Friday, January 23, 2015

Nursing Staff Levels and Payments Related to Outcomes

An interesting news item describes a study that was planned in the state of Minnesota but that was unable to be completed.  Some say that the hospitals chose not to provide information.  The hospital association in the state claimed that providing the data would have place an undue burden on the members of the association.  Regardless, it is worth considering what the study was trying to examine.

There have been a number of studies that have asked the question, "What happens when there are lower levels of nurse staffing in a hospital?"  And, as the news item points out, there are some studies that suggest that lower levels of nurse staffing have been associated with failure to rescue after surgical complications, falls, medication errors, and missed aspects of nursing care.

The challenge is that few studies have shown that after a change from a lower level of nurse staffing to a higher level of nurse staffing there is an improvement in these types of outcomes.

Why might there not be?  Perhaps in cross-sectional observations hospitals with higher nurse staffing have other positive characteristics that encourage better outcomes.  In this case, if a hospital simply hires more nurses, that may not solve the problems.  The problems may continue if there are not other structural and systematic changes made in the hospital.

As hospital and health system payments become more dependent on outcomes, what should a hospital do?  If the hospital does not hire more nurses and has poor outcomes, the hospital will have to bear the costs of the extra care for complications without reimbursement.  This could lead to losing money.  If, on the other hand, the hospital hires more nurses it would have to spend more money up front.  The key question is whether this is less costly (and whether it is more predictable) than the cost of poor outcomes.  In addition, it should help to improve the hospital's reputation and bring in more patients.  And if the hospital hires more nurses but there are not other systematic changes that may be necessary, then the hospital will definitely lose financially compared with where it is now.

As we move ahead, having information on the value of increasing nurse staffing (or any other type of staffing in hospitals to improve outcomes) will help to make better resource allocation decisions.  Failing to provide this information is unfortunate.  Hopefully in the future Minnesota hospitals can provide information at the unit level to shed some light on this subject without overburdening their data systems or another state will take up the challenge to conduct such a study.      

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