Leadership
Hospital of the Future: The Staffing Challenge
In 2006, a roundtable of healthcare experts convened to examine the many critical issues facing hospitals today. Among these issues are the growing elderly population, greater demand for emergency care, increased numbers of those suffering from chronic conditions, increased costs, and the need for access to care.
The roundtable’s goal was to examine current healthcare issues such as socioeconomic trends, the physical care environment, technology, patient-centered care values, staffing challenges, and how those issues impact the hospital of the future. Following is a summary of the discussion and conclusion on the topic of the staffing challenge:
Workforce Shortages
Though the healthcare industry has contributed more jobs to the U.S. economy than any other industry in the past few years, the demand for certain health professionals still outstrips supply. According to the American College of Healthcare Executives, the shortage of staff has ranked among the top five issues facing hospital CEOs.
Vacancy rates for physical, occupational, and speech therapists exceeded 11% by the end of 2006, and have been increasingly difficult to recruit. Registered nurses, pharmacists, nursing assistants, license practical nurses, and laboratory and imaging technicians have vacancy rates from 6% to 8% for technicians and RNs, respectively. Physician shortages are a problem in several states already, with expectations that it will worsen. There is a high turnover of hospital executives as well, with as many as 50% of nurse executives and 14-18% of CEOs leaving their jobs within their first year.
The ability of hospitals to perform even the most basic functions is challenged by staffing issues. According to studies, there is an association between RN staffing and hospital-related mortality, failure to rescue, and an increased risk of complications. Beds that are not staffed cannot be filled, thereby decreasing the number of admissions, particularly those from emergency departments. The top-cited reason for diversion–a hospital closed to incoming ambulances–is a lack of staffed critical care beds.
Staffing shortages also lead to job dissatisfaction. Hospital-based nurses express job dissatisfaction at rates three to four times the national average for U.S. workers. Those employed in Magnet status hospitals, those facilities recognized by the American Nurses Credentialing Center (ANCC), report increased satisfaction. Those facilities also enjoy strengthened nursing recruitment and retention. In addition, patients in Magnet hospitals have lower mortality rates, shorter lengths of stay, and higher satisfaction.
The average voluntary turnover rate of new hospital nurses is 27% during the first year on the job. This may be a reflection of inadequate educational preparation for the realities of hospital practice as well as work environment issues. Included in those issues are long hours and persistent fatigue, lack of empowering leadership, unavailability of supportive technologies, and lack of innovation in improving the role of the nurse.
Almost one-third of a medical-surgical nurse’s time is spent on documentation and only one-fifth is spent on direct patient care, which also contributes to job dissatisfaction. This indicates a need to examine the role of the nurse and the inherent processes of the job.
An increasing shortage of nurse faculty is increasing the gap between supply and demand in the nursing workforce. In 2007 alone, over 30,000 qualified applicants were denied entry into baccalaureate nursing programs due to lack of capacity.
The Food and Drug Administration (FDA) has approved more than 500,000 new medical devices since the late 1990s, while concurrent technological developments in pharmaceuticals, biologics, and genomics are increasing the knowledge demands of practitioners. The addition of new developments in robotic preparation and automated distribution has had an effect on the hospital pharmacist and the level of technological expertise now required. In answer to this, the profession raised the entry-level degree for a pharmacist to a doctorate. The negative aspect of the higher standard is a roadblock created for new pharmacy students, resulting in an 8% vacancy rate for pharmacists in 2006.
Team-Based Care
To address the issue of staffing shortages, hospitals are faced with accomplishing more with less. Studies have shown that well-functioning teams can accomplish more with fewer errors than individuals, with a positive impact on patient safety.
The team-based care models may be expanded by the potential payment model proposed by the Medicare Payment Advisory Commission (MedPAC), which advocates a bundled Medicare payment approach. At present, hospitals and physicians are paid separately under different payment schemes. It is thought that a bundled approach, one that pays hospitals and physicians a fixed payment, will reduce cost variations and encourage joint accountability. This concept is being tested, as of January 2009, with its Acute Care Episode demonstration, offering bundled payments in 4 states for 28 cardiac care and 9 orthopedic inpatient surgical services. The expectations include influencing physicians and hospitals to more closely integrate their services, which is required to accept bundled payments.
Leadership: Creating a Culture of Safety
In the white paper Leadership Guide to Patient Safety, published by the Institute for Healthcare Improvement (IHI) in 2006, leadership is called the critical element in a successful patient safety program. The first step in creating a culture of safety within an organization is for leaders to change their responses to errors and failures from asking “Who made the error?” to “What happened?”
Too often leaders maintain the opinion that “it couldn’t happen here,” though approximately 80% of errors are system-driven. Errors do and will occur, even among the most skillful and knowledgeable clinicians and staff within today’s increasingly complex systems. Acknowledging this, the key to patient safety is designing care delivery systems in a way that errors are caught and remedied before harm comes to a patient.
Understanding Medical Errors
The design of such a system begins with understanding medical errors. Also known as “adverse events,” they include delayed and missed diagnoses, errors during treatment, medication mistakes, delays in reporting results, miscommunications during transfers, mistaken identity, and inadequate postoperative care.
One type of error is the error of commission, or doing something incorrectly. An error of commission, such as misreading a label under non-stressful situations, occurs 3 times out of 1,000. Errors of omission, or the failure to do something that should have been done, occur 1 time in 100 absent reminders. The more steps involved in a process, the greater the potential for human error.
For example, we can look at the process for filling a physician’s order for medication. This process is estimated to have 40 to 60 steps in a hospital environment. If each step of an average of 50 carries with it a 1-in-100 chance of error, the expected rate of success for all 50 steps is 0.61, i.e., there is only a 61% chance that the process will be completed perfectly. To improve the likelihood of success, either the number of steps must be reduced, the reliability of each step increased, or both.
Medical errors are often the result of today’s technology and complexity moving faster than measures to change the processes of past practices are addressing. Old care delivery methods are inadequate in ensuring reliability with today’s new demands. Improvements in patient safety are not only a professional and moral imperative, but a financial one. The annual cost to national healthcare institutions for medical errors is estimated to be $6 billion.
Leadership and a Culture of Patient Safety
Jim Conway, IHI Senior Fellow and former Executive VP and COO of Dana-Farber Cancer Institute, says, “Leaders play an extraordinary role in patient safety.” Leaders must “provide focus and make patient safety not just another ‘program de jour’ but a priority corporate objective. You must make everyone in the institution understand that safety is part of his or her job description.”
Organization leaders must focus on establishing a culture that both supports and advances patient safety, but there are significant barriers to this “just” culture in place that are embedded within the traditional practice of medicine. In Managing the Risks of Organizational Accidents, James Reason defines a “just” culture as one that supports the discussion of errors so that lessons can be learned from them. However, the culture in most healthcare organizations is still defined by factors that contribute to an unsafe patient environment. These factors include a tradition of blame and punishment of staff involved in an event, lack of teamwork, poor communication, and lack of transparency about medical errors. A culture of trust can be facilitated by leaders where communication is encouraged across clinical disciplines about the causes of medical errors, along with a non-punitive approach to reporting.
The greatest single risk of harm to patients in hospitals is adverse drug events. Detecting these events has traditionally been focused on voluntary reporting and tracking of errors. However, only 10 to 20 percent of errors are reported, according to public health researchers. Increased reporting, including reporting of near misses, is crucial to understanding the underlying system that led to the error in order to redesign the system to ensure the error will not be repeated.
An effective reporting system requires leadership support and should be easy to access. The root cause analysis of adverse effects needs to answer three questions: What happened? Why? What can be done to prevent it in the future? An organization with consistent systems in place to identify failures and potential weaknesses, along with an ability to address them, is one embracing a culture of safety.
Botwinick L, Bisognano M, Haraden C. Leadership Guide to Patient Safety. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2006.
Reason J. Managing the Risks of Organizational Accidents. Hampshire, England: Ashgate Publishing Limited; 1997.