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Volume 44, Number 7/8, pp 388-394
Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


Care Redesign
A Higher-Quality, Lower-Cost Model for Acute Care

Pamela T. Rudisill, DNP, RN, NEA-BC, FAAN

Carlene Callis, BS, MHA

Sonya R. Hardin, PhD, RN, CCRN, NP-C

OBJECTIVE: The aims of this study were to design,
pilot, and evaluate a care team model of shared ac-
countability on medical-surgical units.
BACKGROUND: American healthcare systems must
optimize professional nursing services and support
staff due to economic constraints, evolving Federal
regulations and increased nurse capabilities.
METHODS: A redesigned model of RN-led teams with
shared accountability was piloted on 3 medical/surgical
units in sample hospitals for 6 months. Nursing staff
were trained for all functions within their scope of
practice and provided education and support for
RESULTS: Clinical outcomes and patient experience
scores improved with the exception of falls. Nurse
satisfaction demonstrated statistically significant im-
provement. Cost outcomes resulted in reduced total
salary dollars per day, and case mixYadjusted length
of stay decreased by 0.38.
CONCLUSION: Innovative changes in nursing care
delivery can maintain clinical quality and nurse and
patient satisfaction while decreasing costs.

Author Affiliations: Senior Vice President and Chief Nursing
Officer (Dr Rudisill), Community Health Systems, Franklin; and
Assistant Vice President Strategic Resource Group, Vice President
Strategic Planning American Group (Ms Callis), HCA, Nashville,
Tennessee; Professor (Dr Hardin), College of Nursing, East Carolina
University, Greenville, North Carolina; and Professor Emeritus
(Dr Dienemann), School of Nursing, UNC Charlotte and Nurse
Researcher Carolinas Medical Center University, North Carolina;
and Chief Nursing Executive (Dr Samuelson), Poplar Bluff Regional
Medical Center, Missouri.

Community Health Systems is a registered trade name of
Community Health Systems Professional Services Corporation.

The authors declare no conflicts of interest.
Correspondence: Dr Rudisill, Community Health Systems, 4000

Meridian Blvd, Franklin, TN 37067 ([email protected]
or [email protected]).

DOI: 10.1097/NNA.0000000000000088

Jacqueline Dienemann, PhD, RN, NEA-BC, FAAN

Melissa Samuelson, DNP, RN, NEA, BC

Healthcare systems in the United States must bridge
the transition from volume to value-based models. Com-
ponents required to succeed include clinical integration,
implementation of technology, and clinical performance
improvement with operational efficiencies to manage
financial constraints.1 Nursing services encompass the
majority of the workforce in today’s acute care hospi-

Historically, models of care have been based on

a mix of registered nurses (RNs) and unlicensed assistive
personnel (UAP) with occasional reference to licensed
practical nurses (LPNs) and the assignment of work-
load. Evidence supports that patient needs are best
met by planned skill mix and recognition that nurses
are knowledge workers and need to be utilized in that
manner.3,4 Models-of-care redesign that embeds im-
proving efficiency and increasing accountability to
patients’ clinical outcomes requires a cultural transfor-
mation.1 All major changes in care design should be
evaluated for their evidence-based and desired changes.
The purpose of this study was to evaluate a pilot im-
plementation of a shared accountability delivery model
for medical-surgical patients that allowed licensed
nurses and UAP to practice at their full authority
through delegation and collaboration in RN-led teams.


The healthcare system in the United States is in a state
of rapid and unprecedented change with pressures to
improve clinical quality and patient health and increase
patient satisfaction, while curtailing costs. The Institute
of Medicine report5 cites 10 recommendations to en-
sure better health, higher-quality care, and lower costs.
One recommendation was to optimize operations by
continually improving healthcare operations to reduce
waste, streamline care delivery, and focus on activities
that improve patient health. The primary challenge of
delivering care in acute settings is managing increasingly

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complex patients with shorter lengths of stay (LOSs)
while ensuring integration of care upon discharge
and beyond.

Recent studies demonstrate that lowering costs is
dependent on increasing patient safety rather than
changing nursing salary or staffing expenses. 6 Nurs-
ing factors influencing patient outcomes include num-
ber of hours per patient-day (number of staff), quality
of work environment, educational level of nurses, and
mix of skills among nursing staff. These factors inter-
act among each other with varying effects on patient
outcomes.7-11 Increasingly, nurse satisfaction is related
to recognition that RNs are knowledge workers whose
time should be utilized in decision making regarding
patient care and safety.4

Nursing Care Delivery Models

Delivery of nursing care has traditionally been delivered
in 1 of 4 ways.12-14 Shirey14 discusses the advantages
and disadvantages of various models. The earliest model
is patient allocation or total patient care with groups of
patients assigned to 1 nurse with no UAPs. Because of
shortages during and after World War II, task or func-
tional nursing was emphasized, allocating more com-
plex care to RNs and routine care to UAPs. Team nursing
evolved with RNs as leaders of UAPs for a group of
patients. Primary nursing identified 1 nurse to assume
24-hour responsibility for a patient with communica-
tion to RNs, LPNs, and UAPs who participated in care
throughout the patient stay. This model of care has been
coined relationship-based care.12 One new, novel ap-
proach is to expand primary care to coordinating care
after discharge, with the RN assuming care as the pri-
mary nurse for readmissions.14,15 This model of care
fits in the new modes of accountable care transition

The recent Institute of Medicine report on the fu-
ture of nursing16 advocates for RNs to perform to their
fullest potential and to become effective leaders and part-
ners in the organization. This parallels the American
Organization of Nurse Executives guiding principles
for the role of the nurse in future patient care delivery.17

These position statements call for new innovative mod-
els of nursing care delivery. In 2005, Partners Healthcare
in Boston, Massachusetts, conducted a search of inno-
vative nursing care delivery models for adult, acute care
patients that integrated technology, support systems,
and new roles to improve quality, efficiency, and cost.
They identified over 40 models that shared common
elements of an elevated RN role, sharpened focus on
the patient, smoothed patient transitions and handoffs,
leveraged technology, driven by results that were mea-
sured systematically, and used for feedback to improve
the innovations.18 A few new models emerged requiring
shared accountability.19 In reviewing these models, our

team realized several approaches underutilized RN del-
egation, did not utilize LPNs at all, and did not require
RNs, UAPs, or LPNs to practice to their full scope.

We did identify 1 computer simulation model uti-
lizing the RN, LPN, and UAP, which incorporated
principles of the lean to enhance the role of the RN,
LPN, and UAP in the care delivery of patients.20 Lean
is a concept adapted from manufacturing to stream-
line processes, reduce cost, and improve care delivery.
Each process must add value or be eliminated as waste
(or muda in Japanese) so that ultimately every step
adds value to the process. 21 The simulation demon-
strated that teams of RN, LPN, and UAP assigned
in a mix to fit patient acuity of a group of patients
wasted less time than patient allocation assignments.

Development of Novel Nursing Care Redesign

We decided to develop a shared accountability model
utilizing RN-led teams with LPNs and UAPs, func-
tioning to their fullest potential, matching the skill-
mix potential to meet the patient’s needs. We piloted
the model on medical-surgical units in 3 community
hospitals in 3 states.

The goals were to improve clinical quality of care
and nurse job satisfaction through use of accountable
teams and balanced caregiver workload while con-
trolling or reducing costs.


The pilot was implemented on 1 medical-surgical
unit at each of 3 hospital sites in Alabama, Tennessee,
and Mississippi. Each hospital differed in overall bed
size and urban/rural market location. The leadership
in administration (chief executive officer, chief nursing
officer) was supportive and knowledgeable of lean
principles, the purpose of the nursing care redesign,
and the importance of evaluation.

Our 1st step was to review the scope of practice for
RNs, LPNs, and UAPs in each state where we planned to
pilot the program (Alabama, Tennessee, and Mississippi).
We then reviewed the job descriptions at the hospitals
and found that all legal functions were not included.
Policies, competencies, and job descriptions were revised
for the LPN and UAP to ensure highest level of prac-
tice. To ensure patient safety, education was developed
and provided to UAPs and LPNs to achieve competen-
cies in all functions. Examples of the enhanced compe-
tencies for the UAPs included simple dressing change,
oxygen setup, performing blood sugars, discontinuing
Foley catheters, and discontinuing peripheral intrave-
nous lines. The LPN-enhanced competencies varied the
most among the selected states. Some included admin-
istering intravenous medications and starting intrave-
nous lines.

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In order to assess level of patient needs, an acuity
tool was needed that was valid, efficient, portable be-
tween units, reliable, and maintainable.22 Duke Uni-
versity Hospital System had designed and evaluated a
tool beginning in 2003 that assesses patient’s acuity
based on the complexity of care or instability of a pa-
tient’s health status. Nurses used it with a personal
digital device. In time, it had been modified to reduce
input while maintaining validity for multiple settings.
Patients are assessed on 6 patient factors and 4 nursing
care demand factors, resulting in 1 of 4 levels of com-
plexity of care. The results are to ensure balance of work-
load with competency level of staff and patient acuity.
The tool was used with permission (e-mail communi-
cation, August 2012, November 2012, August 2013).
The Morse falls risk assessment23 and Braden skin care
assessment24 were added to the tool. No formal evalua-
tion of the modified tool has been made. New processes
adopted were bedside shift report for all caregivers of
the team and formal bed huddles for teams to be done
at a minimum of every 4 hours with new acuity assess-
ment, daily patient goals, and expected LOS review, as
well as any identified patient safety issues (Figure 1).

The clinical outcome data chosen for evaluation
were based on existing methodologies and collec-
tion practices reported to the Centers for Medicare &
Medicaid Services and other national organizations.
These included falls per 1,000 patient-days, falls with
injury severity of greater than 1, rate of hospital-acquired
pressure ulcers, medication errors per 10,000 doses, num-
ber of sentinel events, and number of near misses. Unit
LOS; rate of readmissions for congestive heart failure
(CHF), myocardial infarction (MI), and pneumonia
within 30 days; and core measure scores were also col-
lected. Cost was based on average LOS and cost per
patient-day. Patient satisfaction used the Hospital Con-
sumer Assessment of Healthcare Providers and Systems
(HCAHPS) data across the 8 domains.25 New survey
questionnaires on nurse and physician satisfaction were
developed for the specific medical-surgical units that re-
flected key elements on the model design and based on
the hospital-wide surveys performed by Press Ganey.25


Institutional review board approval was received from
the University of North Carolina at Charlotte, Charlotte,
NC. Materials were prepared, and site coordinators
were trained in data collection of patient outcomes and
confidentiality processes to distribute and collect ques-
tionnaires. Upon collection, data and questionnaires
were forwarded to the office of the corporate chief nurse
executive for data entry. Original forms were stored in
a locked cabinet.

To establish a baseline for all key metrics prior
to implementation, the following were collected: (1)

nurse/staff and physician satisfaction, (2) patient
outcomes and patient safety indicators, (3) financial
information, and (4) patient satisfaction. For the clini-
cal outcome and financial metrics, data for the same
6 months of the planned pilot in the previous year
were used.

Each pilot hospital assumed responsibility for im-
plementing the education in new skills and verifying
that all UAPs and LPNs had mastered the identified
competencies prior to initiating the model. Job descrip-
tions were updated. RNs’ job expectations shifted to
focus on decision making for delegation and assurance
of quality, patient teaching, patient care coordination,
and collaboration with other health professionals. Each
team had an RN leader and either 2 UAPs or 1 LPN
and 1 UAP. Patient assignments were for that shift.
Each job description was reviewed to ensure clarity
of role function.

An 8-hour course for all the nursing staff on the
pilot medical-surgical units at the 3 hospitals was de-
signed and led by the research team. The course began
with an overview of the new delivery model and job
descriptions for RNs, LPNs, and UAPs. The new acuity
tool was reviewed, and its purpose to share workload
fairly discussed. The plan to assess patient care needs
and review in huddles every 4 hours to maintain equity
was reviewed. Delegation and collaboration were then
discussed with case examples. Emphasis was placed on
each person working to their enhanced scope of prac-
tice and to share accountability for patient outcomes.
This was followed by a simulation exercise where staff
was assigned teams with case scenarios. Nurses left ex-
pressing enthusiasm for their new roles.

Implementation and Evaluation

The new model was introduced, and all staff was pro-
vided support to comply. When turnover occurred dur-
ing the 6 months of the study, categories of new hires
were chosen to support the model implementation. At
the end of the 6-month period, all metrics were collected
and measured against the established baseline.


Nurse satisfaction showed the most statistically signifi-
cant improvement in comparison to all other measures
included in the study. Forty-four nurses (86%) com-
pleted the presurvey, and 36 (69%) completed the post-
survey. A paired-samples test was performed to identify
any significant change from the implementation of the
new care model. While all responses demonstrated a
positive trend, 6 items showed statistically significant
improvement: teamwork among coworkers, appro-
priate delegation, sense of accomplishment in their
work, enjoyment coming to work, satisfaction with

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Figure 1. Bed huddle.

workload, and satisfaction with job (Table 1). Pa- Within the 8 domains, physician communication re-
tient satisfaction showed slight improvement accord- sulted in a statistically significant improvement at P =
ing to the HCAHPS scores in 3 of the 8 domains. 0.013 when an analysis of variance was performed.

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Table 1. Paired-Samples Test Nurse Survey

Paired Differences

95% Confidence
Interval of the


Pre-Post Response Items (n = 36) Mean SD SE Mean Lower Upper t df P (2-Tailed)

Pair 1: good teamwork 0.69444 1.26083 0.21014 0.26784 1.12105 3.305 35 .002
Pair 2: delegation appropriate 0.75000 1.25071 0.20845 0.32682 1.17318 3.598 35 .001
Pair 3: sense of accomplishment 0.41667 0.99642 0.16607 0.07953 0.75381 2.509 35 .017
Pair 7: enjoy coming to work 0.47222 1.13354 0.18892 0.08869 0.85576 2.500 35 .017
Pair 9: satisfied with workload 0.68571 1.47072 0.24860 0.18050 1.19093 2.758 34 .009
Pair 11: satisfied with job 0.44444 1.25230 0.20872 0.02073 0.86816 2.129 35 .040

P e 0.05.

Most clinical quality indicators showed signs of
improvement, including core measures, hospital-acquired
pressure ulcers, medication errors, near misses, and
CHF, MI, and pneumonia readmissions. Independent
t tests of samples were performed to examine the dif-
ference between the mean of incidence of indicator
before and after the intervention. Although improved,
none were statistically significant (Table 2). A com-
posite core measure score for the hospitals, excluding
elements of care provided in the emergency depart-
ment, revealed improvements in the pilot hospitals.

Financially, the pilot resulted in reductions in
costs. Cost reduction was realized through the use of
proper discharge of lower-acuity patients, proper work
allocation, and staffing-mix allocations resulting from
workload rebalancing. Based on analysis on each unit,

using year-over-year comparison, case mixYadjusted
LOS decreased by 0.39 days on average for all 3 units.
In addition, the ALOS average for the 3 units was
below the mean LOS by 0.38. In addition, all 3 units
resulted in reductions in salary per patient-day of ap-
proximately 2% to 3%. One of the 3 units proved to
be the best comparative model, as it had the most
stability in its workforce and adhered closely to the
staffing workload balance guidelines. This unit reported
an equivalent decrease in RN hours to the increase in
LPN and UAP hours (a rebalance of approximately
5.0 full-time equivalents).

Improving the Environment of the Workplace

Although the study did not set out to improve the
workplace environment, the achievements in this area

Table 2. Independent-Samples Test of Quality Indicators

Levene Test
for Equality
of Variances t Test for Equality of Means

95% Confidence
Interval of the

Equal Variances Difference
Assumed or Mean SE
Not Assumeda F P t df P (2-Tailed) Difference Difference Lower Upper

Decubitus (1) 4.484 .042 1.112 34 .274 0.41056 0.36922 j0.3398 1.16091
ulcer (2) 1.112 17 .282 0.41056 0.36922 j0.36844 1.18955
CHF (1) 2.254 .142 1.671 34 .104 0.5 0.29918 j0.108 1.108

readmit (2) 1.671 29.643 .105 0.5 0.29918 j0.11131 1.11131
PN (1) 0.297 .589 1.219 34 .231 0.33333 0.2735 j0.22248 0.88914

readmit (2) 1.219 33.971 .231 0.33333 0.2735 j0.2225 0.88916
Acute MI (1) 4.321 .045 1.087 34 .284 0.22222 0.20435 j0.19306 0.6375

readmit (2) 1.087 24.808 .287 0.22222 0.20435 j0.1988 0.64325
Fall rate (1) 0.446 .509 0.122 34 .903 0.11278 0.92281 j1.7626 1.98815

(2) 0.122 32.337 .903 0.11278 0.92281 j1.76616 1.99171
Fall injury (1) 11.102 .002 j1.458 34 .154 j0.11111 0.07622 j0.26601 0.04379

(2) j1.458 17 .163 j0.11111 0.07622 j0.27192 0.0497

Abbreviations: CHF, chronic heart failure; MI, myocardial infarction; PN, pneumonia.
P e 0.05.
a(1) Equal variances assumed, (2) equal variances not assumed.

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deserve special recognition. It was noted by all 3 pilot
sites that the engagement in innovation, education,
and new tools and methodologies brought about an
excitement to the workplace, which resulted in improved
job satisfaction and caregivers reporting a feeling of
significance and value.

For example:

The care redesign resulted in an almost immediate
and significant improvement in patient, physician,
and staff satisfaction. The improvement in teamwork
has been remarkable. The unit went from the most
challenging unit for nurses to work, and therefore, a
unit to avoid, to the unit where most med/surg nurses
want to work. (Hospital chief executive officer)

Participating in the care redesign pilot gave a focus
and spotlight to the unit for the physicians and staff.
We worked diligently on turning around the culture
and motivating the staff toward embracing change and
the new processes. (Hospital chief nursing executive)

The teamwork that occurs with the UAP having a
higher skill allows the licensed nurse to spend more
time with patients. (Hospital staff nurse)


Several limitations were associated with doing research
in a natural setting. For example, 1 site lacked optimal
staffing, and turnover in nursing leadership occurred at
another. There was an omission to include physicians in
the education about the model that resulted in some
confusion. This may have impacted physician response
rate before and after implementation. A limitation was
that 13 physicians (76%) completed the preimplemen-
tation survey, and only 6 (35%) completed the post-

implementation survey. This was too small of a sample
to statistically evaluate the perspective of physicians on
the units where the intervention was implemented.
Future studies are needed with a larger sample of
medical-surgical units for a longer period to rule out
the Hawthorne effect for increased satisfaction and
possibly allow for changes in clinical outcomes to
reach significance over time.


This novel, shared accountability model for medical-
surgical units that emphasized utilization of RN, LPN,
and UAP full scope of practice had promising initial
findings. Results suggest that positive clinical outcomes,
along with nurse job satisfaction, can be obtained while
providing cost savings. The findings are similar to other
results reported by Hall et al10 and Fairbrother et al,26

who reported on new care delivery models with advanced
nurse responsibility and team shared accountability.
However, Tran et al19 found that job satisfaction de-
clined because of the delegation required. They also
differ from Aiken et al7 regarding improvement in
clinical outcomes; that study found the key variable
to be increase in the RN-to-patient ratio. These pre-
liminary findings in our study support further inves-
tigation on the use of these innovations.


Nursing has a crucial role in shaping the future of
healthcare delivery. It is imperative that innovation
to engage nurses in leadership for better health, better
care, and less costs be ongoing. This model is 1 ex-
ample to further evidence-based delivery models of
care maximizing the skills of the existing workforce.


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