Clerical, clinical changes increase nursing efficiency

New system lets nurses be nurses

(Editor’s note: Only six health care systems in the nation have received the Magnet Nursing Services Recognition Award from the American Nurses Credentialing Center in Washington, DC. This prestigious designation acknowledges quality of patient care services and the development of successful, professional nursing practices and strategies. Here is how one hospital used clerical staff to help it win this award.)

How can hospitals reduce nursing costs without increasing skill mix? By letting nurses be nurses — not inventory clerks, patient transporters, or paper chasers, says Vickie Moore, RN, MSN, chief nurse executive and vice president of operations at St. Joseph’s Hospital in Atlanta.

Rather than increasing nursing efficiency by employing more aides, the Magnet hospital changed clerical and clinical portions of its care delivery system. As a result of the initiative, nurses now spend 50% of their time in direct patient care, rather than 38%, says Moore.

"It’s a natural tendency to look at the nursing payroll and to attempt to decrease it by reducing the number of nurses and adding more aides, but a system can also be made more efficient by making changes that allow nurses to do their jobs more effectively," says Moore.

The foundation for the project was laid in 1993 after a Deloitte and Touche assessment surveyed nursing to find how many hours nurses spent in direct patient care as well as what factors prevented them from doing so. "They told us that performing inventory, transport, and paperwork functions reduced the amount of time at the bedside and made many suggestions as to how to change the system," she says.

A "care delivery task force" composed of a clinical nurse specialist, representatives from risk management and quality management, as well as staff nurses, then took the suggestions and devised a time frame and a plan for implementing them.

For the four-month pilot project, the team selected a floor that contained a 23-bed renal/pulmonary unit and a 25-bed medical cardiology unit. "We selected these because they were distinctly different: The renal/pulmonary patients had a length of stay of 5.1 days, and the medical cardiology had 2.42 days," says Shahin Vojdani, RN, nursing project leader. "We figured if these changes would work on the pilot floor they would work throughout the med-surg division."

The team tracked qualitative and quantitative data prior to implementation, including patient falls, medication errors, infection rates, patient satisfaction, overtime/additional hours, hours per patient day for direct caregivers, FTEs, and occupancy rate. "We wanted to make sure that changes were not affecting our quality in a negative way," explains Vojdani.

Although the team members would spend another 19 months implementing the project on 11 units, they provided paperwork relief by implementing several clerical changes house-wide in less than six weeks.

"We wanted secretaries to have more information about the unit’s activities and its patients so they could field telephone questions from other departments and not interrupt the nurses when they were giving direct patient care," she explains. "Our goal was to make the secretary the information person on each unit. (See story, at left.)

To begin the standardization process, team members first collected a sample of each form, such as admission and census forms, and assignment sheets from all units. "Then we asked nurses what they needed each form for and consolidated the essential elements, cutting the total number of forms in half and streamlined the rest," Vojdani says.

The team also created some new forms that would enable secretaries to have more information at their fingertips. "For example, a patient travel log told them at a glance the name and room number, how they were traveling, and whether they had an IV or oxygen. It is done in pencil at the beginning of the shift and updated throughout. When patients leave, information is erased," she explains.

The team also trained secretaries to deflect more distractions for nurses by using new technology to communicate rather than the nosier intercoms. "We bought nurses and assistants pagers that can script a message so secretaries can send a message and nurses can quickly glance down and see if it can wait or needs to be answered immediately," she says.

These intra-and inter-unit devices not only improved communication, but they also reduced interruptions of the bedside nurses. "We held inservices for the secretaries and gave them a very detailed explanation on the why and how of the change," she says. The team also identified one person on each unit — usually the day shift clinical manager — to make sure these changes were carried out.

The team also eliminated the time nurses spent in charging and taking inventory on supplies. "We looked at how much time it to took to apply stickers or bar-codes to send to central supply. It may seem like an insignificant amount of time, but it does add up," she says. The team worked with the finance department to find out how much it actually costs to charge back items under $20. "After they examined how much was lost in nursing time as compared with how much revenue they could get back, it averaged out," Vojdani explains. "We eliminated about 600 items." To make up for lost revenue, charges were increased incrementally.

The team also established par levels for supply stock so material management staff can examine the carts themselves. "Nurses now have no involvement with stocking. We pay them too much to have them be stock clerks," she says.

Who does what and how?

After making clerical changes, the plan called for the following clinical ones:

Assignment changes.

The current shift now makes assignments for the upcoming one, explains Vojdani, who admits there was some staff resistance at first.

"It was hard for them to understand at first that equal numbers of patients do not mean an equal workload. For example, three high acuity patients require as much work as five low acuity ones," she says. To help staff make an easier transition, Vojdani provided inservices on time management, delegation, communication skills, and team building. She also held meetings to help staff on all shifts "talk about the expectations and the appropriateness of their assignments."

End of the shift changes.

All care summaries are collated according to the next shift’s assignment for each RN, she notes. Shift report is also taped. "This way [outgoing] nurses get to spend less time in report, and all the [incoming] staff — including the assistive personnel — get to listen to the whole unit’s report," she explains. "Only the incoming shift is in report, and the outgoing shift is available for patients."

Change in role and responsibilities.

The team also expanded the nurses’ roles to include management of unlicensed assistive personnel. "We use a modified form of primary nursing practice," says Moore. "Every patient has an RN responsible for him or her; every nurse is paired with and supervises a patient care tech."

The clinical changes, however, required a comprehensive planning and implementation process that lasted 10 to 12 weeks on each unit. "We spent about two weeks observing and the rest implementing clinical changes. We did not leave a nursing area without making sure the staff had a good understanding of the new model," Vojdani explains.

Vojdani shares with Patient-Focused Care and Satisfaction the steps the team took on each unit to ensure success.

1. Prepare staff.

The vice president of nursing and the project leader met with the staff and presented an overview of the upcoming clinical changes as well as why, how, and when they would be implemented.

"I can’t say enough about this preparation process," stresses Vojdani. "We thought we had prepared enough because the majority of the staff would say they understood why it was necessary to make these changes, but when it actually affected them, they had a change of heart!"

The key to preparing staff was the director or manager on the unit. "There was a direct relationship between his or her understanding of the project and the success of the new model on that unit," Vojdani says. "We realized that when directors or managers were supportive, the staff had an easier time during the transition period."

2. Observe.

After meeting with staff, Vojdani spends time on all shifts of each unit to learn about the following factors: patient population, activities, workload, efficiency, overtime. "We did not make changes during this time but made observations and obtained data," she says. Vojdani also considers this observation period as a time to build relationships with staff. "I never went in street clothes; instead I kept scrubs on to send the message ‘I am one of you,’" she says.

3. Communicate with staff.

At the end of the observation period, Vojdani scheduled a meeting with the staff to review the data that were collected as well as to talk about expectations during the upcoming implementation. She continued to communicate by holding meetings throughout the implementation phase. "We went to them on all three shifts and the weekends, rather than asking them to come at our convenience," she explains. The team also informed physicians before making changes that would affect their practices on a unit.

Finally, Vojdani and the team encouraged feedback but discouraged negativity. "We didn’t accept comments such as ‘I don’t like this.’ They had to tell us why they didn’t like a certain change as well as how it could be improved," she says. By insisting on a reason for the resistance, Vojdani and the team could then figure out if the problem was really with the process or the personality.