Wednesday, July 27, 2022

Hospital Span-of-Control? Or Span-out-of-Control?

Span-of-Control has been a hot topic for some time in healthcare, and it has undergone dramatic change over the years. 

There was a time when every nursing unit, regardless of size, on every shift, had a person designated as the Charge Nurse. Anyone, including patients, family members and MDs, at any hour of the day, whether weekday or weekend, could always ask to speak to the Charge Nurse on a unit.  

The Charge Nurse was empowered to address with knowledge, wisdom and compassion any questions or complaints about every patient under their care.  

In decades of cost cutting initiatives, head nurses are no more, and there are far fewer Charge RNs.  

Today's Charge RN often has responsibility over multiple nursing units, a greater range of specialists and hospitalists, each with their own span of authority to contend with.

Physicians are less available for each patient, expecting Charge RNs, RNs, extender mid - levels and hospitalists to fill the gaps. Eyes on patient has now been replaced with eyes on EMR. Critical judgement in real time has been replaced with critical paths and their flags. 

In theory these specialists and technology resources should provide better, more pro-active and preventative care than ever before. However, that still requires real-time teamwork. Each job has its own siloed priorities, so the work is arranged around volume not teamwork. Work is moved from one person's list to another person's list, creating batching, prompted only by EMR outlier flags. Now real-time live teamwork is an added separate task in its own box, limited to patient outliers, rather than a function of pro-active care for every patient. 

Years ago nurses were trained not to focus exclusively on tasks, but on the patient. Now with the advent of the EMR, tasks have won.

In the absence of functional supervision (and in the newer corporatization of healthcare, where supervision is now remote, where front-line management is being replaced by corporate functionaries netting zero margin improvement) supervisory hours are greatly reduced.  The system and its participants are disconnected from each other, the patient and their care, requiring care navigation among the layers and silos. 

Newer employees no longer have the live mentoring that experienced Charge RNs once provided on all shifts. The result is not simply greater delay orienting new colleagues. It is the absence of real-time on-the-floor oversight and knowledge of a patient's condition and progress by more than just the lone RN given primary care responsibility. Now that RN is truly alone. And so the work environment's safety and support for patient and care-giver through transparency and collaboration has become a more singular and lonely experience for both.

Care Navigation is its own art, but can never replace the top-of-license pro-active synergies generated by real-time supervision. 

The various professionals involved in care are like several pieces of cloth held together at the seams to cover parts of the patient's care.  The garment is no longer the patient, but the standardized protocol and critical path. The seams are often stretched, an effort to take an off-the-rack garment of perpetually wrong size.

 But these same threads can be interwoven into a single bespoke cloth of care that also includes the patient's own threads. The patient can become their own garment. In truth, the patient IS the garment, and all care-givers, at best,  are not working to cover up the patient with diagnoses and tasks. They are part of the patient.

The case of Radonda Vaught illustrates the reactive and blind blame-placing that takes place when a system of real-time visibility, accountability and  management is not functionally in place. Yet if ever there were a true justification for such management, it must surely be patient care.

True frontline supervision is fully empowered  with the responsibility, time and authority to inspect and intervene with anyone and everyone at any and every hour of the day. 

Supervision isn't only reacting immediately when asked for help. It is seeing pro-actively where help is needed before anyone asks and offering it first.  It is seeing the stress on the face of the nurse and having time to partner with them before even they realize they are becoming stressed.  

Supervision is taking the time to watch others work with patients. It is investing in that time in the design of the management structure.  

Hospitals used to be the employer of  choice. Not so much today. Progress in technology and staff specialization represent incredible untapped resources for synergy. Hospitals can become the employers of choice once again. To sustain they must.

On our next post,  for your viewing and sharing pleasure, is a slide show  providing a general overview of Span-of-Control work. 

Or you can click below to go there...

Hospital Span-of-Control II

Where there are quality, service, cost and productivity issues, Span-of-Control is a  crucial foundational area for investigation and re-engineering. Because blame is so last-century, reactive and dysfunctional. But building a better health system actually gets things done right. Let's get woke to the work of management!

And remember you can always reach out to Dirk and I at..

By Spence Tepper and Dirk Pattee

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