Wm. Dan Roberts, DNSc, ACNP-BC

DIVISION OF NURSING Wm. Dan Roberts, DNSc, ACNP-BC Associate Director of Nursing Quality, Research, and Nursing Support Services Acknowledgements for this presentation: A. Kabackinski, NM; E. Rubin, CNS; E. Valdez, Admin Asst

A REGIONAL RESOURCE 597 beds 34,000 discharges 88,000 emergency visits 345,000 hospital OP visits 4,000 births 5,600 employees 1,700 nurses 1,000 physicians 496 medical students and 481 resident physicians 634 research projects with $113 million in funding

Framing Methodology IHI Triple Aim: Value based with focus on Access, Quality, Cost Access: Available bed for the optimal medical service Quality: Clinical excellence reported as outcomes but controlled by best practice processes and measurement of these processes [e.g., Central Line Bundle] Cost: An appropriate plan of care with an expected length of stay

IHI TRIPLE AIM: ACCESS Division of Nursing response to Access : The right patient [the patient is appropriately admitted for necessary care needs] The right diagnosis [assigned primary working diagnosis] The right unit [appropriate level of care for the diagnosis and acuity of the patient] The right plan of care [comprehensive plan of care that addresses all immediate care needs] The right nurse [appropriate assignment with skill set to meet the nursing needs of the patient]

IHI TRIPLE AIM: QUALITY

IHI TRIPLE AIM: QUALITY

IHI TRIPLE AIM: QUALITY

IHI TRIPLE AIM: QUALITY

OPERATIONALIZING QUALITY DATA: MED/SURG UNIT Clairvia PCR FMR Daily Operational Budget Budgeted Clairvia PCR Volume 26.6 FTEs 59.45 Filled FTEs 53.5 Clairvia Avg. Daily Census 26.6 Clairvia Cumulative Census 880.83 Skill T&R III RN(RN+DN+Admit RN NA NSC Telemetry UE Total Source MARCH 2012 12S Clairvia Dashboard Report for March 2012 321343 Annual Operational Budget Total paid FTE 60.82 Unschedul ed Absences to OT hrs. 0.37 Productive Hours Target Hours Variance T/P Ratio Float Out Float In % of FMR Unscheduled Budgeted %OT /Total Absence to HPPD 10.4 Hrs Wkd 10.92 hours worked 4.05 Productive HPPD Target HPPD Extra Shift Total OT *Sick/LOA/FMLA/ hours 1000.58 Fam Sick Extra Shift DRL *Unscheduled Absence 744.00 296.00 448.00 39.78% 0.84 0.34 54.75 20 4288.00 4771.25-483.25 111.27% 120.00 20.00 4.87 5.42 138.5 16.5 144.67 3384.00 3395.78-11.78 100.35% 56.00 779.33 3.84 3.86 603.58 124 744.00 537.75 206.25 72.28% 24.50 0.84 0.61 187.25 82.5 0.00 #DIV/0! 0.00 0.00 0.00 #DIV/0! 0.00 0.00 0.00 #DIV/0! 0.00 0.00 0.00 #DIV/0! 0.00 0.00 0.00 #DIV/0! 0.00 0.00 0.00 #DIV/0! 0.00 0.00 9160.00 9000.78 159.22 98.26% 176.00 823.83 10.40 10.22 984.08 16.5 371.17 Productivity Report Productivity Report Productivity Report Productivity Report Clairvia Staff Manager Clairvia Staff Manager Productivity Report Productivity Report Clairvia Staff Manager Clairvia Staff Manager Clairvia Staff Manager

OPERATIONALIZING QUALITY DATA

Workforce and Capacity Management Solutions Staffing and Bed Management Managed Services Care Value Analytics Services Demand Manager Patient Progress Manager Outcomes-Driven Acuity Care Cost Manager Staff Manager Physician Scheduler ShiftAlert CareAware Patient Flow Resource Assignment Manager CareAware Tracking

* Featured Solutions Cerner Clairvia at Stony Brook Medical Center

Target/Scheduled Staffing Cerner Clairvia at Stony Brook Medical Center

Patient Pattern Manager: Cerner Clairvia at Stony Brook Medical Center

Patient Acuity Cerner Clairvia at Stony Brook Medical Center

OPERATIONALIZING QUALITY DATA: MED/SURG UNIT Two patient falls on March 27, 2012: Harm score 3 Post Falls Analysis: mini-rca within 1 hour of the event Assessment of Operational Data Target/Staffing Assessment: Scheduled for one less RN Scheduled for two less NAs Operational Data Trend: Reduction in OT as operational target Increased Absences in RN staff and NA staff March 2012

Target/Scheduled Staffing Cerner Clairvia at Stony Brook Medical Center FALLS

OPERATIONALIZING QUALITY DATA Mar Apr May Jun Jul Aug Sept Oct Nov Dec RN 111.27 91.35 96.23 96.23 96.05 92.76 91.24 91.64 87.98 88.32 NA 100.35 90.16 119.26 119.26 119.54 111.12 109.46 103.83 109.12 115.02 T/P > 105 = Not enough staff T/P < 95 = Too much staff

OPERATIONALIZING QUALITY DATA Mar Apr May Jun Jul Aug Sept Oct Nov Dec RN 111.27 91.35 96.23 96.23 96.05 92.76 91.24 91.64 87.98 88.32 NA 100.35 90.16 119.26 119.26 119.54 111.12 109.46 103.83 109.12 115.02 T/P > 105 = Not enough staff T/P < 95 = Too much staff

Med Surg Unit Demographics: OPERATIONALIZING QUALITY DATA 60-75% of patient population have a Psych/Behavioral Health co-diagnosis Large Orientation group annually: 4-6 RNs are in orientation each quarter 28% RN Turnover rate; Training unit for Med Surg experience in order to transfer to ICR or ICU level care At least 7 FTEs are utilized each month in SCA/1:1 sitters

OPERATIONALIZING QUALITY DATA Mar Apr May Jun Jul Aug Sept Oct Nov Dec RN 111.27 91.35 96.23 96.23 96.05 92.76 91.24 91.64 87.98 88.32 NA 100.35 90.16 119.26 119.26 119.54 111.12 109.46 103.83 109.12 115.02 T/P > 105 = Not enough staff T/P < 95 = Too much staff

Solutions: Operationalizing quality data OOPERATIONAL DATA: SOLUTIONS Target staffing needs: Nursing Matrix: how many staff members of a certain skill are needed for a given number of patients [Target] Per shift: How many staff members of a certain skill mix are working [Productive] Watch for over and under staffing by skill mix For Stony Brook: Falls and Pressure Ulcers are sensitive to NA HPPD

Solutions: Operationalizing quality data OOPERATIONAL DATA: SOLUTIONS Understand the unit demographics, in a meaningful way, for each metric [e.g., post falls assessment for Patient, Environmental, Location, Patient Activity, Unit Acuity, Staffing and Staffing Skill Mix Use Operational-Quality data to change Staffing and Skill Mix Be compliant with the New York State Nursing Care Quality Protection Act [e.g., data driven Staffing Models

Operationalizing quality data OOPERATIONAL DATA: SOLUTIONS NDNQI: Medical-Adult 0 Direct + Indirect Nurse: Pt Ratio 1: 4 ADC 25.2 Occup 87% Nurse: Pt Ratio 1: 4 ADC 25.2 Occup 87% Care Beds 29 Beds 29 Staffing Plan: RN, NA, NSC 7 days; NM 5 days RN1&2 NA LPN Total NM NSC HA Aides RN3 Total Day 7.00 5.00 0.00 12.00 Day 0.40 1.00 0.00 0.00 1.00 2.40 Evening 0.00 5.00 0.00 5.00 Evening 0.00 1.00 0.00 0.00 1.00 2.00 Night 7.00 5.00 0.00 12.00 Night 0.00 1.00 0.00 0.00 2.00 3.00 Total 14 15 0 29 Total 0.40 3 0 0 4 7.4 36.40 FTE Calculation FTE Calculation Hrs/Day 168.00 120.00 0.00 288.00 Hrs/Day 3.20 24.00 0.00 0.00 48.00 75.20 Hrs/Week 1,176.00 840.00 0.00 2,016.00 Hrs/Week 16.00 168.00 0.00 0.00 336.00 520.00 Hrs/Year 61,152 43,680 0 104,832.00 Hrs/Year 832 8,736 0 0 17,472 27,040 FTE 29.40 21.00 0.00 50.40 FTE 0.40 4.20 0.00 0.00 8.40 13.00 PTO 18% 5.29 3.78 0.00 9.07 PTO 18% 0.00 0.76 0.00 0.00 1.51 2.27 Overtime 0.00 Overtime 0.00 Subtotal FTE 24.78 0.00 59.47 Subtotal FTE 0.40 4.96 0.00 0.00 9.91 15.27 74.74 Use text box for Readjust NA's to 5due to increased sitters averaging 7 FTE's/month. Add Nurse Educator to night shift under indirect RN 3. Average of float in NA hrs. comments ---> =300. NA HPPD are under the NDNQI mean.