Twenty years of experience and research reveal two indispensable truths about hospitals and health care organizations that can no longer be ignored: Those institutions neglecting the basic fundamentals of patient care risk jeopardizing the quality and safety of care they provide.
Nothing can have a greater short and long-term impact on the cost of delivering health care services than nurses.
The central role of the nurse in patient care
For more than 60 years, the model of patient care has been changing. Hospital operations generally has fallen short in keeping pace with that change. Technology, protocols, and treatments are just a few of the dramatic shifts in recent years.
In the middle of all that change, the chaos of ringing bells and flashing lights, are nurses. Underneath the hum and buzz of delivering health care to patients lie dysfunctional and costly processes, essentially forced onto nurses and their colleagues.
The concept of team nursing was designed and implemented during the early part of the 1950s. This new team-based model included staffing with a charge nurse, two or three registered nurses (RNs), along with a licensed practical nurse (LPN) and a certified nurse assistant (CNA) both of whom had less clinical training than an RN. This team was responsible for the care of eight to ten patients.
Nursing stations then were centralized, including connected supply rooms, linen stations, and equipment. Because of this, it made sense to localize supplies and services. Likewise, connections to patient charts, doctors, pharmacists, and phones were centrally located too, just a few steps from the nurses station.
Nursing by design
In the 1970s, a man named Gordon Friesen, an architect, and logistics expert, proffered a simple notion: Provide the highest quality of care possible for the individual patient at the lowest possible cost to the patient. Friesen’s solution the closer supporting people, equipment, and information were to nurses and their patients, the more efficient and effective nursing would become. The added efficiency would, as the thinking went, lead to better quality of care at continually less cost.
Friesen had landed on one of the few aspects of health care that everyone agrees on — patients are best served by having nurses with them in their rooms. Patients, their loved ones, executives, doctors, and nurses themselves all want to have nurses face-to-face with patients as much as possible.
Yet, despite this common desire, due to myriad daily system failures, today’s nurses are able to spend only a mere fraction of their time in direct contact with patients. Admissions and discharges take up most of this face-to-face time. Generally, patients see their nurses briefly every hour or two, which neither patients nor nurses find satisfactory.
Today the nursing station is all but gone. Medication frequency, dressing changes, and other prescribed care are ordered from a computer located in a patient’s room, or just outside the door.
The nursing scenario today
In a scenario we have seen repeated hundreds of times, a nurse hurries to get medication, which is nowhere near the patient’s room.
As the nurse hustles to the med room, her aide asks for help with another patient, which delays the nurse’s ability to deliver her original patient’s meds. Now already several minutes behind in getting medication, the nurse is assessing another patient who, say, needs supplies too. But unfortunately, those supplies are stocked in a different room from the medication.
Leaving to get both, the nurse runs into a family member there to see their loved one. It just so happens to be her patient, and that patient needed their medication seven minutes ago. She provides a quick update and tells the family member they can see their loved one, and that she’ll be right back.
But then transport calls. They’re running late, which delays a patient’s discharge, the one who’s still waiting for the medication.
At present, nursing is a decentralized system of continually changing needs. As seen in the preceding paragraph, the failure to connect services to nurses increasingly burdens the daily activities of nursing. The difficulty arises for nurses because while nursing activities are decentralized, supporting services remained centralized.
This mismatch in operational processes ensures each nurse will spend time hunting for, fetching, and clarifying what their patients need. This is further complicated by frequent failures in these mismatched processes. It’s certainly true nurses need to be available for the patient. But when nurses aren’t available, it’s primarily due to hospital operations failing to meet the needs of nurses as the principal providers of care to patients.
Consider our proxy for hospitals across the country: AnyWhere in America Hospital (AWH).
A different approach
At AWH, medical equipment is upgraded regularly by contract with vendors in an effort to keep costs low, or to replace older outdated equipment. Usually, this new equipment requires specific supporting supplies. A great example is an IV pump: a piece of equipment used all the time at AWH to introduce vital fluids and medications to the body. At AWH, leaders coordinate the new equipment supply needs for the upgraded IV pumps for each participating department during the roll-out phase.
However, many times implementation proceeds faster than expected. Confident in their planning and adaptability, AWH decides to roll the entire project out in record time, ahead of schedule.
Unfortunately, materials management hasn’t been notified of the timeline change and can only support the roll-out plan as originally designed. Nurses in various departments, lacking the proper supporting equipment and documentation, panic; adding tension to an already stressful job. Urgent calls begin as nurses from several departments, frustrated by the new equipment’s impact, request large quantities of supplies that Materials doesn’t have.
The sudden flurry of ordering hits the materials supply department, which then overcompensates by over-ordering, then overstocking. The overstocking causes both storage and delivery issues as problems begin to ripple outward.
The terrible truth
The reality here is that health care organizations/hospitals (HCOs) function in a manner that requires nurses to focus more of their limited time and attention diagnosing systems needs than patient needs. Nurses scrambling for linen, supplies, equipment, or waiting to clarify a medication prescription are just a few examples. These types of process failures and hundreds more like them, happen thousands of times every day in every hospital across the United States.
Sometimes these impacts affect the patient. It leaves nurses stuck caring for patients in a system that’s failing them, or at least making it tremendously difficult to manage the operational chaos, rather than being able to maintain the health and recovery of their patients.
There is a serious scandal in health care: the toll that health care takes on the people who deliver it. The burdens of regulation, cost reductions, and quality initiatives piled onto nurses and other clinicians are undeniable. Without real operational gains and improvements, nurses will continue to be inundated with yet more of the same, and its impact will be ever more noticeable.
When things go wrong operationally, it’s the nurse who feels the pain first, leading to less-than-optimal care for their patients.
Colin Baird is the author of The Scandal of Healthcare: Nurses, Waste & Customer Service.
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