• Actively manage the process of change.

  • Engage workers in nonhierarchical decision making and in the design of work processes and work flow.

  • Establish the organization as a “learning organization.”

Because HCOs vary in the extent to which they currently employ the above practices and in their available resources, the committee also makes the following recommendation:

Recommendation 4-4. Professional associations, philanthropic organizations, and other organizational leaders within the health care industry should sponsor collaboratives that incorporate multiple academic and other research-based organizations to support HCOs in the identification and adoption of evidence-based management practices.

Maximizing Workforce Capability

Monitoring patient health status, performing therapeutic treatments, and integrating patient care to avoid health care gaps are nursing functions that directly affect patient safety. Accomplishing these activities requires an adequate number of nursing staff with the clinical knowledge and skills needed to carry out these interventions and the ability to effectively communicate findings and coordinate care with the interventions of other members of the patient’s health care team. Nurse staffing levels, the knowledge and skill level of nursing staff, and the extent to which workers collaborate in sharing their knowledge and skills all affect patient outcomes and safety.

Regulatory, internal HCO, and marketplace (consumer-driven) approaches are traditionally advocated as methods to achieve appropriate staffing levels. The committee determined that each of these approaches has limitations as well as strengths; their coordinated and combined use holds the most promise for achieving safe staffing levels. The committee also took particular note of the need for more accurate and reliable staffing data for hospitals and nursing homes to help make these efforts more effective and to facilitate additional needed research on staffing. Finally, the committee identified a need for more research on hospital staffing for specific types of patient care units, such as medical–surgical and labor and delivery units. The committee therefore makes the following recommendations:

Recommendation 5-1. The U.S. Department of Health and Human Services (DHHS) should update existing regulations established in 1990 that specify minimum standards for registered and licensed



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