The proposed reduction in workforce among the registered nurses employed at Kaiser Permanente Hawaii clinics is a distressing signal of disruptions to come in the reform of the nation’s health care delivery system. The concern is less about the churn in health labor, which seems inevitable, but that staffing adjustments could happen chaotically, jeopardizing the quality of care.

All of this worry stems from reports of the proposal gleaned by Star-Advertiser writer Kristen Consillio. According to a memo sent by Kaiser to its union partner, the Hawaii Nurses Association, the nonprofit health maintenance organization proposes to cut at least 47 registered nurses in primary care positions at some of its 18 clinics statewide.

The operational "redesign" would have some of these positions replaced with licensed practical nurses and medical assistants. These staffers surely can handle some of the tasks but not the entire burden shouldered by the RNs, who have a higher level of skills and training. As seen in protests mounted this week, LPNs and the assistants are worried themselves about what they will be asked to do.

The question for Kaiser members is going to be: How will the staff be redeployed to manage the demand for primary care services?

What’s being invoked — not only in Hawaii but in other cities where similar cutbacks are being implemented — is the Affordable Care Act, the Obama administration’s health care reform law that will take full effect next year.

Health administrators are anticipating a decrease in federal government reimbursements for care. Under the ACA, those payments, primarily from Medicare and Medicaid programs, will be based increasingly on quality measures as opposed to the quantity of services provided.

Some industry observers have said that a lot of the administrative tasks that RNs now handle can and should be taken over by staff at lower salary levels to reduce costs.

While that may be true, Kaiser and the union, with which the company has a "labor management partnership," is being tight-lipped about details of the plan. It certainly would help Kaiser members and the public policy overseers at the state Legislature to have more information about the rollout of this redesign.

"Redesign" is one of the buzz words coming out of the industry that is struggling to find a way to reduce costs with less downsizing. Studies on the redesign process have been done by the union’s parent American Nurses Association, research highlighting the need to involve the front-line employees, the nurses themselves, in planning for the changes. Unfortunately, the reports from the front lines here is that there have been few discussions of this sort.

And health care experts also believe that the need for the primary-care services that RNs provide — the assessment of patient symptoms that can lead to efficient referrals to doctors and treatment — also will continue to increase. Lacking more information, critics of major staff reductions, such as in this Kaiser proposal, can reasonably conclude that dispatching experienced nurses is a shortsighted survival strategy.

Health maintenance organizations like Kaiser should be more forthcoming with the public on how it is adjusting to the changing marketplace. Achieving the right formula encouraging health care efficiency and quality will be a precarious balancing act, and patient confidence in the medical delivery system depends on the industry showing more transparency than the public has seen so far.