Assessment of Staffing Effectiveness in Healthcare Organizations

1. Assessment of Staffing Effectiveness in Healthcare Organizations

2. Current national focus on staffing… • Shortage of qualified professional personnel • Identified linkages between staffing effectiveness and patient safety • Legislation regarding staffing

3. 2001 National Study’s Findings:Outcomes Found Sensitive to Nurse Staffing MEDICAL Patients Strong evidence: • UTI • Pneumonia • LOS • Upper GI bleeding • Shock • MAJOR SURGICAL • Patients • Strong evidence: • Failure to rescue • Weak evidence: • Pneumonia • UTI Needleman J, Buerhaus P. “Phase I1Final Report: Nurse Staffing and Quality of Care in Inpatient Units in Acute Care Hospitals,” April 20, 2001 (cosponsored by HCFA, AHRQ, NINR, NIG, NHRSADN).

4. LTC Staffing Study • 54% of nursing home residents receive less than 2 hours care each day by CNAs • 31% of nursing home residents receive less than 12 minutes care each day by RNs • Outcome measures that correlate with staffing: • Acquired pressure ulcer rate • Prevalence of malnutrition • Weight loss • Staff turnover rate • Hospital admissions Harrington C, Zimmerman D, et al. “Experts Recommend Minimum Nurse Staffing Standards for Nursing Facilities in the United States.” The Gerontologist, 2000, Vol. 40, No. 1.

5. ANA’s Study of Nursing Sensitive Measures • Nosocomial infection rates • Patient injury rates (falls) • Patient satisfaction with nursing care • Patient satisfaction with pain management • Patient satisfaction with educational info • Patient satisfaction with overall care • Maintenance of skin integrity (pressure ulcers) • Nursing staff satisfaction • Staff mix • Total nursing care hours provided per patient day “More Nurses, Better Patient Outcomes,” The American Nurse, May-June 2000.

6. ANA’s Study 9 million patients in 1000 hospitals and 3.8 million Medicare-only patients in 1500 hospitals With more RNs involved in patient care: • Lower LOS • Lower rates of pneumonia & postop infections • Lower rates of pressure ulcers • Lower complication rates

7. American Organization of Nurse Executives Staffing decisions must be based on: • Patient acuity • Competency, education and experience of nurses • Support available for those nurses Using ratios does not include the above 3 variables Pamela Thompson RN MS, American Organization of Nurse Executives in Nursing Spectrum Career Management

8. Joint Commission’sStaffing Effectiveness Model

9. Purpose:Staffing Effectiveness Strengthen the assessment of staffing effectiveness in accredited organizations What? An approach that utilizes screening indicators that are sensitive to staffing effectiveness How? Pilot testing, and identification of additional indicators Next Steps?

10. New staffing effectiveness model does not… • Prescribe staffing levels • Require submission of screening indicator data

11. Staffing Effectiveness Defined as… • The number, competency, and skill mix of staff as related to the provision needed services.

12. Expert Panel on Staffing Effectiveness • Formed to analyze proposed staffing models and rate sensitivity of screening indicators, summer 2000 • Included representatives from several settings including Behavioral Health, Hospital, Home Care, Lab, Ambulatory, and Long-Term Care • Represented multiple disciplines including 20% currently providing direct care

13. Recommended Approach • Uses clinical/service and human resource screening indicators believed to be sensitive to staffing effectiveness • Views screening indicators in a matrix • Considers direct and indirect care givers • Allows organizations to select from JC identified list, and to self-select screening indicators • Recognizes no one indicator directly measures staffing effectiveness

14. Staffing Effectiveness Model Human resource indicators encompass all staff: • Direct caregivers • RNs, LPNs, CNAs • Respiratory, physical and occupational therapists • Etc. • Indirect caregivers (clinical support professionals) • Pharmacy • Laboratory • Radiology • Housekeeping

15. Staffing Effectiveness ModelDraft Standards New: HR.X • The organization uses data on clinical/service indicators in combination with human resource indicators to assess staffing effectiveness. Modifications to Intent Statements: • HR.2 • PI.3.1.1. and PI.4.3 • LD.4.3

16. Screening Indicators… • Joint Commission screening indicators will be based on expert consensus and research regarding sensitivity, and will consider accessibility of data • Health care organization identified screening indicators allows the flexibility to reflect each organization’s unique characteristics

17. Analysis of screening indicator data… • May indicate the need for the organization to further evaluate • The organization’s analysis should focus on staffing effectiveness • Other variables may need to be considered as a possible cause of variation

18. Surveyors will review… • The heath care organization’s staffing plan • Organization’s actual staffing vs. plan • Rationale for screening indicator selection • Data collected for selected screening indicators • Organization’s response to analysis of data from screening indicators – if indicated

19. Standards Compliance Based on… • Organization’s review of data • Organization’s response to data • Demonstrated impact of the response

20. Pilot Test / Feasibility Study • June-July 2001 for hospitals • Over 40 hospitals to comprise 1st pilot test • Virtual survey involving a 2-3 hour mock survey conducted by a surveyor over the phone to representatives from each hospital’s key staff involved in pilot study and surveyable standards

21. List of JCAHO Screening Indicators* Clinical/Service • Falls • Injuries to patients • Length of stay • Adverse drug events • Patient/family complaints • Pneumonia • Postoperative infections • Pressure ulcers • Shock/cardiac arrest • Upper GI bleeding • Urinary tract infections Human Resource • Nursing care hours per patient day • On call or per diem use • Overtime • Sick time • Staff injuries • Staff satisfaction • Staff turnover rate • Staff vacancy rate • Understaffing compared to staffing plan *Updated to include outcomes found sensitive to staffing in research studies

22. Analyze and Display Data • Individual indicator analysis: • Line graphs, run charts, control charts, etc, • Historical trending for each indicator • Common cause or special cause variation?

23. Analyze and Display Data • Aggregate and summarize: • Combine information pertaining to the set of screening indicators you selected • matrix format (tabular display) • other diagram approaches • statistical correlation studies • etc.

24. Analyze and Display Data • Decide if: • Similar trends exist across multiple indicators for the same time periods? • Similar causes can be established linking some of the indicators? • Use cause & effect diagrams, process flow charts, brainstorming techniques • Where and what times are incidents occurring? (off shifts, weekends) • Is one department having more incidents than others? (collaborate, share lessons learned)

25. Identify opportunities for improvements • Identify opportunities for improvement based on indicators in sub-optimal ranges • Or, corresponding changes between indicators that may be related to staffing effectiveness issues, such as: • Number of staff • Skill mix • Competency

26. Utilize PDCA methodology • Brainstorm or research potential staffing effectiveness strategies: • Staff recruitment • Education/training • Service reduction • Equipment enhancements • Reorganization of work flow (use of ancillary or support staff)

27. Re-evaluate screening indicators selected • Continuously evaluate for: • Relevancy of indicator for your organization • Sensitivity of indicator for your organization • Modify screening indicator mix as needed if indicators found not to be relevant and/or sensitive to your organization’s staffing effectiveness monitoring

28. Assessment of Staffing Effectiveness Quality and Safety Human resource indicators (JCAHO & HCO specific) Clinical/service indicators (JCAHO & HCO specific) Select relevant indicators Implement improvement activities No Collect and analyze data Yes No Indicators still relevant and sensitive? Need for further analysis? Compare indicators and identify opportunities for improvement Assessment of Staffing Effectiveness Sensitivity analysis-drill down and consider staffing effectiveness as potential variable Plan-Do-Study-Act

29. A Matrix Approach • The following slide depicts one organization’s approach to analyzing human resource and clinical indicators together to assess its staffing effectiveness.

30. *JCAHO expert panel consensus driven indicators

31. Spider Diagram* Approach • Shows relationship of organization’s current performance on selected staffing indicators to its & customers’ expectations • 3 levels depict performance: • Inner ring is sub-optimal range • Middle ring is requested range • Outer ring is delighted range • To be used with run charts for trended studies *Caldwell, C. Mentoring Strategic Change in Health Care: An Action Guide, ASQC Quality Press, Milwaukee, WI, 1995, p. 101-110.

32. An Example of the Spider Graph Approach • Current Time Period: • The following slide depicts one organization’s approach to analyzing human resource and clinical indicators together • White dots/line are actual performance for the current time period. What zones do each fall in? • Historically Trending: • Line graphs, run charts or control charts should be used to trend individual indicators over time AND

33. Medication Variances (4.4) ICU, Quarter 3 4 0 1.5 % O/T Hours (14%) 6 Falls Rate (5) 5 2.9 8 10 4.3 Full Time Staff Vacancy (40%) 20 0 30 60 35 5 Restraint Rate (90) 20 1 4 10 3 Patient Satisfaction (1) 2 5 0 Full Time Staff T/O (10%) 0 Agency/Contract Hours - % Worked Hrs/Pt. Day (15%)

34. A Statistical Correlation Study Approach • The following slide depicts another organization’s approach that incorporates statistical correlation analysis for its selected human resource and clinical indicators in evaluating its staffing effectiveness.

35. Surgical Unit: Correlation Study #1 TRENDLINE: Shows a positive correlation between these 2 indicators

36. Timeline:Staffing Effectiveness Identified relevant indicators January 2000 Developed 2 proposed staffing models May 2000 Expert panel Q3 2000 Develop more sensitive approach Fall 2000 SSP, field review, additional indicators 2001-2002 Pilot testing Summer 2001 Target for implementation 2002

37. Benefits:Staffing Effectiveness Relevance • Addresses a complex and pertinent issue • Recognizes the uniqueness of each healthcare organization Method • Consistent with JC survey methodology • Uses screening indicators that are frequently collected and sensitive Design • Better approach than ratios • May preempt further attempts to legislate ratios

38. Address Your Questions and Comments To… E-mail: cgilhooley@jcaho.org