By Barry P. Chaiken, MD, MPH, Chief Medical Information Officer, Infor
Twitter: @bchaiken
For more than 50 years, the Boston Ballet entertained audiences around the world with classical dance such as Swan Lake and the Nutcracker. As information technology advanced, the Boston Ballet deployed numerous systems to manage ticketing, payroll and personnel management in an effort to automate processes and lower costs. In spite of these efforts, the budget for the Boston Ballet rose every year leading to progressively higher ticket prices and a greater need for grants and donations. A performance of Swan Lake requires a minimum number of “swans,” soloists and principal dancers. Mikko Nissinen, the current artistic director, cannot progressively reduce the number of dancers to lower costs.
In many ways healthcare is like Mikko’s ballet company. Although information technology can enhance care planning, assist in medication administration and reduce duplicative testing, it cannot replace the people required to deliver care services to patients. Nurses are needed to administer medications, therapists are needed to provide treatments, and physicians are needed to diagnose illnesses and provide treatment plans.
On average, hospitals devote close to 70 percent of their budget to labor costs. Until robots replace humans in the delivery of patient care, selection of the proper skill mix and number of nurses remains a significant factor that determines cost in provider organizations.
Improper Staffing Leads to Medical Errors
As the healthcare industry shifts to value-based reimbursement the pressure to decrease costs grows. With nurse salaries making up the bulk of labor costs, hospital leaders first consider shrinking nurse staffing to reduce costs. Although this approach makes financial sense, it delivers unacceptable outcomes if deployed unintelligently. Improper staffing leads to medical errors, poor quality patient care, over-burdened nurses and disgruntled patients. In addition, in the worst cases provider organizations may face malpractice lawsuits and nursing shortages as staff leave due to overwork and burnout.
Some organizations utilize nurse to patient ratios to assign staffing levels in their institution. Currently only two states, California and Massachusetts, set legal minimums for nurse to patient ratios. In 2004, California established minimum ratios that varied by unit and ranged from 1:1 in operating rooms to 1:6 on psychiatric wards. The legislation also requires “hospitals maintain a patient acuity classification system to guide additional staffing when necessary, assign certain nursing functions only to licensed registered nurses, determine the competency of and provide appropriate orientation to nurses before assigning them to patient care and keep records of staffing levels.”
Last year Massachusetts joined California and set minimum ratios, but only for intensive care units. Seven other states require hospitals to maintain standing staffing committees responsible for plans and staffing policy (CT, IL, NV, OH, OR, TCX, WA), while five states require some form of disclosure and/or public reporting (IL, NJ, NY, RI, VT).
For more than a decade, the federal government required hospitals accepting Medicare funding to, “have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed.”
On April 29, 2015, Representatives Lois Capps (D-CA) and David Joyce (R-OH), and Senator Jeff Merkley (D-OR) introduced the Registered Nurse Safe Staffing Act which requires participating Medicare hospitals to establish a committee, comprised of at least 55 percent direct care nurses, to create nurse staffing plans that are specific to each unit.
The Agency for Healthcare Research and Quality authored a policy innovation profile that reviewed the medical literature to better outline the problems associated with low nurse-patient ratios and the benefits of the California law. They discovered numerous studies identifying the negative impact of low ratios on patient safety and patient outcomes including premature death and complications.
Avoid Census Driven Nurse Staffing
Most organizations set nurse staffing levels based upon patient census. Although the legislation noted above attempts to offer some guidance on how to staff, the ratios do not take into account the needs of patients. Staffing to patient census provides only a blunt instrument to identify the nursing needs of patients and it ignores the availability of valuable evidence-based guidelines that link patient care delivery requirements with a patient’s diagnosis and related acuity. In addition, patient data, newly available from the HITECH act driven implementation of electronic medical records (EMRs), allows for a refined evaluation of patient care delivery needs and the staffing skills required. EMR data utilized in patient acuity evaluation produces a robust, accurate assessment of patients and their care requirements, allowing for more accurate clinical staffing.
Although information technology tools will never replace patient care staff, it offers a means to intelligently deploy them in the most efficient way possible to help patients. Unlike other industries that may cut staffing in ways that may negatively impact the consumer experience, healthcare providers must consistently deliver exceptional service to patients who rely upon them for their wellbeing.
In addition, organizations must provide a patient-safe working environment by protecting nurses from overwork and fatigue that can lead to errors. Utilizing newly available information technology tools offers a way to honor patient needs and preserve the investment in nursing staffs while effectively managing the cost of care.
About the Author: Barry Chaiken is the chief medical information officer of Infor. With more than 20 years of experience in medical research, epidemiology, clinical information technology, and patient safety, Chaiken is board certified in general preventive medicine and public health and is a Fellow, former Board member, and Chair of HIMSS. As founder of DocsNetwork, Ltd., he worked on quality improvement studies, health IT clinical transformation projects, and clinical investigations for the National Institutes of Health, UK National Health Service, and Boston University Medical School. He is currently an adjunct professor of informatics at Boston University’s School of Management. Chaiken may be contacted at barry.chaiken@infor.com.