Nurse Staffing Committees - NJHA

Nurse Staffing Committees:Legislative Trends & Best PracticesGladys Campbell, RN, MSN, NC-BC, FAANPrinciple, Campbell Coaching & Consulting

Plan For Our Time Together1. Context & History of Nurse Staffing Laws2. Legal trends related to staffing and staffingcommittees3. Requirements of law vs. intent of law4. What has been learned from other states?5. What are best practices related to staffingcommittees?6. Why are successful staffing committeesimportant to us?

History & Context Long standing concerns, across the nation,about nurse staffingUnion Tensions State nursing associationsCreation of NNU – National Nurses UnitedSEIUStaffing as a primary issue for unions and why

Setting the Context:Our Labor Climate Mergers and Affiliations are not just forhospitals NNU – National Nurses UnitedSEIUAFL-CIO – Includes the AFT whichincludes 5 state nursing associations

History and Context Emergence of legislative proposalsrelated to nurse staffingNursing ratios enacted in CaliforniaDevelopment of the NDNQI andCALNOC National Database for Nurse QualityIndicators Collaborative Alliance for NursingOutcomes

The DataTwo NSQI data bases exist:NDNQI (Nursing Database for Nursing QualityIndicators)CALNOC (Collaborative Alliance for NursingOutcomes)Nursing Sensitive Quality Indicators:History & Definitions6

What Is the History of NurseSensitive Quality Indicators? In 1994, The American Nurses Association (ANA)started a long-term commitment to establish thatpatient care (quality and safety) was linked tonursing care.The purpose of this work was to educate nurses,consumers, and policy makers about nursing’scontribution to inpatient hospital care.7

National QualityForum (NQF)2004The first 15 NursingSensitive Measuresundergo extensivereview, evaluation,and consensusapproval throughthe National QualityForum.8

What Does “NurseSensitive” Mean? Nurse sensitive quality outcomes are thosepatient outcomes that have been specificallyand reliably linked, though research, to thepresence or absence of the volume (“dose”)and quality of nursing care.9

What are the Nurse Sensitive Quality Indicators? Outcome Indicators: Process Indicators Hospital acquired pressure ulcersHAPUPatient fallPatient fall with injuryUrinary catheter associated UTICAUTICentral line catheter associated bloodstream infection CLABSIVentilator associated pneumonia orevent VAP/VAEFailure to RescuePediatric IV infiltrationSurgical wound infectionPsychiatric physical/sexual assaultRestraint prevalence Nursing SatisfactionTotal hours of nursing care perpatient, per dayStaff skill mixVoluntary nurse turnoverNursing vacancy ratePatient satisfaction with painmanagementPatient satisfaction withnursing carePatient satisfaction withmedical information providedOverall patient satisfaction

Centers for Medicare andMedicaid Services:Non-Payment for “Never Events”CMS declares there should not be payment for“never events”, those adverse events thatshould “never” occur. Examples include:surgery on the wrong body part, mismatchedblood transfusions, falls, or hospital acquiredpressure ulcers Almost all CMS never events are nurse sensitive!

So What Does This Mean to Us? There is a direct correlation, based on research,between appropriate staffing and patient outcomes. Ifstaffing is inadequate this should be seen by acorresponding drop in patient quality outcomes.Because CMS will not pay for “never events”, most allof which are NSQI – there is a financial cost to poorstaffing for the hospital.

History and Context Emergence of significant researchon Nurse StaffingLinda Aiken Jack Needleman Woman who does financialresearch. Peter Buerhaus

Peter Buerhaus, PhD, RN, FAAN“There is no scientific evidence supporting amagic number for nurse staffing.”The idea of applying ratios is absurd, counterproductive, & backward thinking Ratiosare a bankrupt idea, and their widespreadimplementation could slowly bankrupt theprofession. I would not want to beassociated with a profession that alloweditself to be dummied down to the pointwhere it self-inflicted onto the professionthe very notion that it abhors: a nurse is anurse is a nurse.”

Hey What’s Wrong Witha Little Legislation? You can’t legislate judgmentLaw and ethics are differentBy its nature, laws are linear and reductionist they seem to simplify complex issuesDo you like “big” or “small” government?A law creates a platform that can be built onThe process of creating law can bring peopletogether, or divide them

The First Staffing Committee LawOregon HB 2800 on Nurse Staffing Equal numbers of nurse managers & direct carenurses on the committeeCommittee is to develop nurse staffing plans basedon: Accurate description of individual & aggregatepatient needs Requirements for nursing care Specialized qualifications & competencies ofnursing staffEstablish minimum numbers of nursing staff includingLPNs and CNAs required on specified shifts

Oregon Specific History HB 2800 on Nurse Staffing Include a formal process for evaluating andinitiating limitations on admission or diversion ofpatientsStaffing plans are developed, monitored, evaluated,and modified by the staffing committeeStaffing plans are to be consistent with nationallyrecognized evidence based standards andguidelinesAny nurse on the staffing committee may requestthat the Oregon Department of Human Servicesassist in resolving any staffing impasse

Oregon Specific History 2011 the ONA and OAHHS collaborated on aproject to study the effectiveness of the statestaffing committeesOregon Nurse Staffing Law: is it working?JONA, volume 42, number 3, pp 134-137, March2012 Hospital to hospital experience was widely variableInfluence of the CNE is highly correlated with a highfunctioning staffing committeeA true participative management culture is requiredfor full success“You can’t legislate judgment”

2014 Review of the Status of Compliancewith Staffing Committee Laws in the NWWhy do a review? By 2014 we had over a decade of experience with our nursestaffing committees. Are we maintaining compliance? Are weimproving our processes?We had frequently heard from our union colleagues that thecommittees are not working as they shouldNurse leaders hoped to gain knowledge about the status of ourcommittees, but also hoped to learn what “best practices” instaffing committee work were, and where we might be able tooffer assistance to help committees improve their processes.Where process was “broken” -- why & what does “bestpractice look like?

What Did We Do on Our Site Visits? At each hospital we: Silent observers were allowed into the hospitalbased staffing committee After observing a staffing committee the reviewers: Held a 90min focus group with the staff nurse members ofthe committee only Held a 90min focus group with the leadership members ofthe committee only Each focus group was asked the same 45 questions Used the focus groups for not just data collection but forteaching/learning dialogues as well Met with hospital leaders as requested for verbal reportouts

On Site Visits, Compliance with the Requirementsof the Law and the Intent of the Law WereReviewedCompliance With TheLaw Do you have a staffingcommittee?Right membershipcomposition?Does the committeemeet at least Q6mos?Create a Staffing Plan?Get CEO review of theplan/Review the plan at leastQ6mos?Post the PlanCompliance with the Intent of theLaw To create a participative & collaborativeapproach to nurse staffing between frontline care providers & managementAssure that nurse staffing is driven bythe needs of patients, while consideringthe budget – instead of just being drivenby budgetTo use evidence, research, and data tosupport staffing decisions – rather thanemotionTo create a fluid and continuous processfor the re-evaluation of staffing, patientoutcomes, & patient utilization trendsTo support transparency in hospitalnurse staffing

So What Did We Find Relative toCompliance With Nurse Staffing Laws? Most hospitals had established a nurse staffing committee with theright composition, who met with regularitySome simple questions turned out not to be so simple -- Have youcreated a staffing plan?CEOs were compliant with staffing plan reviews when these planswere forwardedNurse Staffing plans were posted, but there were some consistentmisunderstandings about the posting requirements.Most committees tended to review aspects of the staffing plan withsome regularity, but did not do a formal, specific mid-year reviewMany committees had “flipped” the process for creating a staffingplan.

What does “Flipping theProcess” Mean? The laws required that staffing plans were tobe created by the staffing committee & thatthe CEO would respond to that staffing planInstead many staffing committees were givenfinancially based staffing metrics (which wereassumed to be non-negotiable) which in factindirectly defined the staffing levels for eachunit.A staffing committee then became the“responder” to these financially drivenstaffing metrics rather than the creator of astaffing plan

So How Do You “Unflip” theProcess? The staffing committee process demands that there beunderstood and equal respect for both the quality ofthe care provided to patients and for the financial andbusiness health of the organization.Without “health” and strength in both the quality andbusiness arenas, no hospital will be a strong orsustainable organization.

How Do You Manage & Balance theTension Between These Two Demands?Clinical Care Needsand QualityFinancial Successand BusinessImperatives

Setting Your Committee Up ForSuccess Begin with the most basic requirement of the law youare to create a staffing planThe law says the plan is to be based on data – theexamples of data provided in the law include but are notlimited to: Census data Patient intensity Staff experience (Including Specialty Certification & Training) The design & geography of the unit(s)National Staffing guidelinesPush the data to your committee, don’t make thembeg for it!

What Other Data Does the CommitteeNeed? Quality Data – Nurse Sensitive Quality IndicatorsPatient Utilization Trend DataStaffing Data - Including experience levels of the staff, floatnurse and agency useSatisfaction Data – staff and patient satisfactionWhat Members of the Staffing Committee Might Want toConsider: Who are our patients and what are their needs?How can we use our data to ask additional questions, or to drilldown to develop more in-depth understanding of how nursestaffing, processes of care, and patient outcomes may be linked inour setting?

In God We Trust,From Everyone Else We RequireData .

The Data – Patient Utilization DataWhat Does This Data Include?29

Patient Utilization Data Diagnostic Groups – typesof patientsWorkload based on patienttypePatient workload intensityDaily Census (midnight?)LOS – Length of StayCode team activations –volumeED volumes% of ED patients who areadmitted Volumes by time ofday, day of week,month of year – totalsand by specialtyADT – Admissions,Discharges, Transfers– total average/dayand volume by timeof day – also referredto as “churn”Readmission rates

Historical Use and Volume PatternsSeasonality and Trend gSepOctNovDec

Historical Use and A/D WorkloadPatternsInpatient Discharges by Time of DayJanuary, 7181920Hour (Rounded)Hospital#1St.VHospital #2PPMC212223

The Data – Nurse Staffing DataWhat Does This Data Include?34

Nurse Staffing Data Total Nursing Hours PerPatient DaySkill MixPercent of Agency UseVoluntary Turnover RateNurse Vacancy RateNursing SatisfactionMissed breaksOvertime utilizationOn-call utilizationStaffing complaints Nurse Characteristics Years ofexperience Education Certification Years in thespecialty practice