The Health Roundtable

1. The Health Roundtable Nursing Workforce Sustainability Group 4 April 2008

2. Health Roundtable UHC IHI An Innovation Clearinghouse • Share problems • Share solutions • Develop skills • Compare results • Provide CEO network

3. 40 Organisational Members – 76 Hospital facilities

4. Health Roundtable Program for 2008 Core Optional

5. Today’s Agenda

6. 1.Knowledge 1.Knowledge 3. Decision 3. Decision 2. Persuasion 4. Implementation 5. Confirmation Fostering Innovation The Health Roundtable Process From Everett Rogers

7. Focus on Benchmarking for Innovation… • Voluntary comparisons • Search for differences • Data Methods • Clinical Practices • No “right or wrong” • Opportunity focus • Gradual fine-tuning

8. …Not Benchmarking for Accountability • Mandated • Uniform • Tightly defined • Score – “win/lose” • Denial “by losers” • Gaming the system • “Inspectors” needed

9. Four Key Lessons

10. Basic Questions • Are our results different? • Why are we different? • Who can we learn from? • How do they do it? • How can we make it happen here?

11. Nursing Workforce Sustainability Group Draft Charter • Identify evidence-based innovations that provide improved patient care and provide a working environment that supports nursing workforce sustainability. • Collect and evaluate data that links patient morbidity and satisfaction outcomes with nursing attraction and retention outcomes. • Focus attention on: • Identifying future trends and directions for nursing (e.g. Workforce projections) • Organising nursing staff working hours and optimising flexibility • Understanding key components of role of the nurse, and scope of practice issues • Improving nursing staff retention • Evaluating the data on • Skill mix – Casual / Agency; RN / EN, management competencies • Nursing Ratios (Casemix adjusted hours / day) • Patient related morbidity indicators (e.g. UTI, pressure ulcers, wound infection) • Develop Action Plans(targets and key strategies) specific to local needs and concerns. • Follow upprogress against action plans and targets with e-mail discussion groups.

12. Nursing Workforce Sustainability Group • Worked closely with Di Twigg (Sir Charles Gairdner), Sharon Donovan (Bayside), and Veronica Casey (PAH) on their development • Developed initial Nursing-Related Patient Care Indicators based on the Coding Rules for Adverse Outcomes developed by Needleman et al. (2002) • additional New Zealand/Australian Coding adjustments were developed by Barbara McCloskey, RN, DNSc • Included initial survey focused on Nurse workforce staffing and demographics • First meeting today to review materials and identify issues and changes required • Need direction from you on how to proceed in future • Steering Group Composition • Topic for October

13. Nursing Workforce SustainabilityData Available • Nursing-Related Patient Care Indicator Report Note: Each hospital also has its own report, with their comparator group based on their hospital level (Level 1, 2) 2. Nursing Data Dictionary 3. Briefing document containing the survey data and a summary

14. Nursing Workforce Sustainability KPI Report • Contains 13 measures covering: • ALOS • Rate of: • UTI • Pressure ulcers • Hospital-acquired pneumonia • Shock • GI bleeding • Hospital-acquired sepsis • DVT • Central Nervous System Complications • Surgical Wound InfectionPulmonary Failure • Metabolic Derangement • Failure to Rescue • Based on Casemix data

15. Nursing Workforce Sustainability KPI Report • All Measures are defined in the Nursing Data Dictionary • Combination of ICD-10 and DRG Inclusions, Exclusions • Matches Dr. McCloskey’s work (based on the Coding Rules for Adverse Outcomes developed by Needleman et al. (2002) )

16. Nursing Data Dictionary • All measures have the following exclusions from episodes potentially sensitive to nursing • LOS less then 1 and greater then 90 days • Age less then 18 • MDC 14 (Obstetrics) • MDC 15 (Newborn) • MDC 19 (Mental Illness) • MDC 20 (Substance Abuse) • Error DRGs 9*

17. KPI Report Summary

18. KPI Summary highlights methodology issues and perhaps nursing issues

19. Average Length of Stay Jaguar and Regulus have the lowest Lengths of Stay – 3.0 and 4.6 days respectively. Polaris >8 days Nursing-Related Patient Care indicator report, N1.01

20. Rate of Urinary Tract Infections Range between 1% and 6.4%. Jaguar and Gemma are both under 2% Nursing-Related Patient Care indicator report, N1.02

21. Rate of Pressure Ulcers Jaguar was a 0% rate-is this correct? Achilles and Polaris both over 2% Nursing-Related Patient Care indicator report, N1.03

22. Rate of Hospital-Acquired Pneumonia Jaguar low again at 0.8% - due to patient mix… Titan, Achilles, Polaris, Scorpio, Achilles2 all >7% Nursing-Related Patient Care indicator report, N1.04

23. Rate of Shock or Cardiac Arrest Altair, Titan, and Jaguar all very low, under .2%. Achilles >1.6% Nursing-Related Patient Care indicator report, N1.05

24. Rate of Upper Gastrointestinal Bleeding Jaguar and Titan both at zero. Athene over 2% Nursing-Related Patient Care indicator report, N1.06

25. Rate of Hospital-Acquired Sepsis Jaguar and Titan at .1%. Most hospitals between 1 and 2% Nursing-Related Patient Care indicator report, N1.07

26. Rate of DVT Very tight range. Less than .5% separate the 25th percentile from the 75th percentile. Dionysis and Cougar both >2% Nursing-Related Patient Care indicator report, N1.08

27. Rate of CNS Complications The highest and the lowest hospitals differ by a factor of 10, with others spread out from .4% to 3.9% Nursing-Related Patient Care indicator report, N1.09

28. Rate of Surgical Wound Infection Titan less than 1/3 the rate number of the next hospital Nursing-Related Patient Care indicator report, N1.10

29. Rate of Pulmonary Failure Jaguar, Titan, Orion and Demeter in lowest quartile – Scorpio highest Nursing-Related Patient Care indicator report, N1.11

30. Rate of Metabolic Derangement Another measure with a broad range; Titan at 1.9% Achilles at 14% Nursing-Related Patient Care indicator report, N1.12

31. Rate of Failure to RescuePresence of any of the previous indicators anda discharge of death. Achilles, Polaris higher than the group; Jaguar much lower (limited patient range) Nursing-Related Patient Care indicator report, N1.13

32. Small Group Discussion Are our results unexpected? What hypotheses about differences? Ideas to improve casemix data comparability?

33. Is measure really related to nursing? Surgical wound infections not related to nursing-it is more surgical technique and what occurs in the OR GI bleeding, CNS complications, and even UTI-difficult to see how this directly is influenced by nursing. It’s more about how managed. Difficult to understand how GI bleed is a nurse-sensitive indicator Data Issues

34. Trends over time Definitional issues (3 measures are surgical only) Pressure ulcers prevalence-documentation notoriously inaccurate GI Bleeds: ? Data exclusions Sepsis is high because hospital tests all patients for VRE Were some of the exclusions included? Inclusion of spinal pts and ventilation nursing would skew data—how can this be adjusted for casemix complexity? Potential confounding issue of palliative care, respecting patient choices with Failure to Rescue rate Care type needs to be factored in Data Issues

35. New Indicators Patient Falls (falls per 1000 bed days) Complications from falls Medication incidents Unplanned return to OR UTI Breakdown to post-insertion (IDC) infection rates IV infection rate Nursing Turnover Rates Hospital acquired MRSA / VRE Exclusions Exclude COPD admissions with acute exacerbation from the pneumonia data as these would normally be coded with pneumonia as a secondary diagnosis Ideas to Improve

36. Introduce risk adjustment Casemix Patient groups By hospital classification Compare peer groups across states Validate indicators against other data sources e.g. other databases (pressure ulcers, cardiac arrests) Ideas to Improve

37. Part II. Survey Data

38. Nursing Workforce Sustainability Briefing Document • Collation of all survey responses • 53 questions covering: • Nursing Demographics • Workforce Characteristics • Measurement • Nursing Practice/Innovation • Executive Summary discusses some of the highlights of the data

39. Total Nursing Positions Highest at Panther at 2075, lowest at Titan at 172 Nursing PreMeeting Survey, 1.1

40. Percent Vacancy Apollo reported 0 vacancies for budgeted positions, whereas Electra is at nearly 20% Nursing PreMeeting Survey, 1.2/1.1

41. Distribution across the hospital Nursing PreMeeting Survey, 1.3a-1.3h

42. Number of Registered Nurses 4 hospitals employ 2000+ nurses Nursing PreMeeting Survey, 2.1

43. Percent of nursing staff who are Registered Nurses In half of the hospitals, over 90% of nurses are registered nurses Nursing PreMeeting Survey, 2.1/(2.1+3.1+4.1)

44. Registered Nurses-Direct Patient Care 70%-95% of all employed Registered Nurses are involved in direct patient care Nursing PreMeeting Survey, 2.2/2.1

45. Percent of New Graduates Over 10% of Falcon’s and Vulcan’s RN staff are new graduates Nursing PreMeeting Survey, 2.3/2.2

46. Percent of Specialty Qualified Nurses High percentage with specialty qualifications at Gemma, Dionysis, Polaris, and Jaguar Nursing PreMeeting Survey, 2.4/2.2

47. Registered Nurse Employment Type Over 50% of RNs work full time at only five hospitals (Falcon, Athene, Sirius, Eagle, Electra) Nursing PreMeeting Survey, 2.5a-2.5c

48. Enrolled Nurses Four hospitals-- Falcon, Centauri, Polaris, Scorpio employ >250 enrolled nurses Nursing PreMeeting Survey, 3.1

49. Percent Enrolled Nurses Enrolled nurses make up over 15% of nursing staff at Falcon, Centauri, Apollo – highlighting state-based differences? Nursing PreMeeting Survey, 3.1/(2.1+3.1+4.1)

50. Enrolled Nurses Employment Type Over 50% of ENs work full time at only two hospitals (Athene, Sirius) Nursing PreMeeting Survey, 3.3a-3.3c