• The Quest to Accomplish More with Less

    Mar 01, 2012

    Innovative hospitals and health systems are not wasting time complaining about their expanding to-do lists. Instead, they are focused on finding solutions to combat growing demands.

    Key Takeaways
    Providers are trying a number of tactics to boost productivity:

    • Match tasks to the right workers with the right skill level
    • Eliminate time-wasting, low-value activities
    • Increase the use of technology, data, evidence, and teams
    • Standardize to avoid rework
    • Rely on evidence-based, personalized care to avert complications

    pg25_feature-more-with-lessAt Appleton Medical Center in Wisconsin, nurses no longer waste time retrieving supplies because most items are stocked within easy reach of patient rooms. In New York, Mount Sinai Medical Center has connected a wireless communication system to ventilator and cardiac-monitoring alarms-and increased caregiver response times. And in Ohio, The Arthur G. James Cancer Hospital is increasing cancer volumes by pairing nurse practitioners with oncologists.

    These types of output-boosting strategies are essential to solving one of the healthcare industry's fundamental problems: lagging labor productivity.

    Compared to other segments of the workforce, health care might appear to be underperforming. Labor productivity in the healthcare sector decreased by 0.6 percent a year during the past two decades, according to a recent NEJM article (Kocher, R. and Sahni, N., "Rethinking Health Care Labor," NEJM, Oct. 13, 2011, vol. 365, no. 15, pp. 1370-1372).

    Those in the healthcare trenches can quickly point to a key reason for declining productivity: complexity. At the same time that medical care has grown more specialized and intricate, the business of health care has gotten more complicated. Providers are having to comply with an ever-growing number of regulations while restructuring to succeed under health reform and adopting complex technologies.

    Nurses, physicians, and other staff complain that they spend too much time documenting, preparing equipment, searching for needed items, and carrying out other nonclinical tasks-and not enough time engaged in direct patient care. Research is on their side: Patients do better clinically when nurses spend more hours at the bedside.

    All of this serves as a reminder that increasing productivity is not only about accomplishing more, but also about ensuring that staff are engaged in work that best matches their skills and experience.

    Using Physician Extenders

    Experts tend to define labor productivity in terms of output per worker, or the volume of all encounters, treatments, tests, or surgeries per unit of cost. The Arthur G. James Cancer Hospital & Richard J. Solove Research Institute in Columbus, Ohio, is improving productivity by using nearly 200 nurse practitioners to help oncologists manage patients and boost volumes. "Here at the James, we are growing by leaps and bounds," says Tracy Ruegg, MS, CNP, AOCN, a thoracic medical oncology nurse practitioner at the hospital, a part of The Ohio State University Comprehensive Cancer Center.

    And that growth will continue. Nationally, the demand for oncology care is expected to increase by 48 percent by 2020, while the number of practicing oncologists will rise by only 14 percent, according to the American Society of Clinical Oncology (ASCO).

    An ASCO study underscores the role of nonphysician providers (NPP)-a term that includes nurse practitioners and physician assistants-in meeting that growing demand for oncology services (The ASCO Study of Collaborative Practice Arrangements funded by Susan G. Komen for the Cure®, June 2011). "The integration of nonphysician practitioners into oncology practices offers a reliable means to address increased demand for oncology services without adding physicians."

    This approach is working so far at the James. Productivity increased by 30 percent in the first year after the hospital began hiring mid-level providers, says Ruegg. The ASCO study, which analyzed 33 oncology practices, found that physicians and NPPs working together is correlated with improvements on two productivity measures: total patient encounters and work relative value units (RVUs), which is the measure of value that Medicare uses to determine reimbursement for physician services.

    The ASCO study also identifies three practice models that lead to successful physician/NPP collaboration (see the exhibit below). 


    Incident-to-practice model. In an incident-to-practice model, the NPP routinely sees patients independent of the physician, but the physician is available in the office suite. For example, on Mondays, Ruegg uses this practice model-which she calls a tandem clinic-with one of the lung cancer specialists at The Arthur G. James Cancer Hospital.

    Each of them schedule up to 40 patients for the day. The oncologist sees patients who discuss their most recent images with the physician, while Ruegg sees patients who need to be cleared for chemotherapy treatments and handles other matters that do not require a physician. "I'm seeing patients independently, but the doctor is right there if a patient needs a treatment change, for example," she says. "The good thing about a tandem clinic is you can increase your volume, and you get more new patients into the system."

    This practice model can essentially double the productivity of an oncologist, as measured by total patient encounters, she says.

    Shared practice model. In this model, the NPP always sees patients in conjunction with a physician. Ruegg uses this model-she calls it a collaborative clinic-on Thursdays. She examines about 25 patients, reviews images, and documents the visit for the oncologist, but the oncologist also sees each patient for a few minutes.

    "The amount of time the oncologist spends with the patients is a lot less than it would normally be because I've done everything, including the physical exam," she says. "He just needs to do what is required for billing purposes."

    A traditional clinic with no NPP typically serves about 20 patients per day, making the collaborative clinic slightly more productive. Because the oncologist spends much less time with each patient, he or she is free to handle administrative or research duties in addition to a full patient load, says Ruegg.

    Independent practice model. Sometimes NPPs see patients completely independent of a physician. For example, on Fridays, Ruegg sees cancer survivors who are no longer in active treatment, and the patients do not see an oncologist during these visits. Ruegg monitors lingering side effects of their treatment, conducts cancer screenings, and adjusts medications as needed. Having the capacity to serve cancer survivors is critical because this is one of the fastest growing segments of oncology care.

    A nurse practitioner for 16 years, Ruegg says simply hiring nurse practitioners and physician assistants does not automatically increase physician productivity. The staffing model and the working relationship between the physicians and NPPs also influence the amount of work accomplished.

    The ASCO study found that practices in which an NPP works with all physicians in the group showed significantly higher productivity than those in which a nurse practitioner or PA worked exclusively with one physician. In fact, the average work RVUs for the "NPP working with all physicians" model was about 25 percent higher and the average number of patient encounters in that model was almost 20 percent higher than for practices in which an NPP was paired with a single physician.

    Ruegg encourages hospital administrators to educate physicians about the proper role of NPPs. "Approach it with, 'This is how we can increase your productivity. This is how we can increase patient access to care while generating revenue,'" she says. "And set the expectation that you will come back after a year and see if the doctor is using the nurse practitioner effectively with these goals in mind."

    Changing the Acute Care Model

    ThedaCare in Wisconsin is launching a new team-based care model in all medical/surgical units in Appleton Medical Center and Theda Clark Medical Center this year after a pilot project found that it improved nursing productivity by 11 percent-while lowering costs, improving quality, and increasing patient satisfaction scores (Bielaszka-DuVernay, C., "Redesigning Acute Care Processes in Wisconsin," Health Affairs, March 2011, vol. 30, no. 3, pp. 422-425).

    In the new model-called Collaborative Care-a team that includes a physician, a nurse, and a pharmacist visits each patient within 90 minutes of admission. Together, they review the patient's medical history and health status, develop a care plan with input from the patient, and begin developing a relationship with the patient and family members.

    From there, nurses are responsible for moving a patient's care forward, ensuring diagnostic and therapeutic processes occur on time. If a process breaks down-for example, lab results are not reported at the proper time-the patient's nurse is responsible for solving the problem, identifying the root cause, and communicating to all parties what happened so the problem will not happen again.

    In the first two hospital units that adopted the new care model, the average length of stay dropped by at least 10 percent and the 30-day readmission rate fell to below 9 percent. The amount of time spent on documentation has been cut in half, allowing nurses to spend more time with patients. Not surprisingly, perhaps, 95 percent of patients on Collaborative Care units rated their satisfaction level as "excellent" in 2010, up from 68 percent before the model was introduced in 2007. 


    Reengineering paradigms. "This isn't just about new process flows," says Jamie Dunham, MS, RN, director of clinical care transformation. "It's a culture change, it involves paradigm shifts, and it involves professionals working together in the same environment in different roles. For example, it requires physicians and pharmacists and nurses and discharge planners to work together differently."

    ThedaCare used the lean improvement methodology to guide its overhaul of inpatient care processes. One of the early steps in that methodology-value-stream mapping, which identifies every step in a process and evaluates the value that it delivers-revealed many areas that needed improvement:

    • Nurses were frustrated at the challenge of accommodating physicians' varying preferences about how to care for patients
    • Because they spent, on average, three hours per shift tracking down and transporting supplies, nurses felt they were wasting effort and being underutilized in patient care
    • Physicians, nurses, and pharmacists each used their own care plans for patients without discussing how their work affected one another or the patient

    The pilot project team tested 24 rapid-improvement events to address problematic issues and redefine care processes and clinicians' roles-creating the new Collaborative Care model.

    After health system leaders realized the benefits of Collaborative Care, they remodeled all the medical/surgical units in one hospital and built a new inpatient unit in the other, designing the space to accommodate the new care model, says Dunham. For example, the units do not have traditional nursing stations; rather, "consultation alcoves" are scattered throughout each unit to allow the physician-nurse-pharmacist teams to convene near a patient's room to discuss the patient's care.

    Copying the model. What works for ThedaCare may not work for other health systems in the exact same way, says Dunham. Any hospital that wants to adopt the Collaborative Care model must go through the same steps-starting with a value-stream mapping of current processes-that ThedaCare has already traveled.

    "My advice is that this has to be your individual journey, and you have to start where you are at," she says. "You can take the concepts, but you can't cookie- cutter the exact process flows we adopted because it won't work."

    Testing Tech Solutions

    In New York, Mount Sinai Medical Center has increased the efficiency of its nursing staff by layering technologies on top of one another. The first step was acquiring staffing and scheduling management software that allows nurse managers to manage their budgets on a real-time basis.

    The technology allows nursing managers to track staffing resources, patient census, and patient acuity whether they are at the hospital or at home. At any point in time, they can see how their actual use of nursing resources compares to their monthly budgets. Because they can share information about under- and overstaffing, they can allocate resources within the department to match patient demand and budget needs. The result: Nursing units reduced overtime, curtail the use of agency nurses, and achieve their targeted nursing hours per patient day.

    "That was the foundation because first you have to get control of your budget," says Carol Porter, DNP, RN, Mount Sinai's CNO and senior vice president.

    Shortly thereafter, the medical center gave each nurse a hands-free communication device-which attaches to a lanyard or can be pinned to clothing-that allows wireless voice communication. Nurse managers working anywhere in the hospital now convene electronically in "e-huddles" at certain times during the day to adjust staffing as needed. They refer to the staff management software to identify the competencies of the nurses on duty so they can shift resources if necessary.
    "Say it's 10 o'clock…what does the ED look like? How many post-op patients are you getting? What's the staffing like on your unit?" says Porter. "The nurse managers can assess the utilization of resources, the flow of patients, and whether anybody has a problem they can help with."

    Next, Mount Sinai connected the wireless communication system to ventilator and cardiac-monitoring alarms in a way that increases response times and, thus, improves patient care. When a nurse signs in to the electronic nursing assignment system at the beginning of a shift, the software identifies which of the nurse's patients are using ventilators or cardiac monitors. Those monitors are automatically connected to the nurse's wireless device so, if the alarm goes off, the nurse is notified immediately. If a nurse does not respond within a designated time frame, other members of the nursing team are notified via their wireless devices.

    The wireless devices are also connected to patients' call buttons so patients can talk to their nurses, regardless of where they are on the unit. If a patient wants pain medicine, the nurse can check the physician orders on the electronic medical record before going to the patient's room. If the patient requests water, the nurse can call an aide-also equipped with a wireless device-to fulfill the request.

    "We are talking about a whole level of communication that we've never had before, and it's instantaneous," says Porter. "Nurses are more efficient because they have information right when they need it. That saves steps and improves patient safety."

    Using Staff Smartly

    All three healthcare organizations in this article are ensuring the best staff for a particular task are in the right place at the right time. For example, at ThedaCare, this translates into having a trio of healthcare experts-physician, pharmacist, and nurse-conduct a joint patient assessment. At Mount Sinai, it means equipping nurses with technology that allows them to conduct e-huddles on demand to work out staffing issues.

    Executing these redesign changes is anything but easy. As ThedaCare's Jamie Dunham says: "It's a culture change, it involves paradigm shifts..." But their hard work is paying off in improved productivity. 

    Interviewed for this article (in order of appearance):

    Tracy Ruegg, MS, CNP, AOCN, is a thoracic medical oncology nurse practitioner, The Arthur G. James Cancer Hospital, Columbus, Ohio (tracy.ruegg@osumc.edu).

    Jamie Dunham, MS, RN, is director of Clinical Care Transformation, ThedaCare, Appleton, Wis. (Jamie.dunham@thedacare.org).

    Carol Porter, is CNO and senior vice president, Mount Sinai Medical Center, New York City (carol.porter@mountsinai.org).