Nurses represent the largest health profession, and shortages of nurses have been
threatening hospital productivity in a number of countries for a number of years. There is a growing number of studies that link aspects of nurse management (together with nurse/patient ratios and nurse skill-mix) to patient outcomes and nurse satisfaction, but unfortunately there appear to be almost none which include costs or that address questions of efficiency as such. Some studies which find positive effects of nurse Box 4.2: Service-line reporting
Service-line reporting allows trusts to monitor income and expenditure – and therefore surpluses and deficits – in each clinical department of the hospital, and to involve the relevant staff in allocating resources. This allows clinicians to be ‘put at the heart of historically contentious debates on resources versus clinical need’ (Fleming, 2007: p17), albeit at some cost in terms of data collection and
management and clinician time. It also allows departments to be rewarded for improving financial surpluses by allowing, for example, some or all of any surpluses to be retained in the department which has generated them. Monitor, which currently regulates NHS foundation trusts and is set to become the economic regulator of the NHS, has reviewed some early experience with using service- line reporting in England and investigated its use in Germany, Norway and the US (Monitor, 2007). It found that service-line reporting ‘has provided a basis for greatly improved strategic planning and has introduced greater levels of efficiency into health care systems and has led to an overall improvement in the general quality of care and patient experience’ (Monitor, 2006).
Service-line reporting was considered by the NHS executives the authors met with to be the most powerful tool for engaging clinicians in securing efficiency improvements. Donal O’Donoghue, Medical Director at Sandwell and West Birmingham Hospitals NHS Trust, says:
The biggest blockage to efficiency is about making change happen. All available resource for making things happen until now has been at divisional level. Service-line management is important in devolving budgets to directorate level and enabling directorates to move faster.
Kevin Stringer, Director of Finance and Information and Deputy Chief Exective Officer at The Royal Wolverhampton Hospitals NHS Trust, agrees that engagement with efficiency initiatives by senior clinicians is crucial. He argues:
It is they who decide length of stay, treatment and care options, they spend 80 to 90 per cent of our costs. So we need them on board, hearts and minds.
The six trusts visited during the present research were at different stages of development with service- line reporting; however, all had moved to greater devolution of financial authority. Barnet and Chase Farm Hospitals NHS Trust has turned its ten directorates into profit centres. Directorates that achieve targets are allowed to keep a percentage of any surplus to reinvest in services, and business units that bring about improvements in their position are granted certain freedoms. David Carter, Director of Finance for the Trust, explains:
Everyone’s motivation is to spend money, because how you cover your risk is through spending money (more tests, more scans, etc.). The lack of any motivations and levers to restrict spending is a real issue.
Richard Harrison, Medical Director, agrees: “It shows people how they can contribute to the financial situation of the trust,” adding that clinical colleagues “believe it is the most appropriate method to introduce incentives.”
management on nurse and patient outcomes are noted here, because often quality is found to be associated with efficiency (see Chapter 5; some further studies which address nurse/patient ratios, nurse skill-mix and efficiency are noted in Chapter 6). The label ‘magnet hospitals’ was applied to a group of US hospitals that were able to recruit and retain nurses successfully during a period of nursing shortages in the early 1980s. The studies in these hospitals identified a set of nurse management and working environment characteristics that were associated with the recruitment and retention of nurses (Scott and others, 1999). They included (among other things):
• a participatory and supportive management style • ‘adequate’ nurse staffing
• a decentralised organisational structure • flexible working schedules
• professional autonomy and responsibility • planned orientation of staff
• competency-based clinical ladders.
These attributes were quantified subsequently in a ‘nursing work index’, which was shown to be associated favourably with both nursing and patient outcomes, including nurse turnover, vacancy rates and satisfaction, and patient mortality and satisfaction (Scott and others, 1999; Kutney-Lee and others, 2009). Some of these associations have been reproduced by hospital nursing research in other countries, such as Belgium (Van Bogaert and others, 2009) and the UK (Aiken and others, 2008).
Subsequent research in the US has suggested that mortality and other outcomes for surgical oncology patients in 164 hospitals in Pennsylvania were inversely associated with three separate characteristics of the nurse workforce:
• the working environment – as measured by a revised nursing work index
• nurse education – as measured by the percentage of nurses with bachelor degrees in nursing
• workloads – as measured by nurse/patient ratios (Friese and others, 2008). Surgical mortality deteriorated sharply with rising workloads when the working environment was poor and only 20 per cent of nurses had bachelor degrees. However, mortality hardly varied with rising workloads when the working
environment was good and 60 per cent of nurses had bachelor degrees (Aiken, 2008). Subject to the significant limitation that these inferences are based on cross-sectional rather than longitudinal evidence, this suggests that if reductions in nurse numbers are required, it might be possible to reduce the risk of nurse burnout and rising
turnover (Aiken and others, 2002), and to maintain or improve quality of patient care by making nurse management reforms and enriching skill-mix. The authors offer pursuit of recognition of magnet status as a possible way of achieving such reforms (Friese and others, 2008).