Casemix issues for nursing

The diagnosis-related groups (DRGs) patient classification system provides information about the type and volume of acute inpatients treated, as well as the length of stay and cost of treatment. Nurses have been involved in casemix development in Australia, providing advice to government departments on nursing issues; researching the relative cost of nursing patients in one diagnosis-related group compared with another; budgeting nursing resources for casemix treated; and using casemix information to change practices to achieve more efficient use of resources and maintain quality of care. Casemix information allows nurses to contribute to the management of clinical services in partnership with other clinicians and managers.

The relationship between length of stay and required nursing care hours

The average length of stay (LOS) of patients in hospitals has declined rapidly since the introduction of the prospective payment system. It has been argued by nurses that reduced LOS is associated with increased nursing resource consumption, but there has been little empirical evidence to support the argument. The authors offer evidence of a relationship between LOS and hours per patient day in eleven clinical specialty areas. These findings have major implications for budgeting and the delivery of nursing care services.

Redesigning the nursing care delivery system at Fairfax Hospital

The redesign of the nursing delivery process at Fairfax Hospital is occurring from the top down and the bottom up. Nursing leaders have identified improvement opportunities that all units are addressing, such as reevaluating skill mix. At the same time, each inpatient nursing unit is redesigning its own processes to meet customer requirements. For example, the postpartum unit shifted to a "wellness" approach. Nurses reduced the amount of time spent in reassessing patients and are focusing instead on those things their patients are concerned about, such as teaching new mothers how to care for their babies.

RESULTS

Customer research revealed that patients, physicians, and nurses wanted family-centered care from competent, caring clinicians. Flow charts identified many improvement opportunities that were common across all nursing units, such as reducing the time nurses spend reporting between shifts. Nurses are more empowered to make local decisions. Additional quantitative results are being tracked for this relatively recent effort.

Adjusting the cost-quality equation: utilizing work sampling and time study data to redesign clinical practice

Quality patient care through effective resource utilization is a health care imperative. While developing a patient classification system based on work sampling and time study data, quality and cost issues were analyzed. The purpose of this study was to compare cost and quality outcomes from practice redesign that resulted from work sampling and time study data. Practice redesign included standards of care documentation, research-based procedures, system reorganization, and role clarification. Results included increased nurse satisfaction, decreased time and money for indirect care, and positive patient outcomes. Work sampling and time study data provide opportunities to impact clinical practice, resulting in improved outcomes for patients and staff.

SERVQUAL: a tool for evaluating patient satisfaction with nursing care

Rising health care costs and competition among hospital facilities have resulted in the need to recognize patient satisfaction as an important indicator of quality care. Nurses provide the primary service to patients; therefore, their role is influential in overall satisfaction. Several instruments have been developed to measure patient satisfaction with nursing care; however, most of them focus only on patient perceptions. One such approach to evaluating patient satisfaction with nursing care involves an instrument, SERVQUAL, derived from a marketing service perspective. Adapting SERVQUAL for use in evaluating nursing care is the focus of this article. SERVQUAL assesses both patient perceptions and expectations of quality service and permits managers and clinicians to view the gaps between the two; thus, the overall areas of improvement in nursing services can be determined.

Supporting operational decision making

The collection and processing of information is a source of power. This fact is true especially in the health care industry. The apparent lack of information related to operational decisions in the health care industry is cause for concern. Data envelopment analysis (DEA) provides information regarding efficiency of resource utilization. This article reports on the use of DEA to measure relative technical efficiency of nursing units and the level of association between efficiency scores and the presence of selected operational characteristics. We found a statistically significant association between efficiency and two of the selected characteristics. Although nursing units are used to illustrate the application of the technique, DEA can be applied to any operational unit of a health care organization. However, we conclude that information systems and a minimum data set are essential to optimizing utilization of a such techniques.

Nursing and self-care theory applied to utilization review: concepts and cases

The following article demonstrates how Dorothea Orem's Self-Care Theory of Nursing serves as a theoretical framework for the hospital-based utilization review process. Orem's theory is a popular and practical one which dovetails beautifully with the goals of any department of utilization management.

[The organization of the nursing service in dialysis centers in Italy. A national study promoted by the EDTNA-ERCA--Italian branch. European Dialysis Transplant Nurses Association-European Renal Care Association]

A 45 multiple choice questions questionnaire was mailed to the nursing personnel of the 687 public and private Italian dialysis units, in 1991. The survey was promoted by the Italian branch of the EDTNA-ERCA (European Dialysis Transplant Nurses Association). The questions related to the following areas: structure of the service, organization of the activities, dialysis methods; number of nurses, communication systems, basic and continuing education and main problems encountered by nursing personnel in some areas. 185 questionnaires were returned (21.2%). The situation is highly dishomogeneous. The working team is formed by physicians and nurses only or may include dietitians, social workers, technicians etc. In 102 centres 55% of the respondents, nurses perform non nursing activities (from the incanulation of the arterovenous fistula to activities related to the maintenance of dialysis apparatus). Problems most frequently encountered include conflicts with the patients on criteria and conditions in handling dialysis procedures and lack of collaboration with physicians.

The quantity of nursing care on wards working 8- and 12-hour shifts

Interest in 12-hour nursing shifts has been renewed in response to demands for improved cost-effectiveness in the NHS, but the effects of this shift on the delivery of patient care have been unclear. This paper describes the results of a repeated-measures study of 10 wards, using activity analysis to describe patterns of care under an 8-hour compared to a 12-hour shift system. Significant reductions in the amount of direct patient care were found under the 12-hour shift, with corresponding increases in unofficial work-breaks. It is suggested that these findings, which were consistent over all study wards and throughout the whole 12-hour day, demonstrate a "pacing" effect by nurses who face 12 hours on duty. Such a detrimental effect should be a major consideration when coming to any decision to implement a 12-hour shift.

Facilitating innovation at the unit level through cultural assessment, Part 2: Adapting managerial ideas to the unit work group

The culture of an organization is a powerful force to contend with in transforming a healthcare system. Culture can either drive or restrain innovation: sometimes cultural values support innovation; but culture can restrain innovation when there is conflict between the culture and the innovation. Part 1 of this series (April 1993) examined the concept of organizational culture fail to materialize when the work group culture is not considered while implementing change. This article uses research data to illustrate a five-step cultural innovation process. The creative nursing unit manager can use the process to implement a variety of practice patterns to help the healthcare organization remain competitive and increase the quality of its care. These practice patterns include team nursing, primary nursing, case management, managed care, patient-centered care, assistive personnel, and computer-assisted care.

Nursing administrators' responses to physically, mentally, and substance-impaired nurses

Impaired nurses--whether the impairment is physical, mental, or substance use--can be a potential hazard in a healthcare setting, both to themselves and to patients. It is therefore imperative that nursing administrators identify such nurses in order to take the proper actions. But just how do administrators react toward nurses with impairments? The authors of this article present the results of a survey in an attempt to answer this question.

Physicians can benefit from a patient-focused hospital

To maintain leadership in their markets, a few innovative hospitals, in the late 1980s, developed a revolutionary concept of health care delivery--patient-focused care. Results from pilot projects have shown a considerable increase in patient satisfaction and increased physician productivity. The patient-focused care model boasts faster turnaround times, increased bedside care by caregivers (especially nurses), and an overall increase in the quality of care provided by the staff.

Computerised care plans: provoking a quiet revolution

The Illawarra Area Health Service has been experimenting with use of computerised nursing care plans. Microcomputer software has been successfully tested in several wards and the intention is to move to implementation which will probably involve porting the software to the area-wide mainframe. The technology was recently extended to multidisciplinary care planning using the managed care/critical pathways approach. This paper describes the development process and some of the initial results.

Activity sampling of nurses of a sub-acute ward of a large hospital

A study was conducted in a 43 bedded subacute family ward of a large hospital to find out the adequacy and efficiency of its nursing service. Activity analysis in respect of nurses was carried out by Activity Sampling Technique. The study revealed that out of 334 activities, observed, 78 (23.3%) were non-productive, whereas 256 (76.7%) were productive. Out of the productive activities, 148 (44.3%) were for direct patient care mainly comprising of 46 (31.1% for carrying out technical procedures, 36 (24.32%) for determining patients' needs, 20 (13.15%) for preparing patients for various procedures and 15 (10.14%) for assisting in technical procedures. Number wise the nurses were found to be adequate.

Strengthening hospital nursing, Part 2. Characteristics of effective planning processes

Characteristics of the planning process for 213 hospitals participating in Phase 1 of the Strengthening Hospital Nursing Program (SHNP) are described. Differences in planning between the Phase 2 implementation sites and those sites not selected for continued funding are explored. Factors associated with positive planning outcomes among participating hospitals are delineated. The use of the SHNP planning process as a model for other hospitals is suggested. This article is Part 2 of a 3-part series on the planning process within the national Strengthening Hospital Nursing Program. Part 1, contrasting single and networked hospitals, appeared in the May issue of JONA. Part 3, which examines interdisciplinary differences, will appear in the July/August issue.

Nursing resource requirement and support services

How can medical-surgical and critical care units reduce their nursing care hours per patient day (HPPD)? When nurse executives understand the impact of professional, nonprofessional, and technological support services on HPPD they can work toward further cost reduction without adversely affecting the quality of patient care.

Nurses want I/S selection power, but do they have it?

A survey of nurse executives shows that the ability to track medications and prepare patient-care plans are the two most important features for a nursing system. Nursing staffs are fairly resistant to new system installations, and a surprising number of nurse executives say they are not involved in the system-selection process.

Nursing care management

Patient satisfaction, patient-perceived quality of life, and nurse satisfaction were compared before and after the implementation of nursing case management in a southeastern acute care hospital. Immune-compromised oncology patients were sampled as proxy for patients with AIDS. Clinical nurse specialists as case managers planned, coordinated, and facilitated patient care on the 36-bed study unit. Patient satisfaction showed a statistically significant increase 6 months after implementation of nursing case management.

Nursing informatics: a Victorian survey

Interviews of selected personnel from a stratified random sample of Victoria's public and private acute care hospitals provided data about current computer systems implementation in nursing departments. Key informants were asked about their hospitals' present level of computerisation and plans for the future. The study found that stand-alone microcomputers are currently driving systems development in nursing. This strategy limits nurses' ability to access data, diminishes their influence in decision-making and undervalues the contribution of nursing information to interdisciplinary health care.

Medicare reimbursement deficits: are nursing costs to blame?

Nursing costs were found to be only 11% of the total operating costs. This finding dispels the myth that nursing service is an expensive expenditure for hospitals. The range of facility cost compared with DRG reimbursement was wide, which points to the need to scrutinize costs other than nursing as the sources of hospital deficits. Nursing costs were found to be lower than facility or OR costs. Nurse managers need to emphasize this cost effectiveness to decrease the chance of staffing cuts and requests for concessions in wages or benefits for nurses. Nurse managers need to plan their financial activities to ensure their hospital cost is less than, or at most equal to, the DRG payment.