The 'hard truth' about staffing shortages: They aren't going away

Instead of studying the connection between hospital staffing shortages and patient outcomes and satisfaction, it's time to implement effective strategies that focus on solutions. 

In a Dec. 28, 2022, tweet, Megan Ranney, MD, newly appointed dean of the Yale School for Public Health in New Haven, Conn., wrote, "What is shocking to me, is that debate still rages as to whether doctors & other healthcare professionals are actually human — whether having us over-worked, under-staffed and under-resourced hurts patient care." 

Unsurprisingly, a recent study suggests it does.  

Dr. Ranney referenced a Harvard Medical School study published in BMJ Quality & Safety that found a "dramatic reduction in medical errors when first-year resident physician work hours were limited." 

Further, according to the study, when a 16-hour shift work limit is placed on residents, "resident-physician-reported medical errors and adverse events dropped by more than a third, and medical errors resulting in patient death declined by almost two-thirds."

Leah Binder, president and CEO of The Leapfrog Group, told Becker's when it comes to practicing medicine in hospitals, "there will always be fires that busy clinicians must put out. Now is the time to put a central focus on patient well-being. Hospitals must do what has to be done to focus on patient safety and quality of care. Period."

That being said, will there even be enough clinicians to fight those fires? 

A recent survey by McKinsey & Company found that 1 in 3 registered nurses who provide direct patient care may quit their jobs in the next year. And that's a prediction for the future. The current shortage is causing many nurses to leave the bedside due to burnout and frustration, opportunities for more compensation as a travel nurse or retirement. 

Further, according to a study published in Academic Medicine, up to one-quarter of physicians' time is spent on administrative duties.

Ms. Binder pointed to two health systems — Virginia Mason Franciscan Health and Duke Health — as models that hospitals can use to reduce redundancies, allowing clinicians to focus on priority work and collaborating to reduce mistakes and improve patient safety, satisfaction and, ultimately, outcomes.

Dianne Aroh, RN, chief nursing officer at Seattle-based Virginia Mason Franciscan Health, said it comes down to priorities because it's impossible to do it all. She suggested clinical leaders "shift their mindsets to change workflows by removing tasks that are not necessary when looking to provide quality care."

The problem of hospital staffing shortages isn't going to solve itself. Ms. Aroh said accepting that your organization needs to make changes means acknowledging what she called "the hard truth." 

"The first step toward improvement is accepting reality. The nursing shortage isn't going anywhere," Ms. Aroh said. "Every time something like this happens it gives us the opportunity to do something differently."

Ms. Aroh said hospitals should look back and remember what they did to get through the worst of the COVID-19 pandemic and do that again now. "Review how to implement some of those teamwork-oriented initiatives for the long haul. We learned how to cross-train and cross-schedule," she said. "We had skilled people coming together — nurses, physicians and pharmacists — who all worked together to provide care as a team. Let's learn from what we had to do then and build on those processes now."

The Virginia Mason Production System, launched in 2002, standardizes hospital workflow using similar methodology to lean management.

"A key element of VMPS is understanding that it is not a short-term cost-containment strategy, a series of projects or a set of tools," said Ms. Aroh. "It is a long-term philosophy — a complex socio-technical system that has shaped our culture to one relentlessly focused on high quality, zero defects, exceptional service, innovation and respect for people."

VMPS is based on the premise that by eliminating waste, our hospitals can successfully improve quality and safety and reduce patient costs.

"Also, it utilizes more innovative thinking around staff scheduling," Ms. Aroh said, adding "clinical leaders must be intentional about how things can be done differently if they want to improve efficiency without compromising quality and patient safety."

Ms. Binder said Durham, N.C.-based Duke Health has been "successful in rethinking the nurse's workday to ensure registered nurses are practicing at the top of their capacity."

Richard Shannon, MD, chief quality officer at Duke Health, said it comes down to determining necessary tasks and activities that simply waste time that could have been spent at the bedside.

"No amount of pleading and wishing or brow beating will affect the necessary change. We must work on improving the 'system of care' through work,'" Dr. Shannon told Becker's. "We ask our front line-team members to attend to sick patients. It is the job of leaders to address 'sick systems' in which these teams work."

The job of hospital leadership is to address the problem by determining what tasks are value-added and which tasks amount to wasted time, according to Dr. Shannon. 

As an example, upon observation at Duke Raleigh (N.C.) Hospital, leaders learned nurses spend 30 percent of their time documenting at a computer and 30 percent in other time-wasting activities.

Given staffing shortages, the work of clinical care delivery must be redesigned, Dr. Shannon said. "This requires understanding the current conditions, knowing how care is delivered today and what needs to be changed based upon what activities create value and what activities are wasted time," he said. 

He called upon chief medical officers and chief nursing officers to "identify non value-added work (duplicative documentation) and work with their teams to eliminate it. Work must be redesigned and co-created by the people that do the work."

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