On Lobby Waterfalls and Safe Staffing


Limousine service, upgraded television setsnurse-to-patient “scripts,” gourmet food service, nurse uniform requirements. Hospitals all over the U.S. are offering more “customer-centric” patient care in order to increase patient satisfaction scores, which are becoming ever more important to raise and maintain Medicare reimbursement amounts.

These efforts, however, often have unintended consequences.

In the first place, customer-centric interventions rarely (if ever) improve the quality of care patients receive. Rather, they merely improve patients’ perceptions of care.

Perhaps the biggest issue with this approach is that nurses have little control over the factors that research shows improve patient satisfaction scores the most. Quality of food service, wait times, physician attentiveness, even staff uniform colors are all factors in patient satisfaction scores—none of which nurses have control over.

Crucially, nurses also have little control over nurse staffing, which research demonstrates is a significant factor in patient satisfaction scores. Short staffing is inherently unsafe and puts patients at risk.

Contrary to gourmet food service, however, improving nurse staffing actually improves the quality of care patients receive, not just their perception of it. The literature shows that improving nurse staffing while controlling for variables (including physicians, LPNs, and nursing assistants) significantly reduces the risk of mortality, lowers the incidence of medication errors and other adverse eventslowers patient readmission ratesreduces nursing-sensitive negative outcomes, and even saves hospitals and insurance companies money—and that’s just the tip of the iceberg.

In an effort to mitigate the unintended consequences of patient satisfaction scores and improve nurse staffing, the American Nurses Association has long advocated for Medicare to include nurse staffing measures next to patient satisfaction scores on its Hospital Compare website.

By doing so, public reporting of nurse staffing on a 1-5 scale will push hospitals to staff more safely and shift patient care interventions from those that improve perceptions of care to those that actually improve care itself. Think about it: nurse staffing is perhaps the single greatest indicator of patient quality of care. Would you rather go to a facility with a five star rating on nurse staffing, or one with a three star rating on nurse staffing, two lobby waterfalls, great patient scripting, and state of the art flat screen tvs?


Give me the better nurse staffing every time.

Unfortunately, Medicare recently declined to include nurse staffing measures on Hospital Compare for Fiscal Year 2018. But the fight is not over. While ANA is proud that we were able to help generate 1,363 comments in support of these staffing measures, and is thankful for the 26 advocacy groups who co-signed our comment letter to the Center for Medicare Services, we are already gearing up for an even bigger grassroots movement next year.

But we’re going to need your help. Stay tuned for more: #nursesunite.

6 thoughts on “On Lobby Waterfalls and Safe Staffing”

  1. Any discussion about staffing must include staffing based on patient acuity not just ratios.

  2. Patients today are looking for a hotel experience in the hospital. I work in a busy postpartum department, and our staffing ratios are horrific. We routinely start with four couplets and move up to five or even six when we are very busy. We are being told to add more and more tasks to our already busy schedules, which leaves very little time for interactive patient care. It’s not safe, and it’s not right. For the most part, our patients are healthy young women, but our acuity level is rising. Women with serious health issues who were previously told they should not have children are now having babies, and we are seeing many first-time mothers well into their 40s.

  3. My hospital staffs by numbers, not acuity. I actually was yelled at by my Nurse manager recently for saying we were working short. We get called off at less once or twice a month if numbers drop, no matter the acuity. The techs have to self- sit confused or agitated patients about 75% of the time making it harder to do my job when my tech is gone 30 minutes every 2 hrs. to sit. Medications are given late. Nurses are also sent home halfway through our shifts if census drop and remaining nurses pick up the patient’s left in that nurses team. At least two of us have to take 6 patients before they will staff another nurse. I used 24 hours of leave time last month in order to have a full paycheck. If we get put on call due to low census, we get paid $4/hour, so again if we want a full paycheck vacation time is used to make up the loss in pay.

  4. If nurses do not have control over nurse staffing, we own that. We have not done our job telling an objective story based in evidence that others (CFO, CEO, etc) can truly understand. We have not owned engaging our care team partners (cm, pt, ot, dietary, rt, etc) to drive appropriate staffing of all care team members to ensure right care by right person at right time. The fact this article suggests we do not own to some extent nurse staffing is down right a lack of accountability.

  5. Let’s have an honest discussion about the role that nurse administrators play in making determinations about safe staffing when these same nurse administrators haven’t worked in a clinical capacity for years. Until nurses who are directly involved in patient care are given a seat at the table on hospital governance boards (and sadly, it will have to be mandated for facilities to follow through) nurses will be underserved by their own nurse Admin for the sake of the almighty dollar.

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