67 Putting Principles to Action Victoria L. Rich, PhD, RN, FAAN Chief Nurse Executive, Penn Medicine Associate Executive Director, Hospital of the University

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Putting Principles to Action

Victoria L. Rich, PhD, RN, FAANChief Nurse Executive, Penn Medicine

Associate Executive Director, Hospital of the University of Pennsylvania Associate Professor of Nursing

Administration, University of Pennsylvania School of Nursing

Safe Practices WebinarJanuary 21, 2010Toll-free Call-in number: 1-866-814-8482

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# 9 Nursing Workforce#10 Direct Caregivers

National Quality Forum Safe Practices

Toll-free Call-in number: 1-866-814-8482

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#9 Nursing Workforce

NQF SP #9


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Nurse researchers have long explored the relationship among RN staffing, skill mix, and hospitalized patient outcomes. Seminal studies such as 1996 IOM Report and others have demonstrated that increases in the numbers of RNs caring for patients in all settings, as education and experience, result in few complications, lower mortality, fewer medication errors, and lower costs.

Background to Current Problem


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Despite the:• 1996 IOM Report• 1999 ANA Principles for Nurse Staffing quality report

card• 2004 National Database for Nursing Quality Indicators

(NDNQI)• 2004 National Quality Forum: 15 Nursing sensitive

quality measures and, as of 2009, 12 states have mandated nurse ratios and 15 have restrictions on mandatory overtime.

• Healthcare organizations retain considerable flexibility in their nurse staffing strategies.

NQF SP #9

Rich VL. AHRQ Web M&M 2009 August


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• A Nursing Workforce that provides safe, evidence-based care begins with the yearly, complex “budgetary dance of the stakeholders.” The stakeholders include nurse leaders, clinical nurses, physicians, hospital administrators, financial offices, regulations, patients, and families.

• It is imperative that the Senior Nurse Leader shepherd and provide nursing sensitive outcome data that substantiates evidence-based nurse/patient ratios.

Nursing Workforce Safe Practice Statements

NQF SP #9


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Both the American Nurses Association (ANA) and the American Organization of Nurse Executives (AONE) state that staffing patterns should not be mandated or standardized, but determined, created, and monitored:

NQF SP #9

• With input from direct care RNs• Based on number of patients and acuity• Based on number of admissions, discharges and transfers each shift• Based on culture of MD/RN-respectful workplace• Based on RN experience• Based on other factors such as orientation, shift leadership, support

staff, physical design of unit, vacancy, and turnover• Based on RN ratio benchmarked with specialty and like hospital

organizationsRich VL. AHRQ Web M&M 2009

AugustToll-free Call-in number: 1-866-814-8482

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I. Focus on new hire on-boarding

Action-Oriented Framework for Safe Practice: Nursing Workforce

NQF SP #9

• Create specialty expertise: highly structured

• Peer hiring screens

• New hire support system: preceptor/residency

II. Address market-driven factors• Market-based competition

• Customized scheduling

• Professional and personal development programs

• Reward/recognition

III. Creation of engaged culture

75HUP-NMEPP©, Jost SJ, Rich VL. NAQ 2009Toll-free Call-in number: 1-866-814-8482

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Take-Home Points• Conduct failure mode effect analysis on nurse staffing for each unit in

order to develop strategies and options to use when staffing levels are not adequate.

• Create an internal resource pool for flexibility and census adjustments.

• Communicate all action plans to staff nurses on the unit plus interdisciplinary and administrative stakeholders.

• Empower staff nurses to identify solutions for staffing issues. Administer annual nurse satisfaction survey, such as NDNQI, to measure and assess if staffing plan is safe and adequate according to nursing staff. Annually involve staff nurses in staffing decisions made for budgetary purposes.

• Benchmark staffing ratios annually with other facilities and correlate with patient outcomes, adverse events, and root causes. Provide data about quality outcomes as evidence to assist in determining future staffing needs. Evaluate patient satisfaction feedback closely and correlate with nurse staffing plan.

Rich VL. AHRQ Web M&M 2009 AugustToll-free Call-in number: 1-866-814-8482

Beyond Measure:RN Vacancy Rates from FY 2005 to 200914%

12%

10%

8%

6%

4%

2%

0%

Hospital of the University of PennsylvaniaToll-free Call-in number: 1-866-814-8482 77

Beyond Measure:RN Turnover Rates from FY 2005 to FY 2009

14%

12%

10%

8%

6%

4%

2%

0%

Hospital of the University of PennsylvaniaToll-free Call-in number: 1-866-814-8482 78

2005

2006

2007

2008

2009

Hospital of the University of Pennsylvania

Beyond Measure:RN Retention Rates from FY 2005 to FY 2009

Toll-free Call-in number: 1-866-814-8482 79

NQF SP #10#10 Direct Caregivers

Toll-free Call-in number: 1-866-814-8482 80

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Licensed and unlicensed nurses assistants represent approximately 54% of healthcare workers. RNs constitute approximately 23% of this percentage. The other direct caregivers (31%) are pharmacists, respiratory therapists, physical therapists, transporters, technicians, technologists, healthcare assistants, etc.

[Bureau of Labor Statistics, IOM Report, 2004]

Background to Current Problem


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Although this group of caregivers does not have direct accountability and responsibility for the patients and families – they do directly impact and affect quality and safety outcomes.

Background to Current Problem (cont’d)

Increased adverse events are associated with staffing levels and competency of both nursing and non-nursing direct caregivers. Denham C. J Patient Saf

2008


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• An engaged interdisciplinary culture that is patient and family-focused is a 21st-century healthcare imperative.

• Boards of Trustees, Senior Executive Leaders, Physicians, Nurses, and Advanced Practice Providers must realize that truth, trust, and teamwork are iterative values to be exhibited to all and by all in the healthcare industry. (Denham C. 2006)

Direct Caregivers: Safe Practice Statement

NQF SP #10


84HUP-NMEPP©, Jost SJ, Rich VL. NAQ 2009

Direct Caregivers: Parity going forward


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I. Focus on new hires

Action-Oriented Framework for Safe Practice: Direct Caregivers

NQF SP #10

• Academic credentials

• Certifications/licensure

• Reading level

• New hire preceptor

• Orientation

II. Address market-driven factors• Market-based compensation

• Lifelong learning – competency

• Advancement opportunities

• Reward/recognition

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III. Focus on new hires

Action-Oriented Framework for Safe Practice: Direct Caregivers

(cont’d)

NQF SP #10

• Role clarification

• Conflict management

• Leadership and Peer Support

• Interdisciplinary respect and team involvement


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Take-Home Points• Provide lifelong learning, and yearly competency updates• Leaders celebrate quality outcomes that recognize, when appropriate,

all direct caregivers’ involvement• Include direct caregivers in Patient Safety and Quality Committees• Provide for 2-way communication forums to discuss conflicts and role

confusion among all caregivers• Involve direct caregivers in root cause and FMEA sessions• Represent direct caregivers as team members in all marketing

materials• Celebrate Interdisciplinary Patient/Family Care!


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Critical Care Manpower

Peter B. Angood, MD, FRCS(C), FACS, FCCMSenior Advisor, Patient Safety, National Quality Forum

Member of Safe Practices Steering CommitteeFormer Chief Patient Safety Officer and Vice President

for The Joint Commission

Safe Practices WebinarJanuary 21, 2010


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Statement

All patients in general intensive care

units

(both adult and pediatric) should be

managed by physicians who have

specific training and certification in

critical care medicine (“critical care

certified”).

Safe Practice 11


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• A “critical care certified” physician is one who has obtained critical care subspecialty certification by the American Board of Anesthesiology, the American Board of Internal Medicine, the American Board of Pediatrics, or the American Board of Surgery, or has completed training prior to the availability of subspecialty board certification in critical care in his or her specialty, and is board certified in one of these four specialties and has provided at least six weeks of full-time intensive care unit (ICU) care annually since 1987.

• Dedicated, critical care certified physicians shall be present in the ICU during daytime hours, a minimum of eight hours per day, seven days per week, and shall provide clinical care exclusively in the ICU during this time.

Additional Specifications


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• When a critical care certified physician is not present in the ICU, such a physician shall provide telephone coverage to the ICU and return more than 95 percent of ICU pages within five minutes (excluding low-urgency pages, if the paging system can designate them). When not in the hospital, the critical care certified physician should be able to rely on an appropriately trained onsite clinician to reach ICU patients within five minutes in more than 95 percent of cases.

• If it is not possible to have a dedicated, critical care certified physician in the ICU eight hours daily, an acceptable alternative is to provide exclusively dedicated round-the-clock ICU telemonitoring by a critical care certified physician, if the system allows real-time access to patient information that is identical to onsite presence (except for manual physical examination). [Rosenfeld,1999; Rosenfeld, 2000]

Additional Specifications (cont’d)

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Roles for the Patient Advocate

Mary Foley, RN, MS, PhD(c) Associate Director, Center for Nursing Research and

Innovation, University of California San Francisco School of Nursing

Safe Practices WebinarJanuary 21, 2010


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Upcoming Safe Practices Webinars February 18 – New Highlights in Infection

Prevention (Safe Practices 21 – 22)

March 18 – Introduction of NQF-endorsed® Safe Practices for Better Healthcare–2010 Update

Documents

67 Putting Principles to Action Victoria L. Rich, PhD, RN, FAAN Chief Nurse Executive, Penn Medicine Associate Executive Director, Hospital of the University