Washington State Nurse Staffing Committees: How Are We Doing & Why Does it Matter?

1. Washington State Nurse Staffing Committees: How Are We Doing & Why Does it Matter?

2. Your Presenters Gladys Campbell, RN, MSN, FAAN CEO, Northwest Organization of Nurse Executives Sarah Schwen, RN, MS, Director of Membership Services, NWONE

3. Plan for our Time Together • Provide some historical context to our work in the Northwest on Staffing Committees and staffing laws • Review the requirements of our staffing committee law • Describe the intent of the law • Explain the process used in Washington to assess the state of our staffing committees • Identify areas of best practice and areas where assistance / support is needed • Explain why the success of our staffing committees is important to us.

4. A Little History • Long standing concerns, across the nation, about nurse staffing • Research by Linda Aiken, Peter Buerhaus, & Jack Needleman • Development of the NDNQI and CALNOC • Emergence of legislative proposals related to nurse staffing • Nursing Ratios enacted in California

5. Oregon Specific History • 2001 Oregon enacted HB 2800 on Nurse Staffing • It requires that each acute care hospital establish a nurse staffing committee • Equal numbers of nurse managers & direct care nurses on the committee • Committee is to develop nurse staffing plans based on: • Accurate description of individual & aggregate patient needs • Requirements for nursing care • Specialized qualifications & competencies of nursing staff • Staffing plans are developed, monitored, evaluated, and modified by the staffing committee • Staffing plans are to be consistent with nationally recognized evidence based standards and guidelines • Any nurse on the staffing committee may request that the Oregon Department of Human Services assist in resolving any staffing impasse

6. Oregon Specific History • 2011 the ONA and OAHHS collaborated on a project to study the effectiveness of the state staffing committees • Oregon Nurse Staffing Law: is it working? JONA, volume 42, number 3, pp 134-137, March 2012 • Hospital to hospital experience was widely variable • Influence of the CNE is highly correlated with a high functioning staffing committee • A true participative management culture is required for full success • “You can’t legislate judgment”

7. Washington Specific History • 2007 The Ruckelshaus Process • NWONE, WSHA, UFCW, SEIU, WSNA • Facilitated by the Dan Evans Ruckelshaus Center at the UW and WSU • Initial goals • Avoid public legislative battles • Work to cooperatively accomplish shared success

8. Washington Specific History • 2008 Accomplishments • Jointly proposed and passed HB 3123 on nurse staffing committees • Provided an accompanying MOA between all parties • Gained the full support of then Governor Christine Gregoire

9. Washington Specific History • Mandates of HB 3123 • All Washington hospitals must establish a nurse staffing committee • Some structural flexibility provided to critical access hospitals • 50% of each committee must be direct care staff nurses • Staff are to participate in the committee on paid time

10. Washington Specific History • HB 3123 – Mandates of the Law: • The committee is accountable for developing an annual staffing plan based on: • Census Trends • Patient intensity • Staff experience, specialty certification, & training • Design and geography of physical units • National staffing guidelines • Staffing plans are to be submitted to the CEO for review • If the CEO does NOT approve the plan s/he must explain this decision in writing to the staffing committee • Approved staffing plans must be publicly posted • Annual Staffing Plan must be publicly posted • Actual shift to shift staffing must be publicly posted • Clinical support staff availability must be publicly posted • No retaliation or intimidation toward staff nurse members of the staffing committee

11. Why We Chose to Do a Review of The Washington State Nurse Staffing Committees • We now have over 5 years of experience with our nurse staffing committees. Are we maintaining compliance? Are we improving our processes? • We have heard from our union colleagues that the committees are not working as they should. • We hoped to gain knowledge about the status of our committees, but also hoped to learn what “best practices” in staffing committee work were, and where we might be able to offer assistance to help committees improve their processes.

12. Where Did We Go? • We wanted to visit hospitals who were: • Big and small, rural and urban • In the east and the west • Those we assumed would have strong committees, and • Those we thought might be struggling • We started with 17 hospitals, visited 23, and have 2 more who would like us to visit.

13. What Did We Do on Our Site Visits? • At each hospital we: • Were silent observers in a hospital based staffing committee • After observing a staffing committee we • Held a 90min focus group with the staff nurse members of the committee only • Held a 90min focus group with the leadership members of the committee only • Each focus group was asked the same 45 questions • Used the focus groups for not just data collection but for teaching/learning dialogues as well • Met with hospital leaders as requested for verbal report outs

14. What Did We Review on Our Site Visits? • We first looked at compliance with the law: • Did the hospital have an established staffing committee? • If a hospital had a committee was it made up of at least 50% front line staff nurses? • Had the committee created a staffing plan? • If the hospital committee had created a staffing plan, was that plan then sent to the CEO for their review? • If the CEO received the staffing plan did they communicate their approval or rejection of the plan to the committee? • Did the hospital meet the posting requirements of the law which include: • Posting the annual staffing plan in a public place • Posting today’s unit and shift-based plan in a public place • Including in today’s plan a posting of additional staff who, when they are absent, impact nurse staffing. These staff might include: a transporter, pharmacist, hospitalist, or respiratory therapist. • Did the hospital conduct, at a minimum, a mid-year review of the effectiveness of their staffing plan?

15. We Also Looked at the Intent of the Law… • We asked committee members what they thought the intent was • Additionally we assessed: • CNE involvement with the committee • Was there an orientation process for committee members? • Did the committee have a charter? • Did the committee have ongoing education for its members? • Did the committee have routine meetings? • Was the committee isolated or integrated into the larger work of the organization? • Did the committee have access to organizational data of relevance to nurse staffing? • Did the committee assess its effectiveness in any way? • What was the organizational milieu? Did committee members have genuine and authentic relationships with each other?

16. What Did Staffing Committee Members Believe the “Intent of the Law” is? • To create a participative & collaborative approach to nurse staffing between front line care providers & management • To assure that nurse staffing is driven by the needs of patients, while considering the budget – instead of just being driven by budget • To use evidence, research, and data to support staffing decisions – rather than emotion • To create a fluid and continuous process for the re-evaluation of staffing, patient outcomes, & patient utilization trends • To support transparency in hospital nurse staffing

17. So What Did We Find Relative to Hospital Compliance With Our Nurse Staffing Law? • The vast majority of hospitals had established committees with the right composition who met with regularity • Some simple questions turned out not to be so simple -- Have you created a staffing plan? • CEOs were compliant with staffing plan reviews when these plans were forwarded • All hospitals posted nurse staffing but there were consistent misunderstandings about the posting requirements. • Most hospitals did not do a specific mid-year review of their staffing plans, but instead tended to review staffing effectiveness at every meeting of the committee

18. What Did We Find That Went Beyond Compliance With the Law?What Were the “Best Practices”? • Formal education/orientation process for new staffing committee members • Orientation to the staffing committee law as part of new employee onboarding • In large organizations, having service-line or specialty committees that “feed-up” to the central staffing committee giving more voice and involvement of staff from all levels of the organization • Committees that meet at least quarterly and preferably, monthly • Committees with an open door policy where employees from other areas are invited to participate in staffing discussions where their help is desired • Ancillary staff • Housekeeping • Finance staff • Facilities management staff • Transporters • Physicians, etc. • Administrators assure that their staffing committees are included in decision making that has a significant impact on staffing

19. What Did We Find That Went Beyond Compliance With the Law?What Were the “Best Practices”? • The staffing committee is formally linked to other organizational committees • The hospital is enrolled in a nurse sensitive outcome indicator database (either NDNQI or CALNOC) • Nurse sensitive outcomes are used as a strong indicator of staffing effectiveness • The committee uses national level professional, specialty guidelines as a benchmark for appropriate staffing in specialty areas • The staffing committee has ready access to organizational data pertinent to the analysis of nurse staffing which could include: • Patient census and census variance trends • Patient LOS • Nurse sensitive outcome data • Quality metrics and adverse event data where staffing may have been a factor • Patient satisfaction data • Staff satisfaction data • Nursing overtime, on-call utilization, and agency utilization • “Assignment by objection” or other staffing complaint/concern data • Patient utilization trends in those areas where on-call is used

20. What Did We Find That Went Beyond Compliance With the Law?What Were the “Best Practices”? • The staffing committee has formal defined methods to communicate their work to the full nursing department, which may include: • Nursing Department newsletter • Nursing Department Annual Report • A specific nurse staffing committee website that can house: • Staffing committee membership and meeting times/places • Unit based staffing plans • Hospital level best practices • The current staffing committee law • Reports that correlate nurse staffing to patient and staff satisfaction and to NWQI • An email process where staff can communicate staffing concerns in real time

21. What Did We Find That Went Beyond Compliance With the Law?What Were the “Best Practices”? • Beyond the creation and evaluation of an annual staffing plan the nurse staffing committee may engage in other activities such as: • Reviewing staffing complaints/concerns • Review of data on breaks missed and the use of overtime • Review of the literature on issues pertinent to staffing such as fatigue, shift options, models of care delivery, staffing process improvement mechanisms • Analysis of variance from planned and actual staffing, planned and actual patient volumes • The committee conducts routine surveys to assess staff satisfaction • The organization provides education to nurses on staffing, scheduling, and budgeting so that they may be both educated and informed

22. What Other Issues of Concern Were Explored? • Meal and rest breaks and their documentation

23. What Other Issues of Concern Were Explored? • The use of on-call and total hours worked • Fatigue

24. What other Issues of Concern Were Explored? Financial Success and Business Imperatives Clinical Care Needs and Quality

25. How Did Nurses Describe their Staffing Committee Experience?

28. Themes from the Focus Groups - Things We Should Pay Attention To • The 2007-2008 economic downturn led to financial “course corrections” for most hospitals. When these corrections were made without input from the staffing committees they felt, from their inception, that the hospitals were not committed to the process. • Many committee members do not seem to understand what a “staffing plan” is - which impacts their ability to “create a staffing plan” • Significant labor/management strife undermines a staffing committee • Current documentation on break compliance is not adequate and needs to be revisited • Hospital policies that address maximal hours worked can significantly change the organizational culture about fatigue • Flipped processes – be careful to assure that the staffing plan is created by the staffing committee and responded to by the CEO

29. Themes from the Focus Groups - Things We Should Pay Attention To • The presence of the CNE/CNO is significantly linked to staffing committee success • Tension between financial goals and clinical goals is healthy in our organizations – conflict avoidance is not • Engagement from the C-Suite is critical to staffing committee success • Nursing is the only clinical discipline that cares for complex patients simultaneously, rather than sequentially

30. Looking Ahead… What Should We Be Doing? • Actively support the success of your staffing committees. • Ensure that your staffing committee is meaningfully integrated into the fabric of your organization by connecting it to your quality committees, patient satisfaction work, workforce planning, and finance workgroups. • Assure that nurse leaders are able to balance and direct the tension between our dual obligations to organizational financial health and quality care. • Developing a firm understanding of the dangers of poor staffing practices on: • Quality and patient safety • Staff safety and satisfaction • Value Based Purchasing • The cost of “never events” balanced against the cost of adequate staffing • Labor – Management relations

31. What We Can Do to Help…. • Provide a simple check list of what your “gotta-do” to be fully compliant with the law • Provide a “best practices” document that outlines steps you can take to move your committee from good enough to great… to move beyond the requirements of the law • Provide a nurse staffing committee orientation book template • Provide a fresh set of eyes to observe, and consult with your team • Provide education for your committee members and nurse leaders

32. Questions?Comments?

33. Gladys Campbell, RN, MSN, FAAN CEO, Northwest Organization of Nurse Executives gladysc@wsha.org Sarah Schwen, RN, MS Director of Membership Services, Northwest Organization of Nurse Executives sarahs@wsha.org