Supply chains and other service industries, like telecom, worry about “the last mile” — the final step in delivering a product or service to customers. Like other industries, health care must connect most meaningfully to the patient, and the nurse is almost always part of (if not the sole manager of) that last mile. The analogy of the last mile defines a deeply rooted issue about nursing’s criticality (and that of other direct caregivers, like LPNs, CNAs, etc.). The last mile for hospitals in a new and rapidly changing environment may be the difference between keeping the hospital open or closing it down. And the cost of not addressing this last mile issue is perhaps the biggest threat — and opportunity — health care organizations (HCOs) face.

One proposed method for closing that last mile of improving patient care while maintaining a reasonable workload for nurses has been to legally mandate nurse-to-patient ratios. Growing numbers of legislative efforts, both state and federal, are moving toward mandated ratios to ensure nurses aren’t overloaded, and patients are well cared for. To date, California is the only state with legislative authority to regulate nurse-to-patient ratios. But California is generally regarded as a bellwether of health care policy, so mandates are surely on their way across the U.S.

Certainly, nurse-to-patient ratios hold the potential to improve quality and reduce overburden. But such an approach, by itself, is flawed because it only reduces the number of patients the nurse has to work with without a concomitant reduction in the chaos that often characterizes their scandalous working environment.

The National Bureau of Economic Research (NBER) in Cambridge, Massachusetts, published “The Effect of Hospital Nurse Staffing on Patient Health Outcomes,” in which they concluded, “that patient outcomes did not disproportionately improve with the introduction of nurse-to-patient ratios.” NBER’s report did suggest that there may be “complementarities between nursing inputs and other (possibly unobserved) inputs and policies that lead to better patient care. Thus, improved nurse staffing might be crucial in improving patient care, but only in combination with other elements.” In other words, just changing nursing ratios alone will not achieve the desired benefits for the working environment of nurses or, most significantly, the quality of care that patients receive.

In the currently swirling whirlwind of overburdened nurses, about five percent of the nation’s 2.7 million registered nurses have left the profession. Various estimates for future departures run at the 25 percent level. Some of this reduction will be due to retirement, but research indicates that nurse “burnout,” as a percentage, is a serious risk to the future of health care. In a recent study of 40 hospital units, more than one-third of nurses reported they intended to leave their position within the next year, citing “emotional exhaustion” and “lack of personal accomplishment,” two key indicators of nurse burnout. And as “growing evidence has shown, nurse-burnout dramatically influences how satisfied patients are with their care.”

Job dissatisfaction among hospital nurses is four times greater than the average for all other U.S. workers. This is scandalous! Despite the fact that enrollment in nursing programs has increased by about 5 percent over the last few years, we are facing a future with fewer nurses than we need. In fact, there are approximately 126,000 nursing positions currently unfilled in hospitals across the United States.”

Even the American Hospital Association, a staunch national advocate for more than 5000 hospitals, measured satisfaction among health care employees and concluded: “That hospitals fail to meet the expectations of their employees far more frequently than employers in other industries do. Indeed, the data shows that health care employers are worse off than the national norm in every category.”

Finally, there is the growing number of nurses reaching retirement age. The average age of a working RN today is 55.3, and that age is increasing at a rate more than twice that of all other workforces in this country. By 2020 the median age of a hospital RN will be 60 and there will be at least 400,000 fewer nurses available to provide care than will be needed.

The scandal of health care is real, and it is affecting patients, nurses, and many others. Organizations must, of course, be patient-focused, but we believe that the most important proxy for patient-focused care is excellent internal customer service for nurses, since they are involved in nearly every aspect of direct patient care.

Because nurses are essential to better and cheaper health care, and because their work life is burning them out and seems destined to become more complicated as fewer of them care for more patients, we contend that organizations must and can succeed by looking at nurses as “customers” of internal services. By taking a system view of meeting patients’ needs, HCOs can work to ensure that their nurses always have exactly the information, equipment, and supplies their patients need at exactly the right moment.

Colin Baird is the author of The Scandal of Healthcare: Nurses, Waste & Customer Service.

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