Case Study: New Ideas For Nurses

Which of these hospitals would you rather be treated in? At Hospital A, a major southwestern facility, the nursing staff is stretched so thin--and the intellectual and emotional demands of the job are so intense--that nurses question their ability to deliver quality care. This summer, the strain finally drove Rebecca Matthys, 40, to quit nursing after 16 years. Too many times, an emergency with one patient had meant postponing care to others, then scrambling to catch up on her remaining duties. "It was like playing Russian roulette," she says. "It was just a matter of time before I made some horrible mistake that I would have to live with the rest of my life."

At Hospital B--UPMC Shadyside, part of the University of Pittsburgh Medical Center--the ambience couldn't be more different. Even on a hectic day, things seem to be under control. There's a sense of energy rather than panic. "I truly love coming to work," says medical-cardiology nurse Cynthia Hostetler, 51.

Check into a random hospital in America, and you're far more likely to be in some version of Hospital A than Hospital B. Across the nation, nurses are feeling overworked and underappreciated, with little more than lip-service support from their managers. "New nurses aren't putting up with it," says Diana Mason, editor in chief of the American Journal of Nursing. "They're leaving hospitals at a higher rate than new graduates in the past." As of late last year, there were 118,000 vacancies for registered nurses in hospitals (8.5 percent of positions), according to the American Hospital Association. That's bad news for patients. A recent study in the journal Health Affairs estimated that increased staffing by R.N.s could avert 6,700 patient deaths a year.

The true shame is that hospital nursing doesn't need to be in a state of crisis. As UPMC Shadyside shows, it's possible to get things right. And no person takes greater credit for that success than Tami Merryman, UPMC's vice president for (get this) quality improvement and innovation. A nurse herself, Merryman knows the convoluted procedures that typically bog nurses down. So nine years ago, when she became chief nursing officer at Shadyside, she started experimenting with solutions.

Early on, she zeroed in on the time nurses spend running to central supply cabinets. "In a year, nurses on the average unit walk the equivalent of the circumference of the globe," she says. So she suggested keeping basics like gauze and bedpans in patients' rooms. This simple fix saved nurses on a single ward more than 700 trips a week.

An even bigger time saver was detailing two nurses on a medical-surgical ward to handle nothing but admissions. Before then, a nurse on her way to hook up an I.V. or get a patient to a lab test on time would be sidetracked by the arrival of a new patient. Admission procedures could take up to 45 minutes; meanwhile, no one else was handling the nurse's other patients. But separating out the functions gave everybody's day a more predictable flow--and the resulting 16 percent reduction in overtime more than compensated for the salaries of the two additional nurses.

To hear Merryman tell it, these reforms were common sense. Still, they were so forward-thinking that, in 2003, Shadyside became one of just three hospitals selected to participate in a new program called Transforming Care at the Bedside (TCAB), a joint initiative of the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement. The mission: to boost nurse retention by improving teamwork and eliminating inefficiencies, such as unnecessary paperwork, that divert nurses from direct patient care.

Every Friday, Merryman now holds a brainstorming session where nurses, managers and even a patient's family member pinpoint problems and seek solutions. In addition, she trades ideas with other hospitals in the TCAB program. The result has been a spate of reforms. The hospital now leaves oxygen equipment in patients' rooms after surgery in case they need it again at night (eliminating 20 minutes of set-up time). If nurses are overloaded and want help, they post red flags on their carts; those who display green flags have time to spare and come to their aid, while those with yellow flags signal a full load but no emergency. Merryman has even given patients' families the authority to summon a rapid-response medical team if they feel an urgent problem isn't being addressed. "Who cares more than the family?" she asks. And for nurses trying to juggle myriad tasks, it provides a safety net. "I may be busy caring for other critically ill patients," says nurse Beth Kuzminsky. "Families can get immediate help this way."

These ideas and dozens of others have apparently been paying off--not just at Shadyside, but at all 10 hospitals that are now part of the TCAB program, including Cedars-Sinai Medical Center in Los Angeles and M.D. Anderson Cancer Center in Houston. At all 10, nurse satisfaction is way up, overtime is down and turnover of R.N.s has plummeted from an average of 15 percent a year in 2003 to 4 percent today. That translates into cost savings for a hospital. Equally important, the average amount of time nurses spend in direct patient care has risen from 40 percent of their shift to 52 percent, leading to fewer patient falls, fewer bedsores and fewer failures to rescue patients from life-threatening complications. "I have entire hospital systems asking to get into TCAB," says Susan Hassmiller, senior program officer at the Robert Wood Johnson Foundation. For the sake of nurses and patients alike, that can't happen soon enough.