It seems like everybody has a new idea for making things better in healthcare, yet, somehow, things seem to be getting worse. For instance, Tessa Love reported on a project to reduce the noise pollution in hospitals, which has doubled over the past 50 years. The proposal included redesigning alarm sounds to be less jarring, and creating a “tranquility room,” characterized by subdued lighting, comfortable chairs and soothing background music, where staff can take breaks to recharge. Seems simple enough, and not really all that costly. Proponents tout the benefits for staff and the positive impact on patient safety.
On the other hand, nurses in New York are threatening to go on strike to force local hospitals to increase nurse to patient ratios because they feel they can’t do the job well under existing conditions. The crux of the issue seems to be whether nurse to patient ratios should be standardized and mandated. Reference is made to California, where such ratios have become part of state regulatory codes. Using these as “norms,” nurses argue their staffing ratio is only about 80% of the appropriate level. Nursing management responds by arguing health care is too complex for simple numerical standards, and that their local unit managers can best assess the correct loads.
“No two hospitals are alike,” said Lorraine Ryan, a senior vice-president of the Greater New York Hospital Association. “Staffing decisions need to be made by nursing professionals based on patient acuity, the experiences and competencies of the nursing team delivering direct patient care, and other demands on the care-delivery team.”
As the article notes, though, the real problem is financial. If the New York hospitals agreed to meet the California levels, costs would rise prohibitively. On the other hand, given the financial constraints, the probability is high that systems will be set to operate at a rate staff can’t sustain. Clearly, this is an issue facing all healthcare organizations, even when nurses are not organized into a union and prepared to strike. Furthermore, in many areas of the country the supply of available nurses is finite. Even when management recognizes the need for more staff, finding them may be difficult.
I have previously emphasized the resilience model that views healthcare organizations at any level as a triangle. Each unit must operate with fiscal, human, and clinical constraints. Resilience is maintained only when the forces are reasonably balanced. With this mental model in mind, I read with interest a report from the Institute for Healthcare Improvement on the management practices that seem to support improvement activities. Their report is detailed and worth reading, but I want to highlight a few of their points.
They identify six management tactics key to supporting improvement. First is standardization—defining role-based daily and weekly standard work. Note this approach obviates “standard” nurse to patient ratios, but also recognizes care must be taken to define a normative amount of work, a standard productivity if you will. The second tactic is accountability—monitoring fidelity to standard work. The third is use of visual “dashboards” showing relevant data to everyone quickly. Fourth is developing problem solving methods to address issues that arise in daily work. This tactic requires specific delegation of authority to commit resources to solving the problem, though. This does not necessarily mean more people, but it may mean giving current staff time to work on the issue by reducing clinical loads. Fifth is escalation—when to “kick it upstairs” and get higher levels of management involved. Sixth is integration—bringing everyone to the table, particularly frontline and mid-level managers regularly to address issues on the spot.
So back to the first two articles. Noise pollution may well be one of those invisible issues—everyone is inured to the beeps and tunes them out. As in the famous “gorilla” and the basketball teams experiment, you simply won’t see what you aren’t looking for if you are too focused on another task. Given the explosion of tasks and documentation in healthcare organizations, it is easy to miss the gorilla. Successful organizations must find ways to get fresh eyes on the issue.
Nurse stress, though, is prevalent, as is nurse turnover. All of these represent hidden costs. So, while we will continue to operate within a cost-constrained environment, we need to become smarter about those hard to capture costs associated with our current approach to getting the job done.
“Standard work” is a term designed to rile clinical staff, but if it is thought of as defining the necessary steps that must be done for each patient, rather than specifying what those steps have to be, it has the potential to permit more rational staffing levels. Current efforts at patient satisfaction may permit opportunity costing when staffing levels are too low and they make it easier to control “mission creep.” I have been in many meetings where some good idea was being considered, but the implementation step was “get the doctors (or nurses) to do it.” Since they are already too busy, the question needs to be what are we going to give up, so we meet the new requirement?
With all the uproar in medical organizations, it is necessary, but difficult, to focus on the basics. Getting the best care for the patient is going to require hard work from everyone and a willingness to change the way we do things. As one friend of mine used to say, “The ultimate disservice to our patients is to go broke.” But maximizing profit at the expense of patient care is also a way to go broke. Are we at risk of failing this way, too? I think so.
8 April 2019
 Love, T. The Simple Change That Can Save Patient Lives. 14 August 2018. Accessed 15 August 2018 at
 McGeehan, P. Patients “Hit the Call Button and Nobody Comes.” Hospital Nurses Demand “Safe Staffing” Levels. 30 March 2019. https://www.nytimes.com/2019/03/30/nyregion/nyc-nurses-strike.html.
 Mate KS, Rakover J. The Answer to Culture Change: Everyday Management Tactics. 6 March 2019. Accessed 14 March 2019 at https://catalyst.nejm.org/high-performance-management-system/
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