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As workloads increase, does quality suffer?
Peeling minutes off of cycle times, multitasking at every opportunity — we hail such strategies as success. But this month, QI/TQM takes a look at the underside — the stress brought on by the push to work harder, faster. What does it do to the quality of clinical decisions? Is it driving away highly trained, experienced staff who chuck their positions for alternate career paths or early retirement? And, finally, what role does the current worker shortage play in health care’s need to keep a fresh supply of qualified employees?
If you’ve gone to any job fairs lately, you know that health care recruiters are right out there with the rest, courting workers and offering signing bonuses and flexible hours. The frenzy to recruit is due partly to the country’s low unemployment rate. Last March, the U.S. Department of Labor reported that 95.8% of the work force had jobs. Unemployment is the lowest since 1970.
Another side of the picture, however, is the average age of the health care work force. It’s over 40, observes Patrice Spath, a consultant in health care quality and resource management with Brown-Spath & Associates based in Forest Grove, OR. Consider the implications: If you’ve ever tried telling a 50-year-old that, starting next week, she’ll have to work faster and smarter, you know she’s not likely to respond cheerfully. "Where a 25-year-old might see change as a challenge," Spath explains, "a 50-year-old wants a more comfortable, predictable job. And health care jobs are anything but comfortable and predictable. So we see a lot of 50- to 55-year-olds retiring rather than learning how to work faster and smarter."
A study by the Hay Group of Walnut Creek, CA, confirms Spath’s point. Retirement ranks as sixth among the 29 most common reasons for job changes among nurse middle managers, and 11th for registered nurses. (For other findings from the study, see box, at left.)
Still another piece of the picture is the downtime from job-related injuries. It escalates among older employees, says Susan Johnston Lynx, RN, JD, director of practice, education, and policy for the Minnesota Nurses Association in St. Paul. When hospitals are hurting for clinicians in the first place, it doesn’t help when people have to stay home with injuries.
According to the association’s (soon-to-be-updated) research, injuries among RNs rose 65% between 1990 and 1994. Among technicians, respiratory therapists, and other staff, the increase was 116%, and 85% among other professionals. The causes, Lynx says, lie in the more serious nature of illnesses among hospitalized patients and leaner staffing patterns.
While common sense might lead us to conclude that heavier workloads compromise excellence of care, others say it is not so. QI/TQM asked Colleen Conry, MD, whether the press to see larger numbers of patients affects the clinician’s ability to know patients well enough to make good diagnoses. "I have no concrete evidence to say it does," says Conry, president of the Denver-based Colorado Academy of Family Physicians. "[Clinicians] believe it’s healing to know patients, to have time to talk with them about their health. It’s one of the things we value. While we get very good at doing it faster, we could reach a limit at how fast we can go. But I have not yet seen it as a widespread problem in the quality of care."
Spath suggests that when job responsibilities are reconfigured, they offset larger numbers. Bedside nurses are taking care of more patients today, she concedes, "but often they are doing fewer functions. Nurses themselves are struggling with the question of how much nursing time is needed if they are doing clinical assessment instead of changing bed sheets. It’s not unusual to see big hospitals with 25 to 30 case managers doing some of the care coordination and discharge planning that nurses used to do."
Spath says that even in the heat of finding workers in a tight labor market, the technical quality of the health care work force is adequate. But, she adds, the quality of service is being undermined because younger workers do not have the interpersonal skills that it took their senior colleagues years to polish.
Within nursing circles, the jury is still out on the effect of fast work on the quality of care. The concern of the moment centers on the scarcity of nurses. A study by the American Organization of Nurse Executives in Chicago shows that even when facilities look for nurses, they have trouble finding them, especially experienced ones.
For example, it takes 45 days on average to fill vacancies for experienced nurses and 20 days to fill vacancies for new graduates. "That’s a lot of patient days on understaffed units," Lynx notes. (See "Nursing shortages compound workloads and tight budgets," p. 68, and "Nursing schools offer dim hope for fresh troops," p. 69.)
Downsizing creates local shortages, she adds. "When nurses get laid off, a lot of them move on and find other jobs, inside or outside of health care, so when hospitals need to increase their staffs, the nurses are not available to come back."
Through state and national nursing contacts, Lynx hears about ethical dilemmas rising from the combination of larger workloads and higher numbers of gravely ill patients. "They’re not complaining about breaks — those went out a long time ago. But assessment time is a big frustration for nurses," Lynx contends. Although she points out that her information is anecdotal, she adds, "I hear many of them say they are frightened for patients’ safety when they feel they cannot do good nursing assessments. A lot of them are getting out of direct patient care because they don’t feel safe. Good nursing care depends on thorough assessment, just as good medical care depends on physicians having time to do their exams." For example, she explains, "Intensive care units, by regulation, must have a certain number of RNs per patient. But nurse aides are not regulated — so they get laid off. That leaves the nurse to do nursing and non-nursing tasks. Care becomes fragmented."
Conversely, where regulations allow higher numbers of less-skilled personnel, Lynx says, licensed nurses face a similar problem. "Patient information gets lost because the unlicensed person doesn’t recognize what’s important to pass on to the RN, or nurses don’t have time to collect data for full clinical assessments." She also expresses concern about pre-surgical intake interviews, which are often conducted by minimally trained workers via telephone the night before the patient is admitted for surgery.
Pharmacists have not escaped the industry’s efforts to do more with less. "For the first time, we are seeing pharmacist shortages in pockets around the country," says William Ellis, RPh, MS, executive director of the American Pharma-ceutical Association Foundation’s Quality Center in Washington, DC. A quality of work life study, conducted by the foundation in conjunction with George Washington University, shows a significantly lower level of job satisfaction for pharmacists in hospital/institutional settings and chain/ supermarket pharmacies than those in independent pharmacies or other practice settings. (For selected findings, see chart, p. 67.)
And, yes, time pressures do compromise a pharmacist’s ability to do a thorough job, although "we may not see a connection as far as documented studies are concerned," notes Ellis.
Even so, the pharmacists’ situation represents a dichotomy. "Part of the answer to the time pressures on other clinicians can be found in the pharmacy department," he points out. But one of their great frustrations comes from being treated as pill counters instead of skilled contributors to collaborative provider teams, Ellis adds.
With cost reduction and quality improvement efforts, however, he is optimistic about the growing recognition of pharmacists’ skills and their role in good patient outcomes.1 "For some pharmacists, this a time of crisis, and for others, it’s an opportunity," he explains.
"There’s a greater realization that appropriate medication use impacts on quality. When pharmacists get involved in direct patient care issues, patient outcomes are better. So health care systems and providers are beginning to see pharmacists as an untapped resource to produce a better quality of patient care," Ellis says. (For more on this issue, see QI/TQM, February 1999, p. 17.)
The belt tightening reaches beyond hospital walls into physicians’ offices, according to a study by the Englewood, CO-based Medical Group Management Association. Between 1996 and 1998, net revenues, after operating costs, dropped 5.5%. "It is a daily struggle to find a balance between what we want to do for our patients and insurance not reimbursing. It’s hard to survive," admits Conry. (See "Medical practice overhead outstrips revenue by 5%," above, for figures on the disparity between costs and earnings in doctors’ offices.)
Conry says she is not convinced that managed care is the problem. It just happens to be today’s economic solution to the enormously expensive job of providing health care in a society where the clinical "tool box" grows each year.
It’s even more complicated when clinicians and patients hold different values, she notes. For example, sometimes patients want prescriptions for antibiotics, while doctors would rather use the time to teach them why antibiotics are not good treatments for their problems. Patients drive up costs when they choose convenience over appropriate use of resources, Conry adds, by going to the emergency room after hours for non-urgent care.
She predicts that before the growth of new health care products and consumer demand peak, providers will hit the wall in how much they can do with limited resources. She insists, "We have to be sure that patients are part of the solution to this issue."
1. Classen DC, Pestotnik SL, Evans RS, et al. Adverse drug events in hospitalized patients: Excess length of stay, extra costs, and attributable mortality. JAMA 1997; 277:301-306.