Staffing Our Health Care
The recent unattended death of a patient at Shady Grove Adventist Hospital gave the public a view of a brewing problem in the health care industry - fewer highly trained staff serving more patients. The question of whether hospitals are adequately staffed by skilled nurses evokes passionate reaction from exhausted professionals and financially pressured CEOs. The fact remains, however, that this lamentable death was not unusual. As many as 120,000 Americans die in a given year as a result of medical errors that occur in hospitals.
Admittedly, the United States has not reached its goals of holding down health care costs. However, for the mounting costs we have built a world class capacity for health care that is sought by citizens the world over. Yet there have been far-reaching changes in our health care delivery over the past decade that beg close examination. When Boeing undertakes a major redesign of a commercial jetliner, the plane does not take off with passengers on board until after the structure and operations have been studied extensively for quality and safety. What mix of skills are needed from the crew? What system redundancy is needed to reduce risk? These are a few questions that the company, that the industry, must address when undergoing change.
By contrast, we have introduced substantial change in the health care delivery system and we have boarded people on it with little evidence about how quality of care has been affected - from the individual provider to the larger organization. This re-engineering has occurred with little investment in research or testing. Not every change is harmful to patient care, but there is little data to identify impact. From individual hospitals to the National Institutes of Health, we as a nation spend very little money to examine the value of our trillion dollar annual health care purchase.
The composition of hospital staff, its organizational design and its readiness for patient care are part of a complex calculus ideally tied to patient condition, treatment protocols and necessary costs. Certainly unlicensed aides and patient care technicians were widely used in hospitals in the 1950s and 1960s. The question is whether and how they can be used successfully in 1999 and beyond, given today's rapid and constant changes in medical and health-related diagnosis and treatments and the proliferation of technology. What are the responsibilities of the hospital and personnel when the system changes?
There are some things we do know. It is generally agreed that medical errors result from a series of unrecognized problems that unexpectedly converge or go undetected because of inadequate system design and contingency planning far more often than from isolated individual mistakes. We are also aware that cost-driven cuts in hospital staffing have, indeed, reduced registered-nurse-to-patient ratios and increased the use of unlicensed assistive personnel. We know from professional association reports that nurses, traditionally the front-line safety net in acute hospital environments, say they cannot perform optimally because they are stretched too thin. …