Applying a system of management designed for the production of wood pulp to patient care
Imagine a hospital
without staff nurses and you can visualize Patient-Focused Care (PFC). A hospital where the only RNs will be called "Patient Care Coordinators," and who serve administrative roles, governing the actions of unlicensed technicians. One, or perhaps two, registered nurses are on duty per hospital department. Managers are carefully shielded behind their desks.
Welcome to another Patient-Focused Care hospital -- the latest "solution" to the health care crisis. It's obvious that problems would develop when trying to apply a system of management designed for the production of wood pulp to the humanistic service of patient care, but let's examine some of the foundations on which PFC rests.
Claims to success for PFC are as varied as the institutions which employ it, but some common data has accumulated. Here are some often-heard claims:
By far the data which was most accurately calculated was the reduction in cost for the institution. Elimination of 10 percent to 20 percent of the workforce added up to an appreciable savings.
The institution reporting reduced usage of sick time also had a policy in place whereby sick employees would not be replaced
the problem of evaluating PFC programs is that no two programs are implemented in the same way, but the biggest problems are discovered when one closely examines the data presented. Most authors offered general trends, and anecdotal reports -- not hard data, and of the hard data presented, just how accurate is it, and what variables were left out?
Length of patient stay is valued as a high quality indicator, but becomes totally meaningless once you discover there is a corresponding increase in the amount of professional home health care required to complete the patient's adequate recovery. This data also totally ignored the advances in treatments and procedures, i.e. laproscopic gall-bladder removal, outpatient surgery, and community outreach services which lead to early discharge or kept the patient out of the hospital to begin with. PFC, in the studies presented, received all of the credit from extended outpatient services.
These same home health services greatly diminish the rates of readmissions for patient complications -- complications which are incurred as a result of early discharge. Only one study can be found presenting readmission rates, and this institution based all of its assumptions on reduced complications from one unit -- the OB/GYN unit. One unit's figures hardly justifies a hospital-wide program, and strikingly absent was a presentation of the actual numbers. It seems authors promoting PFC don't want us questioning the variables.
With regard to patient satisfaction, Martin Strosberg, Ph.D. and Hans Lehr, MBA, writing in Quality Review Bulletin, found that the patient is left out of the process in determining what quality care is for them. According to these researchers, "Health care practitioners are used to making decisions they consider to be in the best interests of their patients, often without consulting them, they are also used to developing quality standards and clinical indicators without consulting patients." They further state that, "in industry, the consumer together with the manufacturer and/or service provider defines quality; in health care, the provider defines quality." Also, they wrote, "the direction of change must be driven by the needs and preferences of the customer, not the values of the provider."
It seems in the complex world of health care delivery, patients are excluded from the process of determining what would be true quality for them. Rating quality based on the number of practitioners seen, on the quality of housekeeping services provided, on how fast a water pitcher is filled, or on the fact that you remained in one room during your hospital stay are not true indicators of the quality of the medical and nursing treatment which was received. Kicking patients out of the hospital faster is also no indicator of quality -- especially when motivated by prospective payment systems. Managers know this all too well, and there still exists a real fear to teach patients what true quality care is, most probably because the number of malpractice suits would rise dramatically.
With regards to so-called improvements in clinical data (infection rates, errors, falls, and so on), I could find no collaborating evidence of such gains. In fact, at one institution in my community beginning to implement PFC, my nurse colleagues reported to me high employee dissatisfaction, and dramatically increased numbers of both patient complaints and incidents reports for errors -- medication and otherwise.
At this same institution, one manager's idea to reduce the time staff spent transporting patients was to have all ambulatory patients find their own way to other departments, such as radiology, for their exams. The net result was lost patients, bitterly upset by the apparent lack of concern for their safety.
As for the physicians rating patient care as-good-or-better in PFC units -- how would they know? Nurses know that physicians seldom read their notes. For a physician to arbitrarily comment on the quality of nursing care is absurd.
And the institution reporting the "happier staff" based on reduced usage of sick time also had a policy in place whereby sick employees would not be replaced. This policy served as nothing less than a total coercion of staff nurses to come to work, sick or not, to prevent their peers from suffering yet more understaffing. The real reason nursing turnover is decreasing is because so many of us have been laid off that the remainder of us are clinging to our jobs for survival -- no matter how poor our working conditions might be.
With the introduction of PFC, hospital costs were reduced -- but at the expense of patient care, staff moral, and job security
1992 the Healthcare Forum, a nationwide organization of hospital administrators, sponsored a conference -- "Patient-Focused Healthcare Delivery: An Executive Conference on Strategic Operational Restructuring." This conference concentrated on the presentation of case studies of five hospitals which had implemented PFC on "Pilot Units." All reported difficulties with implementing PFC. Ironically, all of the presenters indicated they believed that PFC was the only option to restructuring health care -- despite their difficulties.
One of the biggest problems cited was the high initial cost for the physical redesign of the experimental units. There is also a very high price tag demanded by the consultants directing the changes, but management felt these high costs were acceptable if the program would save money in the long term. Another major problem presented at this conference was the staff had difficulty "buying into it."
All administrators claimed that no one was laid off, employees merely had their job descriptions dramatically changed, or were relocated. Of course, there was some turn-over from attrition, and those staff members were never replaced. Nurses were particularly upset by the number of skills which they were expected to acquire or direct (such as taking X-rays and providing respiratory treatments), while at the same time experiencing a great reduction in their numbers. The remaining therapists and technicians found themselves as nothing more than "gofers." These highly trained, certified individuals were relegated to delivering supplies to the units where their jobs were being performed by nurses and aids. Obviously, staff moral, and job satisfaction diminished for all involved.
Another problems with PFC, which was not presented at the 1992 national healthcare forum, was the confusion and disruption caused by implementing this system. An example of such an experience occurred at Fairview Riverside Medical Centre in Minneapolis when American Practice Management, Inc. (APM) was employed to implement PFC.
Connie Curran, a former nurse and now head of APM, accepted a $4 million contract to restructure their health care delivery to a PFC model. The changes proved to be so disruptive that another consulting firm had to be brought in to correct the situation. Maybe hospitals should cut costs by not hiring these types of consulting firms? Ms. Curran, of APM, was also contracted by several Canadian Hospitals, where she is affectionately referred to as the "bounty hunter." The nurses from the Manitoba Nurses' Union confirmed that with the introduction of PFC, hospital costs were reduced -- but at the expense of patient care, staff moral, and job security.
How did PFC receive such a positive spin in the first place? Reduction of cost was all that needed to be said to attract management, and with the providers dictating quality to their consumers they were sure to bias patient satisfaction in their favor.
Prospective payment, or the reimbursement of medical expenses based on diagnosis related groups, has resulted in increasing patient acuity. Patients are not admitted unless severely ill, and hospitals earn more per patient if patients are serviced quickly. Ironically, at the time when hospital patients are more acutely ill than ever before, and are being discharged earlier than ever before, their care is going to be delegated to the least trained, least qualified, and least experienced breed of health care provider than ever before.
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