Washington (D.C.) Hospital Center reportedly spent $6 million last month to hire temporary nurses and cover other costs during a labor dispute. Staff nurses organized a one-day strike and then were locked out for five days.

Similar situations have played out in hospitals across the country for years, and during times of contract uncertainty, administrators walk a fine line figuring out how to treat patients in the event of a strike without aggravating ongoing negotiations. Hospital leaders should develop an action plan before they sit down at the negotiating table, even if a strike doesn't appear likely, says Curt Kirschner Jr., a San Francisco-based partner for the law firm Jones Day who provides outside legal counsel on labor issues for the American Hospital Association.

"You don't want lack of preparation for a strike to be the reason you settle a contract," he says. "Then set it aside, know that it's there. And hopefully, you never have to turn to it."

To draft that plan, hospital administrators should work their way through a series of interrelated decisions, starting with whether to reduce patient treatment services and to what extent, say Kirschner and others. Before making any decisions, they should conduct a detailed, unit-by-unit analysis of which clinicians and other personnel they can tap during a strike.

Count how many nonunion clinicians can step in, including nurse managers, suggests Connie Curran, R.N., chief executive of Best on Board, a health care consulting group in Chicago. Also consider, based on your own hospital's history, how many patients could be discharged to nursing homes, home care and other settings. "Can you, on a given day, discharge 20 to 25 percent of your patients?" Curran asks.

For a one-day strike last summer at Fairview Health Services in Minneapolis, leaders decided to keep essentially normal operations and to hire temporary nurses to provide care, says Paula Phillippe, chief human resources officer at the seven-hospital system.

Administrators at Dameron Hospital in Stockton, Calif., took a different approach when their unionized nurses announced a one-day strike set for June 10, 2010. They estimated it would cost the 202-bed hospital roughly $1 million to continue at full operations during the strike, including bringing in about 80 temporary nurses.

"That's a million dollars cash that goes out of the coffers of the hospital versus we just scale the hospital down," says Nicholas Arismendi, the hospital's chief operating officer.

So administrators began to scale back services June 1, including halting hospital admissions. By strike day, their goal was to provide only the minimum of services required by law, including emergency department admissions, emergency surgeries and imminent baby deliveries.

The patient census gradually would shrink from 165 to 30 to 40, Arismendi says. Roughly three-fourths of the hospital's 1,300 employees would be laid off temporarily by strike day. Services would continue to be scaled back until a contract agreement was reached, he says.

The hospital took out full-page advertisements in the local newspaper, explaining administrators' rationale for the service reduction, as well as what salary and other terms they had offered the nurses during contract negotiations. By June 4, when the nurses called off the strike, the hospital census was down to 110 patients, Arismendi says. Dameron lost about $300,000 in patient revenue.

Regardless of what's occurring at the negotiating table, administrators should strive to maintain a generosity of spirit when talking about unionized employees, Curran says. "You've got to live with these people when they come back in," she says. "And you can't destroy your community's trust in these caregivers."