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Keeping Patients Safe: Transforming the Work Environment of Nurses
Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation standards that required nursing departments to have a system for determining nursing care requirements based on patient needs (Norrish and Rundall, 2001). Today, PCSs are widely used by hospitals (but not nursing homes) despite their frequently noted shortcomings. These shortcomings pertain not as much to how patient acuity is measured as to how corresponding work is measured, the extent to which the PCS methodology accommodates variations in staff expertise and work environment, and how HCOs implement the PCS.
PCSs lack desired sensitivity to variations in patient acuity levels. PCS models identify discrete levels of patient acuity and translate them into estimates of the amount of care individuals at that level typically require. However, patient acuity varies within classification levels. When HCOs fail to appreciate this fact, they can become locked into average PCS predictions and fail to acknowledge the need for flexibility that is an intrinsic characteristic of PCSs (DeGroot, 1994).
Workload estimates for various patient classification levels may be inaccurate and unreliable. Measurements of workload are the product of three factors: (1) product and service (i.e., patient care) classifications (described above), (2) forecasts of volume demand for each classification, and (3) the standard times for each service (Bayiz, 2003). To translate patient acuity into workload estimates, the work performed by nurses when caring for such patients needs to be sampled (DeGroot, 1994). Work sampling involves identifying the activities that are performed and the average time required for each.
HCOs’ use of PCSs has been criticized in several areas pertaining to work sampling. First, work sampling and time estimates are often not derived from the institution using the PCS. Instead, HCOs often use work sampling estimates produced by external PCS vendors or other facilities. To the extent that these external work estimates were derived from work samplings for patient care units that differ from those of the institution using the PCS—in terms of the experience level or skill mix of nursing staff, the availability of support staff, the way patient care is organized and delivered across units, and/or the physical layout of the nursing units and hospital—or are rationally derived using educated “best estimates,” they will likely be inaccurate and unreliable estimates of how long it takes nursing staff within that particular institution to perform certain activities or care for a given level of patients. There is no “one size fits all” set of standard times that can be used across hospitals (Bayiz, 2003; DeGroot, 1994). Accordingly, some have pointed to PCSs as contributing to the perception that “a nurse is a nurse is a nurse,” that all nurses are equal and interchangeable. This perception is inconsistent with the evidence presented in Chapter 3 that nurses vary in their level of knowledge and expertise. It has also been identified as