Chapter 21 . Creating a Safe and High-Quality Health Care Environment

Maintaining a safe environment reflects a level of compassion and vigilance for patient welfare that is as important as any other aspect of competent health care. The way to improve safety is to learn about causes of error and use this knowledge to design systems of care to “. make errors less common and less harmful when they do occur” (p.78). As a result, researchers, policymakers, and providers have intensified their efforts to understand and change organizational conditions, components, and processes of health care systems as they relate to patient safety. Health care is the second-fastest growing sector of the U.S. economy, and nursing is the largest occupation within the industry, with more than 2.4 million jobs and the highest projected growth. As noted in recent reports by the International Council of Nursing and the Institute of Medicine, one of the reasons for the current and future shortages of nurses relates to the work environment. 4 Improving the environment in which nurses work may attract new students to nursing as well as engage current professionals in developing innovative models of care delivery that will help retain and nurture future generations of nurses. Most important, improving the work environment may also improve the quality and safety of patient care. High turnover has been recognized as a problem in many service industries, including health care. In U.S. hospitals, nursing turnover has been reported to range from 15 percent to 36 percent per year. These turnover rates are much higher than those for other health care professionals, which are estimated to average 2.3 percent per year. Past estimates of the cost to replace one medical-surgical registered nurse (RN) range between $30,000 and $50,000; and replacement costs for critical care nurses are closer to $65,000. More recently, Jones estimated the total turnover costs of one hospital-based RN to range from $62,000 to $67,000 depending on the service line. While these cost estimates rely on nurse manager reports of decreased productivity, clearly there are avoidable organizational monetary and human costs related to high turnover of desirable employees. Using multiple databases in an academic medical center, other analysts found the low-end estimate for the cost of employee turnover accounted for greater than 5 percent of the annual operating budget. Clearly, understanding organizational aspects that promote a stable workforce is important. Besides the obvious harm to patients, preventable adverse health care events related to patient safety have major financial consequences for the patient, the provider, the insurer, and often the family and/or caregivers. Using Agency for Healthcare Research and Quality (AHRQ) patient safety indicators, researchers estimated the excess length of stay for postoperative sepsis to be approximately 11 days at a cost of almost $60,000 per patient. While in some instances there is extra payment made by insurers to hospitals for these adverse events, it has been estimated to be considerably less than the total cost of the resources used. Furthermore, with increased discussions about pay-for-performance and mandatory reporting of certain adverse patient safety events, providers may have increased financial as well as other incentives to