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Is acuity the cure to all infusion nursing satisfaction ills?

In the world of infusion centers, patient acuity/intensity scoring has become the perceived go-to intervention to “fix” nurse satisfaction problems.

Infusion center leaders have historically struggled to quantify how much direct nursing care is needed for each day, objectively determine how many nurses are needed on a given day to care for the planned (and unplanned) patients that will arrive at the unit, and communicate the complexity of the patients they care for to justify additional team members. They are also trying to decrease stress and increase fairness by evening out the patient load for each individual nurse. The typical metrics of volumes or total hours of scheduled chair time are the most available data, and the most often used.

But nurses do not feel this tells the entire story. Nursing satisfaction is a complex and multifaceted issue that a single intervention, based on a single imperfect metric, is unlikely to solve.

What’s the evidence that acuity is “the fix” for nurse satisfaction?

Most published literature on outpatient infusion nursing patient acuity uses nursing satisfaction as the primary end point, but never digs deeper and asks, “What’s the real problem we’re trying to solve for?” We often hear of centers using an acuity scoring system for staffing and/or pre-assignment of patients, but they frequently manipulate the outcomes. They share additional pain points that scoring takes too long, or different nurses score the same patient or treatment differently, or their automation produces inaccurate results. Additionally, the published articles typically do not address or measure impacts to efficiency, overtime, or other areas that may be affected by the implementation. Finding objective metrics in addition to nurse satisfaction could boost credibility with audiences outside the infusion world to whom we are often appealing for resources.

Even more challenging is a lack of head-to-head comparisons of the different scoring methodologies. Scoring methodologies vary widely and can be based on chair time, patient characteristics, direct nursing activity time, drug risk profile (vesicant/reactive or a hybrid of variables. Therefore, benchmarking with acuity becomes impossible. This underscores the issue of why, while centers want to use acuity as the variable to indicate the need for additional staffing, finance or organizational management departments still require the use of metrics like visits/APC/hours, which have a universal definition and peer comparison groups to benchmark against. Internally developed tools are perceived as either biased or insufficient because there is not a way to compare against other centers.

What problem are we actually solving for?

After completing a comprehensive literature search and interviewing oncology leaders across the country, the problem we are really trying to use acuity to solve for is the lack of a universal measurement for outpatient infusion nursing workload, and a universal way to distribute that workload equitably among the available nursing staff. For emphasis, that is “equitably”, not “equally.” We often hear from leaders that they struggle with nurse perception of workload. Their nurses compare assignments to one another to ensure fairness of patient counts even with acuity scoring in place. Yet raw numbers of patients clearly do not tell the complete story. This is a sign that existing acuity methodologies and their common usage is still not fully addressing the core need. Infusion teams are trying to find a way to measure not only effort, but difficulty; how much direct nursing care is required and the intellectual complexity of that work. Unfortunately, what often happens is that even with some published literature available, each center tries to make the measurements their own. They modify the scoring methodology, thereby invalidating the expected outcomes and making it extremely difficult to compare metrics between centers and assess multiple end points.

Acuity and benchmarking

In addition to nurse satisfaction, infusion leaders are often pressured to reduce labor budgets by being held to a benchmarking standard. Leaders rarely feel they have a good comparison group and that the unit of service metric accurately reflects the magnitude of work performed by their nursing team. Be it APC, wRVU, hours worked per unit of service, or visits, they were not designed to measure nursing effort. The reality is that nursing (and pharmacy) is the core of infusion care delivery.

Every center believes it deals with unique circumstances, that their patients are sicker or need more social support, that they’re receiving more complex or higher risk medications, or that pharmacy/lab/doctors do or do not do X. But having worked with over 300 infusion centers, there is in fact virtually nothing we have not seen before that does not factor into our thoughts on acuity.

Due to their belief in uniqueness, centers end up bumping up acuity scores by a level here and there or classifying certain patients at the highest scoring value to provide buffer room in staffing. That is a big clue that the methodology has not been honed enough to work as designed and has not addressed the core problem. Because the definition of outpatient infusion acuity is not universal, it becomes impossible to use it as a benchmark. All that’s left is the dictate of an external benchmarking program. We must instead drive toward a universal metric for this environment and define what it should and what it should not be used for. Something is not always better than nothing. At the end of the day, we all want to take excellent care of patients in a fiscally responsible way and having the right tools is key to achieving that mission.

What comes next?

There is clearly a need for a universal evidence-based tool that solves the quantification and equitable distribution problem of infusion nursing workload. Finding the right metric and assignment methodology requires locating the sweet spot of rapid real time classification, a way to use it for load balancing distribution, supporting maximum efficiency, minimizing overtime and still supporting nurse satisfaction. This will require scientifically rigorous efforts using data science, engineering and nursing to bring multiple perspectives and end points into the research. Towards that end, we have partnered with several infusion centers to trial different methodologies in acuity and measure the effectiveness of predicting the nurse staffing needed for the day’s treatments. We will be measuring multiple objective endpoints in terms of methodology and outcomes. The outcomes of our research efforts will be linked here on the LeanTaaS site when available.

This piece originally appeared in Becker’s Hospital Review.

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