One thing we do not want to have in common as a planet: patient safety issues across the globe. Please Read Mark Graban’s post about patient safety statistics from the US, Canada, Britain, Germany, Australia, Bulgaria, and the Netherlands.

http://www.leanblog.org/2009/08/statistics-on-healthcare-quality-and/

No patient is safe anywhere in the world 😦

I am currently taking a course called “Mind Brain Health and Education” offered at the Harvard University Extention School (great courses if you are interested in learning and you can take many of them non-credit and online and you don’t have to be officially enrolled in a degree program).  The premise of this particular education-transformation course is that the brain needs more than content to develop: it needs a toxic free environment, health, nutrition, psychological safety and sleep/rest (click for more about MBHE).

As I apply these concepts to nursing and patient safety, it seems we should follow the same directions for healthy brains and health cognitive functioning. The working conditions of many frontline staff especially nurses is far from supporting of this aim. A recent Leape institute report lamented the absence of joy and meaning at work that exists for many healthcare providers today.  The report offers some workplace improvements in terms of physical and psychological safety which would be in line with what I have learned in the Mind Brain Heath and Education course.  But what else do we need to do?

We need to look at Economics: Nursing departments are often the largest “expense” for a hosptial and as such as a target for cost containment. This leads to what many nurses perceive as unsafe patient loads, limited time to think, take breaks, and spend time really getting to know what a patient needs. Administrators in rebuttal articles argue that quality is not compromised by cuts in nursing and that mandated ratios are not safe either.  One difficulty with this conflict is that we have no way to prove the absolute truth in what either side is implying. Deficits in quality often do not appear immediately after staffing changes as staff can rally for a time to maintain the status quo. But the staff cannot maintain higher levels of productivity or vigilance for long.  Safety experts call this drift. The environment begins to tolerate sub-optimal conditions and the absence of catastrophy leads many to think that there is no danger…until there is. The problem with drift is that is can suddenly lead to disaster illustrated in the story of  NASA and its space shuttle accidents. The agency, constantly under financial contraints, continually pushed the boundaries of productivity over safety and today it is far from the prestigious agency it once was.  None of us want to see the same fate for hospitals. We already have too much patient harm, we cannot tolerate any more.

As I wrote in another post:

“Pfeffer author of What were they thinking: Unconventional wisdom about management reminds us that labor costs depend on wages but also on productivity.  Unsatisfactory working conditions and reductions in compensation make a difficult environment in which to cultivate employees who are committed, creative and engaged.  Pfeffer (2007) argues that it is precisely in a time of challenge that companies need employee loyalty and effort.  Instead of cost cutting labor, efforts should be directed to improving service, quality, productivity and training.  These kinds of efforts require the input of the front line workers.  Pfeffer advises to avoid the death spiral of cuts that go so deep they affect productivity and morale.  Instead of cutting, offer the customer something of value.  A great company with a great product doesn’t save money by reducing the size of the cereal box while charging the same price.  A great company enhances something about the cereal to charge more.  A great company may cut price to increase volume (eg. buy two at a reduced price).  A great company focuses on growth opportunities rather than reduction opportunities.   A great company gives the customer what they want.”

I suggest that cost containment in healthcare should not come from worker cost cutting but from eliminating waste, judiciously investing in new technology, limited spending on property, applying  theories of complexity to managing workload and setting reasonable CEO salaries.  By the way, administrative costs now are about 50 percent of heathcare with more than one of every four health-sector employees in administrative roles.  I think the goal of each institution should be to have the largest clinical staff as these people who are THE REAL PRODUCT. Most Patients come to see your doctors not your new mezzanine.  If a patient needs to be admitted to the hospital it is for no reason other than they need a nurse near their bedside 24 hours a day.  In terms of economic benefits, these front line staff, such as nurses, need working conditions conducive to brain and physical functioning but also economic security. Professional clinicians need to make a decent salary relative to the economic conditions around their place of employment. They need to make enough so that they are at least middle class and can afford restorative activities during their time off.  These values are something I think will do much for patient safety.  Hospitals, in their struggle to deal with fluctuating census, often try to provide that flexibilty on the backs of their employees: cancelling them one day, asking for overtime the next. As such, many nurses hold more than one job to get by and are working an unsafe number of hours per week, or they are doing OT at their own jobs.  Hospitals could manage census in other ways such as smoothing.

Hospitals exist for one purpose only and that is to safety care for patients.  All the other activities such as research and adminstration should all be aimed at supporting that.  I am concerned with the number of nurses voting  to hold strikes in the last few years related to staffing.  This should be a wake up call to all of us in healthcare: we are drifting.  How close are we to the line where productivity becomes disaster?

The front line staff are always the first to recognize drift.   I don’t think anyone wants to have to say in retrospect: We should have listened to the nurses…

http://www.beckersasc.com/lists/50-experts-leading-the-field-of-patient-safety.html

TOP 50!

only 7 out of 50 are nurses. There are 3 million RNs in the US. In 2008 that translated to 854 nurses per 100,000 people (RWJF.org). Nurses are at the front lines seeing patient safety issues everyday. Why aren’t we more involved in leading the patient safety movement? Since the IOM report “To Err is Human…” many have argued we have not made the progress that would be expected. Is this directly attributed to failure to take the lead by nursing?

Is patient safety yet another arena where decisions are made without nursing in the rooom? Nurses prevent errors and make errors, and sometimes take the fall for organizational failures: and are as close to the patient as one can get, at the bedside 24 hours a day. There are still reports of moral distress in that nurses feel they are not able to advocate for their patients. Many nurses have little control over their workload or schedules. How can nurses be at the bedside and at the table? Token nurses on committees may improve the voice a bit but it is not the same as full participation from all the stakeholders in the nursing workforce. According to Axelrod & Axelrod (2000), employee representatives on committees essentially create a parallel organization where these employees temporarily join the management team. Those who are not on these committees wonder why they were not chosen and assume their voices are not important. In essence committee structures common in hospitals today exemplify old change management paradigms and discourage participation. With today’s interactive technology, it should be easier to include all stakeholders in a process. But then again, many nurses are not used to participating.

The Future of Nursing (FON) Report mentions the need for nursing to be full partners in healthcare. Other opinion leaders feel nursing is imperative to the patient safety agenda (http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2010/01/groundbreaking-new-survey-finds-that-diverse-opinion-leaders-say.html). The question is how do we do this? How do we engage all nursing stakeholders? We need nursing leaders in the patient safety movement who can facilitate this.

My interpretation from the FON report is that they are banking on higher education of nurses to be the key. While I agree that safety and improvement science needs to part of every nursing curriculum, education and training is low on the safety intervention effectiveness hierarchy so I do not see this as the ultimate solution.

System changes and work environment changes will make the difference, and valuing everyone’s input does not require advanced education. If we believe what we say in that everyone in the traditional hospital hierarchy from the housekeeper to the MD has an impact on safety, education is not necessarily a factor. We need to find a way to ask the right questions of the frontline nurses and hold sacred their answers so they can remain at the bedside while their voices resonate loud and clear at the table.