A detailed report released last week on the disturbing correlation between nursing shortages and patient safety was the first foray of a major new campaign by the Joint Commission on Accreditation of Healthcare Organizations to influence public policy affecting quality of care.
Although it's the JCAHO's first move into the realm of public policy, the Oakbrook Terrace, Ill.-based accrediting agency is following many other organizations that have already released dire warnings about the nation's nursing shortage.
The 40-page document said nurse-staffing shortcomings were at the root of one in four reported incidents of unexpected deaths or serious injuries caused by errors in hospitals. Under current conditions, the inadequacy of nursing staff coverage will only get worse unless improvements are made in the working climate and educational preparation for nurses, and financial support for nursing, the report concluded (See chart).
The JCAHO's "call to action" followed on the heels of President Bush's signing of the Nurse Reinvestment Act (Aug. 5, p. 6) and an uptick in the visibility of growing nursing shortages nationwide (May 20, p. 20).
But the timing was coincidental, said Margaret VanAmringe, the JCAHO's vice president of external relations. The commission began the policy effort on solutions to the nursing shortage last November with a "roundtable" discussion of 23 experts who contributed their industry knowledge to framing and supporting a broad view of nursing-related problems and solutions.
Those contributions-along with existing studies on aspects of the problem from such sources as the American Hospital Association, American Nurses Association and Robert Wood Johnson Foundation-formed the basis for a "white paper" that was submitted to a May symposium for further comment and additional contributions.
The final report, Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis, was the first product of a policy-development push the JCAHO launched last year that also has included roundtables on preparedness for national emergencies and on overcrowding in hospital emergency departments. The symposium to air the findings on emergency preparedness is scheduled for October in Washington.
As the principal accreditor of quality in healthcare organizations, the commission is in a position to compile data to inform policymakers of massive changes in healthcare during the past decade that have deeply affected patient care, VanAmringe said. "An organization that is physically in healthcare organizations on a day-in, day-out basis has a unique view of quality," she said.
The nursing shortage, like other pressing healthcare problems, is a product of years of rising complexity in care delivery caused by new technology, consequences of reimbursement incentives and higher patient acuity, VanAmringe said. The JCAHO had the credibility to convene a cross-section of healthcare players and researchers to paint a full picture of how managers, payers, physicians and lawmakers are accountable for the problem and responsible for solving it, she said. "The comprehensive, nonpartisan view is important here."
The commission's own research concluded nurse-staffing levels were a factor in 24% of the 1,609 "sentinel events" it has recorded since 1996. But the new report cited other industry studies that linked understaffing and high turnover of nurses to quality of care:
* Hospitals with turnover rates of less than 12% had low death rates and shorter lengths of stay compared with hospitals with turnover rates exceeding 22%.
* Patients in hospitals with fewer intensive-care nurses were more likely to have longer stays and postoperative complications.
* Higher nurse-staffing levels correlated with a 3% to 12% reduction in certain adverse events, including gastrointestinal bleeding, pneumonia, shock and urinary-tract infections.
With those stark findings, policymakers-ranging from members of Congress and officials at the Centers for Medicare and Medicaid Services to executives at managed-care organizations and other insurers-have obligations to recognize the value of nursing, said JCAHO President Dennis O'Leary. They need to foster "an organizational culture of retention" to keep the nursing ranks from thinning even more, and remove disincentives for hospitals to invest in appropriate staffing levels, he said.
But the report also held hospitals accountable for not paying more attention to working conditions and career fulfillment of nurses. Among other recommendations, it called for limits on mandatory overtime, more freedom for nurses to make decisions at the bedside, and better matching of nursing skills and competencies to the types of patient conditions and serious illnesses they're being asked to manage.
The cost of keeping nurses happy can be offset by higher efficiency according to one study cited in the report. Organizations with a turnover of 12% or less averaged a 23% return on assets compared with a 17% return for organizations with turnover rates of 21% or more. Those high-turnover hospitals also had a 36% higher cost per discharge than hospitals with low nurse turnover.