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Nurse staffing costs must be weighed against cost of errors


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Rebecca Hendren, for HealthLeaders Media, August 30, 2011

When revenues fall, hospitals stop investing in the biggest budget expense: nurses. That's a bad short-term solution to a long-term problem. It's time we change the way we think about hospital staffing.

"When we look at all the problems we have [in healthcare right now], what is the first thing we do? Start slashing nurses," says Kathy Douglas, MHA, RN, president of the Institute for Staffing Excellence and Innovation, CNO of API Healthcare, and a board member of the journal Nursing Economic$, which has devoted a whole issue to examining the evidence around nurse staffing.

"Healthcare executives and nurse leaders need to be more aware of thinking about staffing and scheduling from a bigger perspective so we understand all of the financial implications," she says. "How do we manage our way effectively through the maze and chaos we are in right now?"

To deal with ongoing challenges presented by value-based purchasing and healthcare reform, executives must acquaint themselves with studies demonstrating how nurse staffing affects a hospital's overall performance and base staffing decisions on evidence.

"What we know from research and experience is that there are very direct links between staffing and length of stay, patient mortality, readmissions, adverse events, fatigue-related errors, patient satisfaction, employee satisfaction, and turnover," says Douglas. "All of these things have studies that directly relate them to staffing. And all have the potential for significant costs. When we don't look at the relationship between our LOS and our unreimbursed never events and our staffing, we're not looking at the whole picture."

Too few hospitals track staffing data in comparison to these big issues.

"Some of these things people might call 'soft costs,' like nurse turnover," says Douglas. "But to me, money is money."

Soft costs have hard financial implications. Value-based purchasing has already put real money behind patient satisfaction. To make the link to staffing research and why it matters, we have to stop looking at staffing numbers in isolation. Until we look at the whole picture, which includes everything associated with staffing, we're not going to understand financial performance.

"Staffing costs sit in one part of the budget, so we think of the results there," says Douglas. "Then the cost of errors sits in another part of the budget. If I could say one thing to healthcare executives it is to make staffing a top strategic priority in your organization. If you look at top priorities-LOS, safety, quality-all of these things have direct links to staffing."

An organization that has cut back on staffing may not notice that it is overusing overtime and not notice that there's a relationship between the overtime and the number of infections on a unit.

Peter I. Buerhaus, PhD, RN, FAAN, chair of the National Health Care Workforce Commission, a 15-member panel composed of distinguished leaders from academia and the healthcare industry created under The Patient Protection and Affordable Care Act, published research in 2008 looking at unreimbursed errors in healthcare, such as catheter-associated urinary tract infections and central line infections.

"I decided to get out my calculator and add them up. When I looked at it in one year the total came to $21 billion in unreimbursable events," says Douglas.

"When hospital executives tell me there's not enough money to staff well, my first thought is 'what about the $21 billion we spend each year on unreimbursed never events?'"

Douglas believes the answers lie in using data and evidence to make effective decisions and utilizing technology in decision making. She is not a fan of blanket ratios.

"It's not that ratios are bad in and of themselves. Ratios happened, in my opinion, because hospital leadership and nursing weren't communicating well," she says. "My issue with ratios is that it assumes [staffing] is about a number. I disagree with that. It's not about a number. It's about the right number with the right qualifications with the right competencies with the right experiences."

Douglas says hospitals need to be free to examine all the factors and design a system that is flexible and allows flexing up and down based on patient needs and professional nurses' best judgment.

To do so, we need a better understanding of what the research shows about nurse staffing. We also need nurses who understand how they contribute to overall performance and who are accountable for that role.

Source: HealthLeaders Media