c512 the intersection of staffing and work environment ......avalere: food for thought "in...

C512 The Intersection of Staffing and Work Environment: What Leaders Must Know to Succeed

Mary Jo Assi, DNP, RN, FNP-BC, NEA-BC, FAAN

Christy Dempsey, MSN, MBA, RN, CNOR, CENP, FAAN

What Do We Know?

• After more than 3 decades of research, what do we know?

– The strength of available research and evidence is widely variable; mostly focused on acute care

– Difficult to prove cause and effect

– Need a greater focus on the financial impact of staffing (good or bad)

• Avalere White Paper

– Building the economic case for optimal staffing for safe patient care

• Press-Ganey White Paper

– Emphasizes the importance and impact on outcomes of staffing within the context of the total work environment

• Errors of Omission

– Fills in the gaps to explain the why and how staffing links to outcomes—the cause and effect

Avalere White Paper: Optimal Nurse Staffing to Improve Quality of Care and Patient Outcomes • Context

– 2010 ACA

– Aging U.S. population

– National Academy of Medicine/IOM report

– Complexity of patient care needs and nursing care

• As the largest healthcare workforce, reducing nursing labor costs to balance the budget is a repetitive theme

Avalere White Paper

• Many factors influence nurse staffing needs

– Patient complexity

– Acuity

– ADTs

– Staff skill mix

– Physical space and layout

– Proximity to technology and other support resources

Avalere White Paper

• Recent studies demonstrate that nurse staffing can achieve clinical and economic improvement/outcomes by improving:

– Patient satisfaction

– Medical and medication errors

– Patient mortality, hospital readmissions and LOS

– Number of preventable events including falls, pressure ulcers, healthcare-associated infections

– Healthcare costs related to unplanned hospital readmissions

– Nurse fatigue thereby promoting nursing safety, nurse retention and satisfaction

What about ratios?

• California is the only state to have mandated a prescribed nurse-to-patient ratio across all inpatient settings

• Directed research to understand the impact on patient and nurse outcomes

• Findings reported have been mixed

Press-Ganey Special Report: The Influence of Nurse Work Environment on Patient, Payment and Nurse Outcomes in Acute Care Settings

“Recent analyses combining NDNQI data with patient experience data….shows that HCAHPS patient experience performance is significantly correlated with nursing hours per patient day and with RN hours per patient day, with the latter revealing stronger associations across every dimension of the patient experience.”

Press Ganey

• The correlations of RN staffing with Press Ganey patient experience domains shows strong associations between RN staffing and the patient’s entire experience (not just nursing)

– Patient’s perceptions of the discharge process

– The overall patient experience (likely to recommend, etc.)

– Tests and treatments

– Nurses (courtesy, communication, respect, etc.)

– Issues (pain control, privacy, attention to personal and emotional needs etc.)

Press Ganey

“Findings of new integrated analyses of data from multiple performance domains indicate that although aspects of nurse staffing such as hours of care and skill mix definitely influence outcomes, the overall work environment of nurses has a much larger influence across most measures.”

Errors of Omission: How Missed Nursing Care Imperils Patients

• Impact on Patients

“Overall missed nursing care was shown to result in an increase in

patient falls and the adverse events of skin breakdown/pressure

ulcers, medication errors and new infections.”

• Impact on Nurses

“Missed nursing care predicts nursing staff satisfaction, intent to

leave and turnover. The more nursing care is missed, the lower the

satisfaction and the higher the intent to leave.”

http://nursesbooks.org/Homepage/Hot-off-the-Press/Errors-of-Omission.aspx

Staffing and Missed Nursing Care

“All three staffing variables in this study—HPPD, perceived staffing adequacy, and number of patients cared for—were strong predictors of missed nursing care. When staffing is less, nurse are not able to complete all required care. Having less staff also leads to less care because of the unavailability of the staff members to help one another when care is required.”

Kalisch, B., Tschannen, D., & Lee, K. (2011). Do staffing levels predict missed nursing care? International Journal for Quality in Health Care, 23(3), 1-7.

Table 11-3. Predictors of missed nursing care+ (n=4086).

B St. Error t p

Staffing adequacy -0.103 0.007 -14.263 <.001**

Number of patients cared for 0.016 0.003 5.584 <.001** + After controlling for age, gender, job title, experience in role, experience on current unit, overtime and absenteeism.

** p<.01

What Else?

Staffing Measures and Public Reporting

• NQF-2003 endorsement of 15 voluntary nursing sensitive measures • 2 ANA/NDNQI developed measures on Nurse Staffing

– Nursing hours per patient day – Skill mix

• Recent efforts to increase accountability through public reporting through CMS adoption and inclusion of

these measure on Hospital Compare

http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Federal/Agencies/ANA-Leading-Patient-Safety/Public-Reporting-of-Nurse-Staffing-Measures http://www.qualityforum.org/Publications/2004/10/National_Voluntary_Consensus_Standards_for_Nursing-Sensitive_Care__An_Initial_Performance_Measure_Set.aspx

http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Federal/Agencies/ANA-Leading-Patient-Safety/Public-Reporting-of-Nurse-Staffing-Measures





















http://www.qualityforum.org/Publications/2004/10/National_Voluntary_Consensus_Standards_for_Nursing-Sensitive_Care__An_Initial_Performance_Measure_Set.aspx






Principles of Nurse Staffing, 2nd Edition

• Principles

– The characteristics and considerations of the healthcare consumer

– The characteristics and considerations of the registered nurses

and other inter-professional team members and staff

– The context of the entire organization in which the nursing services

are delivered

– The overall practice environment that influences delivery of care

– The evaluation of staffing plans

• When new staffing solutions are developed, they must be

tested and evaluated through quality measurement and research

http://www.nursesbooks.org/Main-Menu/eBooks/Principles.aspx




http://nursesbooks.org/Main-Menu/Specialties/Staffing-Workplace/Principles-for-Nurse-Staffing.aspx

Technology: Decisions on Workforce Management and Acuity Systems

Legislative and Advocacy Activities

• Current regulatory language is extremely broad which has resulted in wide variation in interpretation:

(42CFR 482.23(b)) requiring Medicare-eligible hospitals to “have adequate numbers of licensed registered nurses (RNs), licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed.”

• Federal and State action related to nurse staffing includes support of the Registered Nurse Safe Staffing Act (H.R. 2083/S. 1132). Important elements of this

legislation will:

– Establish adjustable minimum numbers of RNs

– Include input from direct care RNs or their exclusive representatives

– Be based upon patient numbers and the variable intensity of care needed

– Take into account the level of education, training and experience of the RNs providing care

– Take into account the staffing levels and services provided by other health care personnel associated with nursing care

– Consider staffing levels recommended by specialty nursing organizations

– Take into account unit and facility level staffing, quality and patient outcome data and national comparisons as available

– Take into account other factors impacting the delivery of care, including unit geography and available technology

– Ensure that RNs are not forced to work in units where they are not trained or experienced.

State Activities

• 14 states have enacted legislation related to nurse staffing:

• Existing staffing laws fall into three main categories

– Requiring hospitals to have nurse-driven staffing committees

– Public reporting of staffing plans to the public and/or appropriate regulatory body

– Mandated staffing ratios

http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative-Agenda-Reports/State-StaffingPlansRatios

Avalere: Food for Thought

"In essence, we believe that staffing models that optimize quality and clinical outcomes will be essential to achieving the economic outcomes needed to succeed in value-based healthcare.” “Provide greater financial autonomy for nurses, such as developing separate nursing revenue centers within organizations, aligning nursing cost and billing practices with payment mechanisms, and allowing nurses greater control over nursing revenue to achieve the best value of care.” “Nursing leaders must understand data-driven nurse staffing plans to communicate clearly and budget appropriately for nursing resources. More research and sharing of evidence-based or best practices in nurse staffing needs to be completed and shared with the nursing community.”

Staffing and Work Environment

24

© 2015 Press Ganey Associates, Inc.

Patient Loyalty and Nurse Loyalty Are in Sync

R² = 0.2548

75

80

85

90

95

100

3.5 3.7 3.9 4.1 4.3 4.5 4.7 4.9 5.1 5.3 5.5

Patient

Lik

elih

ood to R

eco

mm

end (

For

Tre

atm

ent)

M

ean S

core

RN Likelihood to Recommend (For Employment) Mean Score

Patient Likelihood to Recommend vs RN Likelihood to Recommend

25


Nurse Job Enjoyment Is Related to Patient Loyalty

84

85

86

87

88

89

90

91

92

93

0 - 9 10 - 19 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80 - 89 90 - 99

Patient

Lik

elih

ood to R

eco

mm

end

Mean S

ore

RN Job Enjoyment Score - Percentiles

Patient Likelihood to Recommend vs RN Job Enjoyment

Above 25th Percentile forPatient LTR

Low Job Enjoyment Levels

Higher Job Enjoyment Levels

30th percentile (the cliff)

26


Nursing Structure, Process & Perceptions

Total Staffing HPPD

Intent to

Remain

Status of

Nursing

RN Perception

Job Satisfaction .370** .784** .763**

Quality in General .354** .682** .779**

Patient Experience

Rate Hospital 0-10 .261** .330** .678**

Nurses Listen .190** .342** .634**

Prompt Response .199** .392** .609**

Patient Outcomes

Unassisted Falls -.202** -.248** -.558**

CLABSI -.168** -.142** -.383**

HAPU II -.189** -.202** -.500**

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Composite Measures using NDNQI Data

Staffing Composite measures Nurse Staffing and Expertise

RN Hours per Patient Day, RN Skill Mix, and Education and Certification of Nurses

– Emphasis on RNs rather than non-RNs, Education (higher % BSN prepared nurses) and Certifications (higher % of certified nurses)

Hospitals categorized as above the median or below the median

Nursing Work Environment Composite measures quality of work environment

Uses 4 of the subscales of the RN Practice Environment Survey:

– Foundations for Nursing Quality of Care

– Nurse Manager Leadership and Ability

– Nurse Participation in Hospital Affairs

– Nurse – Physician Interactions

– (Staffing and Resource Adequacy omitted – staffing factors isolated in Staffing Composite)

Hospitals grouped according to quartile from least favorable to most favorable work environment

28


Does Work Environment Trump Staffing?

Work Environment

Fall Rate by Quartile of Work Environment

Fall

Rat

e

2.65

29



Pre

ssu

re U

lcer

Rat

e

Work Environment

1.64

30



Work Environment

Work Environment and Staffing have Similar Impact on RN Perception of Quality

RN

Per

cep

tio

n o

f Q

ual

ity

(Mea

n)

3.5

Safety and Surveillance

32


Theoretical Model:

RN Outcomes Make Contribution

Job Enjoyment Intent to stay

Patient Outcomes RN report of missed care

RN report of quality of care Falls

Pressure Ulcer

Patient Experience Nurse Domain Issues Domain

Overall hospital rating Likelihood to recommend

Pay for Performance Hospital Star Ratings

Hospital acquired condition Penalty Readmissions-Heart Failure Readmissions-Pneumonia

Readmission Penalty Value based purchasing Score

VBP experience VBP efficiency VBP process

Unit RN Surveillance Capacity

Practice Environment RN-MD, Foundations, Hospital Affairs, Resources,

Manager

RN Characteristics Education, certification, tenure, number of patients

Antecedents: (not measured)

Hospital and

Nursing Leadership

Lucian Leape Institute, 2013: “Unless caregivers are given the protection, respect, and support they need, they are more likely to make errors, fail to follow safe practices, and not work well in teams.”

Unit Type

Nursing Unit Safety Programs

Safe patient handling & mobility program System for safe staffing & patient

assignments, Anti-fatigue schedule and meal break

system, collaborative RN-RN interaction program

33


Safety and Job Enjoyment

3.59

4.00

4.25

4.57

3.94

4.05

4.14

4.28

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

1 2 3 4

Job Enjoyment

Safety Surveillance

34


Safety and Intent to Stay

74.01

80.13

83.75

88.59

79.87

81.10 82.01

83.50

65.0

70.0

75.0

80.0

85.0

90.0

1 2 3 4

Intent to Stay

Safety Surveillance

35


Safety and Meaningful Work

3.66

3.90

4.04

4.22

3.86

3.93

3.97

4.05

3.3

3.4

3.5

3.6

3.7

3.8

3.9

4.0

4.1

4.2

4.3

1 2 3 4

Meaningful Contribution

Safety Surveillance

36


Safety and Clinical Outcomes

1.51

1.38

1.30

1.19

1.54

1.40

1.30

1.14

0.8

0.9

1.0

1.1

1.2

1.3

1.4

1.5

1.6

1.7

1 2 3 4

Pressure Ulcers

Safety Surveillance

1.84

1.76

1.71

1.65

1.86

1.78

1.72

1.62

1.6

1.6

1.7

1.7

1.8

1.8

1.9

1.9

1 2 3 4

Fall Rate

Safety Surveillance

37


Nurse Perceptions of Surveillance Capacity and RN Safety, and Patient Overall

Ratings of the Hospital

90.11

90.78

91.13

91.72

90.45

90.81 91.04

91.43

89.5

90

90.5

91

91.5

92

1 2 3 4

Overall Rating of Care Given At Hospital

Safety Surveillance

38


2.56

2.79

2.91

3.11

2.78

2.83

2.86

2.91

2.4

2.5

2.6

2.7

2.8

2.9

3

3.1

3.2

1 2 3 4

Star Rating

Safety Surveillance

Safety, Surveillance, and Star Rating

Caregivers

40


Relationship Between Engagement and Experience

71 70

77

82

75 76

84

31

23

42

37

50

63

47

0

20

40

60

80

100

Nurse Responsiveness Physician Pain Medication Discharge Rating

Av

era

ge

Na

tio

na

l P

erc

en

tile

Ra

nk

Top Quintile of Employee Engagement Bottom Quintile of Employee Engagement

National Percentile Rank Based on Employee Engagement Scores (1)

1. Based on Engagement data from 36 projects, year 2014. HCAHPS data from 2014 PG Database. Created by Healthcare Metrics Team.

41


What Stress & Harm Do Providers Cope With?

• Stress of clinical role - complexity, high stakes activities

• Sympathy overload - secondary traumatic stress of witnessing suffering

• Emotional labor of caregiving role

• Emotional labor of employee demands

• Stress of interruptions, multitasking and task switching

• Stress of pace of change in organization and larger industry

• Lack of education/support to prevent/address compassion fatigue

• Moral distress arising from inability to provide level of quality desired

• Lack of appreciation

• Lack of resources

• Communication break downs, lack of needed information

• Lack of trust in leadership

• Lack of respect

• Emotional abuse (bullying, humiliating, demeaning behaviors)

• Back or musculoskeletal injuries

• Unprotected exposure to blood-borne pathogens

• Physical violence

• Lack of safe refuge to report physical and psychological harm

Inherent

Avoidable

Ro

le

Jo

b

Ha

rm

42


Emotional labor or ‘emotion work’ is an element of job that requires an employee to display required emotions toward customers or others.

Creates an emotional cost embedded in the role.

Requirement to not display (turn off) an emotion you are feeling

Stress, surprise, disgust, fear, uncertainty, sadness, grief

Requirement to display an emotion you are not feeling

Deference, optimism, assurance, compassion

Much of clinician training requires the turning off of felt emotions and then we compound that emotional work by asking to simultaneously turn on the positive emotional displays.

The Burden of Emotional Labor

43


Emotional labor or ‘emotion work’ is an element of job that requires an employee to display required emotions toward customers or others.

Surface Acting - the process of displaying behaviors that would be congruent with the

required emotion.

Associated with burnout

Deep Acting - the process of creating an internal emotional state that is congruent with the

required action.

The Process of Emotional Labor

44


Compassionate Connected Care ™ for the CareGiver

We should acknowledge the complexity and gravity of the work provided by caregivers

It is the responsibility of management to provide support in the form of material, human, and emotional resources

Teamwork is a vital component for success

Empathy and trust must be fostered and modeled

Caregivers' perception of a positive work/life balance reduces compassion fatigue

Communication at all levels is foundational

45


Key Drivers of Engagement

1. I feel like I belong in this organization.

2. This organization provides high-quality care and service.

3. I have confidence in senior management's leadership.

4. This organization treats employees with respect.

5. The amount of job stress I feel is reasonable.

6. My pay is fair compared to other healthcare employers in this area.

7. My work provides me an opportunity to be creative and innovative.

46


What is causing the suffering in nurses? Sometimes we want to reduce that to a phenomenon called compassion fatigue. But you know what? It’s the opposite of that. It’s that nurses are working in systems that keep them from having these moments with [patients]—a caring occasion, a moment where two people see each other, and meet in a place that is beyond time and space.”

—JANET QUINN PhD nurse, Lyons, CO

http://www.humanmedia.org/nurses/

Thank You! Christy Dempsey, MSN MBA RN CNOR CENP FAAN

SVP, Chief Nursing Officer

[email protected]

c512 the intersection of staffing and work environment ......avalere: food for thought "in...

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