Explore the Hidden Variable in Patient Outcomes
Your nursing team configuration matters…
By Donncha Carroll, Partner, Lotis Blue Consulting in partnership with SullivanCotter
The Untapped Lever in Patient Care
Consider the following scenario: we have two hospitals with the same patient population and protocols, but one location experiences significantly fewer readmissions. Despite standardized procedures and compliance with best practices, patient outcomes vary significantly.
What could be driving that difference in performance?
We all know that patient readmission is not just about staffing ratios—it’s also about the individuals and teams that constitute the clinical staff. Most would agree that better talent performs at a higher level and contributes more to achieving patient outcomes…but what do we mean by ‘better talent’?
It’s not just about the quality of individual clinicians. There are features of workforce configuration that create better-performing teams. For example, organizations can reduce system readmission rates by building a nursing team configuration that focuses on high ‘experience density’.1
Experience in Nursing Roles Matters
SullivanCotter and its strategic partner Lotis Blue recently conducted research showing that higher levels of ‘experience density’ are associated with a material and statistically significant reduction in readmissions.2 While the relationship between nurse experience and patient outcomes may seem obvious, this discovery is based on experience ‘in-position’.3 This positional dimension of experience highlights a crucial aspect of how workforce configuration can contribute to performance. Using detailed workforce configuration data from over 100 different health systems – which is further broken down at the individual facility or location level – the relationship between experience and readmission becomes more clearly defined.
Percent of Nurses by Job Experience Group and Readmission Ranking Tercile
Key Observations
– Top tercile readmission facilities have a higher percentage of nurses with 6+ years of experience
– All three terciles have approximately the same percentage of nurses with 2-6 years of experience
– Facilities with a higher percentage of nurses with less than 2 years of in-position experience have higher readmissions
Note: The observed relationship is not due to random variation using two statistical tests
Interestingly, the pattern is observable within a position, but it disappears when an individual’s organizational experience (in years employed) or career experience (in years since graduation) is examined. Insights from position-level analysis provide visibility into nursing organization design – including how teams are formed, managed, and operate in delivering patient services. Maintaining a minimum level of tenured staff ‘in-position’ is an important driver of team cohesion and stability.
This pattern is really an operational manifestation of the following:
- Maintaining an anchor population of nurses developing, retaining, and sharing essential knowledge about “how things work around here” helps to enable the success of less experienced nurses and boosts overall team performance.
- More experience ‘in-position’ translates into higher levels of competence in performing a specific set of responsibilities, delivering higher productivity, and better outcomes for the services offered.
Since organizational structure and nurse deployment decisions are modifiable factors, hospitals and health systems can drive clinical and economic outcomes by configuring the workforce in these ways. More specifically, a minimum level of experienced nurses is necessary in the most critical areas of health care service delivery to achieve optimal patient outcomes.
This prompts three key questions:
- Which parts of the nursing organization disproportionately influence or drive patient care outcomes and readmission?
- Within each of those teams, what is the optimal ‘in-position’ experience profile of today’s nursing staff?
- How does an organization encourage its nurses to stay ‘in-position’ longer when the experience profile is below the desired level?
Economic Impact and Strategic Implications
While health systems are motivated to reduce readmissions to provide the best possible care and outcomes for their patients – there is also a financial imperative.
For major teaching hospitals, avoiding a single readmission can result in a direct financial gain of approximately $18k. For non-teaching hospitals, the benefit is around $15k. Each 1% reduction in readmission rates translates to substantial aggregate savings for a facility. This can add up to millions of dollars annually for larger hospitals.
Illustrative Impact 1% Improvement for Mid-Sized Hospital
Rethinking Nursing Workforce Metrics
The health care industry typically focuses on nurse-patient ratios to guide staffing decisions. It is also commonly used as the primary lens into organizational design effectiveness. However, this measure does not adequately consider these other important dimensions of experience and positional knowledge that materially influence team performance.
While the quality of individual talent in each role is also a crucial factor in driving patient outcomes, configuration-aware staffing analytics – which ensure each area of nursing has a bedrock of experience needed to onboard, orient, and deploy resources efficiently – are essential to success.
Call to Action: Redesign with Purpose
Test the Hypothesis
Looking to build a more optimal experience profile in key nursing positions?
We can help you make the business case using the following approach:
- Select two or more facilities within the health system where patient readmissions are notable (both higher and lower than expected).
- Within each facility, identify nursing teams with 30+ resources who have a disproportionate impact on patient outcomes.
- For each team, calculate the percentage of nurses who are ‘in-position’ for more than six years and capture the patient readmission rate.
- Compare readmissions between each team by plotting the percentage of experienced nurses against the readmission rate on a single chart.
- Calculate the rate at which readmissions decline with increasing experience.
Illustration
‘In-position’ experience is a crucial lever in enhancing patient outcomes, and by extension, operational and financial outcomes as well. Positional experience will matter more in cohesive working teams because the experienced group serves as a curator of domain knowledge, protecting the unique expertise required for the team to operate efficiently and effectively. There may also be material differences between the groups in engagement scores, decision quality, organization cohesion, and other talent management metrics.
Improving Experience Density
What does this mean for your organization? You will naturally start to ask what changes to talent management will create a more optimal experience profile. This is more challenging than it appears on the surface as there are competing dynamics for bedside nursing talent. For example, bedside nurses may leave a position to advance into leadership, to move to an ambulatory environment, become an advanced practice nurse, relocate, and more. – the possibilities are endless.
Organizations will need to develop intentional and innovative pathways that encourage bedside nurses to stay in their role. Compensation is not the only lever for this – and oftentimes isn’t enough on its own. Organizational leadership must think more holistically.
The following approach may help you strike the right balance as you work towards this goal:
- Estimate patient readmission impact and the total economic value of each percentage improvement in nurse experience (up to a maximum of 25%).
- Identify a group of nurses who are respected by their peers, with 4+ years ‘in-position’, and considered happy and engaged as a cohort for focused review and investment.
- Conduct focus groups to understand the unique perspectives, needs, and interests of these nurses; disproportionately invest in changes that improve job satisfaction.
- Consider introducing retention bonuses based on the combination of service years and evidence of sustained performance.
- Develop innovative pathways and programs to support these groups of identified and committed individuals including measures that allow teams to grow together in place, promote from within, gain additional education and skills and have a role in selecting, training, and developing early career individuals.
- Ask these committed individuals to participate in or influence staffing decisions, unit policy changes, equipment selection, scheduling, and clinical practice updates.
- Provide time and resources for these experienced nurses to mentor newer staff while maintaining a clinically fulfilling caseload.
- Invite them to participate in committees, safety projects, and innovation efforts. Then, implement ideas they propose and publicly credit them for their contributions.
- Review and estimate the cost of moving compensation close to the top of the in-level pay range; consider’ in-position’ promotions to ensure pay competitiveness.
- Consider introducing retention bonuses based on the combination of service years and evidence of sustained performance.
- Measure, calculate, and advertise the return on investment achieved by closely monitoring trends in readmission rates as these changes are implemented with consideration of incentives for teams that maintain sustained high performance.
Conclusion
The path forward requires intentional design. Health systems must rethink how they structure teams, how they cultivate the expertise that already exists within their walls, and how they build pathways that allow experienced nurses to thrive in place. These choices will shape not only patient outcomes, but organizational culture, workforce stability, and long-term financial performance.
The challenge to nursing leadership is simple—and urgent: test the hypothesis, measure the impact, and redesign with purpose. The organizations that act now will not only see measurable improvements in readmissions—they will build stronger, more resilient clinical teams capable of delivering consistently exceptional care.
References:
[1] Experience density = ratio of nurses with 6+ years of experience in their current position.
[2] The Sullivan Cotter analytics team calculated readmission ranking using CMS data from the following source https://data.cms.gov/provider-data/dataset/bzsr-4my4
[3] A position in an organization is a specific, defined spot or “slot” within the company’s structure that an individual occupies but remains intact as resources come and go over time.
Want to continue the conversation?
Lotis Blue and SullivanCotter stand ready to help health systems operationalize these insights, validate outcomes, and design sustainable workforce strategies that elevate performance at every level.