Project KCE, HSR : Financing of Hospital Nursing Care. Project Plan

Transcription

1 C.H.U. de Liège UNIVERSITAIRE ZIEKENHUIZEN LEUVEN Project KCE, HSR : Financing of Hospital Nursing Care. Project Plan Introduction This proposal describes the approach and methodology to revise the financing of nursing care in Belgian acute hospitals. In the current hospital financing system, two nursing care indicators that are based on B-NMDS are used: an average cost-weight for surgical, internal medicine and paediatrics departments and a weighted intensive care ratio (ZIP/ZAP) for intensive care departments. This financing system is criticized: (1) it is not linked with DRGs, (2) cost-weighting is based on actual staffing ratios, which favours nursing wards with high nurse staffing levels, (3) except for technical care, cost-weights are not sensitive enough for changes in nursing practice, (4) nursing intensive departments such as geriatrics are not included in the complementary financing scheme etc. The study aims to investigate the feasibility to develop a financing system of nursing care that makes the shift from financing current nursing activities and nurse staffing levels to a system that is based on appropriate nursing activities and appropriate nurse staffing levels. 1

2 DELIVERABLE 1: EVALUATION OF EVIDENCE BASED CHARACTER OF THE PERFORMED NURSING ACTIVITIES Due date: May 31, EBN rule set Determining the level of evidence for a limited selection of nursing interventions, listed in the NMDS-II. 1) Literature review on the level of evidence for a selection of nursing interventions listed in NMDS-II (such as pressure sore prevention, wound care, ). The main focus of the search is on well-established evidence as can be found in guidelines, systematic reviews, EBN-literature and database. 2) Defining rule sets (20-40) in what conditions the use of the nursing intervention is indicated or contra-indicated. 3) Evaluation of literature review and rule sets by a panel of EBN-experts 2. Selection & writing cases o selection & writing of a valid sample of cases to investigate the relation between nursing profiles and staffing levels (nursing cost) selection & writing cases: o Selection of cases Medical-surgical wards (40 cases), paediatric wards (20 cases), ICU wards (20 cases), geriatric wards (20 cases) cases are selected from a selection of hospitals from the NMDS-II test hospitals (non)university, public-private, size of hospital, cases are selected to have maximum variability (in nursing care, staffing needs), with replication selection is based on charge nurses and MDs opinions cases are real patient cases o Writing of cases cases are based on the patient record cases are written in a standard format in a way that they can be understood by nurses, independent from the nursing ward or hospital they are working. The cases are written by the researchers as a result of a conversation with the nurse in charge of the patient, the patient record. All cases are reviewed by the nurses in charge of the patient 2

3 Cases are translated in French and Dutch Length of cases: 1-2 pages Coding of cases o Cases are coded in NMDS-I and NMDS-II (based on patient records) o Cases are coded for the hospital discharge dataset (RCM/MKG) o Note: Codes will not made available for the raters EBN: o 20 out of 120 cases are, based on the information in the patient record, analysed using the EBN rule set. Cases are, when appropriate, rewritten as EBN-cases. o The rewritten EBN-cases are validated by the EBN-expert team timing: o start January 2006, asking hospitals to be involved in case selecting and writing o Writing cases: January March o Pilot testing of cases by experts In total 120 (100 real cases + 20 EBN cases) will be developed 3

4 DELIVERABLE 2: CALIBRATING NURSING PROFILES Due date: September 30, Selecting raters selection of a representative national sample of raters for written cases Recruitment of raters: o Raters will be recruited from the 66 hospitals involved in the NMDS-II development phase. o recruitment criteria At least 5 year of clinical experience as a nurse (medical-surgical, paediatrics, ICU, geriatrics) At least 1 year experience as a charge nurse/adjunct charge nurse Selection of raters: o Distribution of expertise according to the clinical domain o Distribution according to language (French,, Dutch), type of hospitals (university, non-university), size of hospital o For 120 cases (clinical domain specific), 12 raters per case; 10 cases per rater: 144 raters are required. 4. Rating procedure (Delphi) o Determining nurse staffing needs per case (number & qualification) Random allocation of raters to cases (stratified according to clinical domain: medicalsurgical, ICU, paediatrics, geriatrics). o 12 raters per case; 10 cases per rater Two Delphi-rounds: o 1 st Delphi round (cases are sent by ), questionnaire for rating each case on staffing needs (number and qualification level, per shift (day, evening, night). Each question is rephrased to evaluate internal consistency (e.g. how many hours per patient, how many of these patients can be assigned to one nurse, ) o 2 nd Delphi round (having feedback from 1 st round: own score + score other raters) o Discussion in small groups to understand staffing decisions Results from 2 nd Delphi-round are used in analysis (most stable results) Calculating various cost measures: FTE, qualification level, cost ( ) Note: One Delphi-group (randomly selected from all other raters) will be asked to rate supplementary the NMDS-II-set for each of the nursing interventions 4

5 5. Nursing care activities profiling o Developing nursing care profiles based on NMDS-II, NMDS-I and staffing needs. Data o Data: 120 cases, 12 raters per case: approx data Methods: o Use of different methodologies: Multi dimensional scaling, correspondence analysis, hierarchical clustering, K-means clustering Research questions: o Developing homogeneous nursing profiles Clinical homogeneity (based on similarity and differences in nursing interventions) Economic homogeneity (based on similarity and differences in nurse staffing needs) o Construct & criterion validity analysis Based on analysis of variability and replication in cases, questions and raters o Analysis of differences between real and EBN-cases 6. Review of literature Describing how nursing care is financed in different European countries: o Denmark, Finland, Sweden, Luxembourg, the Nederland s, France, Switzerland, Germany, U.K., Ireland First exploration of literature Development of a concise search strategy and reporting framework Detailed analysis of the financing system on nursing care in the various countries (based on literature review and local contacts) 5

6 DELIVERABLE 3: METHODS FOR FINANCING NURSING CARE Due date: January 31, : Linking of nursing profiles with DRGs o Analysing the variability in nursing profiles per DRG Plan Linking nursing profiles to selected DRGs o How are nursing profiles varying according to time (day of stay) o Analysis of the homogeneity of nursing profiles per DRG o Differences in nursing profiles per DRG over hospitals 8. Evaluation of evidence-based nature of performed nursing activities o Based on the EBN-rule set in phase 1, an EBN-filter for a selected number of nursing interventions is developed based on available data in the hospital discharge dataset and NMDS-I / NMDS-II. Plan o Testing of EBN-filter on the 140 cases for sensitivity and specificity o Testing of the EBN-filter on available linked NMDS-HDDS data (66 hospitals) o Calculating financial impact of EBN-correction 9. Development of methodology for inclusion of nursing data into financing o Simulation & evaluation of different scenarios for the use of NMDS-II in hospital financing regulations o Development of different models and scenarios o Testing on local databases (ULg and UZL) o Testing on available linked NMDS-HDDS data (66 hospitals) 10. Final report o Final conclusions and recommendations on the feasibility of using the NMDS (version I as well version II) for hospital financing 6