Margaret "Peg" O’Connor, a nurse who worked at Jordan Hospital in Plymouth for more than 38 years, said she was fired in May for doing the right thing. She reported a violation by the hospital that allegedly put a pregnant patient and her unborn twins at risk. O’Connor, who filed a lawsuit yesterday, had told federal authorities that the woman, who was six months pregnant when she arrived in the Jordan emergency room in March with flulike systems and went into labor, was transferred to another hospital without being examined by a doctor. A state Department of Public Health inspector found in May that the hospital violated a federal law that prohibits hospitals from transferring patients without making sure they are stable and have been examined by a physician. The inspector found four additional violations by the hospital involving patient transfers, exposing the hospital to possible fines of up to $50,000 for each violation. On May 19, the day the Department of Health and Human Services Centers for Medicare and Medicaid Services dispatched a team of inspectors to Jordan Hospital to conduct a broader review, O’Connor was fired.
Facing declining patient volumes and tough economic times, hospitals have sought to minimize costs by reducing staff. Layoffs have been abundant as hospitals have attempted to get by with a leaner staff. However, prudent leadership teams should be mindful that any uptake in patient volume—driven, for example, by a bad flu season—can leave a hospital stranded and scrambling to increase staff. Also, consider the influx of the newly insured entering the healthcare system. The work demand of care providers such as internists, hospitalists, nurses, and personal care assistants will undoubtedly increase exponentially. It is important for health leaders to look forward and be prepared for a potential increase in demand, using all available tools, including one of the most valuable tools: a well-defined incentive program.
Incentives can be a powerful tool to increase workforce capacity when patient volume or intensity increases. A sound and effective incentive program must be time limited, proactively initiated only when very specific predetermined conditions and criteria are present, and provide the type of incentive that motivates the target population. All three of these characteristics must be present; otherwise, an incentive program quickly becomes a very expensive exercise in staffing frustration—one that is difficult to reverse.
Having an incentive program that is time limited prevents it from becoming embedded within the compensation structure or seen as a “given” by the employees. Also, by limiting an incentive to a short period of time, management can evaluate its cost versus its efficacy. For example, limit an incentive to only winter months when workload is expected to exceed the workforce’s capacity. Or, host a popular national event and offer an incentive to staff to commit to be available to work extra shifts during that specific week if needed. By using an incentive in a time limited manner, employees may be more motivated to commit to work while the incentive is available.
Incentives also need to be based on specific criteria and set to motion in a proactive manner. A common mistake seen in some organizations is to put in place a “crisis incentive bonus” intended to be used for a severe shortage of staff, but is unfortunately constructed in a way that incents the staff to drive the system into crisis in order to collect the incentive pay. A preferred operational solution is to offer additional incentives to staff who commit to be available to work before a crisis occurs, especially during high-risk periods. Other organizations have experienced success in offering staff a bonus to sign up to be available for work before the schedule is posted. By using pre-determined quantitative-based criteria, such as staffing deficit by department or nursing intensity measures, an incentive bonus can be enacted if needed. The result is adequate staffing, and the system never reaches the crisis point. The criteria-based proactive approach can save countless hours of work typically spent in trying to find adequate resources.
By definition, an incentive should motivate the workforce to fulfill the needs of the system. Most incentive systems are based on financial rewards; however, an increasing number of studies indicate that time away from the workplace is highly valued by nurses and other healthcare workers and should be considered in an incentive program. Another alternative is to use the annual or biannual employee surveys to understand the workforce specific motivators to build into an incentive program.
However, a cost-effective incentive program should always be preceded by a sound staffing and scheduling system. As powerful and useful as a good incentive system can be, it cannot replace a scheduling system constructed to align with the projected workload and administered so that work assignments are as equitable as possible.
Benchmarking current resource utilization against similar healthcare organizations and departments can serve as good, reliable check of efficiency. Continual scheduling inequities that are perceived to drive an unreasonable or unpredictable workload are a strong motivator for employees to leave an organization. An effective scheduling system is the most efficient and cost-effective manner to save operational dollars and retain staff. However, healthcare workload volumes do tend to fluctuate with seasonal pathogens, physician practice patterns, and other unpredictable patterns, necessitating additional workforce resources.
As healthcare reform comes into focus and changes the manner in which care will be accessed and provided, new techniques will be needed to retain the current workforce and attract new entrants. Using tools such as a sound incentive program will continue to be a powerful tool for health leaders to meet future challenges.
Bonnie L. Barndt-Maglio, PhD, RN, is a vice president at the Camden Group, where she specializes in incentive management and other ways organizations can substantially improve current operations while successfully navigating likely healthcare reform initiatives.
Even as the doors open this month on a new $43-million building to house the inaugural nursing class at Charles Drew University of Medicine and Science, the university's interim president warned that the long-struggling institution is already in danger of losing the facility. Beginning in September, the university will be forced to begin burning through a reserve fund to make loan payments, Dr. Keith Norris said in an interview with The Times. Without assistance from a government agency, foundation, charity or some other organization, Norris said, within six months the school could run out of money to pay for the 120-student nursing school building.
Violence against nurses and other medical professionals appears to be increasing around the country as the number of drug addicts, alcoholics and psychiatric patients showing up at emergency rooms climbs. Nurses have responded, in part, by seeking tougher criminal penalties for assaults against health care workers. "It's come to the point where nurses are saying, 'Enough is enough. The slapping, screaming and groping are not part of the job,'" said Joseph Bellino, president of the International Association for Healthcare Security and Safety, which represents professionals who manage security at hospitals. Visits to ERs for drug- and alcohol-related incidents climbed from about 1.6 million in 2005 to nearly 2 million in 2008, according to the federal Substance Abuse and Mental Health Services Administration. From 2006 to 2008, the number of those visits resulting in violence jumped from 16,277 to 21,406, the agency said. Nurses and experts in mental health and addiction say the problem has only been getting worse since then because of the downturn in the economy, as cash-strapped states close state hospitals, cut mental health jobs, eliminate addiction programs and curtail other services.
What does “meaningful use” mean to nurses? Nursing Spectrum asked Pat Wise, RN, MS, MA, vice president for healthcare information systems at the nonprofit Healthcare Information and Management Systems Society, what nurses can expect as the iniative unfolds.
Until 2007, nurses at Riley Hospital for Children in Indianapolis relied on traditional shift change reporting methods to communicate patient care information from caregiver to caregiver. But when challenged by Riley’s leadership team to find ways to improve hospital documentation, the Clinical Practice Council began looking at a standardized approach to hospitalwide shift change reporting.
After a six-month pilot program, an educational video and PowerPoint® presentation, and another six-month training process, Riley implemented its hospitalwide nurse-to-nurse shift change report at the bedside with families.
Not only did leadership, the nursing staff, and physicians accept the process, but patients and families also became more involved and felt safer as a result.
Riley was recently recognized for its efforts by the National Patient Safety Foundation with the 2010 Socius Award, which symbolizes the relationship between healthcare providers and the patients and families they serve.
Developing a hospitalwide process
Melanie Cline, RN, MSN, clinical director at Riley, teamed up with a 30-person group of staff nurses, educators, the clinical nurse specialist, clinical managers, and the family-centered care coordinator to review current literature and best practices for shift report processes.
“Our highest priority was to include parents in the process as their involvement and input is critical to achieving the best outcomes for each child,” says Cline.
The old process consisted of the charge nurse gathering information from the nurses going off shift about 30 minutes before the change of shift. Another 30 minutes would pass while the charge nurse documented the information.
In addition to making sure the parents were included in the shift report, Cline also had to keep the staff’s best interests in mind. Nurses commonly complained that the handoff information they received could be 60?90 minutes old with the previous process. The staff nurses coming on shift would often find that their patient’s condition had changed by the time they got to the patient.
“When dealing with pediatrics, a child’s condition can change within a matter of minutes,” says Cline. “Getting to the patient sooner is better so potentially avoidable problems are picked up right away.”
Another factor that was vital to determining the components of the shift report was making sure the nurse going off shift and the nurse coming on shift could visualize the patient together, says Cline. This helped develop an understanding of how the patient was assessed on the previous shift.
Finally, Cline and her team developed five standards that are always included in the shift change report:
Head-to-toe assessment
Nurse-to-nurse involvement in viewing
Medication check
Orders verification
Care plan
The five standards of a shift report
The head-to-toe assessment, the first of the five standards, involves the nurses coming on and off shift as well as the patient’s parents. This assessment enhances patient safety—in fact, it has helped identify a few near misses.
“In one case, nurses were discussing pain in a 3-year-old’s left knee, and the mother spoke up and corrected their information, saying it was actually the right knee that was bothering the patient,” says Cline.
The second shift report standard ensures that nurses examine their patient together and discuss how each patient was assessed and monitored. Cline offers the example of a patient’s breathing: Nurses can establish how the patient is breathing and how each patient’s “normal” breathing looks.
The third standard, medication check, is a safety measure that also saves time. During the old process, nurses coming on shift would often have to call the previous nurse at home to double-check medication information.
“By conducting the medication check in real time, it helps save time and eliminates oversights or omissions on the chart,” says Cline.
The orders verification, the fourth standard, involves reviewing all current physician orders and communicating the implementation status of all new orders.
Finally, nurses discuss the care plan with the patient and the family at the patient’s bedside. This is where the next 12 hours of care are planned.
Cline says the entire process takes 30 minutes to complete, and even though the new process takes the same amount of time as the old one, in the grand scheme of things, it saves the staff time.
For instance, nurses no longer need to call nurses off shift to clarify a medication question because the two nurses review this information together during the shift report. Also, with parents now involved in the process, nurses can get questions answered up front as opposed to trying to find the parents later on during the shift.
Education and training
Before these standards and the bedside shift report could be implemented hospitalwide, Cline and her team developed a PowerPoint presentation and video to help educate staff members on the new process. The video reviewed the process step by step—using staff nurses as actors—and reminded staff of the importance of consistency.
Patients and their families also were involved in making the video. At the end of the video, parents described in their own words how the old process was sometimes scary but the new one helped them feel safer.
“It was very powerful for the staff to hear a parent’s testimony about how the old shift report left them out of the process, which can be frightening,” says Cline.
After viewing the video and PowerPoint presentation, those team members responsible for developing the new process coached and observed nursing staff on three occasions prior to rolling out the new bedside shift reporting.
“The 30 staff members who were part of the developmental process came in days, nights, and weekends to coach and mentor their colleagues,” says Cline.
The process took another six months for all units at Riley to successfully implement, making the total time for implementation one year, Cline says.
Finally, in January 2008, all nurses at Riley were involved in the nurse-to-nurse shift change bedside reporting involving parents.
Buy-in from all levels
Some nurses were skeptical of the new process, thinking it would take more time than before because the addition of family involvement would slow them down, says Cline.
As time passed, however, the skeptics began to appreciate the new bedside reporting for the communication it improves and the questions it eliminates—both of which save time in the end.
“The process kind of sold itself to a lot of the staff because of the situations they avoided, like the near misses,” says Cline. The new process ensures that nurses coming on shift visualize patients before the nurse going off shift leaves the unit.
Words of advice
As family-centered care is the focus at Riley, Cline suggests getting the parents or family members involved early on and keeping them engaged throughout the process.
“Having the patient and their family involved is critical,” says Cline. “It helps with any clarification or mix-up in communication that might occur during handoffs and offers comfort to the patient and family during this critical time.” This article was adapted from one that originally appeared in the August 2010 issue of Patient Safety Monitor (Briefings on Patient Safety), an HCPro publication.