At the ground level the nursing shortage created by restructuring became the example used to characterize the problem in Code Green. Weinberg explained that nurses were trying desperately to provide the most basic of care in spite of the restructuring policies. The patient’s long-term interests were often overlooked to meet the needs of all patients—the balance of patient well-being and cost-effectiveness became a daily struggle (Weinberg, 2003).
The administrative priority was to weaken Beth-Israel’s nursing power, since this was identified as a necessity in the change and integration of the nursing models. One way that this was accomplished was by developing a new set of rules for patient care hence changing the reporting structure of the nurses. The nurses reported to the nursing department, and in the new structure, other departments also reported to the nursing department. Power struggles occurred between physicians from both hospitals and resistance to change from the cardiologist and cardiac surgeons.
The impacts of these on the nursing staff was evidenced by orders that deviated from the standard of practice, an increase in the visibility of resident and not of primary physicians in the unit, and the failure to take care of each others’ patient if a nurse required a question to be answered. The direct impact on patient care is not necessarily always negative but a delay in treatment can occur or a non-hospital protocol could be followed just to provide care by a nurse who reverts to a more familiar protocol due to lack of consistency.
Another problem identified was the lack of communication between stakeholders, physicians, nurses and patients both in decisions and plans for coordinating the merger of systems and nursing, the miscommunication between front line nurses and nursing administration. The administration believed that resistance is a self-serving action by nurses, rather than a patient advocate. Nursing concerns were viewed as obstructions to the welfare of the hospital.
Nurse perception of autonomy and control over resources limited decision making of the nurses and also added to a delay in patient care. The result of the merger was “dismantling of nursing” (Code Green) where the administration minimized the importance of nursing. The increased role of nursing assistants who had different levels of training limited the nurse’s connection on an emotional level with the patients. Part of assessing a patient is the face to face conversations that occur, getting to know the patient, and earning their trust.
Primary nursing was no longer the model used but no new model was ever really implemented or enforced. Allegations made by nurses that patient care was suffering were never investigated. In-house arguments continued and decision making was viewed as a sign of power which added to conflict and resistance. Inefficient strategies and research prior to and even after the merger eventually led to a failure of the merged hospital in financial recovery. Weinberg describes nurses as feeling powerless without a voice to fight the changes that were being forced onto them.
Out of frustration nurses began to sacrifice their own well-being and to blame themselves for the decrease in quality of care. It is important to note that hospital administrators held a different view than the nurses. Although administrators denied a reduction in the quality of care patients received the reality of Code Green was that there was evidence that quality care had been affected. Evidence to support Weinberg’s claims came from survey data and patient outcome tracking. Complaints poured in to the central nursing office at BIDMC.
When trying to measure the functional role of a nurse it is at times difficult because many key nursing duties take place in the mind of a nurse (Idel, Melamed, Merlob, Yahav, Hendel, & Kaplan, et al, 2003). Administrators, family members, patients and financial consultants easily overlook the absence of actual physical evidence of what a nurse does—many of her duties are done in her head. The reality that hit the health care system with brute force was that declining care was becoming an acceptable industry practice.
The crux of cost-cutting restructuring is that the main goal of restoring financial viability to the hospital often times does not happen even after the pain of restructuring and decline of patient care becomes evident. The failure of hospitals to become financially viable through restructuring created an even greater nursing shortage (Weinberg, 2003). Code Green exposed the failure of the health care system to provide adequate patient care while the priority is to make a profit. Other issues that were exposed involved nurses and the sacrifices they have made for hospitals.
Nursing was and remains underpowered, underfunded and underappreciated (Mallon, 2003). Suggested possible solution(s) to improve the situation of BIDMC at the end of the book Code Green: Health care executives looking for the next solution to finance management may have to accept that bigger is not always better. The oversight of the patient has been a crucial mistake by hospital executives since it has become obvious that the patient isn’t overlooking them (consider revising this phrase. Oversight and overlooking in one sentence seems redundant).
The failure of hospital executives to develop cost-effective health care facilities have replaced health care with what is commonly called sick-care by professionals in the field (Kjekshus, and Hagen, 2007). While managed care was in its heyday medical technology was also booming. The product innovation of software and hardware has become an arms race in many respects. Hospital executives star struck at the possibilities technology proposes. What they are forgetting is that something simple can often get the job done just as well.
The price tag of technology often is so exorbitant that hospitals run the risk of bankrupting or running in the red for years just to brag that they have acquired the hottest technological advancement. It is this ego amongst hospital executives that is decreasing the quality of care patient’s receive. The solution is simple—if something works don’t fix it and if an old-school technique is getting the job done then use it (Newman, 1999). The goal of creating technology for medical advancement is centered in empowerment in the ideal health care system.
Since the health care system employed currently is anything but ideal the laying the ground work for empowering health care workers is critical to increasing patient care. This solution does not want to avoid technology, instead what would be suggested is to set a goal of creating a technology savvy generation of health care workers that can use the tools of advanced technology with speed and precision. It is in this process that the next generation will find empowerment and hospital executives will begin to balance their accounting ledgers (Newman, 1999).
Another solution to Code Green could be hiring a management company like Streamline Health. Streamline Health is the leading supplier of management tools for workflow, documents, services and operational efficiencies. Streamline Health isn’t a replacement for hospital management—it is a system of integrated tools that are taught to management. Integrated tools include automating documentation through the use of e-forms and document workflow. Technology is also incorporated in the form of optical character recognition, interoperability and portal connectivity.
The advantage of utilizing the services of Streamline Health would be seen in the revenue cycle. Solutions would be implemented to enhance chart coding, physician order processing, pre-admission registration, signature capturing, verification of patient insurance, secondary billing, benefits processing and information processing. Streamline Health has integrated tools that will also address the needs of workflow within Human Resource and Supply Management.
Streamline Health is a possible solution for BIDMC because of its immediate access for clinicians to patient information, its process for improving acute care facilities and its ability to use technology to better serve patients and their families. Centralized documentation of current and past patient health information along with technical support will give clinicians quicker access and a higher standard of providing quality health care services to patients. Another area that should be looked at is, identify the impact on stake holders, physicians, nurses and patients; identify the reaction upon announcement of the merger, e. g.
the changes in pattern of behavior, denial, dissociation, depression or acceptance (Idel, Melamed, Merlob, Yahav, Hendel, & Kaplan, 2003); be prepared for various reactions and educate the staff on ways to deal with these emotions in order to accept the inevitable change; teach the staff to be objective by encouraging the staff to keep a journal that records objective data and proposals for reorganization; encourage staff to record their personal thoughts and feelings; encourage staff to take care of themselves; identify that those with an increased commitment to the organization will have increased stress hence encourage self reward; set-up a support system for staff needing support during the transition phase, and in some cases beyond the transition phase; the administration should find a common ground on which staff from both hospitals can meet or agree on; and last but not the least, encourage staff to form committees for them to feel that they too play an important part in the change being made (Katz & Clemons, 1995). Code Green brings to light the challenge of reducing high vacancy and high turnover rates at hospitals who struggle in the areas of recruitment and retention of nurses. Novice nurses begin their career with an expectation of advanced technology being readily available. Students are looking for flexibility in the nursing and believe that nursing is a way to generate it. For hospitals to attract nurses, executives need to provide choice, flexibility and fairness. There is no greater attraction then satisfied employees. The simplest solution to resolve the issues presented in Code Green is to allow nurses to move freely among units.
Obtaining their work schedule further in advance is a simple solution. Encouraging nurses to choose specialties by allowing them to sample areas of interest will benefit the hospital through exploration of various career paths by nurses. Hospital management also can provide incentives for senior nurses to reenter the workforce along with per-diems. The results of these simple solutions to Code Green include removing the barriers between units. Temporary staffing issues would be handled easier, vacancy rates would decrease, Staffing agencies would help fill the need for staffing of new units at the hospital and the career of nurses would be fostered instead of impeded (Manthey, 2004).