Term Paper: Healthcare Practices in Nursing Today

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[. . .] This is because hospital needs fluctuate, depending on the numbers, types, and individual responses of patients on a given day.

Management developed ways to attempt to predict nursing needs that were based on patient population. This type of patient classification system is a process where RNs document patient needs. Management then uses this documentation to standardize patient care and to predict the right mix of nursing personnel that is required for any particular patient population (White, 1988).

This particular management strategy requires a high level of utilization of RNs, because RNs are more highly educated and better at the documentation process required for patient classification systems to work. In addition, RNs are trained to participate in the process. This system is being widely utilized to measure productivity in the staffing of units on both a daily and monthly basis. It is also used to make budgetary projections within various cost-containment restrictions, as well as to ensure the delivery of high quality patient and family care (Grant, Bellinger & Sweda, 1982).

Decreasing Inefficiencies

Both cost-effectiveness and cost-benefit analysis have been used in preventive, diagnostic, and treatment contexts. Over the past couple of decades, methods have certainly improved for collecting better data and for incorporating intangible quality-of-life valuations into the calculation weighing benefits against costs. One element under the control of nursing departments is to trim the inefficiency associated with the seven top tasks performed (illustrated in Table 1 below), especially focusing on methods for trimming unneeded bureaucratic tasks.

Table 1. A Data-Envelopment Analysis of Average Inefficiency (39 Hospitals, 1991)

Factor (Workload/Input)

Current Value

Workload per Case-Mix-Adjusted Admission

1. General nursing administration

18.6% inefficient

2. Assessing and monitoring physical condition

17.4% inefficient

3. Planning for patient discharge

14.9% inefficient

4. Completing evaluation/outcome documentation

14.8% inefficient

5. Administering tube of IV feedings

9.5% inefficient

6. Placing special tubes (NGs, Foley, O2)

8.2% inefficient

7. Monitoring tech equipment (Swan-Ganz catheter)

7.9% inefficient

Labor Input

1. Nursing administration

21.3% oversupply

2. Nurse extender (technicians)

24.7% undersupply

Source: Grosskopf & Valdmanis, 1987.

Judging by the results for labor inputs, the 22 inefficient nursing departments could cut administrative activities by 21.3% and expand the supply of technician employees by 24.7%. Task delegation to technicians, a leaner nursing administration bureaucracy, and nurse-scheduling systems that utilize Optimizer Linear Programming Software (Shorr, 1991) appear to be three keys to the improvement of nursing productivity. Nurse productivity is critical, since nurses represent over 60% of total hospital employees (Eastaugh, 1992).

Other departments also can benefit from productivity improvement. Better scheduling systems for both staff and patients can certainly enhance productivity in radiology, respiratory therapy, and numerous other departments.

Staffing standards for efficient/good (70th percentile) hospital departments and very good (90th percentile) departments are shown below in Table 2.

Table 2. Productivity Standards for Performance in Select Departments, 1991

Performance

Target Standards per Unit of Service (UOS)

Department

70th Percentile

90th Percentile

Radiation oncology

Respiratory therapy (RT

Pulmonary (in dept. RT)

EEG (in dept. RT)

EKG (in heart center, HC)

Echocardiology (in dept. HC)

Emergency department (ED)

Behavioral services (M.H. - S.W.)

Laundry (linen per diem)*

16 lbs/patients day

14 lbs/patients day

Source: Eastaugh, 1992.

Productivity enhancement can also involve decreasing unnecessary units of activity or unneeded output, for example, minimizing linen consumption per patient per day.

Total Quality Management Approach total quality-management program focuses on both external (e.g. patients, employers) and internal customers. Often, one department does not understand how its work product is used by another department (e.g. quality and productivity may be increased if a hospital laboratory does not skimp on hiring a $7.50 per hour technician who can preclude the problem of a $75 per hour emergency-room doctor wasting time waiting for lab results). The concept of internal customers (Deming, 1986) fosters respect and efficient teamwork between departments and increases morale in the total organization.

In this environment, doctors become "customers" of the nursing department, the medical floor is a "customer" of the recovery room, and the recovery room is a "customer" of the operating room. Some departments may be inappropriate or excessive customers of another department (Eastaugh, 1992).

In one example of doctors as customers of the nursing department, attending physicians at one hospital frequently complained of seldom seeing the same faces twice. A team studied the problem and came up with solutions. The problem was caused primarily by the belief of nurses in 100% RN primary-care nursing. The solution was to maximize the use of the existing RNs' clinical skills by employing technicians to perform the 43% of nursing work that the law allowed a non-nurse to do, rather than to continue the expensive habit of hiring outside agency nurses who were new to the department and unknown to the doctors. Morale among the nurses was significantly improved since their time was no longer wasted doing menial work. Morale among the attending physicians also improved, since now they could identify specific RNs with their individual patients.

Creating a Leaner Organization

Hospitals need to annually reevaluate workload-driven staffing ratio, to ensure that they are in line with fiscal goals and shifts in payment rates. Managers should use "best-cost" standards from appropriate engineering studies. Down-staffing usually correlates with better-quality care (Walton, 1990), while staff-to-patient ratios can be reduced by over 15% in many cases (e.g., Emanuel Hospital in Portland in 1990 and Beloit Hospital in Wisconsin in 1987).

White Memorial Medical Center in East Los Angeles reduced total nursing hours per patient day from 10 in 1988 to 7.1 by September 1990. Redundant staffing in a fat organization almost always leads to lower quality care (Ahmadi 1989; Caldwell, McEachem & Davis 1990). In departments with direct patient care responsibilities, it is clear that much of the bureaucracy, paperwork, and other useless units of activity should be eliminated. For example, one hospital used six separate patient charting forms until that process was replaced by a single flow sheet in 1991. Lab results should be reported by computer, and medication orders should be faxed to the pharmacy or sent by computer systems, in order to eliminate the wasted time involved in transcribing orders (Eastaugh, 1992).

Increasing Nurse Productivity

The results of a 1990 study by Eastaugh showed that employment of technicians to assist nurses in many tasks reduces wasted labor, enhances productivity, and therefore, improves cost-efficiency (Eastaugh, 1990). Judging from the deployment of technicians at prestigious hospitals (e.g., Johns Hopkins), task delegation can enhance the quality of patient care (Eastaugh & Regan-Donovan, 1990).

Beyond the traditional technician tasks of obtaining vital signs and EKG results, patient transport, procuring supplies and equipment, procedural assistance, and paperwork, some hospitals have begun to utilize specialist technicians to dress wounds and to do other basic nursing functions. Some of the other activities that may be performed by technicians are outlined in Table 3 below.

Table 3. Selective Examples of Non-nursing Menial Tasks vs. Important Nursing Tasks

Non-nursing Tasks to Delegate to Technicians*

Important Nursing Tasks

1. Obtaining vital signs

Interpreting vital signs

2. Patient transport

Physical assessment and condition monitoring

3. Housekeeping and bedmaking

Technological monitoring, Infusion pumps, Swan-Ganz catheters

4. Meal trays

Tube and IV feedings

5. Physician procedural assistance

IV Therapy: nitroglycerine, insulin, TPA drips

6. Venipuncture

Evaluation/outcome documentation

7. Getting supplies and equipment

Discharge planning

8. Secretarial (e.g., lab slips)

Special tube placements: NGs, foleys, oxygen therapy

9. Obtaining EKGs

Narcotic count

Source: Eastaugh, 1990.

Non-nursing tasks, often called "scutwork," are activities that can be easily delegated to technicians in a high productivity unit.

Progressive nurse managers should participate in careful studies designed to set the standards, study task-delegation feasibility, and set out the job descriptions for two to three levels of specialist technicians (Powers, Dickey & Ford, 1990; Bennett & Hylton, 1990). With ongoing anticipation of future funding limitations, barebones reimbursement demands that the recent tradition of 100% RN primary-care nursing must be altered. The creation of an efficient staff mix in the field of nursing should only enhance nursing's rising sense of professionalism (Eastaugh, 1992).

Manthey, one of the originators of the primary-care nursing concept, has recently capitulated to the idea that the 100% RN concept is not an absolutely necessary component for primary care nursing (Manthey, 1988; 1970).

Maximizing the employment levels of RNs in hospitals is neither a desirable nor an economical goal unless the United States were in a situation with a huge oversupply of nurses. No such oversupply situation exists, so an increased reliance on specialist technicians is simply good economics, good nursing, and good medicine.

Software Utilization

Software is available in the marketplace today to simplify the employee appraisal process and streamline the accreditation process. It includes medical-specific features with benefits for HR administrators, line managers and the entire organization, helping to increase efficiency and lower costs. One such software package is called Halogen eAppraisal Healthcare.

Features include:

Automatic personalized reminders to decrease the amount of time spent following up and ensuring that processes run smoothly, with appraisals completed on schedule, unique report center providing… [END OF PREVIEW]

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