Measure Information Form

Release Notes: Measure Information Form Version 1.00 (NSC) **NQF-ENDORSED VOLUNTRY CONSENSUS STNDRDS FOR NURSING-SENSITIVE CRE PERFORMNCE MESURES** Measure Set: Nursing-Sensitive Care Measure Information Form Performance Measure Identifier: Set Measure ID# Measure Population.1 Hours worked by RN nursing staff.2 Hours worked by LVN/LPN staff.3 Hours worked by UP staff.4 Hours worked by Contract staff (RN, LVN/LPN, and UP) Performance Measure Name: Skill Mix NSC 12.1 Skill Mix - Registered Nurse (RN) staff NSC 12.2 Skill Mix Licensed Vocational Nurse (LVN)/ Licensed Practical Nurse (LPN) staff NSC - 12.3 Skill Mix - Unlicensed ssistive Personnel (UP) NSC - 12.4 Skill Mix - Contract staff Description:.1.2.3.4 Percentage of hours worked by RN nursing staff (employee and contract) with patient care responsibilities by type of unit Percentage of hours worked by LVN/LPN staff (employee and contract) with patient care responsibilities by type of unit Percentage of hours worked by UP staff (employee and contract) with patient care responsibilities by type of unit Percentage of hours worked by contract staff (RN, LVN/LPN LVN/LPN, and UP) with patient care responsibilities by type of unit Rationale: The skill mix of the nursing staff, typically expressed as the ratio of RNs (LPNs/LVN,s and UPs) to total nursing hours has been widely studied with respect to its effects on the quality of care. If the percentage of hours supplied by RNs is not adequate, less skilled staff may have to perform tasks for which they are not trained, thus increasing the risk of adverse patient outcomes. Examining the relationship between skill mix and processes and outcomes of care within health care organizations may identify opportunities to improve care delivery, patient outcomes, and provide an evidence base for determining the most effective mixture of staffing. Implementation Guide for the NQF NSC 12-1 Joint Commission, 2005

Type of Measure: Structure Improvement Noted as: Either an increase or a decrease in the rate depending on the context of the measure Numerator Statement: Number of productive hours worked as specified in the Set Measure Identifier and Description above.1.2.3.4 Included Populations Excluded Populations Data Elements Productive hours worked by RN staff with direct patient care responsibilities for greater than 50% of their shift. Include: Staff who are counted in the staffing matrix, and Who are replaced if they call in sick, and Work hours are charged to the unit s cost center Contract staff Persons whose primary responsibility is administrative in nature Specialty teams, patient educators or case managers who are not assigned to a specific unit. RN Hours [Contract: gency] RN Hours [Employee] Productive hours worked by LVN/LPN staff with direct patient care responsibilities for greater than 50% of their shift. Include: Staff who are counted in the staffing matrix, and Who are replaced if they call in sick., and Work hours are charged to the unit s cost center Contract staff Persons whose primary responsibility is administrative in nature Specialty teams, patient educators or case managers who are not assigned to a specific unit. LPN and LVN Hours [Contract:gency] LPN and LVN Hours [Employee] Productive hours worked by unlicensed assistive personnel (UP) staff with direct patient care responsibilities for greater than 50% of their shift. Include: Staff who are counted in the staffing matrix, and Who are replaced if they call in sick, and Work hours are charged to the unit s cost center Contract staff Persons whose primary responsibility is administrative in nature Specialty teams, patient educators or case managers who are not assigned to a specific unit. Unit secretary, monitor techs UP Hours [Contract:gency] UP Hours [Employee] Productive hours worked by contract staff (RN, LVN/LPN, and UP) with direct patient care responsibilities for greater than 50% of their shift. Include: Staff not employed by your facility Staff hired on a contractual basis to fill staffing needs for a designated shift or on another short-term basis Registry staff from outside the facility (e.g., not floating staff from within the facility) Traveling nurse staff contracted to the facility for a designated period of time Persons whose primary responsibility is administrative in nature Specialty teams, patient educators or case managers who are not assigned to a specific unit. LPN and LVN Hours [Contract:gency] RN Hours [Contract:gency] UP Hours [Contract:gency] Implementation Guide for the NQF NSC 12-2 Joint Commission, 2005

Denominator Statement: Total number of productive hours worked by nursing staff [RN, LVN/LPN, UP (employee and contract)] with patient care responsibilities by Type of Unit during the calendar month Data Elements: LPN and LVN Hours [Contract:gency] LPN and LVN Hours [Employee] Month RN Hours [Contract:gency] RN Hours [Employee ] UP Hours [Contract:gency] UP Hours [Employee] Year Included Populations: dult medical, surgical, medical-surgical combined, critical care, step-down units. Excluded Populations: Other unit types (e.g., pediatric, obstetrical, rehab, etc) Risk djustment/stratification: Yes Data Elements NSC NSC NSC NSC 12.1 12.2 12.3 12.4 Type of unit Type of Unit Type of Unit Type of Unit Data Collection pproach: Retrospective Data ccuracy: Payroll or staffing records should be audited to remove non-direct care hours (education, sick leave, vacation leave etc.) n eligible reporting unit will calculate nursing care hours data by calendar month IF THE HOSPITL DOES NOT HVE MONTHLY STFFING RECORDS: To calculate the monthly rate for this measure, a hospital should use one of the following options: o Split in half (divide by 2) hours in pay periods that include 4 or more days in another month. (See example table provided in ppendix F: 12.1 Nursing Care Hours Reporting Schedule Example) o Pay periods that go across two months, divide the total hours by 14 to get average daily hours, then multiply by the number of days that belong to each month. Make sure ineligible staff hours are not included (e.g., unit secretary, monitor techs) Unlicensed ssistive Personnel (UP) are individuals trained to function in an assistive role to nurses in the provision of patient care, as delegated by and under the supervision of the registered nurse. Typical activities performed by UPs may include (but are not limited to): Implementation Guide for the NQF NSC 12-3 Joint Commission, 2005

o Taking vital signs o Bathing, feeding, or dressing patients o ssisting patient with transfers, ambulation, or toileting Include: Nursing assistants, orderlies, patient care technicians/assistants and graduate nurses (not yet licensed) who have completed unit orientation Exclude: Unit secretaries or clerks, monitor technicians, therapy assistants, student nurses who are fulfilling educational requirements, sitters who either are not employed by the facility or who are employed by the facility, but are not providing typical UP activities NOTE: In some states assistive nursing personnel may be licensed. For the purposes of this performance measure set, include these persons in the UP category for calculation. Eligible reporting units for this measure are defined by the allowable values for the data element, Type of Unit. Measure nalysis Suggestions: None Terminology: Contract/gency Staff Temporary nursing staff that are not employee by your facility but are: Hired on a contractual basis to fill staffing needs for a designated shift or another short-term basis Registry staff from outside the facility (e.g., not floating staff from within the facility) Traveling nurse staff contracted to the facility for a designated period of time Direct Patient Care Responsibilities Patient centered nursing activities by unit-based staff in the presence of the patient and activities that occur away from the patient that are patient related: Medication administration Nursing treatment Nursing rounds dmission, transfer, discharge activities Patient teaching Patient communication Coordination of patient care Documentation time Treatment planning Employee Persons who are employed directly by the facility and are on the payroll for the purpose of providing nursing care. This would include a hospital s own internal registry staff. Employment Status Nursing staff may be either employees or contracted (agency) staff. nursing care hours includes hours worked by both employees and contract staff. Productive Hours ctual direct hours worked, not budgeted or scheduled hours. Excludes vacation, sick time, orientation, education leave, or committee time. Implementation Guide for the NQF NSC 12-4 Joint Commission, 2005

Unlicensed ssistive Personnel (UP) Individuals trained to function in an assistive role to nurses in the provision of patient care, as delegated by and under the supervision of the registered nurse. Typical activities performed by UPs may include (but are not limited to): Taking vital signs Bathing, feeding, or dressing patients ssisting patient with transfers, ambulation, or toileting Include: Nursing assistants Orderlies Patient care technicians/assistants Graduate nurse (not yet licensed) who have completed unit orientation Exclude: Unit secretaries or clerks Monitor technicians Therapy assistants Student nurses who are fulfilling educational requirements Sitters who either are not employed by the facility or who are employed by the facility, but are not providing typical UP activities NOTE: In some states assistive nursing personnel may be licensed. For the purposes of this performance measure set, include these persons in the UP category for calculation. Sampling: No ge Groups: N Data Reported as: ggregate rate generated from count data as a proportion. NCS-12.1 The number of productive hours worked by RN nursing staff by type of unit as a proportion of total productive hours worked NCS-12.2 The number of productive hours worked by LVN/LPN staff by type of unit as a proportion of total productive hours worked.3 The number of productive hours worked by UP staff by type of unit as a proportion of total productive hours worked.4 The number of productive hours worked by contract staff (RN, LVN/LPNLVN/LPN and UP) by unit type as a proportion of total productive hours worked quarterly rate may be determined by calculating a monthly rate for each unit, summing the 3 monthly rates in a quarter and dividing by 3 to produce a quarterly average. Implementation Guide for the NQF NSC 12-5 Joint Commission, 2005

Selected References: N. National Database of Nursing Quality Indicators. (NDNQI). N. Nurse Staffing and Patient Outcomes in the Inpatient Setting. Washington,DC: merican Nurses Publishing; 1996. NDNQI. Guidelines for Data Collection and Submission on Quarterly Indicators, Version 5.0. Kansas City, KS: The University of Kansas School of Nursing; January, 2005. Needleman J, Buerhaus PI, Mattke S, Stewart M, Zelevinsky K. Nurse Staffing and Patient Outcomes in Hospitals. HRS Report No. 230-99-0021;February 18, 2001. Implementation Guide for the NQF NSC 12-6 Joint Commission, 2005

: The number of productive hours from different staff group in the calendar month : The total number of productive hours from nursing staff in the calendar month STRT : Set = 0 b Critical Care 01 c Step-down 02 d Medical 03 e Surgical 04 f Med-Surg Combined 05 * This refers to the data element. Each case will be stratified according to the allowable value for that. Invalid Not = 01, 02, 03, 04, 05 Missing or Invalid Measure Population Data = 01, 02, 03, 04, 05 Not In Measure Population Z H Z Implementation Guide for the NQF NSC 12-7 Joint Commission, 2005

H = (RN Hours [Contract:gency] + RN Hours [Employee] + LPN or LVN [Contract:gency] + LPN or LVN [Employee] + UP [Contract:gency] + UP [Employee]) Type of Unit = 01 Calculate 4 rates for the strata measure NSC 12b: R1 = (RN Hours [Contract:gency] + RN Hours [Employee]) / R2 = (LPN or LVN [Contract:gency] + LPN or LVN [Employee]) / R3 = (UP [Contract:gency] + UP [Employee]) / R4 = (RN Hours [Contract:gency] + LPN or LVN [Contract:gency] + UP [Contract:gency]) / Hours, UP Hours and are belonged to strata measure NSC 12b = 02, 03, 04, 05 Type of Unit = 02 Calculate 4 rates for the strata measure NSC 12c: R1 = (RN Hours [Contract:gency] + RN Hours [Employee]) / R2 = (LPN or LVN [Contract:gency] + LPN or LVN [Employee]) / R3 = (UP [Contract:gency] + UP [Employee]) / R4 = (RN Hours [Contract:gency] + LPN or LVN [Contract:gency] + UP [Contract:gency]) / Hours, UP Hours and are belonged to strata measure NSC 12c = 03, 04, 05 Type of Unit = 03 Calculate 4 rates for the strata measure NSC 12d: R1 = (RN Hours [Contract:gency] + RN Hours [Employee]) / R2 = (LPN or LVN [Contract:gency] + LPN or LVN [Employee]) / R3 = (UP [Contract:gency] + UP [Employee]) / R4 = (RN Hours [Contract:gency] + LPN or LVN [Contract:gency] + UP [Contract:gency]) / Hours, UP Hours and are belonged to strata measure NSC 12d = 04, 05 Type of Unit = 04 Calculate 4 rates for the strata measure NSC 12e: R1 = (RN Hours [Contract:gency] + RN Hours [Employee]) / R2 = (LPN or LVN [Contract:gency] + LPN or LVN [Employee]) / R3 = (UP [Contract:gency] + UP [Employee]) / R4 = (RN Hours [Contract:gency] + LPN or LVN [Contract:gency] + UP [Contract:gency]) / Hours, UP Hours and are belonged to strata measure NSC 12e = 05 Calculate 4 rates for the strata measure NSC 12f: R1 = (RN Hours [Contract:gency] + RN Hours [Employee]) / R2 = (LPN or LVN [Contract:gency] + LPN or LVN [Employee]) / R3 = (UP [Contract:gency] + UP [Employee]) / R4 = (RN Hours [Contract:gency] + LPN or LVN [Contract:gency] + UP [Contract:gency]) / Hours, UP Hours and are belonged to strata measure NSC 12f Z STOP Implementation Guide for the NQF NSC 12-8 Joint Commission, 2005