Embarking on the Journey
Under the 2014 Standards
The ANCC Magnet Recognition Program®
Gina Boring, MSN, RN, NE-BC
Associate Vice President, HealthLinx
1
Timing is Everything
2
Lack of Support
Panic
Why aren't we outperforming the benchmarks?
Underperforming Data
Project is Lagging
Too Little Time
Financial Constraints
Too Few Writers
Working Evenings
Lack of Communication
ANCC® Standards
THE LAST 50 CLIENTS' CHALLENGES
Copy Editors
Publication Planning Missed Writing Dates
A Feeling of Having to Go it Alone
Writers Not Getting Time Off
SOE Interpretation
Contingency Planning
When Should I Begin Research
SOE Deadlines
Planning
Best Practices
Overwhelmed
NDNQI Membership
Approved Studies
Writer Assessment
Understanding | 3
HealthLinx' Best Practice Timeline
Prior to 36 Months
• CNO-Approved Nursing Strategic Plan &
Alignment with Organizational Plan
- Education and Certification Goals
36 – 24 Months
• Completed Hard Gap Analysis
24 – 12 Months
• SOE Gaps Closed
• Selection of Concepts,
Ideas,
Stories for each SOE/Unit is
Complete
• Nursing Excellence Assessment & Plan
• CNO-Approved 3-year Budget
• 1 RN Satisfaction Survey Complete
• Nursing & Organizational Charts that show • Review of Data Action Plan for
direct and indirect reporting of all nurses to
Underperforming NSI, RN
CNO
Satisfaction and Patient
Satisfaction
• Select and Hire MPD
• Establish Magnet® Steering Committee
• Begin IRB Approved Nursing Research
Studies
• Establish Writing Plan with
precise deadlines
• Establish Content & Copy
Editing Plan with precise
deadlines
• Review Job Descriptions for
Performance Expectations
Related to Magnet® Standards
• Establish Final Approval
Process for SOE Narratives
• CNO Involved Process for
Credentialing, Privileging,
Evaluating APNs
• Begin Writer Selection
• Confirm Can Receive RN Satisfaction Data • Approved Plan for IOM 80% BSN
at the Unit Level
by 2020 (Every Nurse)
• Nursing Shared Decision-making Structure
in place
• Select Method of Document
Submission
• Review Need & Establish Leader
Replacement Plan Based on Unit
Performance
• Select Vendor/Maximize Participation for
• Performance-based Appraisals for
Nursing Sensitive Indicators (NSI) for All Units
Every Nurse (Direct care to CNO)
- Self, Peer, Annual Goals
• Establish Action Plan to Meet Educational
Requirements for All Nurse Leaders
12 – 9 Months
• Review Data & Establish Action
Plan to meet All Empirical
Outcome SOEs
• Writing Assignments &
Resourcing
• Final SOE Delivery Schedule
• Begin Content & Copy
Editing
• Determine Final Publishing
Date
• Determine ANCC Electronic
Submission Notification Date
Nearly
100%
Success
with 50+
Clients
• Professional Practice Model Developed
Expertly Managed
Understanding | 4
Magnet® Phases
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Phase I – Application
Phase II – Submission of Documentation
Phase III – Site visit
Phase IV – Commission on Magnet®
Decision
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Maintaining Magnet®
 Redesignation – every four years
 Annual demographic data collection tool
(DDCT)
 2- year report
 Patient Satisfaction
 Nurse Sensitive Clinical Indicators
 RN Satisfaction
 Repeat application, documentation and
site visit every 4 years
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What’s Our Timeline?
30-Month Reporting Period
Documentation
submission
year 2014
Reporting Period
Begins:
October February
2014
2015
April
2011
August
2012
April
2015
June
2015
August
2015
October December February
2012
2012
2013
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Reporting Period
Reporting Period
All Sources of Evidence should refer to data,
interventions, initiatives, events, and activities for
the 30-month period prior to the submission of
written documentation.
*Pre-data may precede the 30-month reporting
period
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Eligibility Criteria
 CNO with masters degree @ application
 CNO with either BSN or MSN @
application
 100% of all nurse leaders with degree in
nursing, including nurse educators (BSN
or graduate)
 Degree criteria: all interim
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Eligibility Criteria

All nurses direct or indirect reporting relationship to
CNO
 CNO participates on top committees/bodies
 All nursing areas must be included
 Compliance with all local, state, and federal laws and
regulations: OSHA, DHHS, EEOC, US DL, NLRB
 Notification of events: adverse patient outcome, need
for inspection by state or federal agency, ULP charges
or other legal violations (RNs)
 No suspension or exclusion from federal or state
health care programs
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2014 Model
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2014 Application Manual
 Must be used as of August 2014
 Options of 2008 or 2014 Manual for April
or June 2014 designations
 Some SOE requirements do not go into
effect until April 2016 :
 EP3EO: RN Satisfaction
 EP23EO: Ambulatory Data
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2014 Magnet® Documents
 DDCT (demographics)
 Organizational Overview

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20 components
Not scored, base line data—but very important!
 Narratives

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49 Sources of Evidence (SOEs)
350 single-spaced pages


Excludes Organizational Overview
Excludes SOEs for RN satisfaction, patient satisfaction and
NSI
 Supporting Evidence

Maximum of 5 per example
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Evidence and Exhibits
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Strategic Plans, Org Charts
Policies and Procedures
Committee Charters
Bylaws
Quality, PI, Board Reports
Algorithm / Flowchart
Screenshots of web pages, email messages
Data
Meeting minutes and/or rosters
Professional Practice Model schematic
**EVIDENCE MUST BE RELEVANT TO THE NARRATIVE**
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Quality: Addressing The Big 3
The Bermuda Triangle
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Nationally Benchmarked Data
Patient
Satisfaction
Exemplary
Professional
Practice
Nurse
Satisfaction
RN Clinical
Indicators
Must contribute to the
national benchmark used
for comparison
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Nurse-Sensitive Quality
Indicators
EP22EO
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Quality Data Display
 Unit or clinic-level data that outperforms the mean
or median of a national database
 The following 4 indicators for all acute care
organizations with or without ambulatory or
outpatient services
1.
2.
3.
4.
Falls with Injury
Hospital-acquired pressure ulcers (HAPU) stage 2 and
above
Central line-associated bloodstream infection (CLABSI)
Catheter-associated urinary tract infection (CAUTI)
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EP22EO
Acute Care with Amb/
Outpatient
Acute Care without
Amb/Outpatient
Amb/Outpatient
Services Only
1.
2.
1.
2.
1.
3.
4.
5.
6.
Falls with Injury
HAPU stage II
or >
CLABSI
CAUTI
One indicator
from Core
Measure Sets
(pg 52)
One indicator
from primary or
specialty outpt
3.
4.
5.
Falls with Injury
HAPU stage II
or >
CLABSI
CAUTI
Two indicators
from Core
Measure Sets
(pg 52)
Two nurse
sensitive
clinical
indicators from
primary or
specialty
outpatient
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Use of National Databases
 Use national database comparatives for:
– Falls with injury
– HAPU stage II or >
– CLABSI and CAUTI
Further Requirements:
–
Most recent 8 quarters of unit level data
–
Database mean or median against your mean or median
(apples to apples)
• Update for slight variation each quarter
–
See page 49 of 2014 Application Manual
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Use of Benchmarks or
Professional Standards
 Core Measures Data
– Org level data
– National benchmark by CMS
 Nurse-Sensitive clinical indicator from
primary OR specialty outpatient services
– Comparative may come from a national
database, or internal benchmark based on a
professional standard/national goal, literature
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review
Not every unit will be included in EP22EO
NSI benchmarked data
HOWEVER
It remains an expectation that nursesensitive quality indicators are to be
tracked and trended everywhere nursing
is practiced. This condition of
environment will be evaluated onsite!!
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RN Satisfaction Data
EP3EO
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Requirements for EP3EO
Unit- or clinic-level nurse (RN) satisfaction data
outperform the mean or median of the national
database used. Note: Benchmark used must be one to
which the organization contributes data.
► Provide unit-based, national benchmarked nurse (RN)
satisfaction data from the most recent survey
administered within the previous 30 months before
documentation submission.
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Until April 1, 2016 organizations may use the
2008 Application Manual EP3EO:
This is an ANCC update posted October 2013!!
–
–
–
Nurse satisfaction or engagement data aggregated
at the organization or unit level outperform the
mean, median, or other benchmark statistic of the
national database used.
Demonstrate out performance by subscale
Include participation rates, analysis, and evaluation
of the data.
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How to Display
RN Satisfaction Graphs
One graph for each unit with a bar for every subscale
Label Graph with the following:
»
»
»
»
»
»
Organization’s Unit Name
Unit Type (e.g., critical care, medical)
National Database Vendor
Subscale Categories
Date of Survey
Mean or Median (benchmark)
Refer to page 44 of the 2014 Magnet Application Manual
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Effective as of April 1, 2016
Nurse (RN) satisfaction survey must include questions
related to the following seven categories. Data
must be submitted on your choice of four of the
following seven categories:
1.Autonomy
2. Professional development (education, resources, etc.)
3. Leadership access and responsiveness (includes nursing
administration/CNO)
4. Interprofessional relationships (includes all disciplines)
5. Fundamentals of quality nursing care
6. Adequacy of resources and staffing
7. RN-to-RN teamwork and collaboration
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What Does this Mean for You
Today?
 Look at which RN Satisfaction Survey
you participate in!
 Must choose one with these subscales!
 “Nurse Satisfaction Survey” not
engagement survey with isolated RN
data
 Register now to participate in this survey
in 2014!
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Patient Satisfaction Data
EP23EO
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What Data Should be Presented
in EP23EO?
 Do NOT use HCAHPS data
•
•
Not presented at the unit level
Data presented in HCAHPS is aggregated by
category and not question-specific
 Data must come from a national vendor
where data is collected and the facility is
a member
 All inpatient, outpatient, and ambulatory
units
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Oct 2013 ANCC Update
Ambulatory areas:
 Ambulatory data may be compared to internal
goals and presented for each indicator until
February 2016, if national benchmarks are not
available.
 Starting April 2016: ambulatory data,
compared to national benchmarks, must be
presented.
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What Data…..continued
 Use the same, most recent 8 quarters of
data for all units
 “Clinic-level” for outpatient and
ambulatory settings if applicableotherwise, unit level data
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Addressing EP23EO
For each of the six indicators provided, describe the
outperformance of that indicator for the appraisers
where the graphs are displayed:
“The nine inpatient units and two ambulatory settings
eligible for patient satisfaction scores for nurses providing
education about symptoms and problems to look for
outperformed the mean top box scores for the Press
Ganey HCAHPS All Hospitals Database in all of the last
eight quarters, or 100 percent of the time. (Attachment
EP23EOa, Patient Satisfaction Graphs for Education)”
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Any Room Left???
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The Organizational Overview
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Vocabulary Time
Clinical Nurse
 Direct care nurse (can include APNs)
Nurse Manager
 24/7 accountability
Nurse Leader
 Between the nurse manager and the CNO (not
inclusive of the mgr or CNO)
CNO
 The one and only
Nurses
 Any of the above
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CNO

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TL3EO
TL4 (2 examples)
TL6* (mentoring and
succession planning for
all levels)
TL8* (also includes
clinical nurses)
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Clinical Nurses
TL2
TL6* (all levels)
TL7* (also includes
nurse leaders)
TL8* (also includes the
CNO)
TL9EO* (also includes
nurse leaders)
SE1EO
SE2EO
And the list goes on

Nurse Manager
TL6* (all levels)
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Did you catch that?
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Nurse Leader
TL2
TL6* (all levels)
TL5
TL7
TL8
TL9EO* (also includes
clinical nurses)
SE9 * (also includes
clinical nurses)
And the list goes on
Nurses
 SE4EO
 SE6
 SE10EO
 SE11
 EP4
 EP5
 EP6
 EP12
 EP17
 And the list goes on
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FYI
Nurse Leader as defined in the
Manual Glossary (pg 71) and in
the FAQ of the Magnet Website



Positioned between the nurse
manager and the CNO
If no positions exit between the
manager and CNO, nurse
managers may be used even if
they do not have authority over
multiple units
The nurse educator that is the
dept head or director of all nurse
educators
Nurse Leader in EP15

The CNO may be
included as a nurse
leader in this example
(pg. 47 of manual)
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5 pieces of evidence per example
Evidence:

Policies

Minutes

Screenshots

Care plans

Emails
*if you attach it or reference a document from the Org Overview, count on it as
one of your 5 pieces of evidence
Not Evidence:

Self-generated table (i.e.; membership table)
Marginal:

Pictures- can go either way!! Proceed with caution!
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Questions ?
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