Editor's Note

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So the feds have ruled that physicians, hospitals, and insurers shouldn't limit the number of inpatient days for Medicare patients after a mastectomy or require that the surgery be done on an outpatient basis.  Is that good news?

Not in the long run.  It's not that I'm in favor of outpatient mastectomies or stays that are too short—far from it.  It's just that such legislation is a Band-Aid approach to a much larger problem, and it fails to address the biggest issue facing nurses, physicians, and other providers: Bureaucratic rule-making is taking the place of experience-based judgment.  In the drive to cut costs, we're letting the decision making get pushed away from the bedside, all the way to the Beltway.

A good friend of mine called me the other night, frustrated with the recovery room in which she works.  Business is brisk these days, so the nurses are asked to move patients out of the recovery room after 45 minutes of observation.  It's usually fine.

My friend, however, had a patient who—for reasons that only her years of experience could fully justify—just didn't seem right.  In the old days, she would have kept him in recovery for another 30 minutes, just to be sure.  But with patients backed up for a slot in the recovery room and the unit's new 45-minute rule, she moved him out to the floor, against her better judgment.

Thirty minutes later the nurses on the floor called: The patient was going bad.  His blood pressure was falling, and my friend rushed to help the staff.  Soon he was moved to the ICU.

My friend thinks providers are practically being forced to move patients through the system at a pace that sometimes seems to flirt with serious trouble.  A shift of hoping for the best, patient after patient, makes for a day of great tension.

The speed with which patients are being moved from surgery to home or from a major procedure to the floor can only be safe if nurses, physicians, and other providers are encouraged to use their judgment as they assess each situation.  Rules emanating from Washington won't solve the problem.  But trusting in nurses to use their skill and experience is the only way we'll make real progress in managing that delicate balance between cutting costs and ensuring quality.

A clerk at Nordstrom has the authority to make almost any decision on behalf of a customer.  Shouldn't the nurse in the recovery room, or the clinic, or the ICU, be given at least the same level of authority?

Successful businesses have learned that moving decision making close to the customer, the factory floor, and the workstation makes the greatest impact on quality and productivity.

We've learned other good things from business lately.  Let's learn that.

Barbara Bronson Gray, MN, RN
Editor in Chief

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