Cornell University

Healthcare Transformation Project

16 East 34th Street, 4th Floor, New York, NY 10016 Contact: 212-340-2809

Sloan Conference Abstracts

Panel I: Managing Human Capital for High Performance Health Care

Paper 1: Patient Centered but Employee Delivered: Patient-Centered-Care, Turnover, and Organizational Outcomes by Givan, Rebecca; Avgar, Ariel; Liu, Mingwei

Abstract: The healthcare systems in many developed countries are in a state of crisis. Healthcare organizations are confronted with the need to dramatically improve the quality of care provided while simultaneously containing the rising costs associated with such care. In the quest for improved medical and financial outcomes these organizations have been experimenting with the restructuring of methods that are used for delivering care. One of these initiatives, patient-centered-care (PCC), entails a dramatic shift in the organization and delivery of patient care. PCC represents a clear departure from the physician or institution centered model, which places almost all the power and authority regarding patient care in the hands of the treating professionals, primarily the physicians. The overarching PCC goal is to provide care that is most conducive to patients' preferences, needs, and desires.

Methods: Using a unique dataset with patient, employee and organizational level variables from 173 hospitals in the United Kingdom, we examine the relationship between PCC and two outcomes, medical errors and patient satisfaction. In addition, we explore the mediating role of employment outcomes. Specifically, we test the hypothesis that the effects of PCC on medical errors and patient satisfaction are mediated through its effect on employee turnover.

Major Findings: Analysis of our data supports the overarching propositions that PCC reduce medical errors and increases patient satisfaction and that these effects are mediated by a reduction in employee turnover.

Paper 2: Problems in the Nurse Labor Market: Issues of Supply and Demand by Weinberg, Dana B.

Abstract: The policy response by hospitals and public agencies to the nursing shortage has focused on the supply of nurses, particularly in terms of recruitment, with little action, other than salary increases and perhaps schedule flexibility, on the retention front. While current approaches may be easing the US nursing shortage, underlying labor market and workforce issues provide ongoing cause for concern, not only for long-term labor supply but for care quality.

This paper analyzes survey data from the 2004 National Sample Survey of Registered Nurses and data from a study of 10 hospitals in upstate New York.

Major Findings: This paper identifies the underlying labor market strategy by healthcare employers as one primarily reflecting replacement, rather than retention, and characterized by a devaluation of nurses' human capital accompanied by high levels of direct supervision. Nursing education with its favoring of Associate degree preparation reinforces this employment strategy, as it has created a professional workforce that lags behind other professional healthcare providers in educational credentials and training. Together these trends emphasize the task-driven nature of nurses’ work over and against nurses' professional knowledge, while also compromising nurses’ collaboration with other care providers and the long-term value of a career in nursing. Yet, a growing body of research points to the importance of interprofessional collaboration and nurses’ professional practice for patient outcomes. The evidence-base for quality conflicts with employment practices, which are often overlooked in quality improvement initiatives. Addressing this disconnect requires re-envisioning the nursing profession and nursing employment.

Paper 3: Improving the Hospital Work Environment: The Nurse Manager is the Weakest Link by Sugrue, Noreen M.; Kenner, Carole; Finkelman, Anita

Much public policy, administrative, and research attention is paid to improving the work environment of hospital based nurses. Filling the literature dedicated to improving the work life of nurses are studies supporting more democratic decision-making, changing the cultural and organizational contexts of hospitals, giving greater voice to the concerns of nurses, increasing unionization, and providing more flexibility and control to ‘bedside’ nurses. One theme that is present in most of this literature is the importance of nursing leadership and management in affecting the necessary changes. The nurse manager, at once a liaison to and from hospital administrators and a voice for the clinical nurses and the hospital administrators, is central to creating and sustaining work place changes.

Using data from a labor force study of hospitals, we examine the role the nurse manager actually plays in creating work place changes.

Major Findings:
In many cases, the nurse manager is found to be ill prepared for management and unsure of his/her roles and responsibilities. The nurse manager, the weakest link in hospital management structure, appears to be a significant contributing factor to the problem work environment in which far too many hospitals based nurses work.
Using the results from the study, we offer suggestions for how to clarify and improve the work responsibilities of the nurse manager and thereby advance the agenda of enhancing the hospital work environment for 'bedside' nurse.

Panel II: Organizational Change and Engagement of Front-line Workers in Health Care

Paper 1: The Role of Nurses and Nurses' Unions in Addressing Quality and Efficiency of Care Issues in the U.S. Healthcare Industry by Clark, Paul F.; Clark, Darlene

The U.S. healthcare industry spends more money per person than any healthcare system in the world, yet it ranks behind most developed countries in key performance measures. The reasons for this situation are many and varied, however, ultimately, the explanation is that our system falls short in two key areas—quality and efficiency of care. Complex issues like these require complex solutions and the participation of the multiple stakeholder groups involved. One group often overlooked in the development of strategies for dealing with problems facing our healthcare system are registered nurses (RNs). This lack of voice on issues related to patient care, particularly in acute care hospital settings, drives many of the efforts of nurses to organize unions. Once organized, nurses are increasingly looking to these organizations to win a greater voice over how care is delivered. This paper discusses the various strategies nurses' unions are pursuing to give RNs a greater voice in the way patient care is delivered in acute care hospitals. These strategies involve the use of collective bargaining, legislative and political action, and the regulation process.

This paper analyzes a recent membership survey of a statewide nurses' union.

Major Findings: We find that nurse/members place great value on the union's ability to win a greater voice in patient care when assessing the overall effectiveness of the union. These findings suggest that nurses, and the unions they form, desire to play an active role in improving the quality and efficiency of care in acute care hospitals. Any efforts to address these problems should include the involvement of this important stakeholder group.

Paper 2: What's Working and What's Getting in the Way to Engage Front-Line Staff to Improve the Quality Care and Patient Safety in Hospitals by Lazes, Peter; Havens, Donna; Carlson, Peter

Abstract: Hospitals are coming under increasing pressure to improve quality and safety, while controlling costs. Hospitals are responding with a wide variety of improvement initiatives, but with mixed results. And even where those efforts have produced positive results, the improvements have proven difficult to sustain and spread.
The importance of creating and sustaining appropriate front-line staff is consistently noted in healthcare research as a critical activity for improving patient and hospital performance, but there is limited research in terms of how to sustain these efforts.

Methods: This paper presents the results of a 31 hospital study (started in November 2007) to identify what's working and what's getting in the way to engage front-line staff; effective methods of sustaining and spreading these activities; and in unionized hospitals, understanding the role that role that unions and their leaders have played to improve the quality of care of patients.

Major Findings: Results of interviews of key quality and patient safety leaders from each participating hospital will be presented and as well as the trends and issues that affect approaches to engage and sustain front-line staff participation. Suggestions for future research work will also be identified.

Paper 3: A Team Approach to Nursing Home Quality of Life: Labor and Management Partner to Transform Work and Care by Bishop, Christine; Leutz, Walter; Dodson, Lisa

Abstract: Many nursing homes are attempting to transform care philosophy and processes so that care is customized to individual resident needs and preferences. Called "culture change," this transition has parallels to the restructuring that has occurred in some high-value manufacturing and service firms. The empowerment and participation of front-line workers appears to be a prerequisite for successful nursing home culture change. However, the potential for union contribution to culture change has not been studied.

Methods: We conducted a case study of a labor-management partnership developed by Local 1199 of the Service Employees International Union (SEIU) in New York City with senior management in 40 nursing homes to implement culture change. Data for the study included interviews with union and management representatives from 10 facilities and in-depth case studies at 2 nursing homes with deep involvement in partnership activities. The site protocol consisted of interviews with a wide range of administrative and front-line care workers and observations of work on nursing home units.

Major Findings: The two study homes used support from the labor-management partnership to change organizational structures, management practices, staffing, job descriptions, teamwork, care practices, dining, and other resident care processes. The support of both union and management was critical, as were training resources reserved through the collective bargaining contract. Our examination of the contributions and challenges of a labor-management partnership illustrates how unions and managers can work together to transform the culture of nursing homes and the work of direct care workers.

Paper 4: Hardware and Software: Implications of Organizational Culture, Psychological Safety, and Information Technology for Quality by Pfefferle, Susan G.; Cooper, Ben; Layton, Debbie

Information technologies are promising means to track outcomes. They can also be used to facilitate care management and be used to track client referrals. Organizational culture and psychological safety are constructs that have been shown to be associated with provider willingness to attempt new healthcare technologies.

Methods: Data from this study come from a larger study on co-location of depression treatment in nurse home visitation. For this study we use data from surveys of nurses in one nursing agency, semi-structured interviews with nurses and supervisors, direct observation, to explore the association between organizational culture, psychological safety, and attitudes toward evidence supported practices.

Major Findings: We also explore what changes in organizational culture and psychological safety, and work practices are needed to add information technology supported care management for depression and outcome measurement into the organization and sustain it over time. Increased nurse buy-in for information technology could increase their autonomy and efficiency.

Additional Abstracts

Paper 1: A comparison of the Nursing Costs Associated with the Implementation of Mandated Nurse-to-Patient Safety Ratios in California: A Pilot Study by Wells, Shelly

Symposia Overview: Costs for the 2004 implementation of the California nurse-to-patient staffing ratios were estimated by the State Department of Health Services to be in excess of $950 million by 2008 (Lane, 2004). No study has been published since the implementation of the staffing ratios to examine its fiscal impact on the state's acute care hospitals. This descriptive study uses a randomly selected 10% (29 of 293) of the licensed acute care hospitals listed in the California Office of Statewide Health Policy Development (OSHPD) Annual Financial database for both 2002 and 2006. The productive hours of registered nurses (RNS) and licensed vocational nurses (LVNs) from the OSHPD database are used to extrapolate salary dollars by using the Department of Labor Statistics' Occupational Employment and Wage Estimates for RNs and LVNs in California in 2002 and 2006. General linear model analyses are used to analyze the percentage of overall hospital total operating expenses attributed to nursing before and after the implementation of the ratios in 2004.

Results of the analyses along with study limitations and future study implications will be presented. Knowledge of these fiscal implications are of importance as other states look to the California model for mandating ratios.

Paper 2: SEARCHING FOR THE HIGH ROAD: Workplace Partnership, Staff Involvement and Quality Improvement in European Hospitals by Exton, Rosemary; Totterdill, Peter

Abstract: In this paper the authors address an issue of critical importance to European hospitals: where does improvement come from? In particular the paper draws on research into sustainable change and staff involvement in the UK's National Health Service (NHS), on the Irish Hospital of the Future research project which explores the relationship between workplace partnership and performance, and on evidence from the SALTSA European Hospital Network.