Ambulatory RN Transition

1. Ambulatory RN Transition 3/12/2014

2. Workgroup Overview Charge: Develop a proposal of Ambulatory RN position* definitions, position grading, role in clinical structure, and a transition plan from current state to proposed state. *Ambulatory RN titles reviewed include: Chemotherapy Nurse, Clinical Nurse Clinician, Clinical Nurse Clinician Sr., Nurse Clinical, Nurse Clinician, Nurse Clinician Senior, Nurse Clinician Senior - Certified, Nurse Coord Admit/Qual Assurance, Nurse Staff, Staff Nurse Clinical I and Staff Nurse Clinical II. Ambulatory areas reviewed include: Admitting & Registration/Patient Access Services, Cancer Clinic Services, OB/GYN, Internal Medicine, Pediatrics, Pain Clinic, Radiation Medicine, Polk-Dalton, Surgery, Transplant and University Health Service Clinics Team Members: Catie Lasley (Lead), Kathy Poteet, Jennifer Lackey, Dean Hanlon, Patty Hughes, Sharon Welch, Carmen Hall, and Morgan Dezarn Sponsors: Jonathan Curtright, Colleen Swartz, Dr. Marc Randall Timeline: Short cycle – kicked off in October with report out in January, implementation by July 2014

3. Current State • Current Structure: 11 different RN job titles within the Ambulatory Clinics with grade levels spanning grade 8-11 and education/experience ranging from ADN + 0 through BSN + 3 • Organizational changes: Clinic transitions to provider based clinics and other changes related to how we provide care creating increased need for clarity/discipline on how RN titles are graded. • Market changes: Market no longer differentiates RN compensation based on inpatient vs. outpatient setting, which had been a historical driver for UK RN compensation. Also finding Staff Nurse Clinical I (grade 8) is behind market.

4. What work is currently performed by RNs? • Considered a wide range of elements of nursing work: care environment (inpatient vs. outpatient), patient education, procedures, medication management/administration, development of care plans, assessment, patient acuity, and shift requirements (on call/weekend). • Narrowed this list down to two factors which best differentiate level of work performed: procedures and medication management/administration. • Used data from KMSF billing and clinic billing sheets to help build the list of procedures/treatments that an RN could perform. • Survey built with a focus on procedures performed and medication managed/administered.

5. Preliminary Recommendations - Template JAQs

6. Preliminary Recommendations (con’t) • Qualification for a grade 10 position would generallyrequire 50% or more of the patient population served by the RN position to receive higher level procedures.

7. Ambulatory Clinics – Recommended Areas in Scope • Ambulatory areas reviewed include: 20 19 1 1 7 5 • *Except nurses within Radiation Medicine working in Markey

8. Rationale to Exclude Cancer Clinic Services & Admitting & Registration Services • Markey/Cancer Clinic Services: • All RNs in these clinics are already appropriately classified at a grade 10, Nurse Clinical/UKHC, consistent with one of the three proposed Enterprise RN job titles. • Additionally, these clinics have historically followed inpatient nursing policies including: • Hiring and pay equity management • Step scale pay adjustments • Expanded tuition reimbursement • Nursing Professional Advancement pay differential (clinical ladder payment) • Admitting and Registration Services • All RNs in this area are appropriately classified at a grade 10. • The position function does not have significant patient contact. • 85% of position function is Medicare ABN processing.

9. Recommendations • Position classification determinations should be based on RN care provided to the majority of the patient population and additional specialty certification/training required vs. setting. • Workgroup recommends all ambulatory practices in scope follow the same protocols and practice for establishing what work must be performed by a RN, regardless of status (provider based vs. physician based). • Workgroup recommends all ambulatory practices in scope follow the same protocols and practice for determining the grade level for RN positions based upon the anticipated work to be performed by a RN, regardless of status (provider based vs. physician based). • Increase minimum grade for Ambulatory RN to grade 9 (based on market findings).

10. Recommendations (con’t) • Reduce number of Ambulatory RN titles for clinics in scope from 10 to 2 • Roll out standardized JAQs for each of the 2 new job titles: - Nurse Clinical/Ambulatory/UKHC (grade 10) - Staff Nurse/Ambulatory/UKHC (grade 9) • Change in titles and grade applied comprehensively to all RNs in given clinic based on care provided in that clinic*. Advise against having RNs graded differently in the same clinic for cross-coverage purposes, as appropriate. • Recommend standardizing time in position counting methodology for both grade 9 and grade 10 positions • Recommend completing this change by July 1, 2014 (lift and shift). * Will not decrease grade level of existing RNs but will handle through attrition.

11. Next Steps • Communication plan: • Ambulatory and Nursing Directors • Individual meetings with affected Directors/Managers/Administrators • CoM Department Administrators Meeting • Quarterly Ambulatory Leadership Meeting • ASMG • Implementation plan: • Managers confirm work performed by the RN positions in their clinic • Managers confirm TIP counts with their RN employees • If TIP is believed to be inaccurate manager directs employee to update application and manager contacts HR Business Partner to update TIP • Send financial costs by clinic to responsible party • Form a short cycle team to make changes in UKHC Payroll and HR systems • Manager to meet with employee and give letter confirming new title, grade and pay (as applicable) • Managers will be provided with template letter, talking points, and FAQ document for use in these discussions

12. Estimated Implementation Timeline 3/17/14 - Preliminary grading and TIP discussed with departments 3/21/14 – Any necessary TIP updates (including updated applications) are submitted by department 3/31/14 – Clinics receive financial costs based on finalized TIP and grading determinations 4/6/14 – Earliest effective date of changes