Nursing Ratios Is There a Better Way?

Transcription

1 Nursing Ratios Is There a Better Way?

2 Nursing Ratios Is There a Better Way? A PANEL PRESENTATION ON THE PROS AND CONS OF USING NURSE-TO TO-PATIENT RATIOS TO STAFF NURSING UNITS February, 2004

3 Presentation Format ➊Introduction of Panel ➊Patti Rogers, MBA, BSN, RN ➊Frank Overfelt, MBA, FHIMSS, CHE ➊Cheryl McNally, LPN

4 Presentation Format, cont. Presentation Format Background & History of Workload Measurement Systems for Nursing Frank Overfelt Background and History of Nursing Ratios Frank Overfelt

5 Presentation Format, cont. Presentation Format, cont. Why Nursing Ratios? Cheryl McNally Other Alternatives Acuity Acuity (dependency) based staffing Patti Rogers Conclusions & Discussion Frank Overfelt

6 Background and History Workload Measurement Systems for Nursing 1960 s/1970 s Utilized Work Sampling to establish hours of care requirements - Not sensitive to variation in patient type - Not sensitive enough to skill mix - No involvement of Nursing in the process

7 Background and History, cont. Workload Measurement Systems for Nursing (cont.) Mid 70 s to 90 s Evolution of acuity-based staffing - Complex Acuity systems which tried to capture workload every shift (GRASP, Medicus) - Acuity systems which used limited criteria sets tied to one- time workload measurement activities

8 Background and History, cont. Background and History of Nursing Ratios 1990 s Benchmarking evolved as a means of comparing performance - Management pushing to reduce costs - Late 90 s labor unions found a favorable environment in California to push for job security

9 Why Nursing Ratios?? Why Nursing Ratios?? Cheryl Mc Nally, LPN Patient Safety? Nursing Job Satisfaction? Enhanced Outcomes?

10 Why Nursing Ratios?? Why Nursing Ratios?? (cont.) Patient Safety? Major argument is that fixed ratios will improve patient safety. E.g., Aides forget to report issues of patient care/safety to the RN. RNs with too heavy an assignment will overlook certain aspects of care.

11 Why Nursing Ratios?? Why Nursing Ratios?? (cont.) Nursing Job Satisfaction? According to a survey of nurses in Pennsylvania hospitals, the lower the ratio of patients to nurses, the greater the job satisfaction.

12 Why Nursing Ratios?? Why Nursing Ratios?? (cont.) Nursing Job Satisfaction? According to the Pennsylvania survey, increasing the patient to nurse ratio by one increased job dissatisfaction 15% to 23%.

13 Why Nursing Ratios?? Why Nursing Ratios?? (cont.) Enhanced Outcomes? The same Pennsylvania study modeled the impact of staffing ratios on patient deaths

14 Why Nursing Ratios?? Why Nursing Ratios?? (cont.) Enhanced Outcomes? Additional deaths/1000 patients Patient to Nurse Ratios All Patients With Complications 6:1, not 4: :1, not 6: :1, not 4:

15 Dependency-based Options Dependency Based Staffing, an alternative to arbitrary ratios Patti Rogers, MBA, RN Definition Benefits Shortcomings

16 Dependency-based Options Dependency vs. Acuity for Nurse Staffing: Acuity Medical measure of a patient s intensity of illness - not a workload measure Dependenc endency A workload measure of how reliant a patient is on nursing caregivers to meet care requirements

17 Dependency-based Options Essential Elements of a Valid Dependency Classification System: Objective Not subject to individual interpretation (high inter-rater rater reliability) Auditable Traced back to patient chart/orders Discriminating Must differentiate between various patients

18 Dependency-based Options Essential Elements of a Valid Dependency Classification System (cont.): Leadership & staff are: Active participants in data collection and review, start to finish Committed to using the staffing decision- making tool as created

19 Dependency-based Options Benefits: Multi-focal objectivity Accounts for patient age, ADLs, family support on per patient basis Provides staffing level assessment per unit, per shift for central staffing office Staff according to skill mix requirements

20 Dependency-based Options Benefits (cont.): Enables equitable assignment to each nurse Provides an objective agreed-upon method for ongoing dialogue between staff and all levels of staffing decision-makers

21 Dependency-based Options Benefits (cont.): Objective means of determining required staffing for reporting to regulatory agencies and risk management department Magnet Hospital Accreditation: Demonstrates an objective staff-oriented structure in place to support nursing and quality patient care

22 Dependency-based Options Benefits (cont.): Bridges the language gap between clinical care leaders and the finance department

23 Dependency-based Options Shortcomings: It is a system of data-driven driven averages which cannot account for: Accurate forecasting for unknown patients» Offset with KEANU classification

24 Dependency-based Options Shortcomings: (cont.) It is a system of data-driven driven averages which cannot account for: Unanticipated workload peaks and valleys within a shift» Offset with SWAT Team Classification Errors Accidental or intentional» Offset with QI Audits

25 Dependency-based Options Shortcomings: (cont.) Cannot replace nursing judgment Cannot clone nurses Cannot discriminate between a float nurse and a regular unit-based staff member

26 . Conclusions and Discussion

27 Dependency-based Systems vs. Nursing Ratios Comparing Dependency-based Systems with Nursing Ratios Involves unit direct caregivers in the daily staffing decisions Ratios NO Dependency YES Matches patient care requirements to staff availability Ratios NO Dependency YES

28 Dependency-based Systems vs. Nursing Ratios Comparing Dependency-based Systems with Nursing Ratios: (cont.) Budgets nursing resources Ratios YES Dependency YES Forecasts nursing resources Ratios YES Dependency YES

29 Dependency-based Systems vs. Nursing Ratios Comparing Dependency-based Systems with Nursing Ratios: (cont.) Correlates nursing resources to patient outcomes Ratios YES Dependency YES Manages resources objectively within each unit and throughout the house Ratios YES Dependency YES

30 Dependency-based Systems vs. Nursing Ratios Comparing Dependency-based Systems with Nursing Ratios: (cont.) Accounts for variability of patients within a unit Ratios NO Dependency YES Accounts for variability among homogeneous units Ratios NO Dependency YES

31 Dependency-based Systems vs. Nursing Ratios Comparing Dependency-based Systems with Nursing Ratios: (cont.) Accounts for the variability of patients from hospital to hospital Ratios NO Dependency YES Aids in resource management to ensure long-term viability of the institution Ratios NO Dependency YES

32 Dependency-based Systems vs. Nursing Ratios Comparing Dependency-based Systems with Nursing Ratios: (cont.) Incorporates facility design into the staffing requirements Ratios NO Dependency YES Helps resolves the nursing shortage issue Ratios NO Dependency NO

33 Dependency-based Systems vs. Nursing Ratios Comparing Dependency-based Systems with Nursing Ratios: (cont.) Puts the nurse at the bedside more frequently (for those patients who need him/her) Ratios NO Dependency YES Reduces RN time spent in non-patient care activities Ratios NO Dependency YES

34 Nursing Ratios Is there a better Way? Conclusions & Discussion A PATIENT IS NOT A PATIENT Patients require different levels of care throughout their stays Age is a factor Family support is a factor Teaching requirements are factors ADL factors must be considered

35 Nursing Ratios Is there a better Way? Conclusions & Discussion A HOSPITAL IS NOT A HOSPITAL No two hospitals are alike Specialty hospitals, tertiary care centers, and community hospitals all differ

36 Nursing Ratios Is there a better Way? Conclusions & Discussion A NURSING UNIT IS NOT A NURSING UNIT Layout and design affect staffing Equipment affects staffing Ancillary support affects staffing IT support affects staffing

37 Nursing Ratios Is there a better Way? Cost Impact of California s AB 394 Hospitals state-wide will need to hire a combined total of 5,000 additional nurses (keep in mind there is a nursing shortage) Will add an additional cost of $900 million to healthcare

38 Nursing Ratios Is there a better Way? Cost Impact of California s AB 394 Cost of penalties for non-compliance Costly litigation (another full employment act for lawyers)

39 Nursing Ratios Is there a better Way? Quote from Holly DeGroot, PhD, RN, FAAN, in testimony given before the California Legislature: AB 394 is antithetical to real time nursing decision making about meeting patient care needs, creating instead a set of fixed, cookbook style ratios that would stand regardless of what care patients really need. This should offend every nurse, because it takes away the most crucial and complex set of professional decisions and places it in the hands of legislators. it violates the ethical responsibility of nurses.

40 Nursing Ratios Is there a better Way? Bibliography 1) California Nurse-Patient Ratios. United Nurses Associations of California/Union of Health Care Professionals. ca.org/comp/pdf/ratios.pdf (9-5-03) 2) Substantial Changes Required in Nurses' Work Environment To Protect Patients from Health Care Errors. The National Academies. endocument ( )

41 Nursing Ratios Is there a better Way? Bibliography 3) Nurse staffing, mortality and burnout. Bandolier. ( ) 4) Update: New IOM Report Out & California Nurse- Patient Ratios. Texas Nurses Association ( )

42 Nursing Ratios Is there a better Way? Bibliography 5) DeGroot,, Holly A. Testimony on AB 394. Catalyst Systems. testimony.htm ( )