Annual Review of Nursing Services Staffing Plan

1
Annual Review of Nursing Services Staffing Plan

• Sample Outcome Metrics

2
3727.54 Annual Review

• At least once per year the hospital-wide nursing
  care committee shall do the following
• Review how the most current nursing services
  staffing plan does all of the following
• Affects inpatient care outcomes
• Affects clinical management
• Facilitates a delivery system that provides, on a
  cost-effective basis, quality nursing care
  consistent with acceptable and prevailing
  standards of safe nursing care and
  evidenced-based guidelines established by
  national nursing organizations.
• Make recommendations, based on the most recent
  review conducted, regarding how the most current
  nursing services staffing plan should be revised,
  if at all.

3
Dont Reinvent the Wheel

• Use data you have that is consistent with what
  the statute requires and adds value to the
  analysis
• Assess data that is currently collected for
  required reporting, voluntary reporting or
  internal quality (outcome and process) purposes

4
Inpatient Care Outcomes / Clinical Management /
Cost Effective Care

• NDNQI metrics
• Patient falls
• Pressure ulcer prevalence
• NHPPD
• Nurse satisfaction
• Other metrics
• Medication errors, adverse drug events and near
  misses
• Care events
• Patient satisfaction (HCHAPS nursing questions)

• Patient complaints / grievances
• Turnover rate
• Vacancy rate
• Overtime usage
• Agency/traveler usage
• ALOS
• Costs/UOS
• Costs/discharge
• MD satisfaction
• Staff satisfaction
• TJC Core Measures

5
Evidence Based Outcomes

• Needleman Buerhaus et al. (2001) Strong
  consistent relationships between nurse staffing
  and
• UTI,
• pneumonia,
• LOS,
• UGI bleeds
• shock.
• In major surgical patients failure to rescue was
  also related to nurse staffing.

• Cho et al. (2003) An increase of 1 HPPD was
  associated with
• 8.9 decrease in odds of pneumonia,
• 10 increase in RN proportion was associated with
  9.5 decrease in odds of pneumonia,
• increased nursing HPPD gt higher probability of
  pressure ulcers

6
Evidence Based Outcomes

• Aiken et al. (2002) Each additional patient
  cared for by a nurse was associated with
• a 7 increase likelihood of dying within 30 days
  of admission, and
• a 7 increase in failure to rescue rates,
• a 23 increase in nurse burnout
• a 15 increase in job dissatisfaction.

• Rogers et al. (2004) Errors and near errors more
  likely to occur when nurses work gt12 hours.

7
Evidence Based Outcomes

• 2007 AHRQ Report
• Increased RN to Patient Ratios was associated
  with decreased hospital mortality, LOS, failure
  to rescue (but not necessarily causal)
• For every increase 1 RN FTE per patient day,
  decrease in mortality in ICU by 9 and in
  surgical patients by 16.
• For Every additional patient per RN per shift
• 7 increase risk of hospital acquired pneumonia
• 45 increased risk of unplanned extubation
• 17 increased risk of medical complications

8
Evidence Based Outcomes

• 2007 AHRQ Report
• An increase of 1 RN FTE per day in ICU
• 28 decrease in risk of CPR,
• 51 decrease in risk of unplanned extubation,
• 60 decrease risk of pulmonary failure
• 30 decreased risk of hospital acquired pneumonia
• An increase of 1 RN FTE per day in Surgery
  patients
• 16 decreased risk of failure to rescue,
• 30 decreased risk of nosocomial blood stream
  infections

9
Evidence Based Outcomes

• 2007 AHRQ Report
• Death rate decreased by 1.98 for every
  additional total nurse hour per day.
• Nurse satisfaction and autonomy was associated
  with reduction of risk of death.
• Increased nurse turnover was associated with a
  0.2 increase in falls.
• No research on the effect of agency or temporary
  staff or international nurses in staffing.

10
Required Measures
11
Required Measures
12
Required Measures
13
Required Measures
14
Required Measures
15
Required Measures
16
Measures on the Horizon
17
Required Measures HCAHPSHospital Consumer
Assessment of Healthcare Providers and Systems

• Communication with nurses
• Communication with doctors
• Responsiveness of staff
• Pain management

• Communication about medication
• Cleanliness of hospital
• Discharge information
• Overall rating
• Willingness to recommend

18
CMS Hospital Acquired Conditions (never events)

• CABG Mediastinitis
• Catheter Associated Urinary Tract Infection
• Pressure Ulcers
• Vascular Catheter-Association Infection
• Object Left in Surgery

• Hospital Acquired Injuries (i.e.
  falls/burns/fractures, etc)
• Air Embolism
• Blood Transfusion Incompatibility

19
TJC Proposed Nurse Sensitive Measures

• Patient-centered Outcome Measures
• Death among surgical inpatients with treatable
  serious complications (failure to rescue) The
  percentage of major surgical inpatients who
  experience a hospital-acquired complication and
  die.
• Pressure ulcer prevalence Percentage of
  inpatients who have a hospital acquired pressure
  ulcer.
• Falls prevalence Number of inpatient falls per
  inpatient days.
• Falls with injury Number of inpatient falls with
  injuries per inpatient days.
• Restraint prevalence Percentage of inpatients
  who have a vest or limb restraint.

20
TJC Proposed Nurse Sensitive Measures

• Patient-centered Outcome Measures
• Urinary catheter-associated urinary tract
  infection for intensive care unit (ICU) patients
  Rate of urinary track infections associated with
  use of urinary catheters for ICU patients.
• Central line catheter-associated blood stream
  infection rate for ICU and high-risk nursery
  patients Rate of blood stream infections
  associated with use of central line catheters for
  ICU and high-risk nursery patients.
• Ventilator-associated pneumonia for ICU and
  high-risk nursery patients Rate of pneumonia
  associated with use of ventilators for ICU and
  high-risk nursery patients.

21
TJC Proposed Nurse Sensitive Measures

• Nursing-centered Intervention Measures
• Smoking cessation counseling for acute myocardial
  infarction.
• Smoking cessation counseling for heart failure.
• Smoking cessation counseling for pneumonia.
• Each measures the percentage of patients with a
  history of smoking within the past year who
  received smoking cessation advice or counseling
  during hospitalization.

22
TJC Proposed Nurse Sensitive Measures

• System-centered Measures
• Skill mix Percentage of registered nurse,
  licensed vocational/practical nurse, unlicensed
  assistive personnel, and contracted nurse care
  hours to total nursing care hours.
• Nursing care hours per patient day Number of
  registered nurses per patient day and number of
  nursing staff hours (registered nurse, licensed
  vocational/practical nurse, and unlicensed
  assistive personnel) per patient day.

23
TJC Proposed Nurse Sensitive Measures

• System-centered Measures
• Practice Environment Scale ? Nursing Work Index
  Composite score and scores for five subscales
• nurse participation in hospital affairs
• nursing foundations for quality of care
• nurse manager ability, leadership and support of
  nurses
• staffing and resource adequacy and
• collegiality of nurse-physician relations.
• Voluntary turnover Number of voluntary
  uncontrolled separations during the month by
  category (RNs, APNs, LVN/LPNs, NAs).

24
Dont Reinvent the Wheel

• Use data you have that is consistent with what
  the statute requires and adds value to the
  analysis
• Assess data that is currently collected for
  required reporting, voluntary reporting or
  internal quality (outcome and process) purposes
• As new measures of performance are added/required
  consider incorporating them into the annual
  review process

25
Questions?