Transcript Staffing Ratios

Staffing Ratios
ASHLEY BOROWIAK, RN
NURSING 450
FERRIS STATE UNIVERSITY
Introduction
 Nurse ratios are determined by working hours per
patient per day.
 Nursing ratios are the number of patients assigned to
a staff member.
 Nurse staffing can have effects on the quality of care
patient’s receive, patient safety, and adverse
outcomes from the plan of care.
Objectives
 Identify if a correlation exists between nurse to
patient ratios and patient outcomes.
 Recognize mandated staffing ratios and the
consistency across health care locations.
 Identify nursing implications of high and low nurse
to patient ratios.
 Identify systems used to determine staffing numbers.
 Discuss theories related to the subject.
Theories Related to Nurse Staffing
Nursing Services Delivery Theory
 Recognizes that many different factors affect the work demands in the
health care system and nurse staffing.
 Input, throughput, and output interact to determine staffing needs and
work demands.
 Staffing research has shown a correlation with key nurse staffing
indicators and patient outcomes.
Meyer & O’Brien Pallas, 2010
Theories Related to Nurse Staffing
Maslow’s Hierarchy of Needs
 Nurses need to feel safe in the environment they practice, have a
sense of belonging to their organization, and to feel empowered.
This is achieved through Maslow’s Hierarchy of Needs.
 Inadequate staffing raises a nurses stress level, causing job
dissatisfaction. These stressors can threaten patient safety and
negatively affect the environment in which they practice in.
 Nurses are advised to address their basic needs to provide safe
and quality care.
Groff Paris & Terhaar, 2011
Achieving Self Actualization
Assessment of Health Care Environment
Outpatient Environment-Hospice
 Guidelines have been in place since 1994.
 Varying acuity depending on home care patients or short
length of service patients
 Often times family present to assist with cares.
 Uses an assessment process to estimate staffing levels
such as characteristics of the patient population, level of
care, length of service (LOS), and the environment.
National Hospice and Palliative Care Organization [NHPCO], 2013
Assessment of Health Care Environment
 Higher percentage of short LOS which means acuity
could be higher in the first week or two of care, and
the patient ‘s needs are more resource intensive.
 Lower percentage of routine patients who partake in
home care, which indicates a higher number of
inpatients receiving continuous care.
 Issues for nurses to consider when determining
staffing:
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Psychosocial issues of the complexity of the patient’s needs
Safety issues for the nurse
High intensity of services
NHPCO, 2013
Assessment of Health Care Environment
Inpatient Environment-Acute and Long Term Care
 Different levels of acuity of patients
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Confusion, frequent repositioning and toileting, frequent prn medications
Severity of diagnosis and level of stability
 Staffing policies vary between facilities and states
 Delegation is often an underutilized tool that can ease the workload of
nurses and CNAs.
 Ability to pull staff from other units to assist if needed
 Census changes throughout the day
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Discharges, Admissions
Management and Education Services for Healthcare
(MESH)
 MESH is a patient centered acuity system designed to determine
staffing by identifying patient’s distinctive needs.
 The Patient Classification and Staffing System Module (PCSS) is one of
four modules used within MESH to assist with proper staffing.
 Prior to staffing for the next shift, a projected census is formulated to
determine staffing needs and patients are categorized into acuity levels.
University of Wisconsin, 2014
MESH System
 Taking census and acuity information, the system
calculates the number of staff needed.
 The system will notify the person making staff
assignments if the unit will overstaffed or
understaffed depending on the data entered.
University of Wisconsin, 2014
MESH System
 Nurses making staff assignments are able to and
encouraged to documents notes regarding projected and
actual decisions made in regards to staffing.
 All0ws for nurse explanation as why staff decisions were
made to allow for better decision making in the future.
University of Wisconsin, 2014
Census Grids
 Staff is determined solely by number of patients on
the unit.
 Acuity is normally not a factor in census grids.
 Black and white-Nurses do not have ability to make
judgments on staffing decisions
 Staffing adjustments are made according to the
census grid
Root Cause Analysis
California Assembly Bill 394
 In 1994, law was passed that requires acute care
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hospitals to maintain a minimum nurse to patient
ratio.
First state to initiate
Facilities are required to use an acuity
classification system
Mandated staffing ratios are unit specific
Facilities required to record and report staffing
numbers to ensure compliance with the law.
Agency for Healthcare Research and Quality [AHRQ], 2014
California Assembly Bill 394
What were the outcomes of the new legislation?
 Higher staffing levels
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Nurse hours per patient day increased from 6.03 to 7.11
 Reduced Nurse Workload
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Average patients per shift decreased to 4.1
 Fewer patient deaths
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In California, the death rate was 10-13 percent lower than 2 other
states which do not have staffing mandates
 Decrease in nurse burnout and high job satisfaction
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66 percent of nurses in California agreed they are more likely to
remain in their jobs as a result of the legislation
AHRQ, 2014
Michigan’s Safe Patient Care Act
 Proposed by State Representative Jon Switalski and State
Senator Rebekah Warren
 Would implement a staffing plan which would have a minimum
nurse to patient ratio.
 Facilities would create their own staffing plan
 Facilities would be banned from using mandatory overtime to
compensate for poor staffing planning
 Studies show that facilities would benefit due to shorter lengths
of stay, a decrease in readmissions, decreased legal liability for
all complications that are associated with nurse staffing, and less
nurse turnover.
Michigan Nurses Association, 2014
Mandated Staffing Ratios
Positives
Negatives
•Ensure safe care if provided
•Increased job satisfaction
•Increased patient outcomes
•Nurse recruitment
•Reduction in hospital
services
•Increased emergency room
diversions
•Increased unit closures
•Increased expenses
Nurses in Minnesota from facilities speak out on why staffing
mandates would have a negative affect on the care their
patients receive.
https://www.youtube.com/watch?v=fY-fQ4ewPMM
American Organization of Nurse Executives, 2014
Inferences and Implications
Adequate staffing has been proven to:
 Reduce medication errors
 Decrease complications relating to patient diagnosis
 Decrease patient mortality
 Increase patient satisfaction
 Reduce nurse fatigue
 Decrease nurse burnout
 Increase job satisfaction
ANA, 2014
Patient Outcomes
 High Nurse Staffing Reduces
 UTIs
 Pneumonia
 Shock
 Upper GI Bleeding
 Longer Hospital Stay & Preventable Readmissions
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Decreases costs lost by facility for little to no CMS reimbursement
Failure to Rescue
Greater patient and family satisfaction
Failures in the plan of care and meeting outcomes
AHRQ, 2014
Nurse Burnout and Turnover Rates
 Decreased work conditions and stressful environments have been
proven to have direct negative effects on a nurses satisfaction with
their job.
 Patient satisfaction is much less in facilities where nurse burnout and
turnover rates are higher.
 Nurses working in direct
patient care areas (especially
those which are short staffed)
have the highest burnout rates.
 High burnout and turnover
rates have direct negative
affects on patient care.
McHugh, Kutney-Lee, Cimiotti, Sloane, Aiken, 2011
Budgeting
 Hospital budgets are one of the main
reasons for staffing issues at facilities.
 Hospitals spend a large amount of dollars in
overtime pay and incentive pays for outside
nurses.
 Many nurses do not see unit budgets or are
aware the amount of funds paid out to
employees
Centers for Medicare/Medicaid Services (CMS)
Reimbursement
 Medicare spends $15 billion a year on preventable
hospital readmissions.
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Hospital Readmissions Reduction Program
 Research has proven that hospitals with adequate
staffing have a lower level of readmissions.
 Government can assist with decreasing readmissions
by:
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Mandating minimum staffing levels
Using benchmarks and payment incentives based on nurse
staffing
Public reporting of nurse to patient ratios
Mitka, 2013
Recommendations for Quality and Safety Improvements
Quality and Safety Education for Nurses (QSEN)
Competencies
Patient Centered Care
 Recognize the patient as a the main source for providing
compassionate and coordinated care.
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Proper staffing ratios can deliver safe and quality care which the
patient is entitled to.
Evidence-Based Practice
 Integrate the best current evidence to deliver optimal
care.
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Continue to study the positive affects that staffing mandates and
increase staffing have on patient outcomes.
QSEN Institute, 2014
Recommendations for Quality and Safety Improvements
QSEN Competencies
Quality Improvement
 Use improvement methods to design changes to
improve the quality and safety of health systems.
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Discover and test new staffing grids to optimize patient care
Seek out information and formulate a root cause analysis to
determine the cause of staffing issues.
QSEN Institute, 2014
American Nurses Association (ANA) Standards
 Standard Nine: Evidence Based Practice
 The nurse will incorporate research into everyday practice.
 With this, nurses can discover ways to improve upon staffing issues to
deliver quality care and reduce nurse stress.
 Standard 10: Quality of Practice
 The nurse delivers quality care in his or her nursing practice.
 Regardless of staffing issues and/or patient ratios, nurses should deliver
safe, quality care, without taking shortcuts to get tasks accomplished that
could sacrifice the safety of the patient (i.e. leave catheters in too long,
disregard dressing changes)
 Standard 16: Environmental Health
 The nurse practices in an environmentally safe and healthy manner.
 Nurses reach Maslow’s hierarchy of needs and promotes a health
environment so patient care can be optimized.
Ferris State University, 2014
Summary
 Nurse to patient ratios vary between environments
 Research and studies can improve the way facilities
staff their units and improve patient care
 Staffing can have both positive and negative affects
on patients and the facility
 Government mandates are not widely accepted by
those in the health care field
 Using the standards set by the ANA and QSEN,
nurses can continue to deliver optimal patient care.
References
Agency for Healthcare Research and Quality (2014). Hospital nurse staffing and quality of care. Retrieved from
http://www.ahrq.gov/research/findings/factsheets/services/nursestaffing/index.html#Staffing
Agency for Healthcare Research and Quality (2014). State-mandated nurse staffing levels alleviate workloads, leading to
lower patient mortality and high nurse satisfaction. Retrieved from http://innovations.ahrq.gov/content.aspx?id=3708
American Organization of Nurse Executives (2014). Mandated staffing ratios. Retrieved from
http://www.aone.org/resources/leadership%20tools/staffingratios.shtml
Barton, N. (2013). Acuity-based staffing: Balance cost, satisfaction, quality, and outcomes. Nurse Leader, 11(6), 47-50.
Centers for Medicare and Medicaid Services (2012). Design for nursing home compare five-star quality rating system.
Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/downloads/usersguide.pdf
Ferris State University (2014). Standards of professional nursing practice (ANA). Retrieved from
http://www.ferris.edu/HTMLS/colleges/alliedhe/Nursing/Standards-of-Professional-Nursing-Practice.htm
Groff Paris, L., & Terhaar, M. (2011). Using Maslow’s pyramid and the national database of nursing quality indicators to
attain a healthier work environment. The Online Journal of Issues in Nursing, 16(1).
References
McHugh, M.D., Kutney-Lee, A., Cimiotti, J.P., Sloane, D.M., & Aiken, L.H. (2011). Nurses’ widespread job
dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health
Affairs, 30(2), 202-210. doi: 10.1377/hlthaff.2010.0100
Meyer, R.M., & O’Brien-Pallas, L.L. (2010). Nursing services delivery theory. Journal of Advanced
Nursing, 66(12), 2828-2838. doi: 10.1111/j.1365-2648.2010.05449.x
Michigan Nurses Association (2014). MI needs a safe staffing law now! Retrieved from
http://www.minurses.org/legislation/safepatientcare
Mitka, M. (2013). Greater nurse staffing may lower hospital readmissions. The Journal of the American
Medical Association, 310(18).
National Hospice and Palliative Care Organization (2013). Staffing guidelines for Hospice home care
teams. Retrieved from
http://www.nhpco.org/sites/default/files/public/quality/Staffing_Guidelines.pdf
QSEN Institute (2014). Pre-licensure KSAS. Retrieved from
University of Wisconsin (2014). Management and education services for healthcare (MESH). Retreieved
from http://www.uwhealth.org/misc/mesh/management-and-education-services-for-healthcaremesh-patient-classification-and-staffing-system/35619