Transcript Dr. Kathy Baker`s presentation - Virginia Organization of Nurse

Outcomes Based
Nurse Staffing
Kathy Baker, RN PhD, NE-BC
Nursing Director Resource
Management and Emergency Services
What can you expect
from today
•A Perspective on the Importance of
Nurse Staffing
•An understanding of the need for new
models of Nurse Staffing
•Knowledge regarding the barriers to
Creating New Models
•A toolkit of options to inform your
practice as a Nurse Executive
The Importance of
Nurse Staffing
An Administrator’s Potential View of Nurse
Staffing in the 1990’s
A viable source of reduction if
cost pressures warrant
Institute of Medicine (IOM) Report:
Nursing Staff in Hospitals & Nursing
Homes: Is it Adequate?
“…there is a serious paucity of
recent research on the definitive
aspects of structural measures,
such as staffing ratios, on the
quality of patient care in terms
of patient outcomes when
controlling for all other likely
explanatory or confounding
variables.”
(Wunderlich, Sloan, & Davis, 1996)
Cheryl Jones, 2011 – VCU
Health grand rounds
What did that mean for Nurse Staffing in the
1990’s?
When making decisions about staff vs. other investments, must consider
the best area to allocate resources
• Is the investment worth the cost?
• Is the timing right?
• Containing cost, at what risk to quality?
• Achieving quality, but at what cost?
(McCloskey, 1995)
Focus on Outcomes --- Pay for Performance
1980’s
1998
1993
• DRG’s
2007
• Clinton
Healthcare
plan
• Quality
Commission
1999
• To Err is
Human
2001
• Crossing
the Quality
Chasm
2010
• CMS Pay for
Performance
• ACA Passed
Cheryl Jones, 2011, VCU Health
Grand Rounds
The irony of it all…
The U.S. is one of the richest countries in the world
(ranked 4th and 6th, depending on source)
It has one of the most technologically advanced
healthcare systems in the world…
But it also has one of the most expensive
healthcare systems in the world…and
There are other countries with much better societal
outcomes: life expectancy, infant mortality, overall
mortality, cancer rates, consumer perceptions of
satisfaction, obesity, etc., etc., etc.!
Cheryl Jones, 2011, VCU Health
Grand Rounds
Country Rankings
Exhibit ES-1. Overall Ranking
1.00–2.33
2.34–4.66
4.67–7.00
AUS
CAN
GER
NETH
NZ
UK
US
OVERALL RANKING (2010)
3
6
4
1
5
2
7
Quality Care
4
7
5
2
1
3
6
Effective Care
2
7
6
3
5
1
4
Safe Care
6
5
3
1
4
2
7
Coordinated Care
4
5
7
2
1
3
6
Patient-Centered Care
2
5
3
6
1
7
4
6.5
5
3
1
4
2
6.5
Cost-Related Problem
6
3.5
3.5
2
5
1
7
Timeliness of Care
6
7
2
1
3
4
5
Efficiency
2
6
5
3
4
1
7
Equity
4
5
3
1
6
2
7
Long, Healthy, Productive Lives
1
2
3
4
5
6
7
$3,357
$3,895
$3,588
$3,837*
$2,454
$2,992
$7,290
Access
Health Expenditures/Capita, 2007
Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity).
Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International
Health Policy Survey of Sicker Adults; 2009 International Health Policy Survey of Primary Care Physicians;
Commonwealth Fund Commission on a High Performance Health System National Scorecard; and Organization for
Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).
Costs Associated with Quality
Measuring, monitoring, and maintaining
Short-term and long-term investments
Unseen costs
• Underused services
• Overused services
• Misused services
• Poor quality services
• Psychological costs
Both costs and quality vary by geographic region and the practices within
them
Cheryl, Jones, 2011, VCU Health Grand Rounds
Quality First: Better Health Care
for All Americans (1998)
“The purpose of the health
care system must be to
continuously reduce the
impact and burden of illness,
injury and disability, and to
improve the health and
functioning of the people of
the United States.”
Cheryl, Jones, 2011, VCU Health Grand Rounds
To Err is Human (1999)
This report acknowledged what
many knew:
Errors in health care are not
acceptable
• More dangerous than some of the
major killers
Financing system does not
incentivize quality
• Staffing and error – is there a
relationship?
Cheryl, Jones, 2011, VCU Health Grand Rounds
IOM Report:
Crossing the Quality Chasm (2001)
Focused on quality…
Realigning system of healthcare
financing and quality incentives
6 aims of health care
•
•
•
•
•
•
Safe
Effective
Patient-centered
Timely
Efficient
Equitable
Cheryl, Jones, 2011, VCU Health Grand Rounds
IOM Report:
Health Professions Education (2003)
Health Care Professionals
should be educated to…
Deliver patient centered care
Work in interdisciplinary
teams
Utilize evidence based
practice
Engage in quality
improvement
IHI’s 5 Million Lives Campaign (2006-2008)
Added 6 new initiatives focused on:
• Prevention of MRSA infection
• Prevention of errors from the use of high-alert medications
• Reduce surgical complications
• Prevent pressure ulcers
• Reduce hospital readmissions for congestive heart failure patients
• Get hospital boards involved to accelerate quality improvement
initiatives
Retrieved and adapted from:
http://www.ihi.org/offerings/Initiatives/PastStrategicInitiatives/5MillionLivesCampaign/Document
s/Overview%20of%20the%20100K%20Campaign.pdf
March 23, 2010
Patient Protection and
Affordable Care Act (ACA)
Became Law
Health Care Reform
Patient Protection and Affordable Care Act
• Improve the health care system by aligning quality metrics with
payment mechanisms
– Reducing health care costs
• Phased in over time
Cheryl, Jones, 2011, VCU Health Grand Rounds
Pay-for-performance (P4P)
“Quality-based purchasing, also known as pay-forperformance, is the use of payment methods and
other incentives to encourage quality
improvement and patient focused, high value
care.
There are many models for financial and nonfinancial incentives used in pay-for-performance
programs or strategies…. pay-for-performance
programs … are only one component of a
broader strategy of promoting health care
quality.”
(CMS 5/15/07)
So . . . Enter Nurse staffing
The Year of Public Awareness
Nursing mistakes kill, injure thousands
Cost-cutting exacts toll on patients, hospital staffs
By Michael J. Berens
Tribune Staff Writer
September 10, 2000
Cheryl, Jones, 2011, VCU Health Grand Rounds
IOM Report:
Keeping Patients Safe
IOM Report:
Keeping Patients Safe (2004)
Create a satisfying, rewarding work environment
for nurses
• Adequate staff
• Focus on patient safety by Governing Board
• Evidence based management
– Build trust
– Nursing voice in patient care delivery
Cheryl, Jones, 2011, VCU Health Grand Rounds
IOM Report:
Keeping Patients Safe (con’t)
• Effective nursing leadership
– Participate in executive decision-making
• Organizational support for learning
– Adequate support for new nurses
– Educational support, resources
• Promote interdisciplinary collaboration
• Work designs that promote safety
• Cultures that strengthens patient safety
Cheryl, Jones, 2011, VCU Health Grand Rounds
The Future of Nursing: Leading Change,
Advancing Health (2011)
2011 Institute of Medicine – Robert Wood Johnson
Foundation Report
Key Messages
Recommendations
Practice to the full extent of
education/training
Remove scope-of-practice
barriers
Achieve higher levels of
education
Implement nurse residency
programs
Expand % of nurses with BSNs
and doctorates
Promote life-long learning
Participate as full partners in
redesigning health care
Lead and diffuse collaborative
opportunities
Prepare/enable nurses to lead
change
Collect and analyze needed
workforce data
Build an interdisciplinary health
workforce infrastructure
Adapted from Institute of Medicine: The future of nursing: Leading change, advancing
health, Washington, DC, 2011, National Academies Press.
Cheryl, Jones, 2011, VCU Health Grand Rounds
Litvak, et al. (2005) suggest that, of all the patient
safety measures currently being implemented in
health care organizations, none of them can
substitute for adequate nurse staffing
“Rain-maker roles may change for hospitals.
Employment changes and [P4P] reimbursement
may combine to flip the workforce dynamic in
hospitals. Traditionally physicians were rainmakers
who brought in revenue and nurses were overhead.
Through new, [P4P] programs that focus on clinical
quality and patient satisfaction, nurses will have a
significant impact on the key metrics that will drive
reimbursement updates.”
- PricewaterhouseCoopers (2007). What works: Healing the
healthcare staffing shortage, p. 2.
In 2007 the Agency for Healthcare Quality and Research published a
meta-analysis of 94 nurse staffing studies from 1990-2006.
A relative risk reduction was found between the
amount of nurse staffing and nosocomial
infections, length of stay, pulmonary failure, failure
to rescue and mortality. The significance was
greater in surgical populations than in medical
however the relationship was significant in both.
www.hfma.org/valueproject
Achieving improved levels of nursing staffing in P4P
world is not a given
•Must seize this opportunity to demonstrate nursing value in the changing
healthcare landscape.
Relationships among financing, quality, and care
delivery
Value = quality/cost
Quality
This relationship assumes that
Putting ever increasing amounts of money into efforts to improve quality
may not achieve the outcomes intended
Needleman et al., 2006: Investing in certain levels of RN staffing levels
may improve staffing
Increasing RN staffing beyond certain levels may not improve quality
Cheryl, Jones, 2011, VCU Health Grand Rounds
The implication of this is that there is a least cost
volume for any organization . . . You just have to
find it!
Cheryl, Jones, 2011, VCU Health Grand Rounds
Why new models of Nurse Staffing are needed
Finding the value point for nurse staffing is complicated
Measuring the value of nursing is extremely complex, difficult and
unavailable real time.
Outcomes based Staffing
In contrast to Clinical EBP model – Outcomes
based Staffing is Contextual
Acuity of patients
HPPD
Staff Mix
Staff Experience
Geography of the Unit
Work Disruptions
Team Composition
Support Staff
MD/RN relationships
ADT
Difficult to compare like populations on Nursing Units
Must first start with a good work environment
Effect of Improved Nurse Staffing on Mortality
Depends Upon Quality of Work Environment
Aiken et al. Medical Care, 2011.
Odds on Dying
Poor Environment
(0 percent)
Mixed Environment
(16 percent)
Good Environment
(46 percent)
8 to 1
6 to 1
4 to 1
Patient to Nurse Ratio
The difference in the odds on dying in hospitals with 8:1 and 4:1 patient/nurse ratios is:
0 percent in hospitals with poor environments;
16 percent in hospitals with mixed environments;
46 percent in hospitals with good environments.
Results
Each additional patient per nurse associated with a:
-
7% increase in the odds of readmission for heart failure
-
7% increase in the odds of readmission for pneumonia
-
10% increase for myocardial infarction patients
Care in a hospital with a good versus mixed work
environment (or mixed vs. poor) was associated with:
-
4% lower odds of readmission for heart failure
4% lower odds of readmission for myocardial infarction
6% lower odds for pneumonia patients
Achieving Magnet Designation is a
complex, individual, organizational design
But embracing the Magnet principles for
effective work environments is an
opportunity for all Nurse Executives
The Magnet Model is the evidenced based
blue print for excellent nursing work
environments.
Excellent nursing work environments and
span of Control
Transforming Relationships for High Performance –
The Power of Relational Coordination
Jody Hoffer Gittell
Measuring Acuity The controversy of
Patient Classification
System
All Organizations measure Acuity
•
•
•
•
ICU v/s Non-ICU
Progressive Care v/s General Care
HPPD
CMI
The Question is how precisely you want
to measure Acuity.
The new generation of patient classification
systems are demonstrating positive results.
• Patient Classification Systems have been mandated in some states
• Large organizations are describing impressive results with the
addition of acuity systems in their staffing models
•
•
Stonybrook in New York
Arizona
Decentralization v/s
Centralization
Principles of Magnet and Empowered Work
Environments Support Decentralized Staffing
Models
• ANA White Paper on Staffing (Avalere, 2015)
• Staffing Committees are mandated in multiple states
• Decision making at the front line levels are needed to optimize unit
based staffing (McHugh, 2016)
• Many organizations however moving toward
centralized models
Why a Centralized Model
• Need immediate results
• Decentralized Systems are difficult to cultivate
• Decentralization Systems must drive accountability and requires
financial acumen at all levels of nursing
Decentralization
Accountability
* The Penn State Model
Financial Acumen
* Training
* Business Manager
Developing a Staffing Committee
■ A successful staffing Committee is not about the charter, the meeting
times etc. .
■ A successful staffing Committee is about changing the organizational
culture to support the type of decentralized decision making required.
Video on Decentralized Staffing Decisions
HPPD is not an outcome
Must Link the Quality
Conversation with the
Staffing Conversation
Benchmarking and HPPD
• Benchmarking is a tool – but may or may not tell you if you have the
right staffing.
•
At lease ensure that you optimize
• Weighted averages
• Multiple tools
• Customized reports
Must link the Staffing and Quality Conversations
•
•
•
•
Nursing Research
Missed Nursing Work
Nursing Sensitive Indicators – the Balanced Score Card
Nursing M & Ms
Outcomes of In-hospital Resuscitation
McHugh Aiken, et al. Medical Care, 2016
Nurse staffing: Each additional patient added to
nurses’ workloads is associated with 4% lower
survival to discharge
Work environment: Patients experiencing inhospital resuscitation cared for in hospitals with
poor work environments have 22% lower survival
than patients in hospitals with good environments
(independent of nurse staffing)
Nurse Staffing and Pediatric
Readmissions
Tubbs-Cooley, Aiken et al, 2013 BMJ Quality and
Safety
Each 1 patient increase in nurse workloads in pediatric
inpatient services is associated with an 11% increase in
readmissions among children
56
% Nurses
Missed Needed Nursing Care is Common:
% Nurses Reporting Missed Care on Last Shift by
Workload
RN4CAST-US 2015-16
McHugh, 2016 VCU Nursing Grand Rounds
RWJF - Nursing M & Ms
The Nursing Shortage
Supply-demand projections,
U.S. nursing workforce*
Supply
Demand
3
2.5
2
1.5
1
0.5
0
2000
2005
2010
2015
2020
* Source: Bureau of Health Professions, What is behind HRSA’s…Supply, Demand,
and Shortage of RNs? 2004
Age of U.S. RNs
Source: U.S. Department of Health and Human Services (2010). The Registered Nurse
Population: Initial findings from the 2008 National Sample Survey of Registered Nurses.
Available at http://bhpr.hrsa.gov/healthworkforce/rnsurvey/initialfindings2008.pdf
http://bhpr.hrsa.gov/healthworkforce/rnsurvey/initialfindings2008.pdf.
Nursing Shortage
Current Status
Retention is Key
Must have a millennial strategy
Will these efforts ultimately
reduce costs and improve
quality?
Can Nursing capitalize on
the value equation with
Outcomes based Staffing/
Objective
To examine the relationship
between registered nurse
staffing levels and performance
in the HRRP
Rationale: Increasing nurse
staffing levels is a straight
forward solution that has also
been shown to improve
outcomes and patient
satisfaction.
Does it also help hospitals
avoid financial penalties postACA?
Hospitals with better nurse staffing had 25% lower odds of being
penalized at all and 41% lower odds of receiving the maximum
penalty
McHugh, 2016,VCU Grand Rounds
But we know that nursing holds
quality as sacred…
“. . . I am fain to sum up with an urgent appeal for
adopting this or some uniform system of
publishing the statistical records of hospitals. If
they could be obtained…they would show
subscribers how their money was being spent,
what amount of good was really being done with
it, or whether the money was doing mischief
rather than good.”
Florence Nightingale, 1863
Next Steps . . . .
Things to Consider
• VAC - Access to Care Study
• ANA Professional Issues Panel – Fostering RNs ability to Practice to
the full extent of their Education and Training
• ANA – State Initiatives
Thank you!