by Mary Jo Graham

With the advent of diagnosis-related groups (DRGs) in 1983, hospital lengths of stay decreased significantly, but regulatory requirements for care delivery and the number of admissions remained the same. Essentially, we have accelerated the “production” of patient care but often have neglected to update our systems and processes to keep pace.

In addition to speeding up patient-care production, we have instituted other changes that can make it more challenging to provide the highest quality of care. First, we created additional hand-offs by opening up new venues for care delivery (home care, assisted living, nursing home rehabilitation, etc.), and we increased the need to coordinate the care with other pre-acute, post-acute, and community-based providers to deliver aspects of the care previously handled within a longer length of stay at the hospital.

Second, we changed the way we train our care providers. With two-year RNs now making up nearly half of practicing nurses, a field previously dominated by three- and four-year nurses, today’s nursing population is less trained than at any point in the past 100 years.

Third, we increased the volume of information to be managed and added technology to the workplace. And finally, we added layers of staff and increased the number and types of persons with whom nurses must interact (technicians, case managers, specialty departments and services, and the like).

Taken together, these trends—limited training, increased production, increased interruptions, increased need for information processing, and increased hand-offs—are a recipe for disaster. Quality improvement efforts stress the need to simplify processes, decrease the number of required hand-offs, and improve the skills and training of the workforce.

The most obvious answers aren’t always the right ones

As nursing shortages become more acute, hospitals are seeking ways to continue to provide services to their markets, sometimes by providing substitutes for registered nurses, changing the organizational structure for care delivery, adding technology, or modifying the physical layout of the hospital environment. However, modifying existing processes and care delivery without acknowledging the changing environment will not address the problems, nor will it have the needed impact on errors in health care delivery.

For example, adjusting overall nursing hours from the perspective of documented patient acuity and patient volume in the absence of a more comprehensive picture leaves out the true complexity of the patient care environment. Decisions made to reduce or increase staffing numbers, change the mix of staff, or create staffing standards in the absence of a more comprehensive understanding could mean that scarce resources are over- or underutilized. The result could have devastating effects for hospital performance in the form of increased nurse turnover, increased human resource costs, or most worrisome, an increase in “adverse events” for patients that result in additional illness, injury, or death.

Some adverse events are unavoidable, but many are the result of interventions that were done and should not have been done, actions not taken that should have been, or symptoms that were not identified and acted upon. Beyond their obvious impact on the patient and family, adverse events also decrease public trust in the health care system, increase hospital costs, and increase the overall cost of health care on a national level.

A good first step: Examine your current care delivery practices

The first step to addressing care delivery issues is to acknowledge the specific problems. Until you can evaluate your own organization in light of national trends, you will not be able to address the concerns. Following are some areas of potential opportunity for organizations that are critically examining their care delivery.

Dealing with age differences

Review the age diversity of your workforce. Your answers to each of these questions will suggest different strategies in designing care delivery.

• Do you have a significant population of younger nurses who are savvy with technology but less astute with clinical assessment and critical thinking in uncertain situations?
• Do you have an older nurse workforce that may be facing retirement and taking with them tacit knowledge that cannot be replaced?
• Do you have a blending of younger and older nurses?
• Do your human resource policies address the differing needs of various age groups? Or do they instead emphasize consistency, regardless of age differences?

Leveraging competencies

Look at the basic training and experience of your staff. Your answers to the questions below should impact how you design your staffing models. For example, new two-year nurses could be mentored by the more experienced older nurses.

• Have you standardized core processes? Have you identified what could be standardized? (Younger, less experienced nurses may work better in settings guided by protocols, pathways, and decision trees.)
• What systems and processes do you have in place to support formal and on-the-job training?
• Do you promote a culture of learning?
• Do you have expectations for credentials for certain nursing positions?
• Do you pay all nurses the same?

Streamlining workflow

Workflow should be designed to decrease interruptions. Key to workflow design is to identify processes that must be done sequentially and those that can be done in parallel; parallel processes generally reduce delays. Additional workflow assessment could be based on the following questions.

• Do you have a hierarchy that must be traversed for direct-care decision making?
• Do the direct-care workers work as teams?
• Do the care-delivery teams have everything they need in a decentralized location?
• Is the phone system set up with portable units? If so, is there also a centralized phone answering and triaging process? (Remember that portable and cellular phones interrupt nurses doing their work.)
• Is the automated clinical information system easy to use and accessible? Does it mesh seamlessly into the care delivery process or has it added another layer of complexity?
• Are you utilizing more than one system for the patient documentation (i.e., paper and automation)? Is all information interfaced so that it is all on the same system and readily available to whoever needs it?
• Does the medication dispensing system integrate with the documentation and billing system? Does it have safeguards, prompts, and reminders to improve accuracy and decrease errors?
• As technology improves, are you taking advantage of new capabilities?

Coordinating care with external providers

Use the questions below to examine the coordination of care and ensure adequate hand-off processes.

• Do you have a hierarchy of care delivery, or is direct care decentralized into patient care teams?
• How does coordination occur? Is there a department, person, role, or classification of personnel responsible for care coordination?
• Do you have separate processes for internal and external care coordination?
• Is there a core group of facilities from which you receive the majority of referrals? If so, have you standardized the referral process to ensure consistent, comprehensive, and timely referral information in a format that is easy to use?
• Do you provide discharge and follow-up information to referring organizations in a standardized and consistent format?
• Do you follow up with referring and referral organizations for the purpose of continually improving your own processes?

The above areas are just a few to be examined and modified as organizations seek to design safer care delivery models with constrained resources.

Mary Jo Graham, R.N., M.S., is a director in Wipfli’s health care consulting group. She can be reached at 612.867.0121 or mgraham@wipfli.com.