Annual Review of Nursing
Services 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)
2)
3)
4)
Improve inpatient care outcomes;
Positively affects clinical management;
Facilitates cost-effective quality nursing care
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 Outcomes
2007 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 Measures
AMI (Heart Attack)
ASA on arrival
ASA at D/C
ACEI or ARB at D/C
Smoking Cessation
Beta Blockers at D/C
Beta Blockers at arrival
Time to Fibrinolysis
Fibrinolytic Therapy in 30 minutes
PCI in 90 minutes
Time to PCI
Inpatient mortality
TJC
CMS
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Required Measures
CHF Indicators
Discharge instructions
LVEF Assessment
ACEI for LVED
Smoking Cessation
TJC
CMS
X
X
X
X
X
X
X
X
Required Measures
Pneumonia
Oxygen assessment
Influenza Vaccination
Pneumococcal Vaccination
Blood cultures in ED before antibiotic
Blood cultures in 24 hours
Initial antibiotic selection in immunocompetent
patients
Initial antibiotic selection in immunocompetent
patients ICU/Non-ICU
Initial antibiotic in 6 hours
Antibiotic timing
TJC
CMS
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Required Measures
SCIP (Surgical Care Improvement Project)
Prophylactic antibiotic 1 hour prior to incision
Prophylactic antibiotic selection
Prophylactic antibiotic D/C in 24 hours
Post-op glucose - Cardiac
Hair removal
Normothermia - Colon
Peri-operative Beta Blocker
VTE prophylaxis
VTE prophylaxis timely
TJC
CMS
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Required Measures
30 day mortality rates
TJC
CMS
AMI
Heart Failure
Pneumonia
X
X
X
HCAHPS
X
Pregnancy/Related conditions
VBAC
Inpatient infant mortality
3rd/4th degree laceration
X
X
X
Required Measures
CAC Indicators (Children's Asthma Care)
Relievers for inpatient asthma
Systemic corticosteriods
Home management plan of care
TJC
X
X
X
HBIPS Indicators (Hospital Based Inpatient
Psychiatric Care)
Admission screening
Physical restraint
Seclusion
Multiple antipsychotic Medications at D/C
Multiple antipsychotic Medications at D/C with
appropriate justification
Post discharge continuing care plan
X
X
X
X
X
X
CMS
Measures on the Horizon
IPPS Measures (Inpatient Prospective
Payment System)
TJC
43 Proposed
X
Nurse Sensitive Indicators
15 Proposed
X
Venous Thromboembolic Disease
8 Posssible measures
X
Blood Management
19 Possible measures
CMS
X
Required Measures – HCAHPS
Hospital 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 CatheterAssociation 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 hospitalacquired 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 Measures
Patient-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.
b.
c.
d.
e.
nurse participation in hospital affairs;
nursing foundations for quality of care;
nurse manager ability, leadership and support of nurses;
staffing and resource adequacy; and
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?