DOWNSIZING
Decrease Staff, Increase Patient Mortality
Hospitals that lay off staff but do not restructure work patterns may increase patient mortality and morbidity, according to a study by Amherst, NY-based healthcare research and consulting firm E. C. Murphy, Ltd.
The study found that hospitals reducing staff by 7.75 percent or more in response to financial pressures were 400 percent more likely than other hospitals to experience an increase in patient mortality and morbidity during 1990. In addition, the study revealed that hospitals with 3.35 or fewer full-time equivalents (FTEs) per adjusted occupied bed had "significantly higher" 1990 mortality and morbidity rates than other hospitals.
Using 1990 Health Care Financing Administration data, E. C. Murphy compared the staffing structures of 281 general, acute care hospitals across the United States. Through interviews with these hospitals' 502 financial and operational executives, the firm identified the number of FTEs per adjusted occupied bed and the downsizing methodology used (if any). It also evaluated the relationship between the organization of work and the consequences of restructuring by examining 72,250 healthcare workers' work practices.
The firm asserts that its findings "clearly demonstrated that health care work systems are extremely complex and wasteful," compared with those of a control group of more than 1,300 employees from outside healthcare. "Virtually every health care work role . . . was found to be 100 to 800 percent more complicated, either in terms of the scope of resources to be managed or the work activities to be performed," E. C. Murphy reports.
The company suggests that, in addition to fewer staff, poor work design, which leads to wasted time and paperwork, may be a major factor in the increased mortality and morbidity. Healthcare employees in facilities with high and low FTEs reported the same level of waste on an individual basis. "Where there are fewer actual employees, however, this waste takes a heavier toll on patients," the firm acknowledges.
No one doubts that healthcare reform will lead to further staff downsizing. However, according to the firm's president, Emmett C. Murphy, "when staff size is reduced without redesigning the work, . . . fewer people are left to grapple with the same inefficient procedures and complexity, which leaves even less time for patient-focused activities." He suggests restructuring work with the aim of reducing waste and redistributing resources to patient-focused activities. Murphy believes the benefits of this approach include more sustainable savings in the long term, a positive effect on employee morale, and lower patient mortality and morbidity rates.
AIDS
Misplaced Fears
Public education efforts have not succeeded in dispelling misconceptions and irrational fears concerning the AIDS virus, David Gelman reports in Newsweek.
Psychologists hypothesize that the fear of contamination people feel when they are exposed to persons with AIDS goes beyond their concern over becoming infected. For example, a majority of subjects in a study of business and science majors at Arizona State University said they would be uneasy using silverware that had been used as long as a year before by a person with AIDS. Most of the subjects acknowledged that their feelings were irrational.
Clinical psychologist Carol Nemeroff, who directed the study, believes that such fears stem from bias against those with AIDS — a disease many people believe afflicts "bad" persons. Nemeroff suggests that persons in modern Western societies are still prone to a belief in "sympathetic magic," the feeling that "when two objects meet, the characteristics of one can be transmitted to the other." According to this kind of magical thinking, to eat with a utensil used by someone with AIDS is tantamount to exposing oneself not only to a virus, but to qualities a person may find morally offensive, such as homosexuality or drug addiction.
A sad irony in the irrational fear of contracting AIDS is that people outside the highest-risk groups are not avoiding the real dangers. Whatever the reason for this failure, psychologists agree that the only effective way to combat it is through "more and better education."
SOCIAL JUSTICE
Getting Beyond Guilt
During this era of Rodney King and Reginald Denny, it seems the chasm separating black from white Americans is widening. The guilt many white Americans feel concerning this gap is a major barrier to racial justice in the United States, asserts Ellis Cose in his book The Rage of a Privileged Class (HarperCollins, New York City, 1993), recently excerpted in Newsweek. He observes that the feelings of guilt are so powerful that many persons "are in denial." Although "denial may be a great way to avoid an unpleasant reality, avoidance is not a good substitute for changing that reality," adds Cose.
"If ever there was a time to celebrate the achievements of the color-blind society, now should be that time," writes Cose in his book, which focuses on the rage many middle- and upper-class black Americans feel. However, although they have succeeded financially, many ask, "Why am I still not allowed to aspire to the same things every white person in America takes as a birthright?"
Most middle- and upper-class white Americans would be alarmed to learn that their black peers feel this way, admits Cose. He says some people believe that "for African-Americans who are willing to meet whites halfway, race no longer has to matter, at least not all that much." Cose asserts that Americans have to stop pretending that race is no longer a barrier when "legions of those who should be celebrating" feel such rage.
One way to accomplish this, suggests Cose, is to put an end to white guilt, if it "would result in a more intelligent dialogue." He concedes that such a dialogue may not close the racial gap dividing our nation. "But it is certainly preferable to censorship that passes for civility."
Perhaps white Americans will better understand the frustration once they learn what their black peers are up against. In his book, Cose describes the following "dozen demons":
- Inability to fit in. White corporate America often screens minority candidates for employment using criteria that are not applied to white candidates. The assumption is that whites will fit in at a company merely because they are white.
- Lack of respect. Black professionals must prove they are worthy of respect. They "frequently take aggressive countermeasures in order to avoid embarrassment," writes Cose.
- Low expectations. Whatever the likelihood of achievement, blacks often believe they have no option but failure.
- Shattered hopes. No matter how optimistic a black person is about his or her job and company, the person may be passed by for promotions, causing disillusionment.
- Faint praise. Some successful blacks are praised at the expense of those who are not as successful. Cose uses the following example: "It's too bad there aren't more blacks like you."
- Coping fatigue. Blacks often must pay a high price for success. Sometimes, Cose suggests, the price involves accepting the fact that race is seen as something to overcome, not as an asset.
- Pigeonholing. Blacks often fill jobs "where their only relevant expertise concerns blacks and other minorities," notes Cose.
- Identity troubles. Blacks must often disassociate themselves from "any hint of a racial agenda" in the workplace.
- Self-censorship and silence. Although blacks see much racism in the workplace, they often must silence their anger just to make small strides.
- Mendacity. Lies seem to be "an integral part of America's approach to race," says Cose. He gives the example of corporate executives who claim their companies are color-blind. But, he suggests, such lies of "convenience are . . . a source of profound disgust and cynicism for those on whose behalf the lies are supposedly told."
- Collective guilt. Cose writes that white Americans often link racism to the black crime rate. He notes that this sort of thinking "makes hard-working, honest black people responsible for the acts of unregenerate crooks — which is not very different from defining the entire race by the behavior of its criminal class."
- Exclusion from the club. Blacks are not always welcome to join private clubs, such as country clubs, where many white Americans socialize and do business, observes Cose.
MENTAL HEALTHCARE
The Value of Oversight
Most persons who have received mental healthcare in a managed healthcare setting believe that patients benefit most when providers have significant control over treatment decisions, according to a survey commissioned by Medco Behavioral Care Corporation (MBC), San Francisco.
Respondents also supported the need for treatment oversight, with 82 percent agreeing that someone should check to ensure the therapist is providing proper treatment and 92 percent saying someone should check to ensure that a patient's treatment is effective. At the same time, survey respondents believe in the value of some patient participation in the treatment process. Seventy-eight percent agreed that patients should be involved in setting the number of visits and the length of the treatment process, and 89 percent said "homework" should be an important part of therapy.
Respondents did say, however, that therapists should make most important treatment decisions, with 66 percent disagreeing — and only 21 percent agreeing — that patients should take an active role in this area. Most (70 percent) also disagreed with the idea that a patient's active involvement in the therapy process results in more success.
On the other hand, respondents overwhelmingly believed that patients should have some control over the treatment process, with 95 percent agreeing that patients have a right to make certain decisions regarding therapy. Only 10 percent thought therapists should make all the important decisions. More than 80 percent of respondents said therapists should offer more than one approach to treatment.
Study coordinator Lee. B. Konowe, president of Psychnet, Inc., Denver, noted that the survey results indicated that respondents "strongly value and want as part of their therapeutic experience the techniques and approaches to treatment which are the defining characteristics of managed care." According to Konowe, managed care arrangements fit these patients' needs because they give "assistance in selecting the appropriate provider and the appropriate approach to treatment" and provide for professional review of therapists' treatment plan.
Copyright © 1994 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.