Redesign calls for rethinking processes and revamping organizational culture

Even the big guys aren't immune to its difficulties

(Editor's note: The very nature of redesign challenges traditional work roles and organizational hierarchies. Even facilities with stellar reputations for clinical quality are not immune to its challenges. Here's the story of the Cleveland Clinic Foundation, where staff have experienced some of the same basic redesign problems that have challenged lesser-known facilities.)

As mergers transform small hospitals into investor-owned giants that demand rigorous standards of higher quality care and lower costs, these investor-owned entities also affect the way traditional not-for-profit health care does business.

The Cleveland Clinic Foundation (CCF) is a good example. When it found itself competing with two new for-profit systems in the area, administrators decided to respond by pledging to provide health care that was faster, cheaper, and friendlier than the competition. But instead of downsizing, they wanted to reorganize.

"We wanted to position ourselves to make a dramatic improvement in critical performance measures such as cost, quality, capital, and speed of delivery service," explains Sharon Coulter, RN, MBA, the former chairwoman of patient care operations at CCF. Coulter is now vice president of Patient Services at Via Health, an integrated delivery network in Rochester, NY.

The challenge brought a fundamental rethinking of everything that is near and dear to an organization: its processes, job definitions, structure, management and measurement systems, as well as values and beliefs, she says.

The effort would begin by piloting a new care delivery method on the orthopedics and surgery units: Nurses, who would assume more of a managerial role, would be paired with patient care technicians. Patient service associates would assume the "guest services" role.

The redesign team at Cleveland Clinic began by asking the nursing staff, rather than the managers, for ideas on how to improve their work. "We wanted to ask the people who do the work to help redesign the work," explains Coulter.

To analyze their current work, Coulter and a team of staff nurses, nurse managers, researchers, and educators asked the group three questions:

1. What is the outcome of this task or job, and is this outcome still viable in the present environment?

2. How is the task currently being performed? Can it be done more simply or more efficiently?

3. Who is currently performing the task? Is the task being performed by a person at an appropriate skill level?

Putting ideas on the table

The staff then brainstormed as they discussed all the individual jobs and tasks they regularly performed, Coulter adds. "This list covered a 12 x 12 wall and provided the framework from which we developed the subsequent steps," she says. "The task delineation enlightened the RNs because it revealed that much of their time was consumed by activities that did not maximize either their professional education or licensure."

Referring to state regulations as a guideline, the team then reviewed each task to determine whether a licensee was required.

Next, the team sorted tasks that could be performed by unlicensed personnel into clinical and non-clinical categories to create two new roles: the patient care technician and a patient care associate. The first, which replaced nursing aides, sets up equipment, assists patients with activities of daily living (ADL), takes vital signs, and is partnered with an RN. To prepare the patient care technician, nurse education and clinical nurse specialists offered clinical and classroom classes in a six-to eight-week program. For example, one of the skills taught was how to take vital signs and how to promote ADL.

The patient care associate cleaned rooms, transported patients, and restocked supplies. Formerly managed by the housekeeping department, the associate in the new plan is supervised by the unit's nurse manager. Training for these positions was a two-week program from other departments, such as environmental services, which showed correct procedures for cleaning rooms.

The pilot plan also called for redefining the nurses' roles. Nurses received training in managed care, case management, task delegation, supervision, and interviewing job applicants.

"The new role called for them to move from focusing considerable time on activities that didn't utilize their professional stills to functioning at their upper limit of professional education and licensure," Coulter explains.

RNs act as case managers who direct the process of care during and after the patient's hospitalization. The redefined role allows nurses to spend more time preparing patients for care in less-costly environments such as subacute, rehabilitation, ambulatory care, and home care.

"Today there is a better understanding of the patient's needs after discharge," she explains. Even more importantly, the role change helped nurses pay more attention to helping the patient regain health and functional status rather than merely treating the patient's disease."

The skill mix on the two pilot floors, orthopedics and surgery, went from 80:20 (RNs to nursing assistants) to 60:40 (RNs to patient care technicians/service associates).

"This mix allowed for an increase in the number of available personnel - although a greater proportion of them were technicians and associates - while keeping the budget neutral," Coulter notes.

No RNs on either of the redesigned units lost their jobs. "We used unfilled budgeted positions to create positions for technicians and associates," she explains.

Rethinking redesign

Although the redesign elements were expanded to the medical cardiology unit, it hasn't been implemented house-wide, notes Linda J. Lewicki, PhD, RN, senior nurse researcher at CCF.

"We have to work through some of the basic issues that surfaced in the evaluation," she says.

Lewicki used the Job Diagnostic Survey to evaluate these employee responses to work design:1

· specific job dimensions, including activities such as skill variety, task significance, autonomy, and dealing with others;

· experience of psychological states, including meaningfulness and responsibility of work and knowledge of results;

· responses to the job, including general satisfaction, motivation, growth, and supervisory satisfaction.

The scores varied by unit and category of worker, says Lewicki.

"On each unit for each type of worker, some scores remained the same, some showed more satisfaction with the job, and some showed less satisfaction," she says.

For example, one of the redesign units had a statistically significant fall in "skill variety" scores. "When we looked at this, we found technicians were concerned they weren't able to perform the tasks for which they were trained. There was also some difficulty with issues regarding RN delegation skills," she explains.

The other redesigned unit had a statistically significant decrease in the score experience of psychological states. "This indicated that a new team had been assembled; however, trust, teamwork, and partnership had not yet solidified," she explains.

For example, nurses who were accustomed to primary nursing found it difficult to delegate tasks such as having technicians bathe patients.

"They felt they would be missing an opportunity for assessment," Lewicki explains. "Remember, this generation of nurses has been taught to rely on self and no one else. They felt that quality of care would suffer if they delegated certain tasks."

Although the redesign leadership team continues to offer classes on delegation and team-building, they acknowledge it "takes awhile to change attitudes." (See tips on countering resistance to change, p. 43.)

The team is also working on refining the role of patient care associate. "There was some concern that the rooms weren't being cleaned fast enough for a quick room turnover," she explains. "We are questioning whether the associates have too broad of a role, so we are looking again at what work must be accomplished and what role best fits that work."

But the redesign team is being careful not to diminish the intrinsic rewards of the redesign. "One of the best success stories of this effort was that many of the associates reported that for the first time, they feel part of the health care team," she says.


1. Hackman JR, Oldman GE (1975). The Job Diagnostic Survey: An instrument for the diagnosis of jobs and the evaluation of job redesign projects: Springfield, VA: U.S. Department of Commerce (AD-779 828).