office of nursing services - va nursing outcomes database (vanod)

Office of Nursing Services - VA NursingOffice of Nursing Services - VA Nursing Outcomes Database (VANOD) Outcomes Database (VANOD)

11

VA NursingVA NursingOutcomes Outcomes Database Database and the and the

Clinical Nurse LeaderClinical Nurse Leader

Bonny Collins, PA-C, MPA,Bonny Collins, PA-C, MPA,Director, VA Nursing Outcomes DatabaseDirector, VA Nursing Outcomes Database

Jan 30, 2009Jan 30, 2009

22Office of Nursing Services - VA NursingOffice of Nursing Services - VA Nursing Outcomes Database (VANOD) Outcomes Database (VANOD)

AgendaAgenda

VANOD Big picture: Purpose, Goals & VANOD Big picture: Purpose, Goals & Conceptual ModelsConceptual Models

Current Content – What’s in it?Current Content – What’s in it?

Caveats, Challenges and Future PlansCaveats, Challenges and Future Plans

Feedback: What do you need? Feedback: What do you need?


Purpose and Goal of VANODPurpose and Goal of VANOD

Provide stakeholders with Provide stakeholders with tools for:tools for: Managing nursingManaging nursing resources resources

Understanding clinical Understanding clinical processesprocesses that are that are sensitive to nursing practicessensitive to nursing practices

Influencing patient Influencing patient outcomesoutcomes

Goal: No manual data collection or reportingGoal: No manual data collection or reporting


Conceptual Model for Nursing Conceptual Model for Nursing ROLESROLES

Administration

Hospital Support Staff•Case Manager•Infection Control Nurse•Nurse Educator•Wound Care Nurse•Etc.

Direct Care•Charge Nurse, CNL•Staff Nurse, LPN, UAP

PATIENT

Advance Practice Nurses;

(NP, CNS)

Will be used to compute Hours Per Patient Day

(HPPD)

Depends on Assignment

Codes


Caveats to the DataCaveats to the Data

Nurse Role:Nurse Role: Direct Care staff are identified by Human Direct Care staff are identified by Human Resource/PAID Budget Object Codes and Resource/PAID Budget Object Codes and Assignment CodesAssignment Codes

Data probably over estimate the number of direct Data probably over estimate the number of direct care staff prior to FY09 Qtr 3care staff prior to FY09 Qtr 3

Facility ActionFacility Action: : Assignment Code List has been Assignment Code List has been revised; ALL FACILITIES ARE EXPECTED TO revised; ALL FACILITIES ARE EXPECTED TO have updated all RN Codes by Dec 2008have updated all RN Codes by Dec 2008

CNL assignment code is Q4CNL assignment code is Q4


Types of Data Currently Available Types of Data Currently Available (at various levels of granularity and historical trend data from two to four years)(at various levels of granularity and historical trend data from two to four years)

AdministrativeAdministrative: : All nursing staff - all facilities (PAID/HR data) All nursing staff - all facilities (PAID/HR data)

Demographics about Staff and FacilitiesDemographics about Staff and Facilities Age & retirement eligibilityAge & retirement eligibility Role: direct care, hospital support, administrationRole: direct care, hospital support, administration EducationEducation Skill Mix: NP, CNS, RN, LPN/LVN, UAPSkill Mix: NP, CNS, RN, LPN/LVN, UAP Facility Complexity LevelsFacility Complexity Levels

Financial – Financial – Hours and Dollars, worked, and other categories Hours and Dollars, worked, and other categories

Nursing Staff Injuries – incidence reported (ASISTS data)Nursing Staff Injuries – incidence reported (ASISTS data)Nursing Staff Turnover Rates – Voluntary & All Reasons (HR Nursing Staff Turnover Rates – Voluntary & All Reasons (HR data)data)


SatisfactionSatisfaction (annual survey data) (annual survey data) RNs - Practice Environment Survey (PES) RNs - Practice Environment Survey (PES) All nursing staff - All Employee Survey (AES)All nursing staff - All Employee Survey (AES) Coming Soon -Coming Soon - Patient satisfaction (SHEP)Patient satisfaction (SHEP)

ClinicalClinical Skin Risk, Pressure Ulcers Skin Risk, Pressure Ulcers

Data captured from Nationally Standardized Templates Data captured from Nationally Standardized Templates released Oct 07released Oct 07Nursing Processes and Patient Outcome Indicators Nursing Processes and Patient Outcome Indicators available now for Skin Riskavailable now for Skin Risk

Data Currently Available Data Currently Available (at various levels of granularity and historical trend data from two to four years)(at various levels of granularity and historical trend data from two to four years)


Do these questions interest you? Do these questions interest you?

What is the rate of: What is the rate of: Nurse staff injuries reported by type and skill mix?Nurse staff injuries reported by type and skill mix?RNs, LPNs, UAPs voluntarily quitting VA last year? Your RNs, LPNs, UAPs voluntarily quitting VA last year? Your facility?facility?

Which RNs are most likely to quit and leave VA?Which RNs are most likely to quit and leave VA?

What % of:What % of:Patients were at risk for skin breakdown on admission? Patients were at risk for skin breakdown on admission? Patients had documentation of a daily skin inspection?Patients had documentation of a daily skin inspection?Patients had a Hospital Acquired Stage 2 or greater Pressure Patients had a Hospital Acquired Stage 2 or greater Pressure Ulcers (HAPU) by admission treating specialty?Ulcers (HAPU) by admission treating specialty?Patients had A Pressure Ulcer Stage 2 or greater?Patients had A Pressure Ulcer Stage 2 or greater?


Deputy Under Secretary for Operations and Management (10N) Facility Deputy Under Secretary for Operations and Management (10N) Facility Profile - Profile - Joint effort with DSO/DSSJoint effort with DSO/DSS

Inpatient:Inpatient:

1.1. Nursing Direct Care Hours Per Patient Day of Care (HPPD) Nursing Direct Care Hours Per Patient Day of Care (HPPD) 2.2. % of HPPD hours from RNs% of HPPD hours from RNs

Reported by:Reported by: Community Living Center (CLC)Community Living Center (CLC) Critical Care Critical Care MedicalMedical SurgicalSurgical Mixed Medical/SurgicalMixed Medical/Surgical

Data Currently Available Data Currently Available (DSS data at various levels of granularity and historical trend data)(DSS data at various levels of granularity and historical trend data)



Contract/Agency:Contract/Agency: Not correctly captured and Not correctly captured and included in staffing data. DSS has an included in staffing data. DSS has an infrastructure to collect the data, but it hasn’t been infrastructure to collect the data, but it hasn’t been used in a standardize way across the systemused in a standardize way across the system

Facility ActionFacility Action: : DSS has issued (Dec) DSS has issued (Dec) standardized instruction for capturing and standardized instruction for capturing and mapping contract and agency staff. Work with mapping contract and agency staff. Work with your facility DSS Staff to implement these your facility DSS Staff to implement these changeschanges



HoursHours: Hrs worked are attributed to the assigned T&L unit or mapped : Hrs worked are attributed to the assigned T&L unit or mapped DSS unit; if floated off those units hours are attributed to the DSS unit; if floated off those units hours are attributed to the mapped/assigned unit.mapped/assigned unit.

Facility Impact: will require additional data capture and entry Facility Impact: will require additional data capture and entry

VACO Action: OI&T Project is in development to add nursing location worked to the time and attendance process so time off the unit and the location actually worked will be captured and rolled up nationally. Estimate 18 months for release.


Unbelievable units excluded


At Risk At Risk

Which RNs are Which RNs are most likely to most likely to Quit VA?Quit VA?

Would having a Would having a CNL in the work CNL in the work unit help avoid unit help avoid this?this?


RNs that Quit VA in FY08 – RNs that Quit VA in FY08 – 76% left in their first 5 years76% left in their first 5 years

40% left in less than

1 yr

16% left between 1

to 2 yrs7% left

between 2 to 3 yrs

7% left between 3

to 4 yrs

6% left between 4

to 5 yrs


96% of RNs who Quit VA96% of RNs who Quit VA in less than a year in less than a year were Nurse I or II were Nurse I or II

69% left <1 yr were

Nurse I

27% left <1 yr were Nurse II


Caveats to the DataCaveats to the DataNursing Unit Location: Nursing Unit Location: PROBLEM can not yet consistently link the PROBLEM can not yet consistently link the

nursing staff to the point of care (Patient Care Unit) on which they nursing staff to the point of care (Patient Care Unit) on which they worked. worked.

Reports by: Reports by: Local unit, e.g. 3North Med/Surg (From DSS Department)Local unit, e.g. 3North Med/Surg (From DSS Department)

HPPD HPPD VANOD RN SurveyVANOD RN Survey

Time & Leave Unit (T&L) not necessarily a geographic unitTime & Leave Unit (T&L) not necessarily a geographic unit PAID – Demographic/Financial informationPAID – Demographic/Financial information

MAS WARD, Bedsection, Treating SpecialtyMAS WARD, Bedsection, Treating Specialty VANOD Skin Risk IndicatorsVANOD Skin Risk Indicators ActionAction: : Working to have a ‘standardized’ Nursing Unit for Working to have a ‘standardized’ Nursing Unit for

reporting. Probably 18 months awayreporting. Probably 18 months away


Skin Risk AssessmentsSkin Risk Assessments

Data captured electronically from the VANOD Data captured electronically from the VANOD Skin Risk Assessment TemplatesSkin Risk Assessment Templates15 indicators available that describe nursing 15 indicators available that describe nursing processes, patient risk groups and patient processes, patient risk groups and patient outcomes, e.g.outcomes, e.g.Can see in: table, graphs, trend by month, etc.Can see in: table, graphs, trend by month, etc.Can drill to VISN, Facility, MAS Ward, treating Can drill to VISN, Facility, MAS Ward, treating specialtyspecialtyCan see list of patients in the numerator and the Can see list of patients in the numerator and the denominator for each indicatordenominator for each indicator


Some Skin Risk IndicatorsSome Skin Risk Indicators

% pts with initial assessment within 24 hrs% pts with initial assessment within 24 hrs% pts with daily skin inspections% pts with daily skin inspections% pts ‘at risk’ on admission (nursing % pts ‘at risk’ on admission (nursing burden)burden)% pts ‘at risk’ with plan for intervention% pts ‘at risk’ with plan for intervention% pts with any Pressure Ulcer stage 2 or % pts with any Pressure Ulcer stage 2 or greater (nursing burden)greater (nursing burden)% pts with Hospital Acquired Pressure % pts with Hospital Acquired Pressure Ulcers (HAPU) stage 2 or greaterUlcers (HAPU) stage 2 or greater


VHA: Initial Skin Risk Assessment (Initial Assessment and Braden score) within 24 hrs of

admission - BY MONTH

Click to see table of # of pts assessed and # discharged

Click on a bar to see the VISN distribution


VHA: Hospital Acquired Pressure Ulcers Stage II and above, Oct 08

BY VISN

Click on a bar to see the monthly trend

for the VISN


Use drop down menu to select

facility

Hospital Acquired Pressure Ulcers Stage II and above


% of Patients Screened within 24 hours of % of Patients Screened within 24 hours of Admission Using the Braden ScaleAdmission Using the Braden Scale ( (All Discharges) - All Discharges) -

Higher is BetterHigher is Better

Can drill down to

facility and to admitting treating specialty


Can drill to specific patient

information (If you have SSN Access)

% of Patients with Hospital Acquired Pressure % of Patients with Hospital Acquired Pressure Ulcer (HAPU) Stage II or higherUlcer (HAPU) Stage II or higher - - BY Bed-section and Treating SpecaltyBY Bed-section and Treating Specalty

# of pts with HAPU,# of Discharges# of pts with

HAPU &# of Discharges


Fall Risk Indicators Fall Risk Indicators External Peer Review Program (EPRP) Pilot DataExternal Peer Review Program (EPRP) Pilot Data

1.1. % of pts with a fall risk assessment using the Morse % of pts with a fall risk assessment using the Morse Scale w/I 24 hrs of admission (Ns6)Scale w/I 24 hrs of admission (Ns6)

2.2. % of pts identified as high risk (Ns7)% of pts identified as high risk (Ns7)

3.3. % of high risk pts with plan for intervention within 24 % of high risk pts with plan for intervention within 24 hrs of admission (Ns8)hrs of admission (Ns8)

4.4. % of pts with documentation of a fall during % of pts with documentation of a fall during hospitalization (Ns9)hospitalization (Ns9)

5.5. % of pts who had more than one fall (Ns10)% of pts who had more than one fall (Ns10)


EPRP Data:EPRP Data: % Patients Screened for Fall Risk % Patients Screened for Fall Risk w/i24 hours of Admission w/i24 hours of Admission Using the Using the

Morse ScaleMorse Scale (Nsg 6)(Nsg 6)

0102030405060708090

100

Q3 Q4

4 Cohorts FY08

0102030405060708090

100

Q3 Q4

4 cohorts FY08

EPRP Data:EPRP Data: % Patients at high risk for falls% Patients at high risk for falls

on admission on admission (Nsg 7)(Nsg 7) (Morse Scale >=45)(Morse Scale >=45)


Extracted Data for National

Reports

Key Data Elements from Patient Assessment, Reassessment & Care PlansKey Data Elements from Patient Assessment, Reassessment & Care Plans

Local ReportsExamples: Summary & Detail Display of Patients

with:1. Admission Assessment done within X hrs2. Skin risk assessment done within 24 hrs3. Fall risk assessment done within 24 hrs4. List of patients at risk for pressure ulcers, falls,

etc.

Embed in Files: Clinical Observations (CLiO), Health Factors, Vital Signs

End of Shift Report Care Plan

Input from other disciplines

Patient Assessment

Reassessment (Shift Note)


Clinical Indicators – the Clinical Indicators – the QueueQueue

Nationally Standardized Comprehensive Patient Nationally Standardized Comprehensive Patient AssessmentAssessment: : Fall Risk Assessment and FallsFall Risk Assessment and Falls Restraint use and Avoidance StrategiesRestraint use and Avoidance Strategies Dysphagia ScreeningDysphagia Screening Pain Pain Heart Failure Education Heart Failure Education

sample already collected via EPRP chart reviewsample already collected via EPRP chart review Tobacco Use Counseling Tobacco Use Counseling

sample already collected via EPRP chart reviewsample already collected via EPRP chart review

Falls templates already available


What Do You Need? What Do You Need?

Administrative Information Administrative Information

Clinical InformationClinical Information

SatisfactionSatisfaction


More Tools - Patient Flow SheetMore Tools - Patient Flow Sheet

What is it?What is it?

Generic flow sheet tool that can be configured locallyGeneric flow sheet tool that can be configured locally

Standardized terms: Clinical Observations Database (CliO) Standardized terms: Clinical Observations Database (CliO)

In ICU links to peripheral monitoring equipment to bring data In ICU links to peripheral monitoring equipment to bring data into flow sheet and CPRS into flow sheet and CPRS

Currently in pilot testingCurrently in pilot testing

Creates the opportunity to:Creates the opportunity to:

Locally develop a variety of flow sheets, e.g. wound care, Locally develop a variety of flow sheets, e.g. wound care, dialysis, restraint/seclusion monitoring, etc. using nationally dialysis, restraint/seclusion monitoring, etc. using nationally standardized terms and national repository of data.standardized terms and national repository of data.

Ability to track and trend data locally and nationally Ability to track and trend data locally and nationally


VANOD Next GenerationVANOD Next GenerationContinue to pursue unit level data and link staff to patientsContinue to pursue unit level data and link staff to patients

Find new data sources: i.e. eProficiency or LMS for nurse Find new data sources: i.e. eProficiency or LMS for nurse specialty certification dataspecialty certification data

Lead the initiative to create standard clinical terms to be used Lead the initiative to create standard clinical terms to be used in all products:in all products:

E.g. CliO, Patient Assessment, CIS/ARK Databases (CareVue, PICIs)E.g. CliO, Patient Assessment, CIS/ARK Databases (CareVue, PICIs)

Create new reports that consolidate several data sources into Create new reports that consolidate several data sources into one web-based tool – Performance Point Dashboardsone web-based tool – Performance Point Dashboards

Collaborate with DSS, IPEC, OI&T, & our Nursing Collaborate with DSS, IPEC, OI&T, & our Nursing stakeholders to develop products that improve the work stakeholders to develop products that improve the work environment of both front line and administrative nursesenvironment of both front line and administrative nurses


Contact VANODContact VANOD

VANOD Data: (On the VSSC Website)VANOD Data: (On the VSSC Website)

VANOD Website: VANOD Website: http://vaww.collage.research.med.va.gov/collahttp://vaww.collage.research.med.va.gov/collage/VANOD/ge/VANOD/

Bonny Collins, Bonny Collins, Program ManagerProgram Manager

VANOD Program Team:VANOD Program Team: Diane BedecarrDiane Bedecarree Dee BishopDee Bishop Mimi HaberfeldeMimi Haberfelde Alicia LevinAlicia Levin Shawn Loftus Shawn Loftus Email: Email: V21SFC VANOD Program TeamV21SFC VANOD Program Team


http://vssc.med.va.gov/products.asp?PgmArea=17VANOD DataVANOD Data


Be Critical Consumers of DataBe Critical Consumers of Data

What do these data represent?What do these data represent?

Example: “FY08: VHA had 38,513 Direct Care RNs”Example: “FY08: VHA had 38,513 Direct Care RNs”

Full Time Employee Equivalent (FTEE) or Employee Full Time Employee Equivalent (FTEE) or Employee Count?Count?

If Employee Count – does that include full-time, part-time, and/or If Employee Count – does that include full-time, part-time, and/or intermittent?intermittent?

Full year or end of year snapshot?Full year or end of year snapshot?

Nursing Cost Center or in ANY Cost Center? Nursing Cost Center or in ANY Cost Center?


How to Find DSS ReportsHow to Find DSS Reports

VSSC Webpage VSSC Webpage http://vssc.med.va.gov/http://vssc.med.va.gov/ DSS linkDSS linkIndex of Reports, scroll to “N” (for nursing)Index of Reports, scroll to “N” (for nursing)

Nursing Hours / Costs / Workload by Clinic and Outpatient Nursing Hours / Costs / Workload by Clinic and Outpatient Encounter Encounter

Nursing Hours / Costs / Workload by Ward and DSS Bed DNursing Hours / Costs / Workload by Ward and DSS Bed Days of Careays of Care


Comparison of HPPD & % RNsComparison of HPPD & % RNsUnit TypeUnit Type VHAVHA11

(Oct 07 - July 08)(Oct 07 - July 08)

LMILMI(2007)(2007)

NDNQINDNQI(2007)(2007)

Mental Health – Mental Health – Acute: HPPDAcute: HPPD 7.67.6 7.97.9 4.34.3

Mental Health – Mental Health – Acute: %RNAcute: %RN 51%51% 50%50% 59%59%

CLC (LTC):CLC (LTC):

HPPDHPPD5.15.1 7.17.1 N/AN/A

CLC (LTC):CLC (LTC):

% RN% RN31%31% 36%36% N/AN/A

1VHA Data from DSS: see other slides for caveats

office of nursing services - va nursing outcomes database (vanod)

Health & Medicine

data hours

availabledss data

types of data

data contractagency

staffing data

data nurse role

skin risk data

assignment codes data