Obtaining Support
Stakeholder engagement is critical not only in securing approval for the proposed policy change and its successful implementation. The policy requires approval by the hospital’s leadership, who must consider its cost and quality implications, in the context of the organization, in order to determine whether it can be implemented sustainably. On the other hand, its implementation requires the active involvement of the organization’s medical practitioners (nurses, technicians, physicians and orderlies) Firstly, therefore, it is important to create a shared vision for change, by ensuring that key stakeholders have access to credible information about the current problem and possible solutions. Seminars, public lecturers, and formal/informal communications on issues such as medication errors, evidence-based recommendations on nurse-to-patient ratios and quality implications among other important information would be provided. Further, it is critical to create a guiding coalition of supporters for the plan, develop a strategic plan and initiatives so that decisions-makers can get a clear idea of the direction that the proposed change will involve and the expected outcomes. Once this is done, it is important to identify the restraining forces that may prevent the successful implementation/approval of the plan, and with the help of the guiding coalition, volunteers, and evidence-based research, counter the forces. For instance, if the finance department and the human resources departments raise issues on cost implications, then reports on the quality and cost-reducing effects of the proposed change will be availed to them to facilitate favourable decision-making.
Problem Statement
With the implementation of Public Law 111-148 and the 2012 enforcement of the Hospital Readmissions Reduction Program (HRRP), health care providers are under increasing pressure, at the pain of financial penalties, to reduce Medicare costs, while at once bolstering the quality of care. These twin problems represent an important and difficult decision for hospitals. Intuitively, higher nurse-to-patient ratios should lead to better patient outcomes, but higher staffing levels have cost implications on care providers, many of which are financially struggling. The status quo is not sustainable. High patient loads on nurses are associated with poor quality of care (re-admission rates, length of stay in hospital, medication errors, failure to rescue and patient dissatisfaction, etc.), heightened risk of litigation and poor brand equity (Anderson & Townsend, 2010; Zhu, et al., 2012). It also has negative impacts on the nurses’ job satisfaction (up to 20% of nurses are dissatisfied), organizational commitment, work-life balance, motivation and numerous other outcomes. Further, with many nurses/physicians living the profession, the labour market would be short by upwards of 566,800nurdses and 90,000 nurses and physicians by the close of 2022, and possibility of this being eased by immigration is also hampered by the fact there is a shortage of 4.3 million nurses globally. Effectively, the solution to the nursing shortage in this organization and the entire country cannot entirely rely on infinite increases in the nursing staff levels.
Proposed Solution
Meeting the nursing staff solution requires a multi-pronged solution. It is proposed that the nurse-to-patient ratio being increased to at least 0.6 (Zhu, et al., 2012; McHugh, Berez, & Small, 2013). This ratio is associated with acceptably high quality of care outcomes. It should translate into cost savings (HRRP penalty savings, increased patient/employee satisfaction, and brand equity) that will generate adequate savings to counter the costs of bringing on more staff. Effectively, if implemented correctly, this policy would have a neutral effect on the human resources costs. Further, the increased utilization of part-time RNs will help ease pressure at peak times, while at once avoiding the necessity overprovision resources. However, given the overall labour market shortages, additional staff would come at a premium, and therefore it is important to explore the potential of building the existent human capital and increasing the nursing skills mix in order to improve quality. According to McHugh, Berez, & Small (2013), while higher skills mixes are important, high nurse-to-patient ratios should not result in reduction of skilled nurses in preference of inexperienced and least qualified staff to ensure cost savings. Effectively, this plan seeks to ensure increased human capital development to foster efficiency and quality of care improvements, coupled with the increased utilization of non-medical staff, and nursing interns to ease the patient load (Hariharan, 2015; Cho, Kim, Yeon, You, & Lee, 2015).
Implementation Logistics
The first step in implementing the proposed policy change is the development of a strategic vision and plan to facilitate the organizational leadership’s approval. Once approved, it will then become necessary to engage key stakeholders. This will begin with the identification and mapping of different stakeholders (including senior managers, staff members and business partners, etc.) who need to buy into the plan to given it the required momentum. The strategic plan will also include a budget, whose approval will allow the finance department to formally allocate resources to be used in the implementation of the project. From this initial engagement; a guiding coalition will be selected to champion the plan among other stakeholders, before forming an inclusive and functional steering committee to implement the policy change. The committee should include senior managers from the HR, finance, staff representatives and possibly the senior administrative managers (given the scale of the proposal and its potential impact). The steering team will also be charged with developing the strategic communication goals and content, prepare and lead the communication and awareness phase of the project.
Communication is critical to eliminate uncertainties and irrationalities that feed fears that ultimately result in change resistance. It helps ensure that organizational members and other stakeholders understand the necessity for change. Communication will utilize both formal and informal channels. Formal communications will include official letters and emails, internal memos, and meetings while unofficial communications will comprise caucuses, and team discussions. Seminars/conferences will be held for the affected stakeholders too.
The actual plan implementation will begin with the evaluation of the nursing skills portfolio to determine the gaps in attaining the recommended patient loads. This will be followed by a pre-intervention evaluation of the quality of service outcomes, patient, and nurse satisfaction. With the evaluation results, performance goals will be set. An internship program will then be launched to tap into the cheaper and relatively qualified student nurses, who would be coupled with non-medical staff to ease the pressure on the existent nurses e.g. by taking care of menial jobs. To ensure the organization has higher skills without necessarily hiring more (which is costly and disruptive), the organization will facilitate the acquisition of more skills among the existent nursing staff by launching a program that will include college scholarships, flexible schedules to allow nurses to pursue further education and employer-sponsored training programs. Further, if the evaluation determines that considerable skills deficits exist, more nursing staff will be hired on a permanent or part-time basis depending on the evaluation results as well as the available resources. Part-time nurses offer an attractive alternative because of the lower fixed costs burden, but in the long-term, the organization will look to replace them with permanent employees. At the close of six months, the post-intervention evaluation will be done, followed by remedial measures. Lastly, policies will be developed to inculcate the patient loads, staff skills composition and other factors for the institution’s future.
The resources required for communication will include letters (postage costs), emails, educational and conference facilitates (halls at the organization and/or rented hotel space), conference/seminar facilitators (including external consultants). Assessment tools may include pre and post-intervention surveys, which require interview facilities, questionnaires (and other stationery), and data analysis tools/software. The services of external evaluators will also be explored.
References
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Appelbaum, S. H., Habashy, S., Malo, J.‐L., & Shafiq, H. (2012). Back to the future: revisiting Kotter's 1996 change model. Journal of Management Development, Vol. 31 Iss: 8, 764 - 782.
Buerhaus, P., Donelan, K., Ulrich, B., & Norman, L. (2014). Impact of the Nurse Shortage on Hospital Patient Care: Comparative Perspectives. Health Aff. vol. 26, 3853-862.
Cho, S., Kim, Y., Yeon, K., You, S., & Lee, I. (2015). Effects of increasing nurse staffing on missed nursing care. International Nursing Review, 62(2), 267-274.
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Kotter, J. P. (2007). Leading Change: Why Transformation Efforts Fail . Harvard Business Review, 96-115.
McHugh, M., Berez, J., & Small, D. (2013). Hospitals with higher nurse staffing had lower odds of readmissions penalties than hospitals with lower staffing. Health Affairs, 32(10), 1740-1747.
Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press.
Zhu, X., You, L., Zheng, J., Liu, K., Fang, J., Hou, S., et al. (2012). Nurse Staffing Levels Make a Difference on Patient Outcomes: A Multisite Study in Chinese Hospitals. Journal Of Nursing Scholarship, 44(3), 266-273.
