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Transparency and accountability in nurse staffing


Organizational transparency and accountability have come to represent efforts to measure and hold providers responsible for their actions through accessible and often comparative channels. Along with performance- based payment programs, both the Department of Health and Human Services and the Institute of Medicine have recognized transparency and accountability as key components to healing a US healthcare system that is inefficient, fragmented, and unsafe.

Nursing represents the largest healthcare segment and, according to ANA Nurses by the Numbers, close to 58% of RNs work in hospitals. The impact of transparency in nurse staffing on patient outcomes cannot be overstated. Research in the US and abroad continues to reinforce a relationship between low nurse staffing, missed care, and adverse outcomes (Needleman, 2016). For example:

• If a nurse is responsible for four patients and the care load is doubled, there is a 31% increase in the patient death rate. In patients who had complications, this rate is even higher. (Aiken et al, 2002)

• The higher the proportion of care provided by registered nurses, the shorter the length of stay in the hospital, the lower the rate of urinary tract infections and upper gastrointestinal bleeding, and the lower the rate of pneumonia, shock, cardiac arrest, and “failure to rescue.” (Needleman et al, 2002)

• Nurses are responsible for 86% of all interceptions of medical errors. (Leape, 1995)

The Registered Nurse Safe Staffing Act

In April 2015, Senator Jeff Merkley (D-OR) and Representatives Lois Capps (D-CA) and David Joyce (ROH) introduced into the House of Representatives the Registered Nurse Safe Staffing Act (HR 2083/S 1132). The bill would require Medicare-participating hospitals to develop a hospital-wide staffing plan for nursing services by using a committee composed of at least 55% of direct care nurses who are neither hospital nurse managers nor part of the hospital administration staff.

Endorsed by ANA, the Registered Nurse Safe Staffing Act is viewed as a balanced approach to ensure appropriate RN staffing by recognizing that direct care nurses, working closely with managers, are best equipped to determine the staffing level for their patients. Within the Act are references to research linking appropriate nurse staffing to maximize patient safety and health, and minimize costs. The Act also provides for daily posting of staff levels by unit, as well as avenues for public review of any individual hospital staffing plan.

Accountability through public reporting

In today’s complex healthcare arena, there is no national benchmarking, and lack of transparency hampers efforts to truly measure and ensure accountability for safe staffing. One way to facilitate transparency in nurse staffing reporting is to require hospitals to publicly report nurse staffing on the Center for Medicare and Medicaid Services (CMS) Hospital Compare website and other similar, nationally based metric and comparison sites.

Hospital Compare gives a snapshot of over 4,000 Medicare-approved hospitals based on categories such as a summary of 64 quality measures; patient experiences; complications; readmissions and deaths; and payment and value of care. ANA has strongly advocated for the incorporation of transparent nurse-staffing reporting into the metrics on Hospital Compare. By continuing to push for such transparency, ANA fights to save lives and prevent harm.

Sharon A. Morgan is a senior policy advisor in Nursing Practice & Work Environment at ANA.

Selected references

Aiken LH, Clarke SP, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987-93.

American Nurses Association. Safe staffing.

HR 2083, Registered Nurse Safe Staffing Act of 2015. May 14, 2015.

Hospital Compare.

Joint Commission on Accreditation of Healthcare Organizations. Health care at the crossroads: Strategies for addressing the evolving nursing crisis. 2002.

Kavanaugh KT. Transparency in healthcare. November 16, 2007.

Kurtzman ET. (A transparency and accountability framework for high-value inpatient nursing care. Nurs Econ. 2010;28(5):295-306.

Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274(1):35-43.

McMeniman P. ANA Nurses by the Numbers. June 2016.

Needleman J, Buerhaus P, Mattke S, et al. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med. 2002;346(22):1715–22.

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