Work redesign is about jobs, and that gets complicated when unions are involved. After all, what a hospital CEO may see as efficiency, workers may view as job losses.
Alta Bates found that out in September when it was sued by the California Nurses Association over its work redesign program, which would change the skill mix on nursing units.
Executives of the 435-bed hospital are working to implement the redesign in two units for an initial savings of $600,000 annually. By early 1996, the hospital hopes to implement it in all 199 units.
Meanwhile, the CNA is seeking an injunction to block the plan, which it contends endangers patients and violates the association's union contract. In an advertisement in The New York Times, CNA calls Alta Bates' work redesign "untested (and) experimental," adding that it amounts to "dangerous short-staffing (that) leads to death and injuries."
It hasn't been the first time that relations got contentious between Alta Bates and the nurses union. Last year, Alta Bates was one of five Northern California hospitals that were the target of a one-day strike over staffing issues. The strike was averted (Aug. 16, 1993, p. 12).
Even so, the hospital's president and CEO, Albert Greene, is doing what he believes is the right thing. "The (registered nurses) find better use of their professional training," Mr. Greene said, adding that "patients receive better continuity of care."
Even though CNA doesn't agree: "We have reached an impasse...and we have the right to implement," said Mr. Greene about the work redesign.
New jobs.Alta Bates is already interviewing workers for its new jobs. The salary range is still being negotiated. The jobs are:
Care coordinator: a registered nurse who supervises, assesses patients, directs emergency interventions and collaborates with physicians.
Care associate I: an employee who provides personal patient care and nutritional support; measures and records vital signs; and does bedside lab tests, simple respiratory functions and electrocardiogram tests.
Care associate II: a licensed vocation nurse who does nursing functions under the care coordinator's supervision.
Administrative coordinator: a clerical employee who coordinates patient-care activities, keeps medical records, prepares time cards and monitors staff compliance with regulatory requirements.
Support associate: an employee who orders and stocks supplies, greets and orients newly admitted patients, and assists with patient discharges.
Noting that nurses spend only 25% of their time in patient care, Mr. Greene said nonprofessional work that had been performed by nurses will now be done by other employees.
Essentially, that will reduce the number of registered nurses neededby Alta Bates. Currently 25% of the hospital's 2,700 workers are unionized, a percentage that likely will decrease with the work changes.
Care-mapping.The work redesign
followed another cost-cutting project, care-mapping, that began in 1991. So far, the hospital has about 25 care maps, designed by a team of physicians, home-care nurses, case managers and other professionals. By mapping a patient's care from the physician's office to the home-care follow-up, Alta Bates has been able to save money and increase quality.
A look at a single procedure -transurethral resection of prostate, or TURP, which treats an enlarged prostate-shows how care-mapping can cut costs.
A one-page care map accompanies a patient's chart throughout the process. The map is a grid that details steps that are taken in the office visit, during pre-operative testing, on the day of surgery, on the post-operative half-day and at home. It includes diagnostic tests, treatments, medications, diet, instructions to patient and family, discharge planning, nursing assessments and outcomes.
"If the patient isn't following the care map, bells and whistles go off," Mr. Greene explained.
The mapping method changed one way TURP patients are cared for. "It used to be if a patient still had a catheter, you don't send that patient home," he said. Now, that patient goes home and receives two follow-up visits from a home-care nurse. Not only does Alta Bates cut its length of stay, but it gets paid for the home-care visits. Home-care visits for Alta Bates patients have increased 67% in two years to 250,000 annually.
Through care-mapping, Alta Bates shortened the average length of stay for the procedure to 1.9 days in 1993, compared with 3.3 days the previous year. In 1992, only 9.6% of patients had a one-day stay. In 1993, that increased to 64.2%.
The bottom line is Alta Bates' profit margin on those patients was $183,096 in 1993, compared with $73,371 in 1992.
Mr. Greene said saving money is just one side of the equation. "You can't save your way to prosperity," he said, adding that hospital executives need to make sure the revenue side is growing as well. "If the only thing you're doing is reducing your work force, that's a little bit like anorexia. You will get thinner, but you won't get healthier," he said.