Annual Review of Nursing Annual Review of Nursing Services Staffing PlanServices Staffing Plan

Sample Outcome Metrics

NH Nurse Staffing Toolkit 2010

Annual Review• Core principles mandate at least a yearly review by the

hospital-wide nursing staffing committee:A. Ensure the most current nursing services staffing plan does all of

the following:1) Improve inpatient care outcomes;2) Positively affects clinical management;3) Facilitates cost-effective quality nursing care 4) Remains consistent with acceptable and prevailing standards of safe

nursing care and evidenced-based guidelines established by national nursing organizations.

B. Make recommendations, based on the most recent review conducted, regarding how the most current nursing services staffing plan should be revised, if at all.

Don’t Reinvent the Wheel

• Use data you have that is consistent with what you require for credible metrics and adds value to the analysis

• Assess data that is currently collected for required reporting, voluntary reporting or internal quality (outcome and process) purposes

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

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 > higher probability of pressure ulcers

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 >12 hours.

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

Evidence Based Outcomes2007 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

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.

Required MeasuresAMI (Heart Attack) TJC CMSASA on arrival X XASA at D/C X XACEI or ARB at D/C X XSmoking Cessation X XBeta Blockers at D/C X XBeta Blockers at arrival X XTime to Fibrinolysis X XFibrinolytic Therapy in 30 minutes X XPCI in 90 minutes X XTime to PCI X XInpatient mortality X

Required Measures

CHF Indicators TJC CMSDischarge instructions X XLVEF Assessment X XACEI for LVED X XSmoking Cessation X X

Required MeasuresPneumonia TJC CMSOxygen assessment X XInfluenza Vaccination X XPneumococcal Vaccination X XBlood cultures in ED before antibiotic X XBlood cultures in 24 hours X XInitial antibiotic selection in immunocompetent patients X XInitial antibiotic selection in immunocompetent patients ICU/Non-ICU XInitial antibiotic in 6 hours X XAntibiotic timing X

Required Measures

SCIP (Surgical Care Improvement Project) TJC CMSProphylactic antibiotic 1 hour prior to incision X XProphylactic antibiotic selection X XProphylactic antibiotic D/C in 24 hours X XPost-op glucose - Cardiac X XHair removal X XNormothermia - Colon X XPeri-operative Beta Blocker X XVTE prophylaxis X XVTE prophylaxis timely X X

Required Measures30 day mortality rates TJC CMSAMI XHeart Failure XPneumonia X

HCAHPS X

Pregnancy/Related conditionsVBAC XInpatient infant mortality X3rd/4th degree laceration X

Required Measures

CAC Indicators (Children's Asthma Care) TJC CMSRelievers for inpatient asthma XSystemic corticosteriods XHome management plan of care X

HBIPS Indicators (Hospital Based Inpatient Psychiatric Care)Admission screening XPhysical restraint XSeclusion XMultiple antipsychotic Medications at D/C XMultiple antipsychotic Medications at D/C with appropriate justification XPost discharge continuing care plan X

Measures on the Horizon

IPPS Measures (Inpatient Prospective Payment System) TJC CMS 43 Proposed X

Nurse Sensitive Indicators 15 Proposed X

Venous Thromboembolic Disease 8 Posssible measures X

Blood Management 19 Possible measures X

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

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

TJC Proposed Nurse Sensitive Measures Patient-centered Outcome Measures:

1. 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.

2. Pressure ulcer prevalence: Percentage of inpatients who have a hospital acquired pressure ulcer.

3. Falls prevalence: Number of inpatient falls per inpatient days.

4. Falls with injury: Number of inpatient falls with injuries per inpatient days.

5. Restraint prevalence: Percentage of inpatients who have a vest or limb restraint.

TJC Proposed Nurse Sensitive MeasuresPatient-centered Outcome Measures:

6. 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.

7. 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.

8. 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.

TJC Proposed Nurse Sensitive Measures

Nursing-centered Intervention Measures:

9. Smoking cessation counseling for acute myocardial infarction.

10. Smoking cessation counseling for heart failure. 11. 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.

TJC Proposed Nurse Sensitive Measures

System-centered Measures:

12. Skill mix: Percentage of registered nurse, licensed vocational/practical nurse, unlicensed assistive personnel, and contracted nurse care hours to total nursing care hours.

13. 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.

TJC Proposed Nurse Sensitive Measures

System-centered Measures:

14. Practice Environment Scale ― Nursing Work Index: Composite score and scores for five subscales:

a. nurse participation in hospital affairs; b. nursing foundations for quality of care; c. nurse manager ability, leadership and support of nurses; d. staffing and resource adequacy; and e. collegiality of nurse-physician relations.

15. Voluntary turnover: Number of voluntary uncontrolled separations during the month by category (RNs, APNs, LVN/LPNs, NAs).

Don’t 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

Questions?