Patsy A. Hardy, RN, MBA, FACHE, CEO, St. Joseph's Hospital, Parkersburg, West Virginia

ORGANIZATIONAL INFORMATION
The facility is a 68-bed acute care hospital located in the fastest growing area of the state and serving a total population of more than 60,000. The hospital employs a staff of 285 to 300 full-time equivalents. In operation since 1984, the facility offers acute care services, including medical/surgical, intensive care, and telemetry units. The emergency department handles more than 17,000 visits per year and continues to show ongoing growth in all service lines. Major competitors are larger acute care and tertiary facilities located within 35 minutes of the facility. Ongoing growth and survival are dependent on making the best decisions for investment of capital dollars so that market share as well as margin improvement increase. This results in greater flexibility for the organization to offer a competitive wage/salary program and buy medical resources that cannot be capitalized but are critical to daily functioning in each setting.

BRIEF STATEMENT OF THE PROBLEM
As the CEO of the facility, my responsibility to use capital dollars centered on the enhancement of day-to-date operations to grow volume resulting in an increase of return on investment. When a request for more than $425,000 to purchase new patient beds for an intensive care unit and a medical/surgical unit was presented by the chief nursing officer (CNO), the request was denied. Being a nurse who had been a CNO and COO, I gave the CNO feedback to rework the request because the dollar amount for the beds represented more than half of our annual allocation for capital funds. Moreover, nursing could obtain the same benefit from less-expensive features.
One humbling aspect related to the position of CEO is the necessity to realize when additional consideration should be given to a specific request. In this particular instance, the CNO approached me again, asking for reconsideration regarding the purchase of new patient beds. Additional data cited that our current beds had been purchased as refurbished beds in 1984 and were now more than 16 years old. Replacement parts were no longer available, and many of the beds were considered to be beyond repair. Additionally, the wheel-locking mechanisms did not work for patient safety when entering and exiting the beds. The company being considered would take a trade-in for our current beds to lower expenses.
A request was made for me to tour the facility in which the beds were being produced and to learn more about all the features that were available. Agreement was reached to try to obtain additional capital funds and to consider a visit with a group from the hospital if this was achieved.

ADMINISTRATIVE DECISIONS
The amount of planned capital dollars available to the hospital for this venture was approximately $164,258. To even consider the project, additional capital dollars had to be obtained. A proposal was submitted to the division office, our reporting entity, requesting additional funds. Data provided in the report included hospital safety statistics indicating several patient falls as well as employee injuries while moving patients in and out of beds, repair costs hitting the hospital's income statement, and the number of beds that were no longer in operation. The summary included safety requirements for the patients and employees with an outline of our current experience with loss of work because of these factors. A conference call was held with me, the CFO, CNO, and the division office. Division was very supportive of our request and allocated an additional $260,000 for this purchase. Our estimate to make the purchase to replace 60 beds in the hospital was a total of $423,000 to $424,000.
The sales representatives offered for us to fly to their plant via corporate jet, which could accommodate only five people, including the members of the hospital's senior team and middle management. This method of travel was declined, and a request was made to travel by bus to allow a larger group of nine. To make an informed decision regarding recommending purchase of the new beds, the CNO and I appointed a multidisciplinary team. This team was responsible for further exploring the features of the proposed beds and determining which model would be appropriate for our needs as well as meeting the capital allocated for the purchase. To show a return on investment the following criteria were identified:

• Save nursing time
• Decrease the use of specialty beds
• Decrease the number of patient falls and employee injuries resulting from lifting patients

The best way to be successful in meeting established criteria was to organize the appropriate team for the task at hand. This group consisted of myself, three registered nurses, two nurse technicians, two licensed practical nurses, a clinical director, and the director of operations (individual responsible for biomedical/equipment). A follow-up conversation took place with the CNO, during which time the salesperson reviewed the enhanced features of the beds that contribute to the overall safety of patients and staff:

• Built-in bed exit alarm system
• Ability to weigh patient while on the bed
• Mattresses that inflate/deflate according to patient weight
• Adjustable to a sitting chair
• Position of bed lower to the floor
• Automatic release of headboard for the administration of CPR

Each member of the team was provided an itinerary, objective for the trip, and dollar amount of capital funds available. On the day of our arrival at the facility, features for all the beds were demonstrated. The company's routine process was to walk everyone through the showrooms and then provide a tour of the facility. Instead of touring the plant, a request was made to have a conference room so the team could discuss the features on all of the beds and the costs for each. The company provided calculators for each team member. A lengthy group discussion followed, with a staff nurse facilitating the meeting. Priorities and concerns were listed on a flip chart. Additionally, each recommended feature and the associated cost were placed on the list. The following items were identified by the group as being beneficial to patient care:

• The bed could be adjusted to a sitting chair position. This feature would assist nursing personnel so that they would not have to pull in a bedside chair. When families came to visit, they could actually see their loved one sitting upright, quite different from a bed that would only move forward in a semi-Fowler's position.
• The bed was closer to the floor. The majority of patients at the hospital were over the age of 65, so the low position of the bed helped from a safety perspective should a patient need to get out of bed. Also, the soft light underneath the bed would illuminate the floor.
• Weighing could be done in bed. The nursing staff explained that it takes approximately 20 minutes a day to weigh a patient because not enough scales are available. The hospital was equipped with a scale bed that was shared by several units of the hospital. It had to be located then moved to the patient care area where it was needed; afterward, the scale lift had to be changed if soiled or dirty and the scales had to be calibrated before the patient could be weighed, then it had to be returned to its home unit for use on the next patient. Therefore, the ability to weigh a patient while in bed was a most attractive feature and received priority consideration.
• The bed was equipped with an exit alarm system. Our current equipment contained a bulky belt system that placed belts in three locations on the bed; when a patient got up, the alarm sounded. The alarm also hung off the end of the bed. The nursing assistant said that she did not like the thought of buying all new beds and felt that we would continue to have problems with the bed exit alarm.
• The beds would have special mattresses. The beds required the patient to be turned frequently to prevent any breaks to the patient's skin, which could result in decubitis or infection. The vendor offered for consideration a mattress that was approximately $3,000 per bed, versus a traditional mattress with extra foam overlay for comfort. When we compared the cost of these new mattresses compared to the cost of the current rentals, we made the decision to also include this feature.

Our discussion ended, and we shared our results. We determined that we did not have enough capital dollars to place a new bed containing all the features we identified in every patient room. Our conversation continued, however, and it became apparent that buying only a certain number of beds would be a major disadvantage for nursing personnel because physicians would request their patients to be placed in the new beds; therefore, nursing would be spending a large amount of time moving beds around to accommodate physician requests. Consensus was reached to place new beds in all rooms and include the features that would allow us to come within the allocated amount.
After tabulating all of the data, we found we were over budget by $100,000. We again prioritized and came to the same conclusion: all the beds would include the ability to weigh patients, the feature of upright positioning for use as a cardiac chair, and the special mattress. Potential nursing time saved by purchasing beds with these features was also estimated.
The team members spoke about how much they enjoyed being part of the decision-making process. They also stated that including the end user when considering capital expenditures is important to ensure monies are used to facilitate patient-safety requirements and convenience for nursing staff. Although the team understood that only a certain amount of capital was available, they shared their disappointment in not getting the bed-exit alarm system. Points made were that our current belts were bulky, often unreliable, and would hang over the end of the new beds. The new alarm system would alert nursing personnel immediately if a patient tried to exit the bed, possibly preventing the use of restraints, because of the weight change on the mattress. Both comments centered on the changes in patient-safety standards and patient rights.
Upon return to the hospital, the group again reviewed its summary and decided to recommend purchase of the new beds. Discussion about how long it would take for the beds to arrive and be implemented in the hospital took place. The plan was finalized on the return trip back to the facility and I spoke with the sales representatives. Three days passed between the return to the hospital and the next senior team meeting. Comments about the bed-exit alarm system were assessed. (The statements made by the nursing staff were on my mind the entire weekend and then shared with the senior team.) Consideration was given to costs associated with adding the alarm system at a later time and the effect of the interruption in workflow this would cause. Capital dollars remaining for the rest of the year in the regular capital budget amounted to $180,000. At the meeting, I gave an overview of capital fund allocation and asked senior management if they were willing to use some of the contingency fund to purchase the bed-exit alarm system. The senior team consulted and agreed that purchasing the bed alarm feature would complete the needs identified by the bed team. A meeting was held with the bed team, and everyone was thrilled with the decision to obtain all the features.
Planning the exchange of 65 beds in a hospital organization can be quite an endeavor. A communication plan was developed for the patients, families, staff, and physicians. The vendor played a critical role, along with the bed team, in taking out the old beds (which were being traded in) and receiving the new beds arriving at the facility. It took at least two days to complete the process, during which time extensive training was occurring with nursing personnel to ensure familiarity with all the new features on the beds.

LESSONS LEARNED
Training
The CNO and I received feedback when the training had been completed; however, one month after the new beds arrived, we received complaints that they were not working as intended. We discovered that we did not have on ongoing process in place to demonstrate competency in using this new technology. Competency criteria were established for all nursing personnel, particularly for weighing patients in bed, placing the patient in a cardiac chair position, and establishing the appropriate pressure in the specialty mattress to achieve maximum patient comfort. Newly hired staff also received training during orientation.

Condition of Plugs to Operate Beds/Equipment
Another mistake made was that all the new beds had been connected to old ports. Although the wall ports did not need to be changed, the mount had become weakened. The nurses conveyed that they were spending as much time on the floor making sure the beds stayed connected as they had previously in locating bed scales and placing a patient in a bedside chair. Engineering now became part of the process, and a request was made for all wall mounts to be secured and replaced as necessary. Additional mounts had to be ordered from the company, as well as plugs, so that if a patient was transferred for surgery, the alarm system would not ring continuously.

Benefits Realized
Because of the size and maneuverability of the beds, the benefits of transporting a patient from their room to the operating room and back without difficulty were not discovered during the initial assessment. Benefits were found particularly with orthopedic cases and other difficult cases where the patient had to leave an area and go immediately to the intensive care unit. Figure 1 identifies the amount of nurse time saved, the fact that no additional employee injuries occurred, and the overall benefits of purchasing the new beds, all of which resulted in a total savings of $25,389.50.

FIGURE 1 Benefits of New Bed Purchase

SUMMARY
In evaluating this bed-purchase process and the resulting return on investment, I identified the following critical success factors related to capital investments:

• Evaluation of capital equipment for return on investment from the expense side, particularly when looking at use of manpower for critical positions in the organization.
• Evaluation of capital equipment for increasing nursing satisfaction, a factor in addressing the healthcare worker shortage in today's environment.
• Involvement of a representative team to create personal ownership through individuals wanting to take care of something they are involved in purchasing.
• Spin-off timesaving that can be realized through the adage "form follows function." For example, this was found not only in savings of nurse staff time but also in pharmacy because the weight function on the new beds saved approximately one hour, allowing for speedier calculation of creatinine clearance in antibiotic dosing.

Changing my position and perspective was rewarding. The persistence of the CNO and the involvement of the employees made the experience gratifying on a personal level as well.

SOURCE MATERIALS
References used include the hospital's strategic plan (1997-2001), capital budget (2000), and reports of the safety committee (1999-2000).