VeHU Class 247 VA Nursing Outcomes Database (VANOD): Surviving the Process

1. VeHU Class 247 VA Nursing Outcomes Database (VANOD): Surviving the Process Office of Nursing Services - VA Nursing Outcomes Database

2. HOUSE KEEPING This is 1.5 Hours Lecture class Restrooms are located… Cell Phones Please turn off or change to vibrate If you must answer a call, please leave the room. Office of Nursing Services - VA Nursing Outcomes Database

3. HOUSE KEEPING Please, No questions during the presentation. Questions written on the 3X5 card will be answered at the conclusion of the presentation. For questions not answered, the question and the answer will be available on the web. Office of Nursing Services - VA Nursing Outcomes Database

4. VeHU Class 247 • Segment 1: Overview, Data & Projects in Development • Bonny Collins, PA-C, MPA, VANOD Program Manager • Segment 2: Patient Fall Risk Assessment Template • Alicia Levin, RN, MS, VANOD Implementation Coordinator • Segment 3: Facility Experiences – Validation & Application of VANOD Data • Michelle Ernzen, RN, MSN, CCRN, Patient Safety Manager, Durham VAMC • Toni Phillips, RN,MSN, C, Nursing Informatics Coordinator,North Florida & South Georgia HCS • Segment 4: Summary andQuestions and Answers Office of Nursing Services - VA Nursing Outcomes Database

5. Segment 1: Overview, Data, and Projects in Development Bonny Collins, PA-C, MPA, VANOD Program Manager Office of Nursing Services - VA Nursing Outcomes Database

6. Presentation Objectives • Describe the current status of VANOD and the new indictors available • Describe the significant features of the VANOD • Describe a facility level approach to VANOD data validation • Describe a facility level approach to using VANOD data Office of Nursing Services - VA Nursing Outcomes Database

7. Simplified Version of the Mission of VANOD • Provide stakeholders with tools/data to: • Manage nursingresources • Understand clinical processes that are sensitive to nursing practices • Influence patient outcomes Office of Nursing Services - VA Nursing Outcomes Database

8. VANOD Data Goals • Scope of Data • Structures, Processes, Outcomes • Full Continuum of Care • All Nursing Personnel, Skill Mix, Role • Administrative, Clinical, Safety, Satisfaction (Staff and Patient) Indicators/Reports • Granularity of the Data • Unit/Clinic, Specialty, VAMC, Complexity Group, VISN, VHA • Shift, Day of Week, Pay Period, Month, Qtr, FY Office of Nursing Services - VA Nursing Outcomes Database

9. Business Rules • Manual data collection only as a last resort • Provide front line staff the tools they need to document the good care they are providing • Extract the data from nursing point of care documentation • Standardize terms, data & indicators to allow for comparison across the VA and with non-VA facilities • Provide facilities the tools they need to understand and validate their data Office of Nursing Services - VA Nursing Outcomes Database

10. Nursing Staff Data Currently Available(Sample of Key Indicators) • Distribution of Resources - % of hours worked that were in (Role): • Administration • Direct Care • Consultative (Hospital Support) • Advance Practice • Staff Evidence Based Demographics • % of Direct Care (DC) staff that are RNs • % of DC RNs that have at least a Bachelors degree • Financial: hours and dollars for PAID, e.g. Annual Leave (AL), Sick Leave (SL), Leave With Out Pay (LWOP), Comp Time Earned (CTO), etc. • % of Hrs worked accrued from Overtime or Comp Time Earned (OT/CTE) • Nursing Staff Turnover Rates (all reasons, voluntary) • Staff Injury • RN Satisfaction • Nursing Staff Retirement Eligibility Office of Nursing Services - VA Nursing Outcomes Database

11. Understanding Our Work ForceVHA Staff Demographics(FY2007) • Direct Care Nursing Staff:** 62,268 • % of Direct Care Staff who are RNs 60% • % of Direct Care RNs with least a Bachelors Degree 58% • % of Direct Care RNs eligible to retire 28% • Voluntary Loss Rate of RNs leaving the VA: 6.3% • RNs in the VA less than 5 years 33% **RN, LPN, Unlicensed Assistive Personnel (UAP) with direct patient care assignments – Inpatient or Outpatient. ** RN, LPN, Unlicensed Assistive Personnel (UAP) with direct patient care assignments – Inpatient or Outpatient Office of Nursing Services - VA Nursing Outcomes Database

12. How Much Can You Trust the Data? • Trustworthy - Data used for Payroll • Administrative indicators for skill mix, hours and dollars • Reports assigned T&L Unit - won’t capture float off T&L (Unit) • Need Data Validation for ‘less used’ data • Assignment code (used to determine roles) • Education level – from PAID/HR • Built in to new products: New DSS and VANOD Skin Assessment/Reassessment • Data has to be corrected locally • Local Validation tools available (Class III VistA reports): • Active NURS Staff file report • NURS Staff Education report Office of Nursing Services - VA Nursing Outcomes Database

13. Nurse Staff Turnover Rate • Segment by: • All reasons for departure, e.g. retirement, death, etc. • Voluntary departure – JCAHO Nursing Sensitive Indicator, “quit”, “regrettable loss” • Data from HR – current limitations • Only at the facility level • Can’t segment out Advance Practice Nurses (NPs & CNSs) from other RNs (Only HR Codes) • VANOD is working to add: • T&L Unit granularity • Tenure in VA, VAMC, Time &Leave (T&L) Unit • Ability to segment NPs & CNSs from other RNs (Budget Object Codes) • Nursing Role, e.g. Direct Care, Admin, Consultative, Advance Practice Office of Nursing Services - VA Nursing Outcomes Database

14. FY07 Voluntary Quit Rate by Occupation Name, by VISN RN: Avg 6.3% Range 3.8% to 9.5% Nursing Assistant LPN Office of Nursing Services - VA Nursing Outcomes Database

15. Percent of Hours Worked That Were Overtime or Comp Time Earned Which skill mix has the highest percent of worked hours acquired through overtime or comp time earned? • RN • NP • CNS • LPN, LVN • Nursing Assistant Office of Nursing Services - VA Nursing Outcomes Database

16. Scale 0% to 5% Nursing Assistant RN LPN NP CNS FY08 Qtr 1 & Qtr 2 Percent of Hours Worked That Were Overtime or Comp Time Earned Office of Nursing Services - VA Nursing Outcomes Database

17. 3.8% 3.8% 3.5% 3.8% 4.6% 4.7% FY04 FY04 FY05 FY06 FY07 FY08 Q1 & Q2 Nursing Assistant Overtime or Comp Time Earned, TrendFY04 - thru April 12, 2008 Office of Nursing Services - VA Nursing Outcomes Database

18. Nurse Staff Injuries • Types of injuries • Types of staff • Numbers and rates • Staff demographics Stop by and see the POSTER & Hands-on training Class 250 Office of Nursing Services - VA Nursing Outcomes Database

19. Current VANOD Projects in Development • Facility Alert Profile • Deputy Under Secretary for Operations and Management (DUSHOM 10N) • Nursing Indicators - Data from Decision Support Service (DSS) • Comprehensive Patient Assessment Office of Nursing Services - VA Nursing Outcomes Database

20. Facility Alert Profile: Nursing - Inpatients 1. Hours Per Patient Day of Care (HPPD): all direct care nursing staff 2. Hours Per Patient Day of Care (HPPD): RNs • HPPD reported in six areas: Critical Care, Medical, Surgical, Mixed Med/Surg, Mental Health, and Community Living Center (NHCU) units 3. % of Direct Care Hours by RN • Data are from DSS – nurse staff mapping is critical • Lowest time granularity is “Month” Office of Nursing Services - VA Nursing Outcomes Database

21. Facility Alerts Profile: Nursing - Outpatients 4. Average # hours per encounter for all support nursing staff (RN,LPN,UAP, excludes CNS, NP) by clinic type 5. % of ambulatory care support nursing staff who are RNs by clinic type Clinic type: • Mental Health • Primary Care • Procedures Clinics, e.g. GI Endoscopy, etc. • SCI/Rehab Clinics • Specialty Clinics, e.g. HTN, DM, etc. Office of Nursing Services - VA Nursing Outcomes Database

22. Facility Alert Profile • What is the ‘threshold’ for being noted as an “Alert”? • To be developed Office of Nursing Services - VA Nursing Outcomes Database

23. Nationally Standardized Comprehensive Patient Assessment Project • Opportunity to move locally developed Class III software patient assessment to Class I (National Release and ongoing support) • When released, the assessment will be required for ‘at least’ acute Medical and Surgical Units Office of Nursing Services - VA Nursing Outcomes Database

24. Development Team 36 members from 17 VISNs and 26 VA Medical Centers chartered March 9, 2008 representing stakeholders including: • Content and Work Flow Experts: Front line staff, Nurse Managers, CNSs, CNLs, NPs • Clinical Settings in ICU, Med/Surg, MH, SCI&D • Informatics: CACs, Clinical Informatics Subgroup, BCMA Coordinators, Taxonomy/Data Standardization • Research: Nurse Researchers • Administration: Nurse Executive,Magnet Coordinators • OI&T: Programmers and OIFO Patient Safety • VANOD Team, Field Advisory Council and Site Coordinators Office of Nursing Services - VA Nursing Outcomes Database

25. Software Specifications & Functionality • Reviewed and validated a list of 64 specifications or functionality items • Highest Priority – provide optimal work flow support for front line nurses (reduce fragmentation, disruption, redundancy) • Save partially completed data Office of Nursing Services - VA Nursing Outcomes Database

26. Software Specifications & Functionality • Combination of structured point and click and free text • Data pulled from other sources to make available for review • Production of local reports Office of Nursing Services - VA Nursing Outcomes Database

27. Local Reports Examples: Summary & Detail Display of Patients with: 1. MRSA Swabs 2. Admission Assessment done within X hrs 3. High risk for skin break down 4. Fall risk assessment done within 24 hrs 5. List of patients at risk for .....?? Vision Patient Assessment (including fall risk) Extracted Data for National Reports Reassessment (Shift Note) Identify Key Data Terms from Patient Assessment, Reassessment & Care Plans Embed terms in Files: Clinical Observations (CLiO), Health Factors, Vital Signs End of Shift Report Care Plan Office of Nursing Services - VA Nursing Outcomes Database

28. Contacts • Chief Nursing Officer: Cathy Rick • VANOD Program Manager: Bonny Collins • VANOD Implementation Coordinator: Alicia Levin • VANOD Education Coordinator: Mimi Haberfelde • VANOD Informatics: Diane Bedecarre • Analyst: Becky Kellen Office of Nursing Services - VA Nursing Outcomes Database

29. Segment 2: Patient Fall Risk Assessment Templates Alicia Levin RN, MS VANOD Implementation Coordinator Office of Nursing Services - VA Nursing Outcomes Database

30. Tackling Another Patient Safety Issue Preventing and Tracking Falls Office of Nursing Services - VA Nursing Outcomes Database

31. Rationale • Estimate is that by the year 2020 in the U.S., there will be 17,293,000 falls resulting in injury. A projected cost of $85.37 billion. (this includes community as well as healthcare settings)* • Falls are the leading cause of injury-related death for individuals 65 and older** • Thus the need to apply current best evidence to reduce fall risk is clear *Poe, S.S. et. al., An Evidence-based Approach to Fall Risk Assessment, Prevention and Management; Lessons Learned, Journal of Nursing Care Quality, Vo. 20, , No 2, pp 107 – 116, 2005 **National Center for Patient Safety Office of Nursing Services - VA Nursing Outcomes Database

32. VANOD Approach to Addressing Patient Falls Creation of two nationally standardized nursing documentation templates: • Fall Risk Assessment • Post Fall Note Office of Nursing Services - VA Nursing Outcomes Database

33. Fall Risk Assessment Template Assessment – Fall risk identification (Morse Fall Scale) • All patients are assumed to be at risk of falling in acute care settings Fall prevention strategies (evidence-based review of current measures) • Basic interventions for universal application are put into place for all patients Office of Nursing Services - VA Nursing Outcomes Database

34. Fall Risk Assessment Definitions • Fall: a unplanned decent to the floor, either with or without injury to the patient • Assisted fall counts as a fall • Injury: a disruption of structure or function of some part of the body as a result of an unplanned event Office of Nursing Services - VA Nursing Outcomes Database

35. Fall Risk Assessment Indicators to be Tracked • Rate at which patients fall during the course of their hospital stay • Rate at which patient fall and incur physical injury during the course of their hospital stay • Rate of repeat patient falls (for current episode of care) Office of Nursing Services - VA Nursing Outcomes Database

36. Fall Risk Assessment Indicators to be Tracked 4. % of admitted patients who had a fall risk assessment using the Morse Fall Scale within the first 24 hours. 5. % of patients who had a fall risk assessment and then fell and were injured 6. % of moderate or high risk patients who had fall prevention protocols in place Office of Nursing Services - VA Nursing Outcomes Database

37. Instructions for use of the template General information on conducting the Morse Scale can be viewed. Office of Nursing Services - VA Nursing Outcomes Database

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39. Breakdown of “History of Falling” questions Office of Nursing Services - VA Nursing Outcomes Database

40. Breakdown of “Secondary Diagnosis questions Office of Nursing Services - VA Nursing Outcomes Database

41. Universal Fall Precautions are put into place on for all hospitalized patients Office of Nursing Services - VA Nursing Outcomes Database

42. Interventions are selected based on assessment findings from Morse Scale Office of Nursing Services - VA Nursing Outcomes Database

43. Interventions offered for a positive response to “History of Falling” question Office of Nursing Services - VA Nursing Outcomes Database

44. Interventions offered for a positive response to “Secondary Diagnosis” question Office of Nursing Services - VA Nursing Outcomes Database

45. Interventions offered for a positive response to “Gait or Transferring Problems” question Office of Nursing Services - VA Nursing Outcomes Database

46. Clinical Judgment Interventions Content box opens when selected Links to ordering therapies Office of Nursing Services - VA Nursing Outcomes Database

47. Post Fall Note • A standardized national template to track occurrence of falls along with some levels of injury which may occur as result of the fall. • Short term goal is to collect information that will be similar to or the same as data collected in patient incident reports (patient event reports) • Long term goal is to have the information from the post fall note link to an electronic incident report so that duplicate entry will not be required Office of Nursing Services - VA Nursing Outcomes Database

48. Ward list – sites are able to edit Office of Nursing Services - VA Nursing Outcomes Database

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50. Information is recorded on the fact that a patient is/is not in restraints Office of Nursing Services - VA Nursing Outcomes Database