by Katherine Kany, BS, RN
Chances are you, like most of us, have more anecdotal stories about near-misses, “thank God” recollections, and horrifying examples of what goes wrong when staffing is insufficient; when mandatory overtime has been imposed; or staff are left under-resourced for their work. And, it’s also likely that despite the fact you have shared those stories with hospital managers, with policy- makers, with journalists, or with the public, nothing has happened to change policies.
Influencing policy-makers is easier if we can add objective information to subjective recollections, but few of us are fluent in speaking “data,” or aware of what data are even available in our place of work or on our units. You will notice that none of the agencies that accredit healthcare facilities or reimburse them for care provided want stories. Instead, they require data, standardized across facilities, aggregated (or averaged, and monitored over time to show trends. Since policy is made on many levels, from the units, departments, agencies, facilities or schools where you work, to the state and national level, starting as close to “home” as possible is a good way to build skills and to look at what you do, and the impact on the safety and quality of care delivered, through a different lens. Let me give you an incredible example of how this was done by others struggling with similar problems.
Well over 20 years ago, I sat in an educational session that was described as a success story on improving the number of direct staff in a long term care facility (LTC). In the first few minutes, I listened to three CNAs talk about working with a very frail, older-adult population, and the challenges they faced in delivering care to residents with current staffing levels – particularly on day shift. Well, I was more than a bit skeptical about what these presenters could do that I hadn’t tried. And, as we all know, staffing is usually at its best on days in any healthcare setting. Was it really as bad as they thought? I was interested in hearing how they tackled the problem.
Here’s where the brilliance begins to shine!
First—qualifying the problem:
Anecdotes about specific situations are a great way to get attention, but that only lasts for a while. These staffers knew they had to do more than just talk about what wasn’t done, or how they felt patients weren’t getting all the care and attention they needed. So, they met and strategize about how to tackle this chronic problem differently. As a result, they organized a list of all the care activities that were included on “days.” (In some cases, particularly for RNs, these lists might include activities off the unit or communication/interaction with patients and families no longer on the unit.) As you would expect, days included baths, dressings, bed changes, getting patients up and out of bed, meals, etc., etc.
Second — gathering the data:
Once the list was comprised, the CNAs took notebooks around and documented the time associated with various activities. In essence, they did their own time and motion studies by recording the time for everything they did on days. The information was astounding—to them and to me! That which took up five of the eight hours, or 62 percent of their day, was spent on meals!! Passing out trays, hand feeding or encouraging patients to eat, and then getting all the trays and putting them back on the food carts was time and labor intensive.
Even more impressive, the CNAs pulled additional data to show that, despite the enormous time and labor devoted to feeding patients, there was an incremental but steady decline in the monthly weights taken on each of the residents. In doing this, I believe they actually struck gold. This information showed without question that actually more time, or more staff, was needed to feed residents sufficiently in order to help them maintain weight and nutritional status and prevent all the negative sequellae that follow poor nutrition. Just telling staff to work faster around meals would actually be seen as unethical in light of the information garnered from their research.
Third — using existing regulations as a leveraging point for change:
Today, longterm care surveyors see patient weight (trends) as a proxy for quality of care (through attention to nutrition). Facilities risk accreditation status when resident weight loss is significant. I know from personal experience that when patients aren’t eating—whatever the reason(s)—families are pressured to have feeding tubes placed. This begs a longer discussion about ethics, but you can see how tube feeding might address some staffing issues, as well as nutrition needs, in a much more efficient manner. The point here is that looking at state and federal regulations against which hospitals and other care facilities are accredited and licensed, we can find the points where our concerns can be addressed in ways not previously successful.
Almost every hospital in the US accepts Medicare reimbursement and therefore must meet certain requirements from the Centers for Medicare and Medicaid Services (CMS) for data collection and submission. This data is public, very easily accessed, and informs the sufficiency of staffing, if you know how to read it. Have you ever gone to HospitalCompare.gov ? What makes the information found here so useful in our efforts to change policy is that many of the outcomes on which hospitals are evaluated, and on which they risk losing reimbursement, are nursing-sensitive! We can look at our own hospital report and see the areas where they might be falling behind other hospitals and where they are losing reimbursement, and find ways to work together on solving problems that affect patients, facilities, and those providing nursing care.
What can we learn from these incredibly smart direct care staff that presented on their unique research? Understanding the situation with which you struggle can be clarified by capturing the problem with objective data. Whether we create our own research project, or use the data the hospital has collected and submitted to CMS, data is a powerful and objective tool. Looking at those regulations, and other levels of accountability for the facility— such as contract language or policies developed by the facility itself—and working within that framework is vital. In the end, this becomes an improvement for patients, for the staff, and for the facility itself.
The CNAs at the LTC facility not only were able to improve staffing based on the data they presented, but their work and commitment to patients also informed a broad range of managers and others about how time was actually used. In doing so, the staff also turned around the “work smarter” mentality that they had found frustrating and insulting. The challenge now goes to you – are there issues you would like to address using data from your own place of employment?