“The Nurses are Already There, Can’t They Just Grab a Mop?” – Florence Nightingale

First of all, Florence Nightingale most certainly didn’t actually say that. We recently read of a hospital administrator, however, who invoked Nightingale in defending a new plan to have nurses mop and clean patient areas. Her reasoning: Cleanliness improves the patient’s health and experience, and “even Florence Nightingale” knew that was true. Even though Nightingale did pioneer environmental theory to improve patient experience, we doubt the nurses at this hospital embrace the administrator’s analogy. And we’re not buying it, either.

But we do recognize the cost control pressures that administrator feels these days. Thus the title of our post, which we imagine some misguided hospital executive in a boardroom saying out loud, earnestly suggesting it as a way to cut skyrocketing costs.

It’s “efficiency by desperation,” and while we can understand its roots, we question its effectiveness. Asking scarce and overworked nurses to “just do more” non-clinical activities threatens to wreck morale and diminish bedside time with patients. [UPDATE: Just to reiterate, we do not think that asking nurses to also take on the job responsibilities of environmental services is a good idea. It’s a short-sighted quick “fix” to cut costs, while harming care quality and patient and nurse satisfaction. In the end, it will cost hospitals much more in diminished throughput and experience.]

We did find a second reference to Florence Nightingale that we think hits the mark much better. On the Health Facilities Management website, nurse and consultant Debbie Hurst shares a thoughtful overview of Nightingale’s philosophy of nursing and the patient experience. She champions collaboration, celebrating the efforts of nurses, environmental services, transport, technicians and everyone responsible for care to deliver Nightingale’s vision of the ideal patient experience. In doing so, she says, hospitals will build positive spirit across all teams while improving care quality and HCAHPS measures. 

Her vision of teamwork across departments mirrors that of the hospitals we see transforming operations to truly do more with less, while still keeping patients, doctors, nurses and executives happy. Instead of cutting corners and temporary costs by handing mops to nurses, hospitals must embrace efficiency and continuous improvement in every aspect of patient care coordination. It requires new logistical thinking proven in other industries, supported by technologies and tools built to make the system work. We’re working on a case study with a Southeastern hospital now that adopted a logistical control system for patient throughput as part of a committed transformation journey. The results in six months have been remarkable:

  • Reduced the average patient length of stay by 0.4 days
  • Saved $4 million in annual costs by improving efficiency
  • Added capacity to care for 2,200 additional patients per year with no additional increase in fixed costs
  • Provided more responsive and efficient care even as patient clinical needs increased, improving length of stay as adjusted by case mix index by 17 percent

And here’s a San Francisco Gate article from just last week showcasing how San Francisco General Hospital is applying the logistical management methods of Toyota to improve efficiency in patient care. Teams work together to improve communications and handoffs and continuously improve care quality and processes.

These hospitals are improving care quality and patient experience while driving down costs by working as a system to coordinate care. Groups and departments work in harmony to advance patient care and throughput, not at cross purposes. Patients win, nurses and other caregivers win, hospitals win. We think Florence would approve.

POSTED BY Doug Walker

10 thoughts on ““The Nurses are Already There, Can’t They Just Grab a Mop?” – Florence Nightingale

  1. There are efficient ways to control spiraling healthcare cost and to improve patient satisfaction. Squeezing the last strength out of the nurses and demeaning their professional status to say the least will not provide a solution. We have workers in fine coats and ties roaming around and milking the cash cow without actually contributing directly in the care of patients. These are the top two percent that this writer should focus on. Nightingale will feel sorry for this generation of nurses providing compassionate care and having to deal with complex electronic medical record and other medical gadgets, if she happened to be alive today. It is appropriate to remind this writer that the present generation of nurses are college graduates.

    • Hi Peter, thanks for your comment. And if you reread my most, you’ll see that I agree completely with you. It’s not at all strategic for hospitals to ask already overworked nurses to take on more responsibilities that distract from direct patient care. This reactive costs cutting hurts morale, safety, care quality and patient experience. Hospitals should instead apply logistics to improve efficiency and communication across all people and departments providing care. It’s the point that nurse Debbie Hurst made in the second linked article–efficient collaboration among nurses, environmental services, transport, service technicians and everyone providing care improves throughput, quality and experience for all patients. Centralized well coordinated care, and the commitment of hospital leaders to provide it, ultimately improves care quality and patient experience, without burdening skilled nurses with yet more non-clinical responsibilities.

  2. This article and the current state of hospitals reminds me of the story of the 1906 San Francisco earthquake – probably the worst ever to hit the United States. Bad as it was, killing hundreds and knocking-down thousands of buildings and homes, worse was waiting in the wings: broken gas lines exploded and started raging city-wide fires. Not to worry! Trained volunteer fire brigades were ready; the engines had steam-up, horses were bridled and rearing, axes, hoses, hooks, and ladders loaded and ready to go! The assembled teams charged to the fires, lives on the line … do or die (and many would)! Men charged into hellish infernos, that collapsed around them. Other men speedily hooked into hydrants and turned them on … full-force! But the lines stayed limp; no life-saving water flowed. Dry as the desert … the earthquake had severed the water lines, too.

    Just as fire companies need water to flow to fight fires, all hospitals – for-profit or not-for-profit – survive on cash in-flow; it’s that simple. As cash in-flow dwindles – the net result of payment reductions by insurers and governments – and swelling patient loads, morale alone just isn’t enough to meet these challenges. Hospitals face three problems, all of which bear directly on these overarching issues:

    1. They lack a statistical understanding of the service-on-demand nature of ED patient flow. While the actual flow is random, the overall flow of differing causes can be isolated statistically: weekday accidents, poisonings, accidental overdoses, weekend accident patterns, holiday accident patterns,etc. Coupled with an understanding of outbreak phenomenon, hospitals can build demand models and predict and staff effectively to manage the influx and treatment.

    2. A blind reliance on cost-models for managing operations. One can only cut so much and then … things go bad in a hurry. And, it’s not surprise that cost-cutting eats at morale.

    3. Hospital management fails to pursue the one thing they can effectively control – revenue sources. While most EDs are expected to run at a loss, other services generate revenue regardless of whether they are for-profits or non-profits. The first step in exploiting existing revenue sources and creating new ones is to re-examine major practices and their pricing structures. They (as well as almost ALL other businesses) rely on per line item profitability. Profitability per line item is determined by subtracting the fully allocated overhead cost (dividing fixed expenses by all billable line items) from the billable charge to yield a “net profit”.

    These cost-accounting burdens are invariably arbitrary and mis-represent the profitability of any service. That means that it is very difficult to determine what practices, what line items are truly valuable and generate spendable cash. In the interests of survival, hospitals need to drop this practice of applying arbitrary overhead charges. By dropping the overhead burden and looking SOLELY at the cash generated by the line item, hospitals can re-order the value of the services they offer and move the cash-rich services to the top of the list and cash-poor services to the bottom. Once re-ordered, then they need to move their promotional efforts to the cash-rich services AND drop any promotional activities that go to generate activity on those cash-draining line items.

    To most, this is a radical, although sound approach, as no one can dispute the actual cash derived from any procedure, but one can readily question/challenge almost ANY fully allocated overhead charge. This is a radical intervention, at a radical time. Hospitals run on CASH, not “paper profits”.

  3. I think that this proposed “idea” is so ridiculous and insulting that it shouldn’t even be brought to print. It is as ludicris as saying Doctors should clean dishes, since they are washing their hands anyway.

    • Thanks for commenting Colleen. I agree completely. Hospitals should instead look to improve overall care coordination processes and operations in ways that empower nurses to focus on what they do so well–the quality, compassionate care of patients. Just wanted to clarify again that our post disagrees with the “just grab a mop” mentality. It’s a reactive, short-sighted mentality that harms morale for caregivers and care and experience for patients.

  4. Nurses are the “bowels of the hospital” there has never been a job where one individual has had to be the “jack” of all trades. Throughput has been indoctrinated into our mentally; and the new way of thinking thus causing increased job dissatisfaction and high burnout rates. The novice nurse has never been taught about cost saving measures while in school, this is not part of the curriculum. There are far to many people developing and implementing policy without looking at evidence based practice and its effects on clients when corners are cut.
    I was one of those nurses who ran with a code blue and then mopped the floor…..the more I did the more administration wanted.

  5. Hi Maryanne…. I am not quite sure I would have used your choice of words… the “bowels of the hospital”. Nurses are the “heart and soul” of the hospital and bring care, comfort, healing, and tenderness to patients and their families.

    I agree that the more one does the more is asked. We need to be sure we can have the more done be for the betterment of the patient and not to the determent of the nurse.

    • Hi Lynne, thanks for your comment. And I agree, there are many common sense things that all members of the team can take on to improve care and efficiency. I’m curious, how would you rate the overall efficiency of care coordination at that hospital where you worked? And how well did management communicate? I imagine often people resent the way they are asked to take on new responsibilities more than the activities themselves.

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