Collected Input: Administrative Practices (Staffing/Service Volume & Staffing Mix) Original information from MDH worksheet is in orange highlight, italicized serif font. When original information is used or modified in input materials, the original information is italicized. Staffing volume relative to service volume including quantity of nursing attention Nursing hours per patient day OR Nurse to patient ratio OR Nurse staff full-time equivalent employment (FTEE) [Nursing hours per patient day OR Nurse to patient ratio OR Nurse staff full-time equivalent employment (FTEE)] [Nursing hours per patient day OR Nurse to patient ratio OR Nurse staff full-time equivalent employment (FTEE)] Includes registered nurse (RN), licensed vocational/practical nurse (LVN/LPN), unlicensed assistive personnel (UAP), and contract nurses. Only includes inpatient productive hours and excludes non-patient care hours for documentation, supervision, care coordination and other noninpatient care as well as time off for illness, vacation or continuing education. Nurse to patient ratio is expressed as: Nurses Patients = Productive Nursing Hours Patient Days X 24 Full-time nursing staff is assumed to have productive hours of 85 percent of a potential of 52 weeks per year at 40 hours per week, resulting in 1,768 potential hours per year: FTEE = Total nursing hours/1,768 Data is provided at the inpatient care unit level and provided in both medical/surgical and intensive care categories. A patient day is 24 hours. Is adjusted for patient turnover. Is adjusted for patient acuity Includes registered nurse (RN), licensed vocational/practical nurse (LVN/LPN), unlicensed assistive personnel (UAP), and contract nurses. Hospital staffing reports from payroll or management system. The MHA website will be an unadjusted source of this information for all inpatient units in all Minnesota hospitals
careful matching of nurse staffing on a shift-by-shift basis with the actual patients cared for during that shift. (Shekelle, p. 407 referencing Needleman) Measurements of Inputs: Staffing HPPD Resource Availability Inventory 24 hours is helpful, [but] data at the 8 hour shift level might be more informative as it reflects changes in number of staff as well as changes in mix that may occur at different times of the day Includes registered nurse (RN), licensed vocational/practical nurse (LVN/LPN), unlicensed assistive personnel (UAP), and contract (definition?) nurses, calculated separately. Only includes inpatient productive hours and excludes non-patient care hours for documentation, supervision (what is the definition of supervision?), care coordination and other non-inpatient care as well as time off for illness, vacation or continuing education. Nurse to patient ratio is expressed as: Nurses Patients = Productive Nursing Hours Patient Days X 24 Full-time nursing staff (definition?) is assumed to have productive hours of 85 percent of a potential of 52 weeks per year at 40 hours per week, resulting in 1,768 potential hours per year: FTEE = Total nursing hours/1,768 (is productive hours synonymous with direct patient care?) Data is provided at the inpatient care unit level and provided in both medical/surgical and intensive care categories. A patient day is 24 hours. Is adjusted for patient turnover. Is adjusted for patient acuity.(these items are accounted for later in patient care section Hospital staffing reports from payroll or management system. Electronic medical record.
If the unit of analysis is the hospital, then we should measure at least an average activity adjusted N-P ratio or activity adjusted productive nursing hours per patient day. I would advocate for looking at N-P ratios, The average N-P ratio can be close to the target N-P ratio in a unit, but the variability can be significant. For a unit level analysis, I would recommend that there be a metric that captures not just the average activity adjusted N-P ratio, but also the variability. I don't know if this is a reasonable request from hospitals in terms of how hard it would be for them to create the data to produce it. Process Measurements Filled/Unfilled shifts on final schedule Planned HPPD Actual HPPD
Staffing mix Type of nursing staff (share of RN,LVN/LPN,UAP) Experience levels of staff Concentration of nurse(s) to patient (single nurse attention or many) [Type of nursing staff (share of RN,LVN/LPN,UAP)] [Experience levels of staff] Type of nursing staff (share of RN,LVN/LPN,UAP) Categories of providers [not Staffing Mix] Skill Mix - Experience, education levels of staff (Benner s model of novice to expert) Non-nursing staff available to support the work of the nurses. If you have a full, competent complement of pharmacists, respiratory techs, lab, housekeeping, etc., the impact on the nursing job could be significant Charge nurses eval staffing mix for pt assignments is experience level. NO charge nurse states that I have all these LPN and UAP so I do not need RNs to perform care. The MHA website will be an unadjusted source of this information for all inpatient units in all Minnesota hospitals This does not currently exist to our knowledge
The use of specialty teams or nursing assignments might need to be captured these nurses are often not assigned to patients and therefore may not be included in the calculations. Here I am thinking of teams such as transport teams, rapid response teams, admitting nurses, float or support nurses (sometimes called the flying squad or other unique names). We need more discussion regarding whether all nursing types would be included as one group (RN, LPN, etc) versus splitting them out. Activity plus LOS adjustment would get at the notion of 'patient turnover'. It will be helpful to gather this in a manner similar to the staffing volume as the mix is not uniform and does change by shift and day. By incorporating the mix with the volume the same data source might be able to be used.
Collected Input: Patient Care (Patient Medical Needs, Patient Demographics) Original information from MDH worksheet is in orange highlight, italicized serif font. When original information is used or modified in input materials, the original information is italicized. Patient Medical Needs Reason for admission, clinical service type, patient acuity, discharge status, disposition of patient [Reason for admission, clinical service type, patient acuity, discharge status, disposition of patient] Measurements of Inputs: Patient Days LOS Acuity Score Admissions/discharges [Reason for admission, clinical service type, patient acuity, discharge status, disposition of patient,] case mix Patients hospital course as compared to the staffing. I would staff a patient who is day 1 post-spine surgery differently than day 3 for example Ideally, the staffing metric should also adjust for acuity workload, but I think an acuity standardized metric across hospitals would be difficult since the acuity software is usually a 'black box' in terms of how it is calculated. Available through claims data at hospital-level, not unit level
Patient Demographics Age, gender, payment source Alone or visited Patient education on reason for admittance (printed or communicated) Cooperative or resistant patient [Age, gender, payment source] Age, gender, payment source Available through claims data at hospital-level, not unit level
Collected input: Patient Outcomes (Nurse Sensitive Indicators) Original information from MDH worksheet is in orange highlight, italicized serif font. When original information is used or modified in input materials, the original information is italicized. Nurse-sensitive indicators Death among surgical inpatients with treatable serious complications (failure to rescue) Pressure ulcer prevalence Patient falls Restraint prevalence Medication administration accuracy Catheter associated blood stream infections [Death among surgical inpatients with treatable serious complications (failure to rescue)] [Pressure ulcer prevalence] [Patient falls] [Medication administration accuracy] [Restraint prevalence] [Catheter associated blood stream infections] Currently reported through SQRMS at hospital-level Variations of this may be collected at hospital level; not publicly reported Not collected to our knowledge Publicly reported to CDC for ICUs PPS hospitals only
Catheter Associated UTI Considers nurse driven catheter removal protocol Pain Management HCAHPS evaluates satisfaction with pain management [Death among surgical inpatients with MDH, Hospital Compare treatable serious complications (failure to rescue)] Mortality Pneumonia length of stay/readmission restraint pulmonary compromise deep vein thrombosis GI bleed Shock arrest Nosocomial infections UTIs Skin breakdown Outcome Measures: LOS/Readmission rates Mortality Rates Reportable Events Patient Experience Scores Accreditation status Ventilator assisted blood stream infections among ICU patients Patient Experience There is evidence to show that this outcome is related to nursing care Many (all?) hospitals are measuring this Should include both positive and negative outcomes