Sets an minimum nurse-to-patient ratio by acuity unit


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Sets an minimum nurse-to-patient ratio by acuity unit

  • Sets an minimum nurse-to-patient ratio by acuity unit

  • Drawbacks

    • No flexibility to adjust for individual facility composition
    • Facilities may not be able to afford to hire additional nurses to meet the required ratios without receiving extra payments
    • Facilities may decrease ancillary staff to compensate for the cost of hiring additional nurses
    • Shortage of nurses may exert pressure on hospitals to reduce capacity in order to maintain ratios
    • Nurses may leave inner-city and public institutions in favor of those with more resources
  • Considerations

    • How are the minimum ratios determined?
    • How will ratios be enforced?
    • How will the success of the ratio mandates be
    • evaluated?


Uses computer software to determine nurse staffing for each shift based on patient acuity, which is assessed by the unit nurse

  • Uses computer software to determine nurse staffing for each shift based on patient acuity, which is assessed by the unit nurse

  • Staffing is set regardless of budgetary limits

  • Drawbacks

    • No universal standards exist for the software
    • Nurses may not trust the results
    • Software can be manipulated to “justify” increased staffing levels


Provides greater payor payments to hospitals that meet or exceed quality standards

  • Provides greater payor payments to hospitals that meet or exceed quality standards

  • Considerations

    • What results should be rewarded?
    • Are the measures nurse-sensitive?
    • Who will govern reporting and payments?
    • Will non-incentivized quality care measures suffer?
    • What has the success been of CMS’ Physician Quality Reporting Initiative?


Limits or ban on mandatory overtime, possibly including time worked at more than one workplace

  • Limits or ban on mandatory overtime, possibly including time worked at more than one workplace

    • Other safety-sensitive industries have taken action to defend against the effects of fatigue by limiting the number of shifts or hours worked in a week
  • Whistle-blower protection for nurses who report unsafe staffing levels in their own facilities





Mandated ratios of 1:2 for ICUs and CCUs have been in place since 1976-1977

  • Mandated ratios of 1:2 for ICUs and CCUs have been in place since 1976-1977

  • Patient classification systems have been required since the early 1990s

  • Years of pressure from nursing unions led to passage of a mandated ratio law for all units in 1999; it took effect in 2005

  • Ratios determined by the California Department of Health Services, with input from nurse unions, the California Healthcare Association, and research from UC-San Francisco and UC-Davis.



Mandated nurse-to-patient ratios (as of 2008)

  • Mandated nurse-to-patient ratios (as of 2008)



Positive

  • Positive

    • Increase of 60,000+ RNs in the workforce and 60% increase in applications for RN licenses
    • Increase in nurse satisfaction
  • Negative

    • Higher costs than originally estimated
    • Staffing difficulties – Ratio coverage must apply at all times, even during staff breaks or restroom visits
    • Inadequate enforcement – The Dept. of Health Services has no authority to impose fines or monetary penalties on hospitals in violation of the ratios
    • Migration of nurses from inner city/public facilities
    • to those paying higher salaries
    • No evaluation measures to assess effectiveness


Excessive nurse workload is a key factor in safety in ICUs

  • Excessive nurse workload is a key factor in safety in ICUs

  • 17 errors per patient day in ICUs

  • Heavy workload leads to:

    • patient supervision
    • Incorrect ventilator/equipment set-up
    • Drug administration problems
    • Insufficient time for clinical procedures to be done properly
    • Inadequate training or supervision
    • Errors


Ratios can be dangerous

  • Ratios can be dangerous

  • Evolve science around care requirements

    • Workload intensity
    • Patient acuity
    • Patient classification




References

  • American Nurses Association. (2008). Improving the quality of care for millions of Americans [Brochure]. Retrieved October 1, 2008 from http://www.safestaffingsaveslives.org/Documents/SSBrochure.aspx.

  • American Nurses Association. (2008). Safe Staffing Saves Lives. Retrieved October 2, 2008, from http://www.safestaffingsaveslives.org

  • ANA survey of staffing. (2008, July). American Nurse. Retrieved September 29, 2008, from Health Source: Nursing/Academic Edition database.

  • Clark, P., Leddy, K., Drain, M., & Kaldenberg, D. (2007, April). State nursing shortages and patient satisfaction: More RNs—Better patient experiences. Journal of Nursing Care Quality, 22(2), 119-127. Retrieved September 29, 2008, from Health Source: Nursing/Academic Edition database.

  • Cortez, Z. (2008, January 4). California’s nurse-patient ratio law saving lives, reducing the nursing shortage. California Progress Report. Retrieved October 21, 2008, from http://www.californiaprogressreport.com/2008/01/californias_nur.html

  • Currie, V., Harvey, G., West, E., McKenna, H., & Keeney, S. (2005, July). Relationship between quality of care, staffing levels, skill mix and nurse autonomy: Literature review. Journal of Advanced Nursing, 51(1), 73-82. Retrieved September 29, 2008, doi:10.1111/j.1365-2648.2005.03462.x



References

  • Hansen, H., & Conant, R. (2008, July). Nurses storm Capitol Hill to advocate for safe staffing legislation. American Nurse, 40(4), 14-14. Retrieved September 29, 2008, from Health Source: Nursing/Academic Edition database.

  • House passes landmark bill on RN staffing and patient safety. (2008, May). Massachusetts Nurse. Retrieved September 29, 2008, from Health Source: Nursing/Academic Edition database.

  • Media Briefs. (2008, July). American Nurse. Retrieved September 29, 2008, from Health Source: Nursing/Academic Edition database.

  • Oklahoma Nurses Association. (2006, November). Position statement on staffing. Retrieved September 29, 2008, from http://www.safestaffingsaveslives.org/WhatisANADoing/StateLegislation/ONAonNu rseStaffing.aspx.

  • Our bills to watch in 2008. (2008, June). Registered Nurse: Journal of Patient Advocacy. Retrieved September 29, 2008, from Health Source: Nursing/Academic Edition database.

  • Pinkham, J. (2008, July). Legislative session ends in stalemate on safe staffing bill. Massachusetts Nurse, 79(6), 3-3. Retrieved September 29, 2008, from Health Source: Nursing/Academic Edition database.



References

  • Robert Wood Johnson Foundation. (2007, October). Charting nursing’s future: Reports on policies that can transform patient care. Retrieved October 3, 2008, from http://www.rwjf.org/files/research/nursingissue5revfinal.pdf

  • Safety in numbers: Nurse-to-patient ratios and the future of health care: MNA goes one-on- one with award-winning health care journalist Suzanne Gordon. (2008, April). Massachusetts Nurse. Retrieved September 29, 2008, from Health Source: Nursing/Academic Edition database.

  • Schmidt, L. (2005, March). Patients’ perception of nurse staffing. Florida Nurse, 53(1), 17- 17. Retrieved October 7, 2008, from Health Source: Nursing/Academic Edition database.

  • Spetz, J. (2004, June 17). California’s minimum nurse-to-patient ratios: Where are we, how did we get here, and where do we go next? Causes and Consequence of the Nurse Shortage: Developing a Solution in Illinois. Retrieved October 21, 2008, from http://www.futurehealth.ucsf.edu/pdf_files/IGPASpetzPaper2004.pdf.

  • Spetz, J. (2008, February). Nurse satisfaction and the implementation of minimum nurse staffing regulations. Policy, Politics, & Nursing Practice, 9(1), 15-21. Retrieved September 29, 2008, doi:10.1177/1527154408316950

  • The Coalition to Protect Massachusetts Patients. (n.d.). The Patient Safety Act [Brochure]. Retrieved October 1, 2008, from http://www.massnurses.org/safe_care/PDFs/CPMP%20H_2059%20Brochure.pdf.



References

  • Trossman, S. (2008, March). A case for safe staffing: ANA bring together RNs, other stakeholders for summit. American Nurse, 40(2), 1-12. Retrieved September 29, 2008, from Health Source: Nursing/Academic Edition database.

  • Unruh, L. (2008, January.) Nurse staffing and patient, nurse, and financial outcomes. American Journal of Nursing, 108(1), 62-71. Retrieved September 29, 2008, from Health Source: Nursing/Academic Edition database.

  • Widowfield, J. (2004, February). Safer nurses; safer care: Ban on mandatory overtime proposed. Ohio Nurses Review, 79(2), 1. Retrieved September 29, 2008, from Health Source: Nursing/Academic Edition database.



National Trends - AHRQ

  • Higher nurse:pt. ratios are associated with lower incidence of nearly all adverse outcomes

  • In hospitals with high RN staffing, medical pts. Had lower rates of five adverse pt. outcomes (UTI, pneumonia, shock, UGI bleeding, longer hospital stay)

  • Higher staffing at all levels of nursing was associated with 2- 25% reduction in adverse outcomes.

  • Adding half an hour of RN staffing/pt. day could reduce pneumonias in surgical patients by over 4%



Pay 4 Performance

  • Intended results of P4P

    • accelerate improvements in hospital care
    • connect pay with performance
    • examine effect of financial rewards and penalties on hospital care (linked with performance on a set of common medical conditions)
    • Studies show improved measures (pneumonia and AMI)


Pay 4 Performance

  • Future of reimbursement

    • P4P with metrics around processes and outcomes
    • CMS Hospital Quality Initiative: empower consumers with information about quality to make informed decisions about health care
    • Realigns competition with value for patients
    • Competition on value revolves around results


Pay 4 Performance

  • “Hospital Consumer Assessment of Healthcare Providers and Systems” (HCAHPS)

  • Patient Satisfaction Survey: Nursing Care Questions

    • Courtesy and respect
    • Listen carefully
    • Explain things in a way patient can understand
    • Help as soon as patient wanted it
    • Help with toileting
    • Medicine/pain control
    • Medication safety steps
    • Preparation for discharge


Current CMS

  • Object inadvertently left in after surgery

  • Air embolism

  • Blood incompatibility

  • Catheter associated urinary tract infection

  • Pressure ulcer (decubitus ulcer)

  • Vascular catheter associated infection

  • Surgical site infection- Mediastinitis (infection in the chest) after coronary artery bypass graft surgery

  • Certain types of falls and trauma



Proposed Rule for FY 09

  •  

  • Surgical site infections following certain elective procedures

  • Legionnaires’ disease (a type of pneumonia caused by a specific bacterium)

  • Extreme blood sugar derangement

  • Iatrogenic pneumothorax (collapse of the lung)

  • Delirium

  • Ventilator-associated pneumonia

  • Deep vein thrombosis/Pulmonary Embolism (formation/movement of a blood clot)

  • Staphylococcus aureus septicemia (bloodstream infection)

  • Clostridium difficile associated disease (a bacterium that causes severe diarrhea and more serious intestinal conditions such as colitis)



43 Measures to be Added

  • Surgical Care Improvement Project (SCIP) – 1 new measure

  • Hospital readmissions – 3

  • Nursing care – 4

  • Patient Safety Indicators developed by the Agency for Healthcare Research and Quality (AHRQ) – 5

  • Inpatient Quality Indicators developed by the AHRQ – 4

  • Venous thromboembolism measures (VTEs)   6

  • Stroke measures (STK) – 5

  • Cardiac surgery measures –15



Pay 4 Performance

  • Clinical outcomes

    • Core Measures
    • Private Insurance P4P plans mirroring measures
    • Hospital Compare
    • CMS campaign for consumer awareness


Pay 4 Performance

  • Nurses contribute significantly to quality outcomes

  • Can create cost savings but nurses not current focus of P4P

  • Payment incentives do not typically reward nurses for higher productivity, quality, or cost savings

  • Value of nursing not consistently quantified

  • Performing “to” measures can increase burden on nurses (recording, extracting, reporting data)



Pay 4 Performance

  • Link standardized Nursing Intensity Weights (NIW) to reimbursement

  • Add nursing-sensitive measures to P4P measures

    • NQF 15 measures
  • Changes will require legislative action




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