slide 1 a business guide for the cns deborah messecar...

NACNS Cost Analysis Toolkit-

a Business Guide for the CNS

Anita White MSN, RN, ACNS-BC, CCRN

Deborah Messecar PhD, MPH, AGCNS-BC, RN

Stacy Jepsen MSN, RN, ACNS-BC, CCRN

Jerithea Tidwell RN, PhD, PNPBC, PCNSBC

Yvonne Dobbenga-Rhodes MS, RNC-OB, RNC-NIC, CNS, CNS-BC, CPN

NACNS Practice Committee Presentation

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Slide 2

2017 NACNS Cost Analysis Toolkit

No speakers have claimed any conflict of interest.

No commercial support or sponsorship has been received

for this activity.

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Slide 3

Objectives

The CNS will be able to:

Replicate tools related to cost of a project

Critique literature related to CNS role and cost

reduction and quality improvement

Critically analyze frequently asked questions from

the NACNS list serve and survey on cost

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Anita White (Chair) MSN, APRN, ACNS-BC, CCRN Clinical Nurse Specialist MICUCleveland ClinicCleveland, [email protected]

Yvonne Dobbenga-Rhodes (Board Liaison) MS, RNC-OB, RNC-NIC, CNS, CNS-BC, CPNMaternal-Child Health Clinical Nurse SpecialistWashington Hospital Healthcare SystemFremont, [email protected]

Sarah Barry RN, CNS-BC Southern Coos Hospital Brandon, [email protected]

Martha J. Biddle PhD, APRN, CCNSAssistant ProfessorUniversity of Kentucky Lexington, [email protected]

NACNS Practice Committee 2016-2017

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Slide 5

Tamera Brown MS, RN, ACNS-BC, CWOCNIndiana University Health Ball Memorial HospitalSpringport, [email protected]

Stacy Jepsen MSN, APRN, ACNS-BC, CCRNClinical Nurse Specialist, Med/Surg/Neuro Critical CareAbbott Northwestern [email protected]

Deborah Messecar, PhD, MPH, AGCNS-BC, RNAssociate ProfessorOregon Health & Science University Portland, [email protected]

Patricia Rosier, MS, RN, ACNS-BC Surgical Clinical Nurse Specialist Berkshire Medical Center Pittsfield, [email protected]

Jerithea Tidwell RN PhD, PNP-BC, PCNS-BCNICU Clinical Nurse SpecialistChildren's Medical Center – DallasDallas, [email protected]

NACNS Practice Committee 2016-2017

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Slide 6

Special Recognition to:

The 2014 Cost and Outcomes Taskforce:

Ginger Pierson, Anne Muller, Pat Gilman, Bobbi Leeper,

Sonya Flanders, Kim Daniels, Pamela Mittlestadt.

Melinda Ray and NACNS staff- Jason Harbonic, Courtney

Cook, and Laura Heustis

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Slide 8

Cost Analysis Toolkit Contents

How to Get Started

Describes a Six Sigma process to guide the CNS

in a change strategy involving cost analysis

Define, measure, analyze, design, verify

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Slide 9


NACNS Crosswalk

Extensive table of resources: All About Project Management,

The Society of Cardiovascular Care, The W.Edwards Deming

Institute®, Project Management Skills, iSixSigma, Gantt Charts,

Mind Tools, Human Factors International, Toptal, Percentage

Mathematical Calculators, and Skills You Need.

Contains embedded links, enabling the CNS to have direct

access to the resources

Literature table: extensive literature review of CNS work cost

analysis, with review and grading of each article.

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Frequently Asked Questions

Series of frequently asked questions from the

NACNS list serv and the CNS Cost Analysis

Survey.

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Slide 11

The CNS & the Business of

HealthcareAnita White MSN, RN, ACNS-BC, CCRN

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Slide 12

Paradigm Shift

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The Value Imperative

Volume → Cost

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Slide 14

What Drives Value?

Unsustained Costs

Varied Quality Outcomes

Transparency

Dissatisfaction

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Slide 15

How Does this Affect the CNS?

CNS & Quality of Care

CNS & Outcomes of Care

CNS & Cost?

Do I now need an MBA?

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Cost Avoidance?

Source Outcomes

Agency for Healthcare

Research and quality

Adverse Drug Events, Disease Specific (asthma,

COPD, Cancer, CAUTI, CLABSI, Falls, Heart

Disease, Hospital Acquired Pressure Injury, OB

adverse events, postop venous

thromboembolism, surgical site infections,

treatment of mental disorders, treatment of

trauma-related disorders, ventilator-associated

pneumonia)

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Slide 17

Cost Avoidance

Source Outcomes

OSHA Safety Pays Program

Estimator

ANA’s Handle with Care

Program

Employee musculoskeletal injuries,

Employee needle sticks,

Robert Wood Johnson

Foundation

Individual State Board of

Nursing

RN Turnover

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Slide 18

Cost Analysis Strategies

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Cost Analysis Strategies

Toptal

https://www.toptal.c

om/freelance/don-t-

be-fooled-the-real-

cost-of-employees-

and-consultants

Fee Yes-Online

Calculator

Employee

versus

Consultant

Employee Cost

Calculator:

‘ Don't Be Fooled:

Calculate the Real

Cost of Employees

and Consultants’

No Yes-minimal Yes Yes-online

calculator

Yes-online calculator

and article

Percentage Change Math

Calculators

http://percentagecal

culator.mes.fm/

https://percentageca

lculator.net/

Free Yes-online

Calculator

for

mathematica

l calculation

of percent

difference

Useful, accurate, for

quick calculations

No No Minimal-

intuitive

calculator

Yes-online

calculator


Skills you need site

http://www.skillsyou

need.com/num/perc

ent-change.html

Free Yes-online

calculator for

mathematica

l calculation

of percent

difference

How to calculate

percent increase and

percent decrease.

No No Yes-intuitive

calculator,

examples and

equations

Yes-online

calculator


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Slide 20

Cost Analysis

Pre/post implementation analysis

Cost Avoidance/cost reduction

Communication of cost savings

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Slide 21

Formulas for Cost Analysis, Benefit-

cost Ratio, Return on Investment

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ExamplesAssumptions:

Total Cost for procedure= $4.24

Total Cost for equipment requested= $20,000

Anticipate 42% decrease in number of procedures

Anticipate 26% greater chance of successful procedure

Projected Total Cost to treat CAUTII== $7,000

Training Cost/class $475

14 participants @ $40/hour x3 hours 1,680

$2,155

What does the

evidence say?

What is the

actual cost?

What is the cost

of a CAUTI?

What is the training

cost?

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Slide 23 Examples- Disclaimer…the numbers below are not

reflective of the actual math.

Cost of 1CAUTI 0.85 Benefit to Cost Ratio <1 = negative

impact

Cost of 72 CAUTIs (ICU 2016) $ 1,326,000= 5.1 Benefit -Cost Ratio

>1=positive

impact

Cost of equipment $260,000

Add in cost to train nurses:

Cost of 72 CAUTII (ICU 2016) $1,326,000=4.22 Benefit to Cost Ratio

>1 = Positive impact for ROI

Cost of equipment & 22 classes $313,875

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Slide 24

Resources/Tools Related to Project

Management

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Tools Related to Process Changes

Tools…necessary component to identify areas for improvement

Project Management

The Scientific Method

Business Charter

Flow Chart

Algorithm

Mapping

Concept Analysis

Fishbone Diagram

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Slide 26

The Scientific Method

Plan

Do

Act

Study

Plan Who, what, when, where, how

Do Carry out the plan

Study What was learned?

Act What changes to be made?

Next Goal/Cycle?

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Slide 27

Types of Tools & Use

Charter

Business terms: formal structure to program/ project

Define intent of project

Make for each key point in the review process and use this to

include the PDSA cycle

Identify Barriers/Solutions

Basic components:

Goal statement, project flow timeline, project scope.

committee members

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Basic Process Structure Tools

Algorithm:

Look at process and determine what is acceptable.

Flow Chart:

Each symbol has meaning connections identified.

Mapping:

Each symbol has meaning and each symbol has

connections identified yet this type is more detailed

than flow chart.

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Slide 29

Flow Charts

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Slide 30

Flow Charting People

Controlling Process

Improvement

1. Rectangle, designating an activity or activities.

2. Diamond, designating a binary decision.

3. Circle, designating an on-page reference.

4. Five-sided “home plate,” designating an off-page reference.

5. Oval, designating the start or end of a process.

6. → Arrow, connects symbols and indicates directionality.

7. Delay, designating a delay in the process.

8. Document, designating a document created in the process.

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By FabianLange at de.wikipedia [GFDL

(http://www.gnu.org/copyleft/fdl.html)], via Wikimedia

Commons

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Slide 32

Communication of Success

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Slide 33

PROJECT COMMUNICATIONS

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Communication…just the basics

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Slide 35

How Much is Enough?

50-60% reduction of

monitor alarms in our

ICUs

Alarms were reduced

from over 8 million

per month per 264

beds to a little over 2

million per month per

264 beds.

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Slide 36 Change Agents: Anita White CNS-Chair ICU Alarm

Committee-reduced alarms in all ICU settings by over 60%

by standardizing alarms. Millions of alarms gone.

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Pay Attention to Details!

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Lift Pad Bath Blanket

Developed Skin Breakdown 28.50% 13.60%

Experienced No Skin Breakdown 71.40% 86.30%

Percentage

The Tower Study Regional Medical Center

February 14 to February 21, 2005 ICU and CCU Combined Results

N=36Lift Pad Skin Breakdown: N=4/14 No Breakdown N=10/14

Bath Blanket Skin Breakdown: N=3/22. No Breakdown N=19/22

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Slide 38

Choosing how to communicate

Paper

Electronic

Meetings

One on one discussions

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Slide 39

Team problem-solving guidelines

Define the problem

Analyze the problem

Develop solutions to consider

Choose a solution

Implement action plan

Evaluate and adjust

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Crosswalk-Evidence Based Practice

OverviewDeborah Messecar PhD, MPH, AGCNS-BC, RN

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Slide 41

Search strategy- Database: Ovid MEDLINE(R)

<1946 to October Week 1 2016>1 Nurse Clinicians/ec [Economics] (185)

2 limit 1 to english language (182)

3 exp Nurse Clinicians/ (7770)

4 exp "Costs and Cost Analysis"/ (203170)

5 3 and 4 (312)


7 1 or 6 (414)

8 ((clinical nurse special* or nurse clinician*) adj7 (cost* or expendit* or financ* or dollar* or econom*)).mp.

[mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word,

protocol supplementary concept word, rare disease supplementary concept word, unique identifier] (41)


10 7 or 9 (434)

11 exp Nurse Clinicians/ (7770)

12 ec.fs. (374020)

13 11 and 12 (366)


15 10 or 14 (520)

16 limit 15 to yr="2006 - 2016" (147)

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Slide 42 Search Strategy-Continued

OVID search strategy was replicate in CINAHL

And in EBM database: NHS Economic Evaluation Database

Articles were selected for inclusion if they met the following

additional criteria:

Studies or reviews were limited to those conducted on US

population

Specifically addressed CNS as part of the projects/studies

conducted

Focused on cost savings / cost avoidance

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Table 3: Literature Review Cost and CNS Work Articles included met all of the above search criteria

The following were addressed for each article:

Design/Purpose

Sample/Setting

Measurements/Instruments

Results

Strengths /Weaknesses

Relevance to Problem Value of CNS Interventions

Level of Evidence / Grade

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Slide 44

Articles Not Included in Literature Review

that Provide Background Information

Additional table contained articles that did not meet the criteria for

inclusion in the evidence table

These articles may have:

Been conducted outside the U.S. with “nurse specialists” who

may have been performing in a role similar to the CNS

Focused on nurse specialists in U.S. who were not CNS

Focused on reimbursement rather than cost savings

No data presented on cost savings

Offered an opinion on how the CNS could save costs

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Slide 45

Overall findings from Table 3

Cost savings have been demonstrated in several practice

settings with a range of patient populations

A number of the articles focused on integrative reviews from

smaller descriptive studies

Several studies focused on transitional care and or reducing

more expensive types of care

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How to use table to assess evidence for

your practice

First, review table for articles pertinent to clinical setting and problem

Each article has enough detail so that you should be able to determine its applicability to your issue/concern

For each article, look at the level of evidence that is noted in the last column – this helps you judge the quality of what is presented

In addition, for each article

Identify important findings

Identify flaws from your perspective

What are the limitations of the match to the issue/concern

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Slide 47

Next step

After identifying relevant articles and retrieving and reviewing them for your setting

Consider contacting the authors in you need more information (contact information should be provided in each article)

Look for tools or approaches outlined in the rest of the tool kit that might be relevant

Collaborate with team colleagues to plan an approach

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Slide 48

How Do I Start?

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Slide 50

How Do I Start?

Let’s look at the steps…

Six Sigma Process approach

Define

Measure

Analyze

Design

Verify

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Slide 51

Define Your Problem

#1 Technology Hazard

Excessive Alarms may lead to Alarm Fatigue

May Ignore or Disable Alarm

Potential to IMPACT Patient

Safety.

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Build The Case-Who are your Key

Stakeholders?

CNS

Frontline

Nurse

Accreditation

Nursing

Director

Data

Pull

Physician

Champion

Quality

Nurse

Manager

Clinical

Engineering

RT

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Slide 53

Stakeholders Prioritization Grid

Power

High →

Low Power →

Interest

Keep Satisfied

Manage Closely

Monitor

Keep Informed

http://www.mindtools.com/subscribe.htm

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Slide 54

Begin to Assess Your Unit/Hospital’s

System

Appropriateness of monitoring

Current state

Staff education and competency

Staff attitudes / perceptions

Survey

Patient outcomes

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Perform Gap Analysis

“Your Project” current state

Unit Gap Analysis

Gather data from clinical engineering /

facilities

# / defined time

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Slide 56

Patient Data

Review Patient outcomes

Organizational data on “your topic”

Do you have data retrieval systems:

manufacturer or your own system on data

retrieved

Patient event data?

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Slide 57

Pre-Change Data Measurement

Alarm Event Data-Coordination with Facility/IT

Rapid Response Team/Code Team Event

Adverse Events

HCAPS

Other Hospital databases

National standards

Pre-Change Assessment

Survey staff on perceptions / attitudes

Staff knowledge monitoring practices

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Measure Metrics

Consider:

Event data such as clinical alarms

safety

staff education/competencies,

surveys/perceptions

patient outcomes

Resource: Crosswalk

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Slide 59

Analyze

Identify goals: determine how process changes will affect process results.

Analyze Data from Measure section

Was there a Frequency increase or decrease?

What did the increase or decrease?

Were there other factors that led to the increase or decrease?

Did patient compromise occur?

Evaluate / Prioritize areas for improvement

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Slide 60

Develop a Plan Overview

Identify stakeholders

Define outcomes

Can the solution be standardized?

Accountability at the bedside

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Design

Work out details of change to be implemented

What to change /process to implement

Include nurse related needs for pilot

Staff education

Competencies

Include dates/times to monitor data

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Slide 62 Develop Strategies for Management of

the Projected Change

Customization

Evidence based use

Clarify accountability

Policy development

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Slide 63

Design Resource

Work out the details for the change

Identify strategies for the problem to be managed

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Verify

PDSA Cycle on pilot units

Outcomes:

Evaluate goals for success

Overall # of alarms

% nurses customizing alarms

% of high, medium, low, and technical alarms

Survey staff on perceptions / attitudes

Pilot Study Units to monitor change

Implement changes

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Slide 65

Frequently Asked QuestionsStacey Jepsen MSN, APRN, ACNS-BC, CCRN

Jerithea Tidwell RN, PhD, PNP-BC, PCNS-BC

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Slide 66

229 responses

Classification

Critical Care

Medical Surgical

Other

Cost Analysis Tool-kit Data: Who..

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Cost Analysis Tool-kit Data: Who..

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Slide 68 Cost Analysis Tool-kit Data: What they want to

know…

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Slide 69 Cost Analysis Tool-kit Data: What they want

to know….

Opportunities for CNS Education

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Cost Analysis Toolkit FAQ

What are the differences between variable and fixed cost?

Total cost = sum of both fixed and variable costs.

Variable costs are items that change as the quantity of

services increase (supplies, direct patient care labor).

Fixed costs occur no matter the quantity of service provided

(heating, lights, building lease/rent).

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Slide 71

What are the differences between

variable and fixed cost?

CNS work can greatly impact the reduction of

variable cost which can lead to a total cost of

care reduction, such as reduction in the number

of x-rays done to verify tube feeding tip location.

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Slide 72 Cost Analysis Toolkit FAQ

What are some of the ways to communicate cost savings?

Cost avoidance can demonstrate savings. The average cost of

a hospital acquired pressure ulcer or other hospital acquired

conditions (CAUTI, CLABSI) can be listed in the saving

associated with a specific intervention/s that lead to

reduction in cases.

Cost reduction through reduction in variable or fixed costs.

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Cost Analysis Toolkit FAQHow can these savings be presented to larger groups?

A scorecard can display measures, associated goals, and other indicators that represent the measures performance.

Financial savings associated with each measure can also be listed.

Refer to the Cost Analysis Resource Crosswalk article titled: Using a Scorecard to Demonstrate CNS Contribution, 2015. See also Clinical Nurse Specialist Tool kit: Chapter 14 Communicating Results: Who Needs to Know What

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Slide 74


Should every project have a cost analysis associated with it?

Having a cost an analysis for projects that you participate in

helps to quantify the work that you do in terms of dollars and

time. This can be very useful when justifying CNS role.

See Cost Analysis Resource Crosswalk Literature Review Articles titled: A Business

Case Framework for Planning Clinical Nurse Specialist--Led Interventions. & Nursing

Knowledge and Theory: Where Is the Economic Value?

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Slide 75


Where do I find an example of an executive summary and what is it?

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Project Charter

Project Name: The RACE

Project Summary

Overview: What & Why

Project Goal / Business

Driv ers:

The RACE is a multidisciplinary process improvement project to improve operational performance and patient care

for Acute Care Service guided by the CNS.

Project Scope & Objectives: ACS units participate in a year-long friendly competition measuring improvement in patient satisfaction,

interdisciplinary communication, and multidisciplinary performance.

Known Deliverables: Create an incentive process aimed at improving specific nursing Sensitive Indicators, family and patient

satisfaction, nurse satisfaction and accountability.

Desired End Date:

Who: Roles & Responsibilities

Project Sponsor:

Project Manager:

Stakeholders:

Support Team Members:

Project Scope

Systems and processes that will be affected:

Systems / Processes Quality and performance metrics have been identified and organized among the four quarters. Refer to Attachment A. Each

ACS unit can create a process that improves their area’s outcomes. Processes proven beneficial may be shared among areas

in order to improve the performance of all ACS areas.

Unit process examples:

Bedside Check/Report

Staff attending rounds/huddles

RT communicates with Charge/White Boards

HUC Callbacks

Nursing M&M (Excluding Peer Review) - Initiatives developed as a result of specific events

Daisy Project

Warm Welcome

Other processes developed by individual units

Data is collected twice a month (one day shift and one night shift) on specific measures as indicated for each quarter. Data is

collected using the following:

ACS Dashboard (Statit) - Metrics determined by Dr. Sheehan, Data collection by Health Information Management

(Judith Leever)

Patient Event Log- Metrics, Data Collection by Allison Langston

EPIC Reports-Carlie Gotieb

NSI Dashboard Metrics- Metrics determined by Magnet focus, Data collection by Serena Lucas

National Patient Safety Goals- Metrics determined by Joint Commission based on serious and sentinel events

reported, Data collection by Quality Review Department

NRC Picker Data

Once data is collected, it is saved in the RACE folder on the k-drive.

Boundaries

Constraints / Dependencies: 1. Time commitment with manual audits.

2. The monthly report will be compiled by the CNS’s and presented to the committee at the monthly RACE meetings.

3. The educators will identify one focus area per month based on the audit results and conduct an analysis

Executive Summary/Project Charter

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Slide 77

Cost Analysis Toolkit FAQ My employer would like for me to design a plan for disseminating

latest research findings to our staff. How do I start? Refer to the article ‘The Impact of Clinical Nurse Specialists on Clinical Pathways in the

Application of EBP, 2010’ in Table 3: Literature Review Cost and CNS Work of the NACNS Cost Analysis Toolkit

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Slide 78 Several of the leadership position list MBA as being preferred;

How do CNS indicate their unique leadership and budget skills in

the absence of having a MBA?

This depends on the position you are seeking.

CNSs have a unique set of skills that can allow versatility in role

i.e. Director of Infection control; Director of Quality, Director of

Professional Development or Director of Magnet.

Refer to the Cost Analysis Resource Crosswalk article titled: Impact on the Clinical Nurse

Specialist Role on the Cost and Quality of Healthcare

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Continued…

One might invest in acquiring the Nurse Executive or

Advanced Nurse Executive certification. This exam It

captures Human Capital Management, Fiscal

Planning, Execution and Accountability and basic

budgeting and accounting principles.

http://nursecredentialing.org/NurseExecutive-

Advanced

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Slide 80 What initial steps do I need to take to bill for my

services? How can I associate fees to services

provided by a CNS?

Investigate credentialing process in your organization. See Clinical

Nurse Specialist Toolkit: A Guide for the New Clinical Nurse Specialist;

Chapter 19 “Navigating the Privileging and Credentialing Process”

Apply for NPI number https://nppes.cms.hhs.gov/NPPES/Welcome.do

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Slide 81

Continued…

Explore requirements for prescriptive authority as a CNS in

your state. Some states require courses/documentation of

clinical hours.

Collaborate with billing specialist and/or administrative

leaders in Advance Practice Service in your organization to

learn about criteria for payment, appropriate documentation

of patient encounters, levels of service, and requirements of a

CPT code.

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Continued…Seek out billing training courses

Consider what billable service(s), procedure(s), education you provide (i.e. diabetes education, complex patient coordination, Advanced WOCN)

Market /create CNS consult in EMR system for service(s) provided

Track /monitor patient encounters (include time in minutes) See Clinical Nurse Specialist Toolkit : A Guide for the New Clinical Nurse Specialist; Chapter 20

See Cost Analysis Resource Crosswalk articles titled : Introduction to Reimbursement of Advanced Practice Registered Nurse Services and Understanding Medicare Part B Incident to Billing; Reimbursement of Advanced Practice Registered Nurse Services: a fact sheet & PRESIDENT SIGNS BILLS REPEALING SGR FORMULA AND INCREASING CNSs' ABILITY TO ORDER MEDICARE SERVICES...Sustainable Growth Rate

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Slide 83

Questions & Answers?

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Slide 84

Thank You!

NACNS Practice Committee

References available on toolkit

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