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In a hospital located somewhere in America, a young woman, a mother of three, steps out into a hallway as the elevator door closes behind her. She looks left then right before crossing, then it's down to the end of the hall to visit her husband recovering from surgery the day before. Opening the door, she sees him lying on his side, his back facing her, blood-soaked sheet covering him. Quickly she moves closer, pulling back the sheet and exposing a very large incision that is leaking blood from where a tube had been. Making her way around the other side, she sees his face is agonizingly pale, his eyes closed, his body shaking uncontrollably. Something has seriously gone wrong she thinks to herself, trying not to panic as she darts out the door, down the hall to the nursing station, to get help. My husband needs help!” she keeps saying. Something's really wrong with him!” she tells the nurse, who asks her to hold on a moment. The woman looks down at the floor for a moment, thinking he could be in serious trouble. Upset, she looks up again. There, suddenly out of nowhere, a friendly face walks around the corner. It is another nurse--a friend who just happened to be on her way to visit. The woman rushes over quickly, telling her friend something has gone terribly wrong with her husband. Surprised, the nurse moves quickly with her friend back to the patient's room. She immediately begins assessing his condition, calling the patient's name over and over with little to no response. The nurse walks around the other side of the bed only to find the pain pump he's attached to broken. Determined, the nurse sets out to get this patient the care he needs desperately. It is a haunting memory--one my family and I will ever forget, because I was the patient. A lucky patient at that. My family's experience was a regrettably predictable result. If it hadn't been me, it would've been someone else. In 1984, the Institute of Medicine estimated 98,000 Americans die each year from medical errors. In September of 2013, new research purports that over the last 30 years, medical errors have grown more than 400 percent, to nearly 400,000 patients annually.” By the time you're finished reading this, two people will have had their lives either altered or ended because of medical errors. Serious harm seems to be 10- to 20-fold more common than lethal harm, and that epidemic of patient harm in hospitals must be taken more serious!” The increase in harm to patients is happening despite numerous nationwide efforts to reduce medication errors. The same is true of many other classes of preventable harm. At AnyWhere in America Hospital, nurses struggle with the constant and continued interruptions in the flow of patient care. These costly system failures persist because of the way in which nurses are forced to problem-solve. It is exactly the constant need to work around system problems that creates even more difficulty in taking care of patients. And because they cannot care for their patients without jumping the system hurdles immediately in their path, priority goes to treating the system failure while their patients wait, absent of the care they need. From my first days as a worker in healthcare, I have seen the awesome responsibility and daily difficulties of nurses and the constant and consistent process failures that negatively impact patient care. This essay and my work, is for them and for all of us who depend on them.

Supply chains and other service industries, like telecom, worry about "the last mile"--the final step in delivering a product or service to customers. Like other industries, healthcare must connect most meaningfully to the patient, and the nurse is almost always part of (if not the sole manager of) that last mile.” The analogy of the last mile defines a deeply rooted issue about nursing's criticality (and that of other direct caregivers, like LPNs, CNAs, etc.). The last mile” for hospitals in a new and rapidly changing environment may be the difference between keeping the hospital open or closing it down. And the cost of not addressing this last mile” issue is perhaps the biggest threat--and opportunity--HCOs face. One proposed method for closing that last mile of improving patient care while maintaining a reasonable workload for nurses has been to legally mandate nurse-to-patient ratios. There are growing numbers of legislative efforts, both state and federal, moving toward mandated ratios to ensure nurses aren't overloaded and patients are well cared for. To date, California is the only state with legislative authority to regulate nurse-to-patient ratios. But California is generally regarded as a bellwether of healthcare policy, so mandates are surely on their way across the US. Certainly, nurse-to-patient ratios hold the potential to improve quality and reduce overburden. But such an approach, by itself, is flawed because it only reduces the number of patients the nurse has to work with without a concomitant reduction in the chaos that often characterizes their scandalous working environment. The National Bureau of Economic Research in Cambridge, Massachusetts, published The Effect of Hospital Nurse Staffing on Patient Health Outcomes,” in which they concluded that patient outcomes did not disproportionately improve with the introduction of nurse-to-patient ratios.” NBER's report did suggest that there may be complementarities between nursing inputs and other (possibly unobserved) inputs and policies that lead to better patient care. Thus, improved nurse staffing might be crucial in improving patient care, but only in combination with other elements.” In other words, just changing nursing ratios alone will not achieve the desired benefits for the working environment of nurses or, most significantly, the quality of care that patients receive. In the currently swirling whirlwind of overburdened nurses, about five percent of the nation's 2.7 million registered nurses have left the profession. Various estimates for future departures run at the 25 percent level. Some of this reduction will be due to retirement, but research indicates that nurse burnout,” as a percentage, is a serious risk to the future of healthcare. In a recent study of 40 hospital units, more than one third of nurses reported they intended to leave their position within the next year, citing emotional exhaustion” and lack of personal accomplishment,” two key indicators of nurse burnout. And as growing evidences has shown, nurse-burnout dramatically influences how satisfied patients are with their care.” Job dissatisfaction among hospital nurses is four times greater than the average for all other US. workers. This is scandalous! Despite the fact that enrollment in nursing programs has increased by about 5 percent over the last few years, we are facing a future with fewer nurses than we need. In fact, there are approximately 126,000 nursing positions currently unfilled in hospitals across the United States.10 Even the American Hospital Association, a staunch national advocate for more than 5000 hospitals, measured satisfaction among healthcare employees and concluded: that hospitals fail to meet the expectations of their employees far more frequently than employers in other industries do. Indeed, the data shows that health care employers are worse off than the national norm in every category.” Finally, there is the growing number of nurses reaching retirement age. The average age of a working RN today is 55.3, and that age is increasing at a rate more than twice that of all other workforces in this country. By 2020 the median age of a hospital RN will be 60 and there will be at least 400,000 fewer nurses available to provide care than will be needed. The scandal of healthcare is real and it is affecting patients, nurses, and many others. Organizations must, of course, be patient-focused, but we believe that the most important proxy for patient-focused care is excellent internal customer service for nurses, since they are involved in nearly every aspect of direct patient care. Because nurses are essential to better and cheaper healthcare, and because their work life is burning them out and seems destined to become more complicated as fewer of them care for more patients, we contend that organizations must and can succeed by looking at nurses as customers” of internal services. By taking a system view of meeting patients' needs, HCOs can work to ensure that their nurses always have exactly the information, equipment and supplies their patients need at exactly the right moment.

Supply chains and other service industries, like telecom, worry about "the last mile" the final step in delivering a product or service to customers. Like other industries, healthcare must connect most meaningfully to the patient, and the nurse is always part of (if not the sole manager of) that last mile.” The analogy of the last mile defines a deeply rooted issue about nursing's criticality (and that of other direct caregivers, like LPNs, CNAs, etc.). The last mile” for hospitals in a new and rapidly changing environment may be the difference between keeping the hospital open or closing it down. And the cost of not addressing this last mile” issue is perhaps the biggest threat healthcare organizations/hospitals (HCOs) face. One proposed method for closing that last mile of improving patient care while maintaining a reasonable workload for nurses has been to legally mandate nurse-to-patient ratios. There are growing numbers of legislative efforts, both state and federal, moving toward mandated ratios to ensure nurses aren't overloaded and patients are well cared for. To date, California is the only state with legislative authority to regulate nurse-to-patient ratios. But California is generally regarded as a bellwether of healthcare policy, so mandates are surely on their way across the US. Certainly, nurse-to-patient ratios hold the potential to improve quality and reduce overburden. But such an approach, by itself, is flawed because it only reduces the number of patients the nurse has to work with without a concomitant reduction in the chaos that often characterizes their scandalous working environment. The National Bureau of Economic Research in Cambridge, Massachusetts, published The Effect of Hospital Nurse Staffing on Patient Health Outcomes,” in which they concluded that patient outcomes did not disproportionately improve with the introduction of nurse-to-patient ratios.” NBER's report did suggest that there may be complementarities between nursing inputs and other (possibly unobserved) inputs and policies that lead to better patient care. Thus, improved nurse staffing might be crucial in improving patient care, but only in combination with other elements.” In other words, just changing nursing ratios alone will not achieve the desired benefits for the working environment of nurses or, most significantly, the quality of care that patients receive. In the currently swirling whirlwind of overburdened nurses, about 5 percent of the nation's 2.7 million registered nurses have left the profession. Various estimates for future departures run at the 25 percent level. Some of this reduction will be due to retirement, but research indicates that nurse burnout,” as a percentage, is a serious risk to the future of healthcare. In a recent study of 40 hospital units, more than one third of nurses reported they intended to leave their position within the next year, citing emotional exhaustion” and lack of personal accomplishment,” two key indicators of nurse- burnout. And as growing evidences has shown, nurse-burnout dramatically influences how satisfied patients are with their care.”

What is the best way to get involved? How do we get the message out? Nurses ARE the backbone of healthcare and the key to reducing cost but most significantly increasing the value for patients..

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A nurse walked into a patient's room one day and she saw her patient didn't eat their soup. Concerned the nurse inquired and the patient replied, It's too painful to sit up all the way to eat soup.” Knowing the importance of nutrition, the nurse left the patient's room to retrieve a large lidded cup from the supply room located just down the hall and around the corner. She went back to the patient's room transfered the soup to the cup handing the cup back to the patient who found it much easier to eat without having to sit up. Many nurses. who were frustrated by the hassle of running around looking for cups, had requested that lidded cups be stock in every patient's room. Yet even with the implementation of the new process and the added cups nurses still reported they didn't have enough cups for their patients. The initial problem reported was stocked out cups. Instead it was a failing process providing nutrition to patients who couldn't sit up needing soup delivered differently. Forcing nurses to jump through hoops in order to ensure the best care for their patient. The Downfall: A colleague of mine, who was working with a healthcare organization, saw another side of the connection with dietary services. Early one morning, a nurse had helped a diabetic patient place an order for lunch. In the interim, the nurse went about caring for her 5 other patients as well as gathering up the supplies and medications this particular patient would need for their pre-blood sugar test, done before the patient eats. Upon arriving, the nurse discovers nutritional services delivered lunch ahead of schedule and her patient was already eating. Many expressed their frustration and were quick to blame the patient, who had been diabetic nearly 20 years. What was she thinking?” Some ask and others assumed, She knows she needs her blood sugar checked before she eats!” At some point, the CEO heard about this problem. Her response stunned me: she said. She thinks we know what we're doing. If a hospital delivered you a meal, would you question whether you should eat it?” Unfortunately, it is processes like these that simply get in the way of patient care. And the many, well-meaning improvements of various support departments can often make things worse rather than better. Now try to imagine the daunting challenge nurses face trying to coordinate the hundreds of other supplies, medications and medical equipment etc., she will need to care for her 5 plus patients! An enormous undertaking when processes flow smoothly, and believe me, that's not often the case. On a typical day, a nurse will walk an average of three miles repeatedly up and down the same thirty-foot stretch of hallway over and over again--hunting for and fetching the many things she needs to care for her patients. In fact, she'll do this 528 times in 8 hours, with no confidence that the healthcare organization will ever change or an expectation that it should. In a typical hospital, the constant hustle required of nurses is a testament to their continued drive to serve patients Healthcare organizations fail to support nurses' efforts to provide precise patient care. The scandalous lack of coordination is bad for us all. All nurses should be able to expect more from the healthcare organizations that employ them. The Scandal of Healthcare is real and it is negatively impacting nurses and many other healthcare workers. Most importantly, it's impacting the patients they serve.

On a typical day, a nurse will walk an average of three miles per 8 hour shift. Up and down the same thirty-foot stretch of hallway over and over again--hunting for and fetching the many things she needs to care for her patients. In fact, she'll do this 528 times in 8 hours, with no confidence that the healthcare organization will ever change or an expectation that it should. In a typical hospital, the constant hustle required of nurses is a testament to their continued drive to serve patients Healthcare organizations fail to support nurses' efforts to provide precise patient care. The scandalous lack of coordination is bad for us all. All nurses should be able to expect more from the healthcare organizations that employ them. The Scandal of Healthcare is real and it is negatively impacting nurses and many other healthcare workers. Most importantly, it's impacting the patients they serve.

Today the nursing station is all but gone. Medication frequency, dressing changes, and other prescribed care are ordered from a computer located in a patient's room, or just outside the door. In a scenario we have seen repeated hundreds of times, a nurse hurries to get medication, which is nowhere near the patient's room. As the nurse hustles to the med room, her aide asks for help with another patient, which delays the nurse's ability to deliver her original patient's meds. Now already several minutes behind in getting medication, the nurse is assessing another patient who, say, needs supplies too. But unfortunately, those supplies are stocked in a different room from the medication. Leaving to get both, the nurse runs into a family member there to see their loved one. It just so happens to be her patient, and that patient needed their medication seven minutes ago. She provides a quick update and tells the family member they can see their loved one, and that she'll be right back. But then Transport calls. They're running late, which delays a patient's discharge, the one who's still waiting for the medication. At present, nursing is a decentralized system of continually changing needs. As seen in the preceding paragraph, the failure to connect services to nurses increasingly burdens the daily activities of nursing. The difficulty arises for nurses because while nursing activities aredecentralized, supporting services remained centralized. This mismatch in operational processes ensures each nurse will spend time hunting for, fetching, and clarifying what their patients need. This is further complicated by frequent failures in these mismatched processes. It's certainly true nurses need to be available for the patient. But when nurses aren't available, it's primarily due to hospital operations failing to meet the needs of nurses as the principal providers of care to patients.

Thank you! Nurses are the backbone of healthcare! Best Regards

Please read: The Scandal of Healthcare: Nurses, Waste & Customer Service. Amazon.com: The Scandal of Healthcare:: Nurses, Waste & Customer Service eBook: Colin Baird, David Sundahl, Adirondack Editing: Kindle Store One reader of the book wrote "This book is as true as it gets.It is not for the nurses, they live it. It is for the Leaders and Managers that create those internal processes that the nurses work in." Another wrote "Baird and Sundahl aptly portray a refreshing look at our healthcare system at the day-to-day operations level. However, most importantly they present the reader with a roadmap of how to fix the problems plaguing the system: Best Regards

I believe that ALL hospital administrators, managers, directors, VP's and hospital presidents should read. The Scandal of Healthcare: Nurses, Waste & Customer Service. As one reader wrote "This book is as true as it gets.It is not for the nurses, they live it. It is for the Leaders and Managers that create those internal processes that the nurses work in" Another wrote, " I enjoyed this book for a couple reasons, it showed me why I left bedside nursing - and it is a great step to assist healthcare decision makers understand, or get a glimpse of what is going on - and why their decisions are so important." And thank YOU for taking on the arduous job of nursing.. You are a Hero to me! Best Regards

One of my most memorable experiences was more than a decade ago while working for a Level One Trauma Center on the East coast. I was sitting in a hospital break room during one of my breaks as an inventory coordinator when a nurse walked in. I simply asked how her day was going and she fell into the chair next to me crying. Surprised by her reaction I asked "What's going on?" and she replied "I just lost my third patient today!" The impact of her personal experience stuck with me. Even now, looking back, I can't help but think how difficult a day it must have been for her. Until that moment, my only experience with nursing had been as a patient. Seriously injured while serving on active duty, it was a nurse who saw me first and it was a nurse who discharged me from the hospital. It was a nurse who was responsible for all of my care. Like an air traffic controller, it was a nurse who coordinated my care as well as the care of many others. The Most Overwhelming Parts of Nursing What I didn't know at the time, but more than a decade later I would learn that the most overwhelming parts of nursing are the constant system failures. More than 30 percent of nursing time is spent hunting, fetching, and clarifying work not patient care. This is not the cause of any one person or processes, patient care has just evolved this way over time. Fast forward more than decade and those experiences of stress and disappointment still exist for nurses. The reality here is that Health Care Organizations/Hospitals (HCO's) function in a way that requires nurses to focus more of their limited time and attention diagnosing systems needs rather than focusing on patients care. Nurses scrambling for linen, supplies, equipment, or waiting to clarify a medication prescription are just a few examples. It's all the unrelated system needs and its failures, not patient care, that adds real cost. Overburdened, a single nurse could be caring for as many as five to six patients struggling in a system that's failing him/her. Between 2000-2007 Healthcare Spending Grew at Nearly 6%/Year In recent years, the cost of healthcare has gotten a great deal of attention and with good reason. Between 2000 and 2007, healthcare spending grew at nearly six percent per year, a much steadier growth rate than inflation or wage growth. Future healthcare costs has even been a security concern--increases in healthcare spending are and will increasingly take money away from military readiness. Many scandalous stories about the costs of healthcare have been told. And while we share Americans' outrage at the cost of healthcare, there is some good news on the cost front: healthcare spending has been leveling off in recent years. The Real Scandal of Healthcare Progress on the cost of healthcare notwithstanding, there is a serious scandal in healthcare--the toll that healthcare takes on the people who deliver it. The burdens of regulation, cost reductions, and quality initiatives piled onto nurses and other clinicians are undeniable. The biggest current and future risk to health care is shortages of nurses and doctors. Especially in nursing, "there is growing evidence that the job people are asked to do is unreasonable and consequently moving people out of the profession"; emerging shortages are weighing down further the workload and feasibility of already overworked doctors and nurses. In a recent study of forty hospital units, more than one third of nurses reported that they intended to leave their position within the next year; sighting emotional exhaustion and lack of personal accomplishment, two key indicators of nurse-burnout. "And as growing evidences has shown, nurse-burnout dramatically influences how satisfied patients are with their care." The performance of nurses and their impact on quality is determined by many factors. In the end, though, all research on the quality of nursing care either concludes the absolute necessity of support departments providing nurses with what they need, or assumes that these departments will do so. Put another way, treating nurses as customers is at the heart of all work on the quality of patient care by nurses. Efficiency--how hospitals must operate--will loom large as the Affordable Care Act (ACA) is rolled out and sequestration cuts continue. Efficiency will equal profitability; without it continued financial pressures will mount. Leaving only two choices for HCO's/Hospital; open or closed!

In October 2015 New York Times published Closing a Hospital, and Fearing for the Future noting Mercy Hospital Independence as the 58th hospital to close in the United States in five years”. In November Modern Healthcare, an industry leader insider's guide on successful hospital operations, underscored the financial hardship by some of America's largest Healthcare Organizations (HCO's). Organizations such as NYC Health who reported losses of 263 million in just the first quarter of 2015” Losses they tied to revenue decline and operating expense increases. State run healthcare exchanges have been stricken with serious financial burdens. The federal government who Initially provide 5 billions dollars in funding, under the Affordable Care Act (ACA), to establish state run healthcare exchanges no longer provide funding and states are expected to cover all operating expenses associated with running state exchanges. Some states have reported operating cost upwards of 30 million or more on an annual basis. Other states like Hawaii have already shut down their exchange sending Hawaiians to Healthcare.gov, and it's still unclear as to how other States will address the exorbitant cost of running healthcare exchanges. Health co-op insurers offering policies through state run healthcare exchanges are struggling with serious financial difficulties as well. In November 2015 Health Republic Insurance of New York, the largest of the nonprofit cooperatives created under the Affordable Care Act closed in bankruptcy after losing hundreds of millions of dollars of American taxpayers money over a two year period. Kentucky Health Co-op lost more than 147 million of taxpayer funded loans and will no longer offer policies in 2016. Twenty one of the twenty three co-op started under the ACA are losing money! Only fifteen of the original twenty three are still in business. Leaving congress wondering Where'd the 2.4 billion dollars go”? In both Georgia and Virginia, state legislators are struggling with a bed Tax”. A fee charged to hospitals in order to help finance healthcare for the poor. In return each state could receive 500 million in new federal funding dollars they'd in turn use to sure up state funded Medicare. Virginia is in such financial depravity that the VHHA President Sean T. Connaughton wrote the mounting financial burden of diminished reimbursements, increased uncompensated care, and federal funding cuts necessitate the exploration of even the previously unthinkable. The status quo is simply unsustainable.” In Georgia Advocates say letting the tax expire could limit access to critical medical care for thousands of Georgians as urban safety net hospitals are forced to cut services and smaller rural hospitals face the threat of closing their doors” of which five hospitals in Georgia have closed in the last three years. All while everyday Americans pay roughly 25 percent of the income to workplace insurance, or pay hundreds monthly for basic healthcare coverage elsewhere. Americans pay these fees plus paying for Medicare and Medicaid. Insurance for other Americans that need medical care. Meaning 1 out of every 4 dollars an average American earns is spent just on health insurance alone! This does not include any out of pocket expenses. Gallup Poll released polling result showing 1 in 3 Americans put off medical attention because of the exorbitant costs. More concerning however the poll reveals that 19 percent put off medical treatment even for serious conditions and that's a dangerous decision. And their more frequently underinsured, those who have insurance coverage but who nonetheless have out-of-pocket medical bills that exceed what they can afford. The costs of deductibles, co-insurance, co-payments, out-of-network providers or medical care not covered by insurance isn't ever factored in. And these costs are crushing everyday Americans all over the United States. The Affordable Care Act offered Americans a fair shake to purchase medical insurance without discrimination nothing more. Making healthcare more inexpensive was NEVER in the bill and all the money we have literally wasted trying to make healthcare more inexpensive has been lost on waste, fraud and abuse. By the end of 2020 the Affordable Care Act will have cost Americans just north of 1 trillion dollars, 30 million Americans will still not have health insurance and tens of millions more will remain under insured. And an increasing percentage of some of our Nation's most ill who are insured won't seek medical care entirely because of cost. The Scandal of Healthcare: Nurses, Waste & Customer Service

Please Read The Scandal of Healthcare: Nurses, Waste & Customer Service. If you are a nurse, love a nurse or know a nurse.... They are Hero's.. Without them I am not sure I'd be here. They took care of me when I really needed help. I hope ALL nurses know just how crucial they are.

Twenty years of experience and research reveal two indispensable truths about hospitals and healthcare organizations that can no longer be ignored. First, those institutions neglecting the basic fundamentals of patient care, risk jeopardizing the quality and safety of care they provide. And second, nothing can have a greater short- and long-term impact on the cost of delivering healthcare services than nurses. For more than 60 years the model of patient care has been changing. Hospital operations--the way work works--generally has fallen short in keeping pace with that change. Technology, protocols, and treatments are just a few of the dramatic shifts in recent years. But in the middle of all that change are nurses. In the middle of all the chaos of ringing bells and flashing lights are nurses. Underneath the hum and buzz of delivering healthcare to patients lie dysfunctional and costly processes, essentially forced onto nurses and their colleagues. The concept of Team Nursing” was designed and implemented during the early part of the 1950s. This new team-based model included staffing with a charge nurse, two or three Registered Nurses (RNs), along with a Licensed Practical Nurse (LPN) and a Certified Nurse Assistant (CNA) both of whom had less clinical training than an RN. This team was responsible for the care of eight to ten patients. Nursing stations were centralized, including connected supply rooms, linen stations, and equipment. Because patient rooms were arranged around the nursing station, it made sense to localize supplies and services. Likewise, connections to important people and information--patient charts, doctors, pharmacists and phones--were centrally located too, just a few steps from the nurses station. In the 1970s, a man named Gordon Friesen, an architect and logistics expert, proffered a simple notion: provide the highest quality of care possible for the individual patient at the lowest possible cost to the patient. Friesen's solution was built around the idea that the closer supporting people, equipment, and information were to nurses and their patients, the more efficient and effective nursing would become. The added efficiency would, as the thinking went, lead to better quality of care at continually less cost. Friesen had landed on one of the few aspects of healthcare that everyone agrees on--patients are best served by having nurses with them in their rooms. Patients, their loved ones, executives, doctors, and nurses themselves all want to have nurses face-to-face with patients as much as possible. Yet, despite this common desire, due to myriad daily system failures, today's nurses are able to spend only a mere fraction of their time in direct contact with patients. Admissions and discharges take up most of this face-to-face time. Generally, patients see their nurses briefly every hour or two, which neither patients nor nurses find satisfactory. Today the nursing station is all but gone. Medication frequency, dressing changes, and other prescribed care are ordered from a computer located in a patient's room, or just outside the door. In a scenario we have seen repeated hundreds of times, a nurse hurries to get medication, which is nowhere near the patient's room. As the nurse hustles to the med room, her aide asks for help with another patient, which delays the nurse's ability to deliver her original patient's meds. Now already several minutes behind in getting medication, the nurse is assessing another patient who, say, needs supplies too. But unfortunately, those supplies are stocked in a different room from the medication. Leaving to get both, the nurse runs into a family member there to see their loved one. It just so happens to be her patient, and that patient needed their medication seven minutes ago. She provides a quick update and tells the family member they can see their loved one, and that she'll be right back. But then Transport calls. They're running late, which delays a patient's discharge, the one who's still waiting for the medication. At present, nursing is a decentralized system of continually changing needs. As seen in the preceding paragraph, the failure to connect services to nurses increasingly burdens the daily activities of nursing. The difficulty arises for nurses because while nursing activities are decentralized, supporting services remained centralized. This mismatch in operational processes ensures each nurse will spend time hunting for, fetching, and clarifying what their patients need. This is further complicated by frequent failures in these mismatched processes. It's certainly true nurses need to be available for the patient. But when nurses aren't available, it's primarily due to hospital operations failing to meet the needs of nurses as the principal providers of care to patients. Consider our proxy for hospitals across the country: AnyWhere in America Hospital (AWH). At AWH, medical equipment is upgraded regularly by contract with vendors in an effort to keep costs low, or to replace older outdated equipment. Usually this new equipment requires specific supporting supplies. A great example is an IV pump--a piece of equipment used all the time at AWH to introduce vital fluids and medications to the body. At AWH, leaders coordinate the new equipment supply needs for the upgraded IV pumps for each participating department during the roll-out phase. However, many times implementation proceeds faster than expected. Confident in their planning and adaptability, AWH decides to roll the entire project out in record time, ahead of schedule. Unfortunately, Materials Management hasn't been notified of the timeline change and can only support the roll-out plan as originally designed. Nurses in various departments, lacking the proper supporting equipment and documentation, panic--adding tension to an already stressful job. Urgent calls begin as nurses from several departments, frustrated by the new equipment's impact, request large quantities of supplies that Materials doesn't have. The sudden flurry of ordering hits the Materials Supply Department, which then overcompensates by over-ordering, then overstocking. The overstocking causes both storage and delivery issues as problems begin to ripple outward. The reality here is that healthcare organizations/hospitals (HCOs) function in a manner that requires nurses to focus more of their limited time and attention diagnosing systems needs than patient needs. Nurses scrambling for linen, supplies, equipment, or waiting to clarify a medication prescription are just a few examples. These types of process failures and hundreds more like them, happen thousands of times every day in every hospital across the United States. Sometimes these impacts affect the patient--leaving nurses stuck caring for patients in a system that's failing them, or at least making it tremendously difficult to manage the operational chaos, rather than being able to maintain the health and recovery of their patients. There is a serious scandal in healthcare: the toll that healthcare takes on the people who deliver it. The burdens of regulation, cost reductions, and quality initiatives piled onto nurses and other clinicians are undeniable. Without real operational gains and improvements, nurses will continue to be inundated with yet more of the same, and its impact will be evermore noticeable. When things go wrong operationally, it's the nurse who feels the pain first, leading to less-than-optimal care for their patients.