Hedge against downsizing: Numbers you need to know

Nurses must show how they add value

(Editor's note: St. Joseph's Hospital of Atlanta was one of the first hospitals in the country to receive Magnet status. Chief Nurse Executive Vickie Moore opened her presentation at last month's Magnet conference with this anecdote she called "the two-for-one sale.")

CEO to CFO: I hired you to maintain the bottom line. Why all this red ink?

CFO to CEO: I've figured out the problem. It's the nursing budget. We need half as many nurses and twice as many unlicensed assistive personnel!

Yet, eroding job security is no laughing matter. In her presentation, Moore discussed how nurses need to articulate value to the organization and survive professionally.

If a CEO walked onto the floor and asked a staff nurse at random what he or she does, the chances are the reply will be "Take care of patients," explains Moore. "And if you asked them what they have done to improve care or reduce costs, many of them wouldn't be able to answer at all," she says.

In this era of downsizing and declining reimbursement, nurses must not only move away from their "patient task" mentality, but be able prove their value to the organization.

"If, as nurse, I am viewed as someone who interacts with the patient and uses resources, then I am a liability and someone who can be replaced," she says. "But if I present myself as someone who saves the organization money by lowering cost and improving outcomes, then I am perceived as being an asset."

She cites clinical pathway development as an example of nursing-led initiatives that gain the attention of administrators. At St. Joseph, a total hip replacement path lowered hospitalwide costs by $350,000 and length of stay (LOS) from five days to 3.7, Moore says. Another pathway for abdominal surgery (DRG 148), decreased the LOS by four days and cut costs by $5,000 per case.

"Those are the kind of figures nursing needs to be able to tell administration," she points out. Moore adds that it's also important for nursing not to lump its figures in with other data. "You need to know not only what is the total cost per patient day, but also the nursing cost per patient day," she says. Such information can pinpoint benchmarking and best practices opportunities.

Case management is another area in which nursing can take the starring role. "Let them know how case management lowered readmission rates," she says.

In both pathways and case management, nurses need to learn to consider more than just the acute care setting.

"As hospitals become part of a larger health care continuum, nurses need to show they are also thinking in those terms. A pathway, for example, should include subacute, outpatient, and home care components. Case management also needs a community focus. "For example, congestive heart failure patients can be more effectively managed in a community clinic than an inpatient setting," she explains. "Extension education and monitoring from nurses can result in fewer readmission rates and lower cost of care."

Nurses also need to internally benchmark the number of hours spent in direct bedside care. "In our 1993 study, we found we were spending 26% in direct patient care. Eighteen months later we were up to 35%; two years later up to 43% and now we are up to 47%," Moore says.

The secret was reducing the inventory, transport, and paperwork functions by reassigning them to other less skilled (and lower-paid) workers. (For more information on how the St. Joseph nursing team increased the ratio of direct patient care, see the February 1998 issue of Patient-Focused Care & Satisfaction.)

"We let nurses do what they do best - nursing," she says. "Nurses are the only caregivers who can assess, plan, and evaluate the total plan of care," she stresses.

Yet, Moore cautions that in their quest to prove their profession's worth, nurses shouldn't overlook the fact that unlicensed assistive personnel are, in many places, a fact of life.

"We must learn to be managers. To operate efficiently, we must know the background of the UAPs and their skill level and delegate tasks appropriately," she says.

Working with UAPs also calls for frequent follow-ups and assessments of their efforts. "Make sure that what you said should be done is being done correctly. It's not like working with an RN colleague whose education and experience are like your own," she says.