Patient Safety at Risk as Hospitals Cut Staff

In an important article entitled A Job Engine Sputters as Hospitals Cut Staff, USA Today’s Paul Davidson and Barbara Hansen detail how hospitals are responding to Obamacare.  Although millions of Americans will now be funneled into the system and into hospitals, hospitals all over the country are laying off staff, including nurses, housekeepers, researchers.  You name it, they’re cutting it.  “Health care providers announced more layoffs than any other industry last month — 8,128 — largely because of reductions by hospitals, according to outplacement firm Challenger Gray and Christmas. So far this year, the health care sector has announced 41,085 layoffs, the third-most behind financial and industrial companies.

Total private hospital employment is still up by 36,000 in the past 12 months, but it’s down by 8,000 since April, and more staff reductions are expected into next year,” the authors write.

Hospitals all over the country are engaged in cutting.  Although I just attended a conference on enhancing patient satisfaction and experience at the Cleveland Clinic, the Clinic has announced that it “will offer buyouts to 3,000 employees as it shaves its annual operating costs by $330 million,” according to USA Today.  I wonder how this will help enhance patients’ experiences.  Nurses, care aides, social workers, techs, housekeepers — all those who come into contact with the patient are key to that person’s experience.  Over the past two decades, patients have often registered dismay at the way they are treated by a variety of hospital staff. I believe some of curt behavior on the part of staff has to do with the fact that the reward for good conduct and concern for patients is often a pink slip?  As one young nurse told me recently,” Why should we help hospitals improve efficiency and care when so often we are laid off when we do?”

I believe it is unconscionable to be brusque and uncaring to sick people.  That said, I can understand that if people feel they consstantly face the layoff axe, they may not be very happy about their jobs or loyal to their employers. Tutorials in how to smile and be empathic may not be very effective,  if people are chronically overworked, exhausted, and demoralized.  It’s hard enough to deal with the relentless needs of the sick if there is stable employment, appropriate hours, and a reasonable workload.  Without the latter, I worry that staff will become less caring and attentive, simply because their brains cannot produce empathy and attentiveness when faced with the stresses many experience in the healthcare workforce today.  If this is true, cutting jobs may also negatively impact hospital reimbursement.  If staff are unresponsive to patient need, patients will be less satisfied and register their disenchantment on patient satisfaction surveys.  This may then reduce hospital reimbursement.  This problem must be considered when staff cuts are contemplated.

The notion that hospitals are cutting staff at precisely the time when millions more people will be flowing into the healthcare system seems hard to grasp.  What is even more worrisome is how reductions in staff will effect patient safety.  We now know that the Institute of Medicine’s estimate that 98,000 patients a year die from medical mistakes is probably a radical underestimation of the problem.  Recent reports suggest that the number is really between 220,000 and 440,000 a year.  Studies suggest that some of these deaths are due to overwork, fatigue, and staffing shortages — particularly when it comes to nurse staffing.  Many are the result of poor infection control in hospitals.  This is why the decision of some hospitals not only to cut staff but to have nursing staff engage in housekeeping duties is so perplexing.   Vanderbilt University Medical Center in Tennessee, Davidson and Hansen report, plans to eliminate 1000 jobs over the next year.  Because it is apparently cutting cleaning staff, Vanderbilt will now be asking nurses to clean floors, empty waste baskets and do other housekeeping chores.  When I heard about this, I was stunned.  So were several infection control experts I consulted.  Physician Michael Gardam, who is head of Infection Prevention and Control at University Health Network in Toronto, Ontario (with whom I co-authored an article on patient safety for the Boston Globe), said that this approach ignores the fact that housekeeping chores are actually very complicated and must be done by specially trained staff.  You can’t just clean a floor correctly because you’re a nurse or a woman, Gardam pointed out.  Gardam also worried about the possibility of cross-contamination if nurses mopped floors and then turned around and engaged in patient care activities.  “Are they going to change their scrubs after they’ve mopped up?” Gardam wondered.  “If you’re going to do this, you’d have to institute very specific protocols to protect patients.  Would all that really be cost effective?”

Another prominent infection control physician was similarly concerned when he learned that some hospitals are assigning housekeeping duties to RNs. “This is a very short sighted approach,” he argued. “Cleaning a hospital room is very complicated.  You have to know about the chemicals and how they are used.  Some chemicals have to be put on longer than others.  Some have to be hot, others cold.  You have to know how to do ‘terminal cleaning.’  You can’t just ask nurses to do environmental management and think that will work out well.  Plus, you are taking nurses away from important patient care activities and overloading them with other activities which will divert their attention and could lead to mistakes.  There are lots of other ways to save money.  This is a very short-sighted, if not simply stupid, approach.”

I worry that once again, we have created a system that encourages healthcare institutions to  lurch from short term crisis to crisis without adopting a sustained approach to either the delivery of quality patient care or patient safety.