nurse sensitive outcome indicators: what they are and how ... · case study your staff are...

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Nurse Sensitive Outcome Indicators: Nurse Sensitive Outcome Indicators: What They Are and How They Are What They Are and How They Are

Measured and BenchmarkedMeasured and Benchmarked

Hosted By: Hosted By: The Washington State, The Washington State,

Ruckelshaus Nurse Staffing Steering Ruckelshaus Nurse Staffing Steering CommitteeCommittee

© CALNOC October 2008: All rights reserved1

Presenters• Gladys Campbell, RN,

MSN, Executive Director, Northwest Organization of Nurse Executives

• Mary Foley, RN, MS, PhD(c), Associate Director, Center for Nursing Research & Innovation, UCSF School of Nursing

Background Information• History: Legislative Concerns• Goal: Collaborative work on nurse staffing,

including nurse sensitive outcome indicators• Parties to the process:

– SEIU 1199 Healthcare– United Staff Nurses Union 141 UFCW– Washington State Nurses Association– Washington State Hospital Association– Northwest Organization of Nurse Executives

Legislation• Hospital Based Nurse Staffing

Committees– Composition – at least 50% bedside

staff nurses– Create nurse staffing plans– Staffing plans reviewed and accepted or

rejected by the CEO– Post staffing plans

Memorandum of Agreement• Report staffing as part of adverse event

reporting (this is now a regulation)

• Collection of data on Nurse Sensitive Quality Indicators (NSQI)

• Survey what indicators hospitals are collecting

• Identify and collect data on at least five NSQI to be collected by Washington hospitals and shared with their staffing committees

Washington State: Nurse Sensitive Quality

Indicators• Falls• Falls with injury• Pressure ulcers• Nursing hours per patient day• Skill mix

Reporting• National Database of Nursing Quality

Indicators • Collaborative Alliance for Nursing

Outcomes• Washington State Hospital Association

NURSING SENSITIVE QUALITY NURSING SENSITIVE QUALITY INDICATORS: THE ORIGININDICATORS: THE ORIGIN

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Professional NursingProfessional Nursing and the Origin of Evidenceand the Origin of Evidence

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Documenting Nursing Documenting Nursing EffectivenessEffectiveness

•• Florence Nightingale, founder of Florence Nightingale, founder of modern nursing was a visionary modern nursing was a visionary

•• What Florence Nightingale was What Florence Nightingale was documenting in the 1800s we are still documenting in the 1800s we are still trying to prove: Nurses make a trying to prove: Nurses make a difference in patients, families, and difference in patients, families, and communitiescommunities

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Florence Nightingale Made Changes, and Kept Records, to Document Care Improvements at Scatari, 1855

Death rate peaked in February 1855 at mortality rate of 43% of cases treated. Reforms began in March and within 6 months the mortality rate was 2%

Source: Cohen, Florence Nightingale. Scientific American 250(3) March 1984.11

What Is the History of Nurse Sensitive Quality Indicators?

• In 1994, The American Nurses Association (ANA) started a long-term commitment to establish that patient care (quality and safety) was linked to nursing care.

• The purpose of this work was to educate nurses, consumers, and policy makers about nursing’s contribution to inpatient hospital care.

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The Nursing Care Report Card for Acute Care, 1995

• The ANA commissioned a study to determine the nature and strength of the linkages and eventually the first list of possible indicators was narrowed from over 100, to 71, 21, and ultimately, to 11 nursing quality indicators.

• Pilot tests were conducted in 1996 (CALNOC was one of the pilots, conducted in California) to test the 11 indicators.

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The Agency for Health Quality Research

AHRQ funded research that further promoted the connection between nurse staffing, nurse work environments, and safe patient care

IOM Report Specific to Nursing

• Released in 2004• Organizational

culture should reflect a safe environment to encourage the reporting of errors, analysis, and prevention

What Does “Nurse Sensitive” Mean?

• Nurse sensitive quality outcomes are those patient outcomes that have been found, by clinical research, to be uniquely linked to the presence or absence of nursing care.

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NURSING SENSITIVE QUALITY INDICATORS: DEFINITIONS OF THE INDICATORS

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National Quality Forum (NQF)National Quality Forum (NQF)--endorsed endorsed NursingNursing--Sensitive MeasuresSensitive Measures

Currently there are 15 Nurse Sensitive Currently there are 15 Nurse Sensitive Indicators:Indicators:

1. Failure to rescue1. Failure to rescue2. Pressure ulcer prevalence2. Pressure ulcer prevalence3. Falls 3. Falls 4. Falls with injury4. Falls with injury5. Restraint (vest and limb) prevalence 5. Restraint (vest and limb) prevalence

Purpose – to promote highest quality and outcomes

NQF-endorsed Nursing- Sensitive Measures cont.

6. Urinary catheter6. Urinary catheter--associated UTI (ICU)associated UTI (ICU)7. Ventilator7. Ventilator--associated pneumonia (ICU)associated pneumonia (ICU)8. Central line catheter8. Central line catheter--associated associated BSIsBSIs (ICU)(ICU)9. Smoking cessation counseling for AMI9. Smoking cessation counseling for AMI10. Smoking cessation counseling for heart 10. Smoking cessation counseling for heart

failurefailure11. Smoking cessation counseling for 11. Smoking cessation counseling for

pneumoniapneumonia

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12. Skill Mix12. Skill Mix13. Nursing care hours per patient day13. Nursing care hours per patient day14. Practice Environment Scale14. Practice Environment Scale--Nursing WorkNursing Work15. Voluntary Turnover15. Voluntary Turnover

NQF-endorsed Nursing- Sensitive Measures

Quality of Care: How is it Quality of Care: How is it Defined*Defined*

•• By StructureBy Structure-- resource use or resource use or characteristics of the environmentcharacteristics of the environment

•• By ProcessBy Process-- the tools and activities the tools and activities used to improve care (think of risk used to improve care (think of risk assessments, admission data bases)assessments, admission data bases)

•• By OutcomesBy Outcomes-- Benefits to the patientBenefits to the patient*Defined by *Defined by DonabedianDonabedian, 1980, 1980

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Skill Mix and Patient Skill Mix and Patient Care HoursCare Hours-- Examples Examples of Structural Measuresof Structural Measures

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Nursing Staffing Nursing Staffing CharacteristicsCharacteristics

Total nursing hours Total nursing hours per patient day per patient day (HPPD)(HPPD)

RN HPPDRN HPPDLPN HPPDLPN HPPDUAP HPPDUAP HPPD

Skill MixSkill Mix% Agency Hours% Agency Hours

Turnover RateTurnover RateNational Quality National Quality ForumForumMagnetMagnet

Job SatisfactionJob Satisfaction

RN CharacteristicsRN CharacteristicsEducationEducationCertificationCertificationYears of ExperienceYears of Experience

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Nursing Staffing CharacteristicsNursing Staffing Characteristics

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Problems exist in the measurement and benchmarking of nursing hours per patient day (NHHP) secondary to a lack of consistency in definition of terms, and a lack of consistency in “who” is included in the hours – including:

• Fixed and Variable FTE

• Direct and Indirect Nursing Hours

• Productive and Nonproductive Nursing Hours

Case Study

Your staff are complaining that they are overworked. They tell you they don’t get breaks, can’t accomplish their tasks and need more staff. What you see on your daily rounds validates this… in fact you are worried that the staffing may be unsafe. As you fill out your requisition to post for a new position you notice that your Budgeted HRS/UOS are 25.24 and yet the actual HRS/UOS are 27.2. When you turn in your requisition for additional staff this request is rejected by your manager and you are told you cannot have more staff as you are already over budget. What’s wrong??

Case Study Case Study –– Analyzing Labor Analyzing Labor Productivity Against the BudgetProductivity Against the Budget

Example Score Board

Actual

.70Budgeted

.54Actual

5Budgeted

3Actual

16Budgeted

18Actual

21.7Budgeted

21.54Actual

5.5Budgeted

3.7

Education Hours (nonproductive)

Nonproductive Hours

(Benefit Time)

Direct HoursTotal HoursTotal Hours

Variable HoursFixed Hours

Actual HRS/UOS –27.2

Budgeted HRS/UOS –25.24

Having the Data to Analyze the Problem… Analysis of Variance

Indirect Hours Indirect Hours (education (education time etc.)time etc.)

Hospital Acquired Hospital Acquired Pressure UlcersPressure Ulcers--

An Outcome MeasureAn Outcome Measure

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Hospital Acquired Pressure Hospital Acquired Pressure UlcersUlcers

•• According to the National Pressure According to the National Pressure Ulcer Advisory Panel (NPUAP), Ulcer Advisory Panel (NPUAP), Pressure Ulcers are measured by Pressure Ulcers are measured by IncidenceIncidence and and PrevalencePrevalence–– Incidence is the rate of new ulcers in a Incidence is the rate of new ulcers in a

population over timepopulation over time–– Prevalence is the number of old and new Prevalence is the number of old and new

cases at any one time (like a specific day)cases at any one time (like a specific day)

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Hospital Acquired Pressure Ulcer Hospital Acquired Pressure Ulcer IndicatorIndicator

Definition:• Pressure Ulcers are measured as the

percent of patients with stage I, II, III, IV and Unstageable ulcers.

• CALNOC collects both • Benchmarking is performed against

prevalence

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Falls=Outcomes Falls=Outcomes

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Falls, and Falls with InjuryFalls, and Falls with Injury•• The concern is of course with patient The concern is of course with patient

injury, but all falls in fact have a risk of injury, but all falls in fact have a risk of injuryinjury

•• While the fall is an outcome measure, While the fall is an outcome measure, many process measures are employed many process measures are employed to assess and mitigate riskto assess and mitigate risk

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There Are Steps That Can There Are Steps That Can Improve Accuracy of Process Improve Accuracy of Process

MeasuresMeasures•• There are common national There are common national

definitionsdefinitions•• There are clearly defined and There are clearly defined and

consistent processes when consistent processes when activities are expected to be activities are expected to be performedperformed

•• Reliable tools help make the Reliable tools help make the activities more comparable activities more comparable

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NURSING SENSITIVE QUALITY NURSING SENSITIVE QUALITY INDICATORS ARE ENDORSED INDICATORS ARE ENDORSED AS NATIONAL STANDARDSAS NATIONAL STANDARDS

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QUALITYQUALITY——A National FocusA National Focus

PresidentPresident’’s Advisory Commission on Consumer Protection and Quality in the s Advisory Commission on Consumer Protection and Quality in the Health Health Care Industry Report (1998).Care Industry Report (1998).

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What is the What is the National Quality Forum?National Quality Forum?

The mission of NQF is to improve The mission of NQF is to improve American healthcare through the American healthcare through the endorsement of consensusendorsement of consensus--based based standards for measurement and public standards for measurement and public reporting of healthcare performance data reporting of healthcare performance data that provides meaningful information that provides meaningful information about whether care is safe, timely, about whether care is safe, timely, beneficial, patientbeneficial, patient--centered, equitable, centered, equitable, and efficient.and efficient.

NQF 2004

The first 15 Nursing Sensitive Measures undergo extensive review, evaluation, and consensus approval

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NQF 2006

As defined by NQF, the number of “never events” is not known, but what is known is that they result in many deaths and additional health care costs.

Significant implications for nursing include the non- payment for Hospital Acquired Pressure Ulcers and Falls (2 of the critical NSQI you will track)

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CMS Roadmap – The ultimate strategic goal –“The right care for every

person every time.”

http://www.cms.hhs.gov/

Centers for Medicare and Medicaid Services:

Non-Payment for Never Events

CMS declares there should not be CMS declares there should not be payment for payment for ““never events,never events,”” like like surgery on the wrong body part or surgery on the wrong body part or mismatched blood transfusion. mismatched blood transfusion.

Washington State Focus• Adverse events reporting• Pledge Not to Bill for Never Events

– Washington State Hospital Association, Washington State Medical Association, Washington Association of Ambulatory Surgery Centers

• Health Care Authority: Planning for Non- Payment for Never Events

Benchmarking with Nurse Benchmarking with Nurse Sensitive Quality IndicatorsSensitive Quality Indicators

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What is a What is a ““BenchmarkBenchmark””??•• In nonIn non--health terms, it is a standard, health terms, it is a standard,

norm, or norm, or ““yardyard--stickstick”” to judge one's to judge one's performance as an individual or performance as an individual or company.company.

•• It is a standard measurement or metric It is a standard measurement or metric used to evaluate the performance of used to evaluate the performance of any entity, from schools, to stock any entity, from schools, to stock portfoliosportfolios

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Benchmarking ReportsBenchmarking Reports•• The purpose of a benchmarking report The purpose of a benchmarking report

in healthcare is to give a hospital, and in healthcare is to give a hospital, and your committees, a succinct summary your committees, a succinct summary of your own performance, together with of your own performance, together with the performance of the performance of ““likelike”” hospitalshospitals

•• Hospital level data may be helpful to Hospital level data may be helpful to senior leaderssenior leaders

•• Unit level data is most useful for Unit level data is most useful for clinicians and clinical leadersclinicians and clinical leaders

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Examples of Benchmarking Examples of Benchmarking Reports from the CALNOC Reports from the CALNOC DataData

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Staffing Effectiveness Report by Unit – MonthlyFalls per 1000 Pt Days with Percent Other (Unlicensed) Hours of Care

From JANUARY 2007 To JULY 2008Unit Name: AOU

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CalNOC Falls Over Time Falls per 1000 Patient Days

All Hospitals Reporting1998-2005

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

Q2 98

Q3 98

Q4 98

Q1 99

Q2 99

Q3 99

Q4 99

Q1 00

Q2 00

Q3 00

Q4 00

Q1 01

Q2 01

Q2 01

Q4 01

Q1 02

Q2 02

Q3 02

Q4 02

Q1 03

Q2 03

Q3 03

Q4 03

Q1 04

Q2 04

Q3 04

Q4 04

Q1 05

Q2 05

Quarter

Falls

per

100

0 Pa

tient

Day

s

MS CCU SD

Performance by averages by type of unit

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QUESTIONS FOR THE QUESTIONS FOR THE STAFFING COMMITTEES:STAFFING COMMITTEES:

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Seeking the Information You Will Need

• Where in your facility will you find information on staffing?

• How is that information collected (hours/skill mix)?

• How are patient days collected?• Who keeps the records for Falls?

Pressure Ulcers?

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Part II: Nurse Sensitive Quality

Indicators• Friday, June 19, 2009 (8:00 - 10:00 AM)• Topic: How Staffing Committees Can

Use the Indicators to Measure Staffing Effectiveness

• For connection information, go to www.wsha.org; click on “web casts”, then “View Connection Information”

http://www.wsha.org/

Thank You for Participating! Questions?

Program Evaluation• At the end of this webcast we will be

emailing you a survey so that you may provide us feedback on our presenters and the usefulness of this presentation.

Thank You!

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