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.
Minimum standards for education, training, and supervision of unlicensed paraprofessionals should be established. Current oversight of paraprofessional health care workers is very uneven, especially among multiskilled paraprofessionals. There is a clear need for greater research into the type of training such individuals require, the kinds of tasks they are assigned, and the relationship of those factors to quality. Such research should pay special attention to rapidly expanding sectors of the industry, including home care and community-based care, where unevenness of quality, training, and supervision appear to be matters of some urgency.
Further steps must be taken to improve the diversity and the cultural competence of the health care workforce, as well as to provide training in the treatment of chronic conditions and disabilities. Despite the strong efforts of many educational institutions, the health care workforce is still not fully representative of the broad diversity of the American people. Differences in cultural experience between caregivers and the people they care for can give rise to miscommunication and problems in health care quality. Educational institutions, supported by public and private entities where necessary, should continue their efforts to diversify the health care workforce and make cultural competence an important part of the educational experience of all health care workers.
Health care workers must be encouraged to identify and report clinical errors and instances of improper or dangerous care. Health care organizations should ensure that they have appropriate internal processes and support to obtain workers' input and respond to concerns in a timely fashion. Accreditation organizations should provide greater opportunities for health care workers to provide input on quality-of-care issues. Health care workers who report improper, illegal, or dangerous care to management, accreditation organizations, public agencies, or others must be protected against retaliatory action.
Action must be taken to reduce the unacceptably high rate of injury in the health care workplace. The Occupational Safety and Health Administration's special emphasis program in the nursing home industry should be used as a model for additional collaborative approaches to identifying and abating occupational hazards in the health care workplace.
Efforts must be made to address the serious morale problems that exist among health care workers in many sectors of the industry. Health care organizations should acknowledge morale problems by taking steps to address the concerns of physicians, nurses, and other health care workers regarding professional autonomy, rising workloads, nonproductive paperwork, and employment security. Organizations undergoing restructuring should involve their employees in the planning and implementation of such changes. Federal and State governments should make funds available to retrain health care workers at risk of dislocation, conduct research into workforce trends, and disseminate information on model workplace partnerships.
Further research should be conducted into how changes in the roles and responsibilities of health care workers are affecting quality. Federal and State governments as well as private foundations should make funds available to conduct such research. Health care organizations should be open to participating in such research.
Changing work systems in the health care industry also will require changes in how all nursing education programs will operate. The Institute of Medicine's Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes (IOM, 1996) identified a number of areas that nursing programs will need to address, including interdisciplinary education and team approaches to care; management of care, including attention to health care costs, professional accountability, and patient outcomes; and new models of care delivery, including community-based care, managed care, and home care.
Many of these workers are pleased with their new skills and enhanced understanding of the patients and the care process. Greiner (1995) found that in some hospitals undergoing work reorganization, nurse aides and licensed practical nurses/licensed vocational nurses working in broader based patient-focused care jobs are more likely than before to pursue advanced education in nursing and other allied health occupations. At the same time, many of these employees would like to have formal recognition of their enhanced roles, such as certification. Without certification, these workers fear that they will be unable to transfer their new skills to other employers, because each employer defines these generalist jobs differently (Greiner, 1995).
The IOM Committee found that hospitals vary widely in the levels of training they provide to paraprofessionals. The Committee cited a study by Barter and colleagues (1994) that found that 99 percent of the hospitals in California reported fewer than 120 hours of on-the-job training for newly hired ancillary nursing personnel. Only 20 percent of hospitals required a high school diploma. The majority of hospitals (59 percent) provided fewer than 20 hours of classroom instruction, and 88 percent provided 40 hours or fewer of instruction (IOM, 1996). Other than this study, however, there are virtually no data on how much hospitals and other health care providers spend on the training the paraprofessional workforce or whether the amount of training provided has changed over time. It also is unclear whether these workers always receive the kind of supervision they require in the performance of their new tasks.
While there are no national standards for paraprofessionals employed by hospitals, some standards do exist for workers employed by nursing homes and home care agencies. The Omnibus Budget Reconciliation Act (OBRA) of 1987 required certification of nurse aides in Medicare- and Medicaid-approved nursing facilities and instituted competency exams and/or training for home health aides employed in Medicare-certified home health agencies. Requirements include 75 hours of classroom and practical skills training as well as annual in-service continuing education (Pindus and Greiner, 1997). Some industry observers, however, argue that 75 hours (roughly 2 weeks) of training is insufficient to fully cover the material that workers should know and that the inservice trainings are often attended by too many workers to make them useful (Home Care Associates Training Institute, 1997).
Community health workers are another set of paraprofessionals who are playing an increasingly important role in the health care system. These workers play a wide variety of roles, such as assisting pregnant women in underserved areas to access prenatal care, teaching those suffering from chronic disease how to manage their conditions, and educating community residents to prevent communicable diseases. There is growing recognition of the need to develop standardized training and practice guidelines for community health workers. For example, Project HOPE -- which sponsors training programs for community health workers around the world -- is currently working with State officials in New Jersey on a set of practice guidelines for community health workers (Project HOPE, 1998).
These challenges must be met in a time of constrained resources. For many years, medical schools and teaching colleges were able to partly fund educational and research programs from revenue gained from reimbursement for clinical services. Efforts to slow the rate of increase in overall health care expenditures have made this more difficult, and the overall financial condition of teaching hospitals is generally worse than that of nonteaching hospitals (Cohen, 1998; ProPAC, 1997).
While a substantial portion of medical care now is being provided outside of hospitals, most physicians continue to be trained in hospitals. Education in ambulatory settings, while increasingly common, often is hampered by resource and time constraints and difficulties in ensuring adequate supervision. A 1995 review of the literature on training in ambulatory settings found that education in ambulatory settings often is characterized by "variability, unpredictability, immediacy, and lack of continuity" (Irby, 1995). The Council on Graduate Medical Education has recommended that residency programs need "to adequately prepare both their primary care and specialty care graduates for the scope of practice, coordinated relationships, and referral patterns found in managed care organizations" (COGME, 1995). The Pew Health Professions Commission also has recommended that 25 percent of the clinical experience of new medical students should be in community, ambulatory, and managed care settings (Pew Health Professions Commission, 1995). In July 1996, the Pew Charitable Trusts took a step toward these goals by awarding a grant of $8.3 million to Harvard Pilgrim Health Care to oversee a 3-year initiative supporting the development of partnerships between academic medical centers and managed care organizations. The grant will support partnerships in six U.S. cities (AAMC, 1997b).
While preserving its historic orientation toward the individual patient, medical education is also having to concern itself with the health status of defined populations. A joint panel of the American Association of Health Plans and the Association of American Medical Colleges concluded that a population health perspective encompasses the ability to assess the health needs of a specific population; implement and evaluate interventions to improve the health of that population; and provide care for individual patients in the context of the culture, health status, and health needs of the population of which that patient is a member.
Another challenge faced by medical educators is to incorporate into the medical curriculum the lessons of nonmedical disciplines for quality improvement. Leape (1994) notes that while the biomedical sciences are invaluable for understanding how to diagnose and treat illnesses in individual patients, many disciplines other than the biomedical sciences -- such as cognitive psychology, systems theory, and the statistical sciences -- provide insights into ways to improve quality and reduce the frequency of error in complex modern medicine. Nonmedical industries such as aviation, nuclear power, and weapons production and design have gained a vast body of practical knowledge about how to prevent error. While this kind of training is important for all types of health care workers, it is particularly important for physicians, as physician leadership is considered critical to the success of these kind of efforts.
This knowledge is just starting to be applied in the health care industry, and educators of health professionals can play a major role in its diffusion. This may require a major change in the culture of the medical profession, which has often held physicians to an unrealistically high standard of performance. As Blumenthal (1994) notes:
All Health Professionals Must Be Able To Use Information To Improve Quality
As health care organizations attempt to implement strategies for improving the quality of their care, they are finding that one of the key challenges is training employees in the recording and use of information. This is especially true if the institution is employing the kind of quality improvement techniques -- process flow analysis, control charts, cause and effect diagrams -- that have been pioneered in other industries (Berwick, 1989). Increased facility with information will also be required as accreditation organizations, group purchasers, and governments require health care organizations to disclose a larger amount of information about the structure, process, and outcomes of care.
The Pew Health Professions Commission has highlighted the importance of health professionals being able to selectively access and use information. In its 1995 report, Critical Challenges: Revitalizing Health Professions for the Twenty-First Century, the Commission stated:
Workforce Education Must Address Issues of Diversity and Cultural Competence
Increasingly, effective communication between physicians and patients demands some degree of "cultural competence." Cultural competence refers to "demonstrated awareness and integration of three population-specific issues: health-related beliefs and cultural values, disease incidence and prevalence, and treatment efficacy" (Lavizzo-Mourey and Mackenzie, 1996).
The need to improve cultural competence among health care workers is particularly important in light of the changing demographics of the United States. By the year 2000, nearly one-quarter of the U.S. population will be members of racial or ethnic minorities, and this number will grow to almost 50 percent by the middle of the next century. As of 1995, however, members of these groups made up only 12 percent of the total U.S. medical school enrollment, 17.5 percent of enrollment in baccalaureate nursing programs, and 12.3 percent of enrollment in master's degree nursing programs (AAMC, 1997a; AACN, 1997). This has an impact on care for the underserved, because minority professionals are more likely to practice in underserved areas. Minority physicians, for example, are twice as likely as nonminorities to practice in Health Professional Shortage Areas and choose primary care careers at a one-third higher rate than nonminorities (NAPH, 1994).
Health professional schools and professional associations have been taking action to improve diversity and cultural competence in the health care workforce. The American Nurses Association, for example, operates an Ethnic/Racial Minority Fellows program that seeks to increase the representation of racial and ethnic minorities among health service researchers as well as to improve the quality of health services provided to these populations. The Association of American Medical Colleges' (AAMC) Project 3000 by 2000, established in 1991, seeks to increase the number of underrepresented minority students entering the Nation's medical schools to 3,000 by the year 2000. In 1995, the AAMC received a Robert Wood Johnson Foundation grant to establish the Health Professions Partnership Initiative, which extends the 3000 by 2000 model to other health professional schools.
Because of chronic shortages of health care providers in inner-city and rural areas, individuals living in those areas face additional obstacles to obtaining quality health care. Federal and State programs, such as the National Health Service Corps, the Area Health Education Centers, and the Rural Health Interdisciplinary Training Program, provide incentives for physicians, nurses, and other primary care providers to practice in underserved rural and urban areas. Many underserved communities also are developing their own strategies to recruit and retain nonphysician primary care providers, such as nurse practitioners, physician assistants, and certified nurse-midwives (Rural Information Center Health Service, 1995).
Public teaching hospitals in underserved urban areas face a particular challenge in adapting to workforce change. There is a growing public consensus that there is an oversupply of medical specialists in the United States, and a number of organizations and policymakers have recommended curtailing the number of specialist residency spots in hospital graduate medical education programs. The newly merged Medicare Payment Advisory Committee will be examining Medicare funding of graduate medical education. However, the existence of teaching programs is one of the major ways in which urban public hospitals attract specialist physicians, and the loss or curtailment of these programs could have a negative impact on access to care for urban residents (NAPH, 1994). This dilemma suggests that some measure of workforce planning may be needed to ensure that changes in the composition of the physician workforce do not adversely affect underserved areas.
There are signs of a growing morale problem among health professionals. Surveys of nurses, the majority of whom work in hospitals, have identified rising levels of dissatisfaction and work-related stress (Davidson et al., 1997; SEIU, 1992; Shindul-Rothschild et al., 1996). The results of a 1997 survey of nurses and therapists that found that two-thirds rated morale at their facilities as fair or poor (Peter D. Hart Research Associates, Inc., 1997).
While surveys of physicians reveal that most are broadly satisfied with their work, many are frustrated with key aspects of their practice, especially their perceived loss of professional autonomy, the loss of control over clinical decisionmaking, and the growing burden of paperwork (Collins et al., 1997, Lewis et al., 1991, Skolnik et al., 1993). A 1993 survey by Baker and Cantor found relatively low rates of dissatisfaction among younger physicians, suggesting that younger physicians may face less of a "culture shock" in practicing in a managed care environment.
One of the largest and most representative of these studies was conducted recently by the Center for the Study of Health System Change. The survey of 9,264 physicians found that the majority of doctors either agree strongly (45 percent) or agree somewhat (31 percent) with the statement "It is possible to provide high-quality care to all my patients." Almost one in four (24 percent) physicians, however, do not agree that it is possible to provide high-quality care to all of their patients, with specialists (27 percent) more likely to express this view than primary care physicians (18 percent) (Reed and St. Peter, 1997).
Another sign of job dissatisfaction is the high degree of turnover that exists in some sectors of the industry, particularly long-term care. The Institute of Medicine has documented extremely high levels of annual turnover in nursing facilities, with rates ranging from 55 percent to 65 percent for registered nurses and close to 100 percent for nursing assistants, who provide the bulk of personal care to residents (Mass et al., 1996). Turnover rates in home care agencies are between 40 percent and 60 percent (Home Care Associates Training Institute, 1997). High turnover rates are a serious problem because they can interrupt continuity of care and act as a disincentive for employers to invest in additional training.
It is unclear whether the problems faced by the existing health care workforce are deterring new entrants into the health professions. According to the Association of American Medical Colleges, applications for medical school rose to record levels each year from 1993 through 1996, and then dropped sharply by over 8 percent in 1997 (AAMC, 1996; 1997a). Enrollment in bachelor's degree nursing programs has fallen over the past 2 years, and enrollment in master's degree programs fell in 1996 for the first time since 1988. On the other hand, enrollment of nurses with associate degrees or hospital diplomas in BSN programs continues to rise, as does enrollment in doctoral programs in nursing (AACN, 1997).
The rate of occupational injuries and illnesses in the health care industry has been rising for some time. Between 1985 and 1995, the injury and illness incidence rate for workers in hospitals rose by 25 percent, while the rate for workers in nursing and personal care facilities rose by 37 percent. During the same period, the rate for workers in private industry as a whole increased by only 3 percent (BLS, 1997; IOM, 1996).
Back injuries -- usually incurred while lifting or moving a patient -- are the most common type of injury faced by health care workers. Certain subsectors of the industry present their own unique risks. For home care workers, work-related automobile accidents are a major cause of injuries. Hospital workers also face the risk of infection from needlesticks and communicable diseases.
The Occupational Health and Safety Administration (OSHA) is working with health care administrators and labor union leaders to reduce the rate of work-related injuries and illnesses in the health care field. In 1996, OSHA unveiled a seven-State initiative to address the rising number of injuries in the nursing home industry. The program involves educational outreach to employers and workers. OSHA offers free 1-day comprehensive safety and health seminars to help participants identify safety and health hazards, including back injuries from lifting residents, slips and falls, workplace violence, and risks from blood-borne pathogens, tuberculosis, and other infectious diseases. A number of nursing facilities participating in the program have already reported savings of hundreds of thousands of dollars, primarily as a result of reducing back injuries, which has cut their workers' compensation insurance premiums (SEIU, 1997b).
While employment in all sectors of the health care industry is expected to grow substantially over the next decade (Franklin, 1995), the outlook for a large number of hospitals is unclear because of the substantial number of excess beds that exist in many markets. A 1997 survey of hospital human resource managers by Deloitte and Touche found that 21 percent intended to eliminate positions in 1997, as compared to 28 percent in 1996 and 36 percent in 1995 (Moore, 1997).
Data from the Bureau of Labor Statistics suggest that hospital restructuring already has had a significant labor market impact, with 163,000 hospital workers losing their jobs between January 1993 and December 1995. While 74 percent of these workers were reemployed by February 1996, their median weekly earnings were 12 percent lower. Seventeen percent of the laid-off hospital workers remained unemployed and 10 percent had dropped out of the labor force (BLS, 1996). While it may be possible for displaced hospital workers to move into jobs in expanding sectors of the industry, those jobs often require different skills than hospital workers currently possess (IOM, 1996).
Wages and benefits in the expanding sectors also are lower than those that prevail in the hospital sector. This is especially true for paraprofessionals. Of the 2 million health care paraprofessionals in the United States, 600,000 are earning wages below the poverty line (Home Care Associates Training Institute, 1997). Home care workers often find themselves excluded from Federal minimum wage or overtime protections because their employers classify them as "independent contractors" or providers of "companionship services" to the elderly. Home care workers generally receive few benefits, and many are without health insurance (Capitman et al., 1994).
In 1995, the U.S. Department of Labor developed a demonstration program to test early intervention strategies for nonmanagerial workers at risk of dislocation in the health care industry. In June 1995, the Department awarded more than $5 million for 12 grants to conduct training programs for at-risk workers. In June 1996, 7 of the original 12 grantees were awarded a total of more $1.5 million in option year extensions to June 1997. The health care demonstrations ended in June 1997, and a final report on the demonstration program is due in 1998.
State governments also have taken action to address the impact of industry restructuring on health care workers. The New York Health Care Reform Act of 1996 made available $50 million to $100 million a year over the next several years to retrain hospital workers at risk of dislocation. An additional $250 million a year is being made available as part of the State's Medicaid demonstration waiver program to "support worker retraining, expand primary care capacity and increase provider readiness for managed care" (New York State Department of Health, 1997).
Nurses also have expressed concern about limitations on their ability to be patient advocates. There are a number of cases where the National Labor Relations Board or State regulators have issued complaints or otherwise sanctioned employers for disciplining nurses or other health care workers who have spoken out publicly about quality problems at their facilities (Marbin, 1995; NLRB, 1996). There are no comprehensive studies of this problem, however, so it is not possible to estimate how widespread it is.
Unions and professional organizations representing nurses and other health care workers have supported bills in a number of States to protect health care whistleblowers. During the 1997 session, a number of State legislatures have debated legislation, including California, New York, North Carolina, and Oregon, with legislation passing in Minnesota, Rhode Island, and New Jersey. Some bills cover only nurses, while others cover health care workers in all classifications. There also is significant variation in enforcement measures, with some bills giving affected workers a private right of action while other bills would enforce through a civil monetary penalty (StateNet, 1997).
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:
St. Vincent's Hospital. St. Vincent, a Catholic medical center located in suburban Indianapolis, was one of the original institutions to implement patient-focused care (PFC) under the name St. Vincent Care 2001. In response to some initial resistance by staff to the implementation of PFC, management made changes to its plan to allow for more employee involvement and began to encourage grassroots-initiated shared decision making. The second PFC unit then was redesigned by a group of affected staff and physicians, and subsequent units have been designed and continually enhanced by employees. PFC has yielded improvements in patient satisfaction, and quality in PFC units has been equal to or better than non-PFC units (Greiner, 1995).
GranCare. While much of the activity in work redesign has been found in hospitals, some nursing homes also are experimenting with ways to improve quality and reduce costs. GranCare, a national nursing home chain, signed an agreement in early 1996 with the Service Employees International to establish Quality Patient Care Committees. These committees have helped address a number of issues at GranCare facilities. At one Michigan GranCare facility, for example, several residents were found to be infected with vancomycin-resistant enterococci (VRE), a drug-resistant strain of bacteria. There were communication problems among the staff regarding infection control procedures, which could have led to more residents or workers becoming infected. The Committee was able to provide information about VRE to managers and ensure that workers on all shifts were informed about the problem (SEIU, 1997a).
Los Angeles County. In September 1995, Los Angeles County was granted a Medicaid waiver that allowed the county to begin a significant restructuring of the public health system. During the 5 years the waiver is in effect, the restructuring effort will reduce hospital beds by one-third and increase outpatient volume by 50 percent. The terms of the waiver, as well as its subsequent implementation, have been negotiated with the unions representing county employees, which has contributed to acceptance of the systemwide reengineering among the workforce.
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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