President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry

Building the Capacity to Improve Quality

Chapter Thirteen
Engaging the Health Care Workforce

The restructuring of the health care industry and ongoing efforts to improve quality are changing how the work of health care is organized. Many health care workers are taking on new roles and responsibilities. Some are excited by these changes and the new opportunities they create. Others are unsure about whether their training has adequately prepared them for the dramatic changes that are taking place. While understanding the need for change, many of these workers are asking for more of a voice in the process of change.

The challenge for industry leaders is to harness the tremendous talent, energy, and commitment of the 10 million people who have been drawn to work in the health care industry because of its strong sense of mission. In order to improve the quality of health care, they must build a health care workforce that is strongly dedicated to caring for patients, knowledgeable and well trained, committed to continuous quality improvement and cooperative work, secure in their employability, confident in the safety of their work, fairly compensated, and competent in caring for the wide diversity of the American people.


Education Must Adjust to Industry Change

Changes in the health care industry are bringing changes in the skills that workers within that industry need to do their jobs. The array of institutions that educate the health care workforce -- academic institutions educating health professionals, employer-based programs, and other entities -- need to embrace change if they are to succeed in preparing the next generation of physicians, nurses, paraprofessionals, and other health care workers.

The Impact of Restructuring on the Workforce

Understanding the impact of industry change on workers is an important part of assessing the industry's overall quality improvement efforts. While policymakers, consultants, and managers can design quality improvement strategies, it is health care professionals, ancillary nursing personnel, technicians, and other health care workers who ultimately have to implement those strategies. Their willingness to strive for continuous improvement in their work will depend, in part, on that work remaining intellectually and emotionally rewarding as well as on the extent to which health care workers are treated as stakeholders in all respects.

Building Workplace Partnerships

The experience of other industries that have undergone significant restructuring is that the most effective initiatives to improve quality and reduce costs are those that involve frontline workers in the planning and implementation of those initiatives. Benchmark firms like Saturn, Xerox, and Corning Glass have all introduced new work systems that rely heavily on self-directed teams of frontline workers taking the initiative to improve quality (Appelbaum and Blatt, 1994).

In the health care context, the Institute of Medicine's Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes observed that many of "the harmful and demoralizing effects of these changes on the nursing staff can be mitigated, if not forestalled altogether, with more recognition on the part of the hospital industry that involvement of personnel from the outset in redesign efforts is critical" (IOM, 1996).

Employers in many sectors of the health care industry, including HMOs, hospitals, and nursing homes, are taking up this challenge. Examples of such efforts include the following:

Work Systems Need More Evaluation

As is the case in many other industries, health care organizations are looking to reengineer internal operations to increase efficiency and effectiveness and improve quality and patient satisfaction. Changes are being made not only in how work is organized, but also in workplace culture. Traditional hierarchies are being challenged and workers are being asked to take on new roles and responsibilities.

The reorganization of work often involves breaking down departmental barriers and professional alliances; challenging commonly accepted assumptions about the need for centralized clinical support functions (e.g., lab, radiology); and reexamining and reconfiguring job requirements and skills (Shortell et al., 1995). Various terminology for work redesign is found in the literature, including patient-centered care; PFC; work redesign; operational restructuring; or simply restructuring.

While the reengineering of the hospital sector has been going on for a number of years, surprisingly little is known about whether it has been successful in improving quality or controlling costs. The Institute of Medicine has noted that while "much anecdotal information is available about these changes, objective data are not available to determine how widespread these changes are and whether or not this redesign accomplishes its dual goals of increasing patient-centered care and cost reductions" (IOM, 1996).

Most hospitals and health plans that attempt to evaluate the quality impact of their changes measure patient satisfaction and some short-term outcomes (e.g., nosocomial infections, readmission, medication errors) pre- and post-intervention. Greiner (1995) compared the impact of work system changes at seven hospitals and HMOs and found that, for most organizations, the results were inconclusive, with some measures showing improvement and others a decline. Organizations that had implemented a PFC model tended to have statistically significant increases in patient satisfaction, with patients being particularly pleased with staff responsiveness and communication.

To date, attempts to estimate cost savings associated with the introduction of new work systems have been inconclusive. More rigorous methodological approaches using longer timeframes for analysis of impact will be needed (Greiner, 1995).

Since a key element of many of these new work systems is changes in staffing patterns, new research in this area could build on existing research into the relationship between staffing patterns and quality. While a number of witnesses before the Commission presented testimony about the negative impact of nurse staffing reductions on the quality of care (Clark, 1997; Foley, 1997; Ziegler, 1997), there is limited empirical evidence to either support or refute such a link. In its recent study on this subject, the Institute of Medicine (1996) concluded that there was a "serious paucity of recent research on the definitive effects of structural measures, such as specific staffing ratios, on the quality of patient care." A number of new research initiatives in this area are under way, including a national nursing research program on staffing and quality sponsored by the Agency for Health Care Policy and Research in conjunction with the National Institute for Nursing Research and the Division of Nursing of the Health Resources and Services Administration (Pindus and Greiner, 1997).

The need for further research, however, should not be interpreted as a call to halt the pace of work reorganization in the health care sector. Significant changes in work organization in all health care organizations are necessary in order to improve the process of care, eliminate waste, and improve quality. Chapter 12 outlines a number of organizational changes that leading health care organizations are making in order to better carry out their mission.


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Last Revised: Sunday, July 19, 1998