Removing clerical chores puts nurses at bedside
New system lets nurses be nurses
How can hospitals reduce nursing costs without increasing skill mix? By letting nurses be nurses not inventory clerks, patient transporters, or paper chasers, says Vickie Moore, RN, MSN, chief nurse executive and vice president of operations at St. Joseph’s Hospital in Atlanta.
Rather than increasing nursing efficiency by employing more aides, the hospital changed clerical and clinical portions of its care delivery system. As a result of the initiative, nurses now spend 50% of their time in direct patient care, rather than 38%, says Moore.
"It’s a natural tendency to look at the nursing payroll and to attempt to decrease it by reducing the number of nurses and adding more aides, but a system can also be made more efficient by making changes that allow nurses to do their jobs more effectively," says Moore.
The foundation for the project was laid in 1993 after a survey of nurses was conducted to determine how many hours they spent in direct patient care as well as the factors that prevented them from doing so. "They told us that performing inventory, transport, and paperwork functions reduced the amount of time at the bedside and made many suggestions as to how to change the system," she says.
A care delivery task force composed of a clinical nurse specialist, representatives from risk management and quality management, as well as staff nurses, took the suggestions and devised a time frame and a plan for implementing them.
For the four-month pilot project, the team selected a floor that contained a 23-bed renal/ pulmonary unit and a 25-bed medical cardiology unit. "We selected these because they were distinctly different: The renal/pulmonary patients had LOS [length of stay] of 5.1 days, and the medical cardiology had 2.42 days," says Shahin Vojdani, RN, nursing project leader. "We figured if these changes would work on the pilot floor, they would work throughout the med-surg division." (For tips on implementing clinical changes, see story, p. 30.)
The team tracked qualitative and quantitative data prior to implementation, including patient falls, medication errors, infection rates, patient satisfaction, overtime/additional hours, hours per patient day for direct caregivers, full-time equivalencies, and occupancy rate. "We wanted to make sure that changes were not affecting our quality in a negative way," explains Vojdani.
Although the team members would spend another 19 months implementing the project on 11 units, they provided paperwork relief by implementing several clerical changes housewide in less than six weeks. These changes included:
Creating standardized forms and logs.
"We wanted secretaries to have more information about the unit’s activities and its patients so they could field telephone questions from other departments and not interrupt the nurses when they were giving direct patient care," she explains. "Our goal was to make the secretary the information person on each unit."
To begin the standardization process, team members first collected a sample of each form, such as admission and census forms, and assignment sheets from all units. "Then we asked nurses what they needed each form for and consolidated the essential elements, cutting the total number of forms in half and streamlined the rest," Vojdani says.
Information is available when needed
The team also created some new forms that gave secretaries more readily available information. "For example, a patient travel log told them at a glance the patient’s name and room number, how the patient was traveling, and whether they had an IV or oxygen. It is done in pencil at the beginning of the shift and updated throughout. When patients leave, information is erased," she explains.
Use of new technology.
The team also trained secretaries to use new technology to communicate instead of relying on noisy intercoms. "We bought nurses and assistants pagers that can script a message so secretaries can send a message, and nurses can quickly glance down and see if it can wait or needs to be answered immediately," she says.
These intra- and inter-unit devices not only improved communication, but they also reduced interruptions of the bedside nurses. "We held inservices for the secretaries and gave them a very detailed explanation on the why and how of the change," she says. The team also identified one person on each unit usually the day shift clinical manager to make sure these changes were carried out.
Inventorying supplies.
The team also eliminated the time nurses spent in charging and inventorying supplies. "We looked at how much time it to took to apply stickers or bar codes to send to central supply. It may seem like an insignificant amount of time, but it does add up," she says. The team worked with the finance department to determine the actual cost of charging back items under $20.
"After they examined how much was lost in nursing time as compared with how much revenue they could get back, it averaged out," she explains. "We eliminated about 600 items." To make up for lost revenue, the room charges were increased incrementally.
Nurses are too valuable to be stock clerks
The team also established par levels for supply stock so material management staff can now examine the carts themselves. "Nurses now have no involvement with stocking. We pay them too much to let them be stock clerks," she says.
After making clerical changes, the plan called for careful implementation of clinical alterations. Some of the affected processes were:
Assignment changes.
The current shift now makes assignments for the upcoming one, says Vojdani. "It was hard for staff to understand at first that equal numbers of patients do not mean an equal workload. For example, three high-acuity patients require as much work as five low-acuity ones," she says. To help staff make an easier transition, Vojdani provided inservices on time management, delegation, communication skills, and team building. She also held meetings to help staff on all shifts to "talk about the expectations and the appropriateness of their assignments."
End of the shift changes.
All care summaries are collated according to the next shift’s assignment for each RN, she notes. The shift report is also audiotaped. "This way [outgoing] nurses get to spend less time in report, and all the [incoming] staff including the assistive personnel get to listen to the whole unit’s report," she explains. "Only the incoming shift is in report, and the outgoing shift is available for patients."
Change in role and responsibilities.
The team also expanded the nurses’ roles to include management of unlicensed assistive personnel. "We use a modified form of primary nursing practice," says Moore. "Every patient has an RN responsible for him or her; every nurse is paired with and supervises a patient care tech."
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