Barnes-Jewish Hospital overhauls its staffing policy so registered nurses can spend more time treating and educating patients.

A hospital is like a manufacturing plant. Work flows in a logical sequence. Tests are scheduled. Patients get transported to the imaging suites or procedure rooms. Results get interpreted, treatment plans are initiated and patients are released to make room for new patients.

For the work to flow smoothly and the assembly line to efficiently restore health, the low-tech tasks must be done as dependably as the complex tasks. Staffers and patients have to be in the right place at the right time.

If a doctor signs orders but nobody follows through, a patient might have to spend an extra day in the hospital. If nurses are spread too thin to perform their routine and high-level tasks, patient care suffers.

Barnes-Jewish Hospital''s midweek census regularly approaches 900 patients. A charge nurse on each unit is responsible for making sure the work flows smoothly. In addition to administrative tasks, these nurses usually care for patients, with little or no time to follow up on why a lab specimen wasn''t drawn or a test wasn''t given.

Coreen Vlodarchyk, vice president of patient-care services, thinks of the nurses who synchronize the flow of patient care as air-traffic controllers.

A new staffing model being rolled out in stages at Barnes-Jewish recognizes the central role of the charge nurse.

The free charge nurse, or care-traffic controller, isn''t assigned patients. He or she accompanies doctors during exams, taking note of what needs to get done, and can jump in to help floor nurses.

The free charge nurse was inaugurated in two adjacent medical units in September as part of a restructuring of nurse staffing. Since then, other units have added a free charge nurse as the first step in their redesign of staffing.

In the new model, a charge nurse, a clinical nurse specialist and a case manager work together to oversee patient care and work flow. The two medical units each have a free charge nurse and a case manager. The case manager works with doctors and insurance companies to track patient care. The units share a clinical nurse specialist. This nurse, who has a master''s degree, explains treatment plans to patients and educates staffers.

The nurse specialist, case manager and free charge nurse can make rounds with physicians or pharmacists. They meet daily to discuss the patients under their care.

The bedside caregiver, a registered nurse who knows the most about what''s going on with a patient, can add to the daily discussions about patient progress and help to shape the care plan, Vlodarchyk said.

The new model is a reversal of a staffing strategy that swept across the industry in the 1990s. At that time, to control labor costs and address anticipated shortages of nurses, hospital administrators embraced a model called patient-focused care. The staffing strategy shifted low-level tasks away from registered nurses to licensed practical nurses or aides who had limited training. Registered nurses were given increased patient loads and responsibility for the aides at a time when managed care was altering the complexion of the hospital population. Only the sickest patients were being admitted for care.

Nurse stress and job dissatisfaction increased. Many fled the profession, adding to the nurse shortage.

Vlodarchyk said that under patient-focused staffing models, there is a 1-to-1 ratio of nurses to aides. Barnes-Jewish is hiring additional nurses to change that mix. The hospital''s plan calls for seven nurses to every three aides.

The hospital''s goal is to have a 1-to-5 average nurse-to-patient ratio. The two inaugural medical units have achieved that staffing. The ability to implement the model across the board depends on the hospital''s success in recruiting more nurses amid a nationwide shortage.

Jennifer Arvin, a hospital spokeswoman, said the average nurse-to-patient ratio in a 24-hour period is 1-to-5 or 1-to-7. It can go higher or lower, depending on patient acuity and staff availability. The ratio of caregivers to patients is lowest in the intensive-care units, where one nurse can attend two patients.

The staffing redesign is intended to give nurses more time for direct patient care and education. "This model redesign is not just ratios; this is a whole way of how we do business," Vlodarchyk said. "We''re looking at the way we are communicating with each other."

Kristy Peterson, 25, of Brentwood, quit a nursing job at Barnes-Jewish in 2003 after working there for less than a year. She took a better-paying job as a hospice nurse. She gets weekends off.

Peterson said her 12-hour shifts at Barnes-Jewish routinely stretched to 15 hours because of paperwork. She quit because as a newlywed, she wanted more time at home and less stress on the job. Peterson said she worked on a 14-bed medical-surgical unit staffed by two registered nurses. The pressure was so high that Peterson noticed that she''d stopped greeting her colleagues in the hall. "I didn''t smile. I didn''t say hi."

Peterson said the 1-to-5 ratio will be more workable. "Their day will still be full, but it will allow more time with patients."