Implementation Considerations and Needed Research
A call for change is persistent throughout this report. The committee’s recommendations call primarily for change on the part of health care organizations (HCOs), but also on the part of the federal government, state boards of nursing, educational institutions, professional associations, labor organizations, and nurses themselves across all settings of health care delivery—acute and long-term, and inpatient and outpatient care. All of these entities have long-standing track records of concern for the welfare and safety of patients, and all have continued to pursue this agenda in the face of the tumultuous changes in the U.S. health care system that have taken place over the last two decades.
The turbulence faced by the health care industry is not unique. All sectors of the U.S. economy have faced the threat of reduced revenue, if not from decreases in reimbursement, then from downturns in the economy or increasing competition. Rapid growth in beneficial technological innovations has occurred in all industries and has sometimes brought unanticipated risks to consumer safety, ranging from identity theft to new sources of environmental pollution and occupational or consumer injury. All industries are affected by changes in the workforce, such as its declining size and aging as the baby boomers reach retirement age. And all industries are forced to address the flood of information from and for consumers, the marketplace, and the external environment that forces them to cope with faster and more layered flows of information (Stacey, 1996).
The ubiquitous nature of this turmoil is helpful in that it provides lessons from a variety of industries about how successful organizations respond in times of challenge. One hallmark of successful, thriving enter-
prises is their capacity to learn and change (Quinn, 1992). This is an important reminder. When considering the recommendations for change presented in this report, the reader may have any one of a number of different responses, ranging from wishing to jump right in, to wanting to wait to undertake new changes until things settle down a bit, to seeking to determine what recommendations are most important and which can be deferred. However, the committee calls attention to evidence that should influence how HCOs and the other entities addressed in this report respond to its recommendations:
The turbulence experienced by the health care industry is not predicted to lessen. HCOs and other entities that have roles to play in protecting patient safety should not wait to make necessary changes.
None of the committee’s recommendations are of lesser importance; entities will need to act on all of the recommendations to keep patients safe.
While some recommendations may have immediate cost implications for some organizations, their implementation also is likely to produce benefits (some financial) for all organizations in addition to enhancing patient safety.
Organizations and individuals need to maintain the capacity for ongoing change and adoption of new work strategies and processes as further research provides additional information on how to increasingly improve support for and deployment of nursing staff to maximize patient safety.
HEALTH CARE ORGANIZATIONS AND OTHER PARTIES SHOULD NOT WAIT TO ACT
The health care system continues to evolve, responding to pressures and opportunities:
Health care spending in the United States grew 9.6 percent in 2002, nearly four times faster than the overall economy. However, while this increase is very high, it represented the first slowing of the growth rate in 5 years, a slowdown that occurred in all four categories of health care spending—inpatient and outpatient care, prescription drugs, and physician services (Center for Studying Health System Change, 2003).
Although the transition to less-restrictive managed care has eased financial pressures on providers, declining Medicare and Medicaid payments continue to squeeze hospitals and physicians. Providers are pressing health plans for better payment rates and contract terms, and hospitals and physicians are increasingly competing for profitable specialty medical and ancillary services, resulting in a continued buildup of capacity and technology. In Indianapolis, for example, six new specialty hospitals have opened or are
under development. In Seattle, medical groups are opening ambulatory surgery and diagnostic centers and adding capacity to deliver radiology, laboratory, and imaging services in their practices (Lesser and Ginsburg, 2003).
Private health insurance premiums increased an average of 15 percent in 2003—the largest increase in at least a decade (Center for Studying Health System Change, 2003). Consequently, employers are shifting more costs to employees. In some communities, malpractice premiums are continuing to rise (Lesser and Ginsburg, 2003).
Fully 80 percent of consumers say they want to receive personal medical information via the Internet. Currently, only 13 percent of physicians report communicating with patients by e-mail, although 39 percent said they would do so if security and privacy issues could be resolved (The Henry J. Kaiser Family Foundation, 2002).
Because of such developments, as well as the rapid growth of diagnostic and therapeutic technologies and biomechanical advances in knowledge,
Governing Boards That Focus on Safety
Leadership and Evidence-Based Management Structures and Processes
Effective Nursing Leadership
the U.S. healthcare system, like many sectors of the economy, is unlikely to reach a steady state in the foreseeable future. Therefore, HCOs should not wait for things to settle down before acting of this report’s recommendations. Indeed, increasing cost pressures may make these safety practices even more imperative.
MULTIPLE, MUTUALLY REINFORCING SAFEGUARDS ARE NEEDED
As the evidence in the preceding chapters attests, there is no silver bullet, or shortcut for achieving patient safety. The work environment of nurses contains the basic organizational production processes and opportunities for human error well described by experts in organizational safety, as captured in the framework presented in Chapter 2. Using this framework, the committee identified the bundles of safeguards needed in nurses’ work environments to safeguard patients, which are summarized in Box 8-1.
Organizational Support for Ongoing Learning and Decision Support
Mechanisms That Promote Interdisciplinary Collaboration
Work Design That Promotes Safety
Organizational Culture That Continuously Strengthens Patient Safety
Each of these safeguards is a defense against the occurrence of errors. As the work of experts in organizational safety attests, error-producing events can arise at any organizational level, within any organizational component, and within any work process. Safeguards are needed for each of these sources of patient safety errors; isolated defenses will be insufficient.
Redesigned work practices will still be unsafe if the number of nurses available to perform the work as designed is insufficient. Moreover, an apparently sufficient number of nurses will not perform as needed if they are suffering from the effects of fatigue, inexperienced in a given work process, or unfamiliar with the HCO’s work processes because they are secured from a temporary or travel nurse agency. And errors will still occur even when the most capable workforce provides care using the best-designed work processes, because neither the nurse nor the work process is perfect. Defenses against human errors can be developed and put in place only if nursing staff are not afraid of reporting the errors and are involved in designing even stronger defenses. Finally, instituting all of these defense strategies can be accomplished only by individuals who have a vision of and command resources for the organization as a whole—that is, an organization’s leadership and management. The actions of these leaders are the essential precursor to the creation of safer health care environments. They must be motivated by a passion to maximize the safety of all patients served by their institution. When implementing the committee’s recommendations, however, they may also observe some additional benefits to their institution.
BENEFITS IN ADDITION TO PATIENT SAFETY ARE LIKELY
The costs of implementing the committee’s recommendations will vary by facility and by recommendation. Some of the recommendations (e.g., establishment of a strong nursing leadership position, education and attention of governing boards with regard to safety, and adoption of management practices that are supportive of patient safety) are not likely to have significant immediate cost implications; other recommendations, such as limiting nurse work hours and ensuring safe staffing levels, may have such implications.
It is not possible to predict the costs that individual HCOs will face in implementing all of the committee’s recommendations. Costs will vary to the extent that organizations have already embraced these practices. Many of the recommendations (e.g., better work design and the creation of cultures of safety) echo those made in two prior Institute of Medicine (IOM) reports—To Err Is Human (IOM, 2000) and Crossing the Quality Chasm (IOM, 2001). As noted throughout the present report, a number of facilities have already undertaken many of those recommendations. Actions of the
federal government to fund more research on why errors occur and how to prevent them, to collect data on patient safety, to support the acquisition of information technology, and to disseminate patient safety information to consumers and providers (Clancy and Scully, 2003) have been a key stimulus for these efforts. Significant improvements in the safety of patients have also been spurred by health care purchasers’ preferentially selecting HCOs based on their adoption of certain patient safety actions (e.g., computerized physician order entry), accreditation standards on patient safety adopted by the Joint Commission on Accreditation of Healthcare Organizations [JCAHO], continued public attention to patient safety from the media, and the internal commitment to patient safety made by many HCOs. However, adoption of patient safety practices has been uneven (Boodman, 2002; Millenson, 2003). HCOs that have been slower to respond to past IOM recommendations will have more work to do in implementing those contained in this report.
The committee adhered strictly to its charge to identify “potential improvements in health care working conditions that would likely increase patient safety.” The committee did not address working conditions that would increase worker safety, nurse retention or recruitment, or patient satisfaction with care. Yet we repeatedly noted how often patient safety practices identified from the evidence reviewed for this study were the same as those recommended by organizations studying the nursing shortage, worker safety, and patient satisfaction. We note that retention of nurses and other health care workers in short supply, increased patient satisfaction with care, and potentially some return on financial investment may also result from undertaking the recommendations of this report.
Better Retention of Nurses and Other Health Care Workers in Short Supply
The nursing shortage discussed in Chapter 3 has been the subject of much study. Many expert panels and organizations have identified the need for HCOs to undertake actions to retain the nurses they already employ as an essential strategy for addressing this shortage (AHA Commission on Workforce for Hospitals and Health Systems, 2002; GAO, 2001; JCAHO, 2002; Kimball and O’Neil, 2002). It has been observed that even if the nursing education pipeline can be stimulated to increase the supply of new nurses, hospitals and other HCOs will still face shortages in nursing staff if work environments are so inhospitable that nurses leave to work in other places or abandon the practice of nursing altogether. Indeed, some have asserted that there is not a shortage of nurses, only a shortage of nurses who want to work in hospitals under today’s working conditions (Lafer et al., 2003).
Strategies consistently recommended by experts to increase nurse recruitment and retention by HCOs include the following (AHA Commission on Workforce for Hospitals and Health Systems, 2002; JCAHO, 2002; Kimball and O’Neil, 2002):
Strengthen nursing leadership within HCOs.
Employ management practices that support staff involvement in care design and organizational decision making.
Decentralize decision making for patient care and resource deployment decisions.
Ensure appropriate nurse staffing levels.
Provide ongoing support for nurses’ education and training after they are hired.
Provide decision support.
Limit nurses’ work hours so as not to create undue fatigue.
Redesign work to increase safety and decrease inefficiency.
Reduce the burden of paperwork and documentation.
Implement and reward collaborative and multidisciplinary approaches to accomplishing work.
Moreover, the research that led to the creation of the magnet hospital designation—denoting hospitals that have higher levels of nurse retention and recruitment in the face of nurse shortages and an environment competing for the available nurse workforce—found the following workplace characteristics to be associated with better nurse recruitment and retention (McClure et al., 2002):
Participatory management that involves nursing staff at all levels in decision making.
Able, qualified and effective nursing leadership.
Decentralized decision making, providing nursing staff with control over nursing work processes.
Adequate staffing and, with few exceptions, low employment of nurses from temporary agencies.
Strong postemployment education and training, including long orientation periods, use of preceptors and mentors for novice nurses, and ongoing education and training support.
Strong interprofessional collaboration with physicians (Hinshaw, 2002; Kramer and Schmalenberg, 2002).
Because of the substantial similarities between the patient safety practices recommended by the committee and those recommended by experts and supported by research as promoting nurse retention and recruitment,
we believe that implementation of the patient safety practices recommended in this report is likely to yield benefits to HCOs in the recruitment and retention of nurses. Moreover, we note that nurses are not the only group of health care workers in short supply. The hospital industry has documented shortages in imaging/radiology technicians; pharmacists; laboratory technicians; speech, physical, and occupational therapists; and respiratory therapists, among others (AHA Commission on Workforce for Hospitals and Health Systems, 2002; First Consulting Group, 2001; JCAHO, 2002). If work environments are constructed in a way that fosters better retention and recruitment of nurses, it is reasonable to expect that these practices will also permeate the work environments of other health care professionals. (The committee believes it unlikely—and undesirable—that HCOs will adopt work environment practices that apply only to nursing staff.) We note that a substantial amount of the evidence underpinning the recommendations contained in this report was obtained from industries other than health care. It is therefore reasonable to believe that these work practices are appropriate and beneficial not only to the nursing workforce, but to all health care workers. In implementing these recommendations across all workers, economies of scale should be achieved, and better retention and recruitment of all health care workers may result.
Increased Patient Satisfaction
Many of the practices recommended by the committee may also increase patients’ satisfaction with their care. While variables not related to nurses’ work environment (e.g., institution size [Young et al., 2000]), have been linked to patient satisfaction, findings from a study of magnet hospitals and hospital units with similar organizational traits suggest that features of nurses’ work environment found in magnet hospitals also influence patient satisfaction (Aiken, 2002). Moreover, increased patient satisfaction is linked to adequate nurse staffing levels (Luther and Walsh, 1999) and to the physical design and layout of patient care units (Fowler et al., 1999).
Potential Financial Advantages
Increased retention of nurses is likely to be cost-beneficial for HCOs. There is also evidence that redesigning work processes to produce safer health care can yield cost savings for HCOs.
A 2001 survey of directors of nursing of all U.S. nonfederal acute care hospitals found that (for the 14.7 percent of hospitals responding), on average, 21.3 percent of all full-time hospital registered nurses (RNs) had resigned or been terminated during the preceding year. While most hospitals reported turnover rates of 10–30 percent, some reported much higher rates.
For example, 2 percent of responding hospitals reported turnover rates of 50 percent or higher (The HSM Group, 2002). Turnover rates among nursing staff in nursing homes are even greater. A national survey conducted in 2001 by the American Health Care Association (AHCA) revealed annual turnover rates of 78 percent for nursing assistants (NAs), 56 percent for staff RNs, 54 percent for licensed practical nurses (LPNs)/licensed vocational nurses (LVNs), and 43–47 percent for directors of nursing and RNs with administrative duties (AHCA, 2002).
Turnover of nursing staff exacts a high price on HCOs. Estimates of the replacement cost per nurse range from “a conservative estimate” of $10,000 per RN (The HSM Group, 2002) to approximately 100 percent of a nurse’s salary ($42,000–$46,000 per year for medical–surgical and other non–intensive care unit nurses to $64,000 for critical care and other specialty care nurses (Kosel and Olivo, 2002) VHA Inc. estimates that, assuming an average cost of $64,000 to replace a nurse, an HCO with an RN workforce of 600 full-time equivalents (FTEs) and an annual turnover rate of 20 percent would spend $5.52 million a year to support its turnover. Cutting the turnover rate to 15 percent (a 25 percent reduction) would result in direct savings of $1.38 million per year (Kosel and Olivo, 2002). The Advisory Board estimates $800,000 in savings to a 500-bed hospital from reducing RN turnover from 13 to 10 percent (Advisory Board Company, 2000 as cited in Aiken et al., 2001). Likewise, a 2001 study conducted by VHA Inc.’s Consulting Services showed that organizations with higher turnover rates (21 percent or greater) had a 36 percent higher cost per discharge than those with a turnover rate of 12 percent or less. In a separate study of 235 hospitals, low-turnover organizations (those with turnover rates of 4–12 percent) were found to average a 23 percent return on assets, compared with a 17 percent return for organizations with turnover rates of more than 22 percent (Kosel and Olivo, 2002). JCAHO (2002) has concluded that there is a strong business case for actions that increase nurse retention.
There also is evidence that adopting health care practices that increase safety can decrease some HCO costs. Increased patient safety has obvious advantages to society and the economy at large, but the financial (business) advantage to an HCO is not always as visible. In case studies of the business case for four medical interventions (i.e., use of a lipid clinic, diabetes management programs, a smoking cessation program, and a workplace wellness program), favorable benefits were estimated to accrue to patients and society at large, but effects on the provider of care generally were judged to be financially unfavorable (Leatherman et al., 2003). However, these case studies did not analyze the costs to HCOs due to errors in health care that might have taken place in the absence of these interventions (i.e., lipid clinic, diabetes management programs, a smoking cessation program, and a workplace wellness program).
Costs to HCOs resulting from medical errors include operating, legal, and marketing costs. When preventable medical errors occur, the organization incurs the immediate cost of staff resources involved in reporting the error to internal (and external, if required) entities and in intervening to prevent recurrence and mitigate the effect of the error. Risk managers and providers expend time in generating reports and designing and carrying out error analyses. An HCO also may incur additional patient care costs created by the error, such as costs associated with transfer to higher level of care, use of additional diagnostic resources, or an extended hospital stay.1 If legal claims are made, direct costs incurred include legal fees, settlements and payments, and the time expended by risk management personnel. Indirect litigation costs include time spent by providers and others in litigation and depositions, which not only decreases productivity, but also can impair morale. Long-term legal costs include higher premiums. Marketing costs are also increased in efforts to contain “bad press” and loss of market share (Weeks et al., 2001).
A review by the Agency for Healthcare Research and Quality (AHRQ) of practices used by hospitals to decrease adverse drug events (ADEs) found that costs to hospitals (excluding malpractice and litigation costs) increased as a result of the ADEs occurring within their facility. These increased costs resulted in part from extended lengths of stay. Patients who experienced an ADE were hospitalized an average of 8 to 12 days longer than those who did not experience such an event. AHRQ estimates that, depending on facility size, hospital costs for all ADEs can be as high as $5.6 million per hospital. AHRQ notes that before the advent of managed care, hospitals would have shifted a large portion of these costs to the patient or the insurer. Today, hospitals are more likely to have to absorb the added expense (AHRQ, 2001).
LDS Hospital in Salt Lake City, for example, found in a 4-year, matched case-control, severity-adjusted study that the occurrence of the ADE resulted in an average increased cost to the facility of $2,013 (p < 0.001), with a range of $677 to $9022. In 1992, direct hospital costs for ADEs were $1,099,413; over the 4-year study period, the excess hospital costs attributable to ADEs totaled $4,482,951 (not including liability costs or the costs associated with injuries to the patient). The authors estimate that, at the time of the study, if 50 percent of the ADEs had been potentially preventable, successfully targeted programs could have saved more than $500,000 annually (Classen et al., 1997). AHRQ notes that a 50 percent reduction in
ADEs is realistic; a number of studies have indicated that between 28 and 95 percent of ADEs are preventable (AHRQ, 2001).
Tracking patient safety errors also can result in cost savings. At LDS Hospital in Salt Lake, such tracking identified 25 ADEs related to a new brand of the drug vancomycin. This brand was being used because it cost $5,000 per year less than the brand used previously. However, LDS discovered that treating the patients who suffered these ADEs cost $50,000 in extra care expenses. Without its error-tracking system, the hospital would have assumed it was saving $5,000 per year when it was actually spending an additional $45,000 per year (Classen et al., 1997).
However, HCOs should not wait for proof of the financial advantage that will accrue to them before pursuing the patient safety recommendations contained in this report. The committee believes that pursuit of patient safety is an ethical and professional obligation of those who work in a health care system that aims to “first, do no harm.” A number of HCO chief executive officers (CEOs) who are investing in high-cost patient safety systems and information technology infrastructure agree (Kinninger and Reeder, 2003; Solovy, 2003).
ADDITIONAL RESEARCH IS REQUIRED TO FURTHER INCREASE PATIENT SAFETY
Changing health care delivery practices to increase patient safety must be an ongoing process. Research findings and dissemination of practices that individual HCOs have found successful in improving patient safety will help HCOs as learning organizations add to their repertoire of patient safety practices. The committee calls attention to several areas in which, at present, information is limited about how to design nurses’ work and work environment to make them safer for patients.
Information on Nurses’ Work
As noted in Chapter 3, because data are not collected routinely on the activities performed by nurses and how nurses spend their time, it is difficult to measure the effects of interventions aimed at redesigning care to improve safety or efficiency or to understand the implications of policy changes for nursing practice. Research is needed on how to collect information on nurses’ work on an ongoing basis.
Better Information on Nursing-Related Errors
Because medication errors constitute a large share of all health care errors, medication administration by nurses has received a great deal of attention from researchers and system designers aiming to develop safer
medication administration processes. Handwashing and nosocomial infections have similarly received attention. However, other nursing activities that might offer the potential for high-yield increases in patient safety are unknown. Analysis of data from state and other error-reporting systems might help identify such procedures or nursing actions and attract the attention of multiple HCOs, offering a critical mass of initiatives for identifying safer patient care practices.
Safer Work Processes and Workspace Design
Similarly, research is needed in how to increase the safety of other specific nursing work processes, such as patient monitoring. Moreover, although Chapter 6 identifies a number of strategies for improving the layout of nursing units and patient care rooms to increase nursing time and the ease of patient hospitalization, these strategies have to date been identified primarily through focus groups and ad hoc user input. Research comparing different layouts of nursing units and patient rooms would help identify principles and practices of safer workspace design.
A Standardized Approach to Measuring Patient Acuity
As discussed in Chapter 5, HCOs use a variety of tools to measure patient acuity as a basis for allocation of nursing staff and other managerial decision making. Nursing research, such as research on staffing levels, often needs to adjust for or otherwise address the acuity levels of patients. However, there is no standard method used across all hospitals for measuring the severity of illness of all hospital patients. This lack of a standardized approach hampers interpretation of research results in the aggregate.
Safe Staffing Levels at the Level of Different Nursing Units
The committee finds evidence for the effect of nurse staffing levels on patient safety to be highly convincing. As discussed in Chapter 5, however, generalizing the results of hospital-wide staffing studies that combine data from all nursing units to the diverse patient care units within hospitals is inappropriate. More studies are needed on the effect of staffing levels within certain types of nursing units (e.g., medical–surgical, labor and delivery), as has been done for intensive care. (The committee believes additional studies of intensive care unit staffing are also needed). The committee notes that such research will be challenging because the smaller number of patients found in individual care units will make statistical analysis difficult. We reiterate that, to best interpret the aggregate findings of such staffing stud-
ies, a standardized approach to measuring and adjusting for patient acuity will be needed.
Strategies to Help Night Shift Workers Compensate for Fatigue
The evidence reviewed in Chapter 6 clearly shows that workers, regardless of the degree to which they are rested, are affected by work hours that are in opposition to the body’s normal circadian rhythms—that is, night shift work hours. Research is needed to identify strategies that can help nurses combat the effects of such work hours.
Research on the Effects of Successive Days of Working Sustained Work Hours
Continued research is needed on the effects of sustained work hours. In particular, such research needs to address the number of successive days that should be worked without a day or days off.
Research on Collaborative Models of Care
Chapter 5 and Appendix B review the benefits to patient safety that are likely to accrue as a result of effective interprofessional collaboration, including approaches to team care. Based on the evidence presented in Appendix B, the committee concludes that there is a need to better understand the mechanisms that produce effective collaboration and team processes:
What interpersonal and group interaction processes contribute to effective collaboration and delivery of safe care? A number of theories exist concerning how teams perform and how their behaviors contribute to safe or unsafe practices. Additional information is needed about which of these theories are most applicable to the delivery of quality health care and which approaches in health care and other industries demonstrate the most potential for favorable effect.
How can effective collaboration among groups of health care practitioners with differing characteristics—such as different skill levels (novice nurses versus competent, proficient, or expert nurses) and different duration of employment (e.g., rotating residents and float nurses)—be achieved? What other factors influence effective collaboration, and what strategies are effective in addressing them?
How do environmental influences affect team performance? For example, what are the effects of stress, organizational culture, and leadership in facilitating or structuring collaborative care?
How applicable are crew resource management principles and other non–health-related strategies in achieving collaboration and error reduction?
How can more-productive interpersonal interactions be fostered across the multiple ways in which health care workers interact (e.g., in dyads, small groups, and unit-based teams)? What interpersonal behaviors facilitate effective interaction, decision making, and error prevention? How can these behaviors best be taught?
In light of the above research needs, the committee makes the following recommendation:
Recommendation 8-1. Federal agencies and private foundations should support research in the following areas to provide HCOs with the additional information they need to continue to strengthen nurse work environments for patient safety:
Studies and development of methods to better describe, both qualitatively and quantitatively, the work nurses perform in different care settings.
Descriptive studies of nursing-related errors.
Design, application, and evaluation (including financial costs and savings) of safer and more efficient work processes and workspace, including the application of information technology.
Development and testing of a standardized approach to measuring patient acuity.
Determination of safe staffing levels within different types of nursing units.
Development and testing of methods to help night shift workers compensate for fatigue.
Research on the effects of successive work days and sustained work hours on patient safety.
Development and evaluation of models of collaborative care, including care by teams.
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