Getting nurse-patient ratios right

Nursing unions are campaigning strenuously in Washington, DC and state capitals for legislation mandating nurse-patient ratios in hospitals. They are right to highlight the connection between those ratios and quality healthcare, but the solution that they propose focuses on the wrong end of the problem and is generating a political stalemate rather than progress. The best way to address the problem is not through mandates but through optimal management of patient flow and transparency.

The political stalemate is already evident. In 2004, California mandated nurse-patient ratios in hospitals. In the 10 years since, no other state has followed its lead.

The issue is not the connection between appropriate levels of nursing and quality care; that's beyond dispute. The issue is how to achieve those appropriate levels.

Mandating nurse-patient ratios simply builds in a required level of nursing, which ignores the reality that patient flow fluctuates dramatically in hospitals, resulting in overstaffing on some days and understaffing on others.

Hospitals throughout the nation typically suffer from what I call "Peak Day Related Disease". That's a condition caused by inefficiencies due to artificial peaks and valleys in patient demand: too many patients on some days and too few on others.

Mandated nurse-patient ratios require that hospitals never dip below a certain point. That means that hospitals must staff to the peaks, leaving the hospitals overstaffed at all other times and the inefficient peaks and valleys intact.

The challenge is, therefore, to smooth the flow of patients, so that staffing levels are consistently appropriate for quality care. That requires hard work on the part of hospitals to implement proven operations management techniques, but that hard work is essential to ensuring an appropriately steady stream of patients and, therefore, appropriate staffing levels.

The hard work involves techniques such as the following:

- Separating scheduled admissions from non-scheduled ones – the predictable from the unpredictable – so that scheduled admissions can be more efficiently managed.

- Clarifying before surgery where a patient will go after surgery – to intensive care or a particular floor of the hospital – to ensure that a bed is available at the optimal location.

- Addressing backlogs at emergency rooms, so the beds to which patients needing admission should be sent are not overtaxed by artificial peaks in patient demand.

The widespread adoption of electronic medical records can also help enhance patient flow, as crucial information can be captured on who needs access to what care, when, and for how long.

With that information available and those techniques employed, decisions can be made on how best to allocate vital resources to ensure appropriate patient flow, staffing levels, and patient outcomes.

Fourteen hospitals participated in a recent 15-month patient-flow collaborative organized by the New Jersey Hospital Association, in conjunction with the Institute for Healthcare Optimization. The results were impressive:

- 11,800 to 17,300 additional patients were treated without adding inpatient beds or operating rooms;

- Roughly 20,000 additional patients could be accommodated in hospital emergency departments;

- Wait times for emergency department patients to be admitted to a hospital bed decreased 21 percent to 85 percent.

Those results are significant, because smoothing the flow of patients increased the efficient use of existing facilities and thereby avoided the need to add facilities or nurses to accommodate peaks. Hospitals tend to build to the peaks, just as nurse-patient ratios would have them staff to those peaks.

Adding facilities is enormously expensive. The capital cost alone of a medical or surgical bed is between $1 million and $3 million depending on the part of the country. Avoiding the capital cost – as well as the expense of operating those new beds – frees up funds for staffing existing beds at appropriate levels.

In the end, the goal should not be prescribed nurse-patient ratios but high-quality and efficient care. That's what patients want and deserve, and that's where transparency is so important. Greater transparency should be mandated on two fronts: quality of care and nurse-patient ratios.

Letting the public know what kind of care and attention they can expect will have the greatest impact on ensuring appropriate nurse-patient ratios and improving patient outcomes.

Eugene Litvak, Ph.D., is President & CEO of the Institute for Healthcare Optimization, and Adjunct Professor at the Harvard School of Public Health.

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