Transcript Slide 1

Putting Principles to Action
Victoria L. Rich, PhD, RN, FAAN
Chief Nurse Executive, Penn Medicine
Associate Executive Director, Hospital of the University of Pennsylvania
Associate Professor of Nursing Administration,
University of Pennsylvania School of Nursing
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January 21, 2010
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National Quality Forum Safe Practices
# 9 Nursing Workforce
#10 Direct Caregivers
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NQF SP #9
#9 Nursing Workforce
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Background to Current Problem
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.
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NQF SP #9
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.
Rich VL. AHRQ Web M&M 2009 August
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NQF SP #9
Nursing Workforce Safe Practice Statements
• 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.
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NQF SP #9
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:
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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 organizations
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Rich VL. AHRQ Web M&M 2009 August
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NQF SP #9
I.
Action-Oriented Framework for
Safe Practice: Nursing Workforce
Focus on new hire on-boarding
• 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
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HUP-NMEPP©, Jost SJ, Rich VL. NAQ 2009
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Take-Home Points
• Conduct failure mode effect analysis on nurse staffing for each unit in order to
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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.
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Rich VL. AHRQ Web M&M 2009 August
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Beyond Measure:
RN Vacancy Rates from FY 2005 to 2009
14%
12%
10%
8%
6%
4%
2%
0%
Hospital of the University of Pennsylvania
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Beyond Measure:
RN Turnover Rates from FY 2005 to FY 2009
14%
12%
10%
8%
6%
4%
2%
0%
Hospital of the University of Pennsylvania
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Beyond Measure:
RN Retention Rates from FY 2005 to FY 2009
2005
2006
2007
2008
2009
Hospital of the University of Pennsylvania
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NQF SP #10
#10 Direct Caregivers
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Background to Current Problem
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]
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Background to Current Problem (cont’d)
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.
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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NQF SP #10
Direct Caregivers: Safe Practice Statement
• 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)
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Direct Caregivers: Parity going forward
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HUP-NMEPP©, Jost SJ, Rich VL. NAQ 2009
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NQF SP #10
Action-Oriented Framework for
Safe Practice: Direct Caregivers
I.
Focus on new hires
• 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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NQF SP #10
Action-Oriented Framework for
Safe Practice: Direct Caregivers (cont’d)
III. Focus on new hires
• 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
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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, FCCM
Senior Advisor, Patient Safety, National Quality Forum
Member of Safe Practices Steering Committee
Former Chief Patient Safety Officer and Vice President
for The Joint Commission
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January 21, 2010
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Safe Practice 11
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”).
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Additional Specifications
• 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.
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Additional Specifications (cont’d)
• 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 lowurgency 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]
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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 Webinar
January 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
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