Introduction

The Advisory Board Company, a Washington, DC, based research group which focuses upon human resource management, healthcare, and banking, has described the growing interest of Wall Street in the health care industry (The Advisory Board Company, 1996). This interest results from the emerging presence of investor-owned healthcare entities. Wall Street presence in other industries has quickly transformed small "Mom and Pop" companies into meganational companies focused on revenue growth, growth in annual earnings per share, growth in profit margins, and healthy shareholder returns. Wall Street's coming interest in healthcare has brought these new and rigorous standards of performance to the healthcare industry, demanding simultaneously higher quality of care and lower costs. Such standards from the "for profit" sector influence those of us in the "not for profit" sector. However, success in delivery of healthcare services can come only through focused attention to meeting and exceeding customer requirements and seamless delivery of compassionate and concerned care at a competitive cost.

Two for-profit hospital systems have recently come upon the scene in the Cleveland area and now all Cleveland hospitals are experiencing increased competition. We are witnessing consolidation of hospitals into integrated delivery systems, hospital closings, staff layoffs, and care being provided in new ways and in new settings. The scene has changed dramatically. The purpose of this paper is to describe the Cleveland Clinic Foundation's (CCF) response to these changes, namely, a redesign initiative.

The Cleveland Clinic Foundation Experience: An Overview

At CCF we agree with the many experts who state that redesign efforts are essential to succeed in a world that now demands healthcare be delivered faster, cheaper, better, closer, and in a way that is more friendly than its competition. Downsizing is defined as a reduction in personnel to do the same work with fewer people (Hammer & Champy, 1994). At CCF we elected to "redesign" the work processes rather than downsize; we define redesign as the reorganization of tasks and personnel performing the tasks.

Our philosophy of redesign and the method used to accomplish it is consistent with Hammer's (1996, p. 14) belief that redesign requires a fundamental rethinking and radical redesign of an entire enterprise, i.e., its business processes, job definitions, organizational structures, management and measurement systems, and values and beliefs. The purpose of redesign is the achievement of dramatic improvements in critical measures of performance. These improvements include cost, quality, capital, and speed of service delivery. With this perspective on redesign also comes the understanding that, although we are a caring profession, a more focused business approach will be required in this new environment of tumultuous change, intense competition, and demanding customers.

The Redesign Endeavor

We followed the management engineering principle of asking the people who do the work to help redesign the work (Hammer and Champy, 1994). We asked the nursing staff, i.e., the doers, not the managers, on two units (orthopedic and cardiac surgery units) for their ideas on how to improve their work. The process began by an analysis of the work currently being done. Here we asked three specific questions:

1. What is the outcome of this task/job, and is this outcome still viable in the present environment?
2. How is the task currently being performed? Can it be done more simply or more efficiently?
3. Who is currently performing the task? Is the task being performed by a person at an appropriate skill level?

Staff involved in the process brain-stormed while discussing all the individual jobs/tasks that they performed on a regular basis on the patient care units. This list of tasks covered a 12' X 12' wall and provided the framework from which we developed the subsequent steps.

Staff involved in the process brain-stormed while discussing all the individual jobs/tasks that they performed on a regular basis on the patient care units. This list of tasks covered a 12' X 12' wall ...

The team then reviewed each task to determine whether a license was required to perform the task. Copies of state regulations served as a guideline and resource in the review process.

The tasks that could be performed by unlicensed personnel were then sorted into clinical and non-clinical categories. This procedure led to creation of the patient care technician role (a clinical role) and the patient care service associate role (a guest services role). The patient care technician role includes specified nursing tasks that can be delegated by an RN to the technician, such as setting up of equipment, assisting patients with their activities of daily living , taking vital signs, and serving as another set of eyes for the nurses by noting changes in patient status. The patient care service associate is a multi-skilled worker who assists with, among other activities, transporting and discharging of patients, cleaning of patient rooms, and restocking of supplies.

The decision to move forward with the redesign effort was reinforced by our site visit to an academic institution already utilizing personnel in these two new roles. While making this site visit, staff were able to observe the redefined RN role, the patient care technician role and the patient care services role in action. These observations assured us of the value and practicality of the redesign plan. We saw first hand how teams comprised of an RN, a multi-skilled worker, and a service associate, functioned together.

Planning the redesign was a valuable experience for all staff. The task delineation and assignments step of the redesign endeavor was enlightening to the RNs since it revealed that much of their time previously had been consumed by activities in which they did not maximize either their professional education or their professional licensure. Task delineation and assignment of tasks also gave the staff nurses ownership in this redesign effort since these nurses ultimately determined what tasks were appropriately delegated to each level of service personnel.

The RN's role was redefined to be that of a care manager who directed the processes of care for the patient during the acute care episode and beyond. The RNs moved from focusing considerable time on activities not utilizing their professional skills to functioning at their upper limit of professional education and licensure. This move resulted in better use of nurses' professional skills and abilities. This role change provided the opportunity for RNs to look beyond the acute care episode to the full continuum of care. Today there is a better understanding of the patient's needs after discharge; the role redefinition outlined here allows the RNs to use their judgment to effect better patient care post-discharge.

Many employees who subsequently went through the Patient Care Technician Program commented about how much better prepared they felt to care for patients after completing the program.

Today nurses know more about the differing settings in which nursing care can be delivered, such as subacute, rehabilitation, ambulatory care, and home care settings; the role redefinition allows the RNs to prepare the patient for care inthese less acute settings and thus reduce the length of hospital stay. Even more important, the role redefinition gave greater attention to the goal of the patient's regaining health and enhancing functional status rather than merely to the goal of treating the patient's disease.

In addition, nursing unit assistants became excited about the redesign because they saw growth potential for their own job functioning. Many employees who subsequently went through the Patient Care Technician Program commented about how much better prepared they felt to care for patients after completing the program. The patient care service associate became an integral part of the unit team, rather than operating from an outside department, such as Housekeeping. Perhaps, however, the most important outcome of this endeavor was that it started a team building process that is continuing today.

A substantial amount of education and training was required to assure that these roles were performed according to established standards. Registered Nurses were taught the strategies of managed care, case management, delegation of tasks, supervision, and interviewing skills. Patient care technicians received clinical and didactic classes covering a variety of the skills to be used in their new role. For example, they were taught how to take vital signs and how to promote the patient's activities of daily living. The patient care service associates received training from other departments, such as Environmental Services, teaching them correct procedures for cleaning the patient care environment. Working together, these newly created teams have been able to meet the majority of the patient's needs.

As a result of the redesign, the skill mix on the units decreased in the proportion of RNs to non-licensed personnel. Specifically, the skill mix went from 80:20 (RNs to nursing assistants) to 60:40 (RNs to patient care technicians/service associates). This mix allowed for an increase in the number of available nursing personnel (although a proportionally greater number of the personnel had lower education and were non-licensed) while keeping the budget neutral.

Evaluation: Findings from Previous Studies

Healthcare literature presents an equivocal picture of the impact of RN staffing on quality of care. Some literature reviews suggest that higher ratios of RNs to other personnel have been shown to lower hospital mortality (Hartz et al., 1989; Knaus, Draper, Wagner, & Zimmerman, 1986; Krakauer et al., 1992; Scott, Forrest, & Brown, 1976.) The Institute of Medicine (IOM) (Wunderlich, Sloan & Davis, 1996), conducted an independent objective study requested by the Secretary of the Department of Health and Human Services, to explore the relationship of quality of care and patient outcomes to nurse staffing levels. In reviewing literature to determine if empirical evidence exists linking RN number and skill mix with quality, they found little evidence of this connection. The IOM commented that a serious paucity of recent research on the definitive effects of structure (such as specific staffing ratios) exists. This IOM study noted that the causal relationship between specific staffing ratios and quality of patient care in terms of patient outcomes while controlling for all other potentially confounding variables is not established (Wunderlich, Sloan & Davis, 1996, p. 121).

A major goal of this redesign effort was enhancing or maintaining quality of care while simultaneously keeping cost the same or reducing cost. Due to the anecdotal reports in the nursing and lay literature concerning the impact of RN staff reductions on quality outcomes, an evaluation goal was to systematically collect data relevant to patient quality outcomes.

A complicating factor in measuring changes in quality of care is the multiple factors that impact the care outcomes (Prescott, 1993). In complex organizations it is often impossible to isolate the determining role of any single factor upon the quality of care.

Due to the anecdotal reports in the nursing and lay literature concerning the impact of RN staff reductions on quality outcomes, an evaluation goal was to systematically collect data relevant to patient quality outcomes.

The performance of a system is determined as much by the "arrangement and interaction" of its parts as by the performance of the individual components (Scott & Shortell, 1983). Therefore, isolating the particular contribution of nursing staff to patient outcomes is challenging. The process of measuring quality is further impacted if other factors or parts change during the redesign process. Simultaneous to the CCF Nursing redesign efforts, other departments also began to examine their work processes. For example, Transportation began exploring a decentralized dispatching system.

Evaluation: The CCF Evaluation Plan

Here at CCF four specific units were studied to determine the impact of the redesign process on cost and quality of care. Two units, an orthopedic and a cardiac surgery unit, served as experimental units and underwent the redesign process described above, while two other units served as controls for these units: a gynecology and a medical cardiology unit respectively. These four units were matched for acuity, census, and staffing ratios. Clinical outcomes, specifically patient status outcomes, patient satisfaction, and physician satisfaction measures were obtained before implementing the redesign process and again six months following implementation on all four units. Additionally personnel satisfaction was measured both before and after implementation. Comparisons were made of the pre and post implementation scores for all four units; additionally each experimental unit was compared with its respective control unit after implementation of the redesign.

Evaluation of Redesign: Clinical Outcomes

Patient status outcome measures selected for the redesign evaluation included: a) safety issues, specifically, falls, pressure ulcer incidence, and medication errors; b) 30 day readmission rates along with incidence of adverse events, morbidity and mortality rates; c) patient satisfaction; and d) physician perception of quality of care. These outcomes were selected because of the theoretical expectation that redesign (staff mix change and new non-license roles) would impact these measures. Additionally the Cleveland Clinic Foundation and the Nursing Quality Management System supported their monitoring.

Our findings show that quality scores have improved for falls and medication errors. That is, the rate of falls per 100 patient days, and the rate of medication errors per 100 patient days, decreased after implementation of the redesign project. Pressure ulcer rates remained essentially the same, i.e., they continued to consist of sporadic occurrences, as was experienced during the pre-implementation period. This finding is partly attributed to the patient populations, i.e., frail, elderly orthopedic patients and acute cardiac surgical patients. Thirty day readmission, adverse effects, morbidity and mortality rates were too low on all units both pre and post redesign implementation to assess statistical differences.

The patient satisfaction measure, a self-developed tool, was administered within the 24 hour period before discharge. It assessed the level of satisfaction with different aspects of the hospitalization and included: nursing skills, time and availability of personnel, communication, and patient and family inclusion in teaching, as well as room cleanliness and availability of necessary equipment. Scores on this measure were high both pre and post implementation indicating patients were "usually" satisfied with care. There were no significant differences, using the t-test with an alpha level of .05, between pre and post implementation scores, nor between experimental and control unit scores post redesign implementation.

The physician satisfaction measure, developed in-house, assessed the same areas as did the patient satisfaction measure described above. Scores on this measure were midrange both pre and post implementation. Again there were no significant differences, using the t-test with an alpha level of .05, between pre and post implementation scores, nor between experimental and control unit scores post redesign implementation.

Evaluation of Redesign: Job Satisfaction and Security

Another important measure of outcome of the redesign process involves the extent to which staff are satisfied with the endeavor and the extent to which they feel secure in their jobs. We used the job satisfaction survey developed by Hackman & Oldman (1974) to measure the impact of redesign on employee job satisfaction. This survey assessed a) specific job dimensions, including activities such as skill variety, task significance, autonomy and dealing with others; b) experience of psychological states including meaningfulness and responsibility of work and knowledge of results; and c) responses to the job, including general satisfaction, motivation, growth and supervisory satisfaction. The post-implementation scores varied by unit and by category of worker, i.e., on each unit for each category of worker and for each area assessed, some scores remained the same, some showed more satisfaction with the job and some showed less satisfaction with the job. Although the experimental units had higher satisfaction scores after the redesign, using the t-test with an alpha level of .05, these differences were not significant. The data did suggest that the process of creating new work partnerships requires attention to the application of various team-building strategies, creation of trust, effective two-way communication and active management.

As might be expected, the RN staff worried about job security after the redesign was implemented. In reality, no RN on either of the redesigned units lost his or her job. Rather, budgeted unfilled positions were used to create the positions for the patient care technician and patient care service associate. The Cleveland Clinic Foundation is being transformed into an integrated healthcare system with a variety of points of care delivery. The Nursing redesign efforts are one example of this transformation. Within the CCF system, numerous opportunities for nurses have emerged. Here at CCF, as well as throughout healthcare, RN job security may be challenged but RN career security is heightened. Career opportunities for RNs continue in ambulatory, rehabilitation, home care, and subacute care, as well as in acute care settings.

Conclusion

As the chief nurse executive, I believe that this experience was a healthy process to undergo. Through the process, quality of care was maintained, career security was not threatened, and participatory management was exercised, all without added cost or resource allocation. Healthcare in the United States is changing on every level. No doubt what we have arrived at today will need to change in the future. Working through this redesign process has given us the confidence to know that we will be able to change with the changing needs of our patients and payers.

Author

Sharon Coulter, RN, MN, MBA, CHE

The Cleveland Clinic Foundation is a multi-specialty, academic medical center, recognized as a National Referral Center and an international health resource. This includes a 928 bed tertiary hospital, an 800 member multi-specialty physician group practice, a Research Institute, and Educational Foundation. It has also created an integrated delivery center which includes community hospitals, ambulatory care centers, rehabilitation services, subacute and home care services.

Sharon Coulter is the Chair of Patient Care Operations and is responsible for nursing and patient care support operations. The major challenge faced is how to provide excellent patient care in the face of declining revenues. This pilot was undertaken to help us better understand how redesign could help with that challenge.

The author gratefully acknowledges the contributions of the following CCF nurse staff in the development of this article: Linda J. Lewicki, RN, MSN; P. Mardeen Atkins, RN, BSN, MPA; Sandra S. Shumway, RN, MSN.

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