Study shows PFC increases direct patient care
Downtime tumbles with new care model
A study at a Toledo, OH, hospital confirmed staff who work in a patient-focused care environment spend more time with patients than those who work within a traditional nursing model.
The study, which measured staff work activities before and after the implementation of patient-focused care, revealed staff on the PFC teams are spending between 6.4% to 8.4% more time with patients and between 3.9 % and 7% less time in non-patient care activities, depending on the position and the unit.
The study, which administrators plan to publish, also showed that the length of stay held steady on two of the units and dropped on the third.
Robert Topp, RN, PhD, one of the study’s authors, says the study is significant because it’s one of the indicators the redesign was worthwhile. He says the study also validates anecdotal reports he has read about the effect of patient-focused care on staff work activities.
"We implemented patient-centered care because we wanted to address the inefficiency of the systems, the time they spent waiting for supplies or resources," he explains. "This study shows it’s working."
The study is probably not the first to measure PFC’s effect on work activities, but Topp says he could not find others.
"I can’t say we’re the first to do this," he says. "In fact, I’m sure someone else has done similar studies, but I reviewed the literature and could find nothing empirically written on patient care activities."
Here, Topp shares the methodology and results of the study with the readers of Patient-Focused Care.
Toledo Hospital began restructuring in 1995 in an effort to cut costs and improve care. A poster on Topp’s office wall stresses the three goals of restructuring:
• boost patient satisfaction;
• provide more cost-effective care;
• use resources more efficiently.
To accomplish these goals, the hospital eliminated management layers; decentralized support services, such as utilization review, phlebotomy, and EKG; and redefined job roles. Caregivers were reorganized into teams that also assumed the duties formerly handled by the centralized support services.
"We wanted each of the units to be self- sufficient," Topp explains.
The new positions are as follows:
• Care Coordinator.
This position in held by an RN who is the team leader. The RN oversees the care of the patient, ensuring the care plan is followed.
• Care Partner.
An LPN or other healthcare worker who has one year of health care experience holds this position. The care partner assists the RN with clinical tasks. The position has picked up some of the duties formerly performed by specialists, such as phlebotomy and administering EKGs.
• Analyst.
This administrative position blends several functions formerly performed by specialized units and positions. The analyst does precertification, utilization review, admitting, and bed booking. The hospital has eliminated some admitting clerk positions and decentralized utilization review.
• Support Partner.
This is a redesigned clerical position. The support partners’ new duties include entering pharmacy medication orders, a task formerly done by the pharmacy staff.
• Service Partner.
This new position blends housekeeping, dietary, and other nonclinical patient care tasks.
In contrast to some models, Toledo Hospital maintained patient transportation as a centralized service. "We looked around at other [hospitals] and decided we wanted to keep our people on the floor. We didn’t want them tied up with transportation," explains Lucy Russell, RN, BSN, one of the study’s authors. Russell is also the project manager for the redesign initiative which the hospital calls Care Center 2000. Some hospitals that initially decentralized patient transportation have reversed their decisions when the change did not save time, cut costs, or improve patient care.
Other changes included stationing a pharmacist on each floor.
The three units slated for the first roll-out were an 18-bed oncology unit, a 40-bed orthopedic unit, and a 20-bed intermediate cardiac care unit (ICCU). These units had operated under a primary nursing care system using centralized support services.
Administrators targeted patient care activities for the first survey because these activities related directly to the redefined roles. They determined that other outcomes, such as morbidity, mortality, and cost are harder to link because they could be affected by other variables, such as changes in medical technology.
Toledo Hospital began documenting staff work activities under its traditional model. The study monitored activities of three positions, those now called the care coordinator, the care partner, and the support partner.
To gather the information, a data collector followed staff members on the three units for their full eight-hour shifts, documenting their activity every 15 minutes for a total of 192 observations per employee. (See pie chart, p. 30.) The study was conducted for a continuous 48-hour period so all shifts could be monitored. Activities were grouped into three categories, direct patient care, indirect patient care, and non-patient care. (See listings, p. 32.)
Once the data were collected, restructuring began. Fifteen months later in May 1996, the data collectors shadowed the staff once again. Topp compared the two sets of figures and determined time staff spent providing direct patient care increased in all positions across all three units, while time spent in non-patient care activities decreased.
For example, RNs in the inpatient orthopedics unit recorded a 10% increase in providing direct patient care, a 1% decrease in indirect patient care activities, and a 9% decrease in non-patient care activities. (See graphs on left.)
The study does not show if this increased time spent with patients has improved actual care, but all units have shown improved patient satisfaction with nursing care.
Length of stay (LOS) held steady in ICCU and orthopedics and dropped by a mean average of 3.4 days in oncology. Topp says the drop in LOS probably resulted from other variables besides PFC. But, he says the significance of LOS in the study is that it did not increase.
"We just wanted to make sure it didn’t inflate after implementing patient-focused care," Topp says.
Topp says the next project is to measure the effect of PFC on costs. He says measuring cost will be more difficult because it is dependent upon variables besides PFC.
[Editor’s note: For more information about the study and its methodology call Robert Topp at (419) 471-5368. For more information about the patient-focused care model, call Lucy Russell at (419) 471-4267.]
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