Wednesday, August 18, 2010


A recent Boston Globe op-ed by Suzanne Gordon argues in favor of state-mandated nurse staffing ratios for hospitals. A response to this was submitted as a letter to the editor by our chief nursing officer. Here are her thoughts:

We can all agree that more nursing time spent directly with patients results in better patient outcomes. But mandated nurse to patient ratios, which Suzanne Gordon advocates in her Aug. 5 op-ed “Critical care,’’ are the wrong way to achieve this goal.

Those of us applying proven improvement methods in health care, such as Lean and Six Sigma, have learned what the manufacturing world has long known. We need to free nurses from the administrative burdens, inefficient activities, and wasted steps that do not directly add value for patient care.

In an environment of rapidly expanding health care costs, legislatively mandated nurse to patient ratios are unsustainable.

Yes, we need more nursing time spent directly with patients. But we must achieve this by aggressively applying improvement techniques to remove waste from our workflow. This is the only sustainable way to both control costs and improve patient safety.

Marsha L. Maurer
Senior vice president, Patient Care Services
Chief nursing officer
Lois E. Silverman Department of Nursing
Beth Israel Deaconess Medical Center


Anonymous said...

I've never understood mandatory ratios. How can they predict a day in a hospital? One day, all surgery goes well, all of the patients are copers. Next day, you've got people who don't respond well to anesthesia, or needles, plus surgery finds a surprise inside, plus they are not copers and demand a lot of attention. One day, the patients are all 30. The next day they are all 75 and up, some with dementia. How does a mandatory ratio handle all of this?

Anonymous said...

Although I am not educated on all the issues surrounding this dilemna, my hospital laboratory experience supports Ms. Maurer's contention that simply throwing more staff at a problem does not necessarily solve its root cause, if that cause lies elsewhere.

Also, it would have been nice if Ms. Gordon had supplied the citation for the paper from which she quotes, so that we might read it for ourselves in terms of how confounding variables were controlled for, how the non-mandated-ratio hospitals were selected for comparison, etc.

nonlocal MD

Pierce Story, MPHM, DSHS said...

The alleged goals of Legislated Nurse Ratios are to improve quality and reduce excess nurse workloads. Mandated nurse-patient ratios have not been shown to achieve either. That’s because the ratio of nurses to patients masks the real issues of variable and excess workload and inappropriate workflow.

We know that hospitals are dynamic systems, changing every hour of every day. So, too, do the demands for resources at the unit and department levels. Just as a bank doesn’t have live tellers available at midnight Wednesday or 6 a.m. on Sunday morning when few customers need services, nursing units should not staff the same way every hour of every day.

Indeed, research has shown that the variability of workload on a given nursing unit can vary even on the same shift, causing one nurse to have much more work than another. Thus, it is not the number of nurses but the work required that should drive staffing.

Furthermore, much of the work does not necessarily require an RN. Ironically, legislated ratios force hospitals to hire extra nurses, which constrains staffing budgets and can lead to a reduction in the number of support staff who aid nursing work (e.g. techs and LPNs). Nurses may therefore end up with more, rather than less, work to do! This is exactly what happened in California, under their onerous laws. Without accounting for the variability in workflow and workload, it is inevitable that some nurses will be over- and underutilized, resulting in the issues and negative results the unions/proponents claim to eliminate.

A far better solution is “engineered” staffing and a movement away from the narrow definitions of nurse-to-patient ratios. Using the proper analytical tools, workload and workflow can be analyzed at the unit and resource level, by hour-of-day and day-of-week, allowing a better understanding of the actual demand for resources in the system. Then, by parsing the tasks and work required to handle the demand, we can more properly assign each task to a proper resource at the right time. This moves us from a focus on the number of nurses on a given unit for a given shift to a robust and dynamic analysis of the workload and the specific resources required to complete it. This, of course, is not restricted to nurses. Indeed, we need to change our thinking away from “nurse-patient ratios” to “staff-patient dynamic staffing”, to include myriad resource types. Care teams can be created to more effectively and efficiently perform the required tasks at the right time, while prevented the overload of individual resource types, such as nurses. Thus, “non-nursing” tasks are assigned to non-nurse resources, thereby allowing nurses to focus on those tasks which they do best…nursing!

Admittedly, this is far easier said than done. Nurses take tremendous pride in their work, and many (quite admirably!) willingly take on the full responsibility of the care for their patients. Getting nurses to “let go” and allow non-nurse resources to perform certain tasks requires special analysis and substantial data on workload and workflow, simulation modeling to demonstrate the results of proposed changes, and lots and lots of trust in the clinical resources guiding the change process. Nonetheless, Care Redesign shows great promise, and has the enthusiastic backing of the staff and managers where it has been tried.

If we want to solve for the real issues of patient safety, quality, and nurse workload control, we will take an “engineering” approach to this issue. With this solution, we can redesign how care is delivered to the advantage of the staff, patients, and overall hospital cost.

Pierce Story, MPHM, DSHS