P., Norton, J., Walker, D., & Verklan, M. T. (2026). Float nurses' association with nurse-sensitive indicators: A cross-sectional study. Journal of Nursing Care Quality, 41(4), 336-342. https://doi.org/10.1097/NCQ.0000000000000948

Xue, Y., Chappel, A. R., Freund, D. A., Aiken, L. H., & Noyes, K. (2015). Cost outcomes of supplemental nurse staffing in a large medical center. Journal of Nursing Care Quality, 30(2), 130-137. https://doi.org/10.1097/NCQ.0000000000000100