acuity-adjusted staffing...28 american nurse today volume 11, number 3 n urse staffing is a complex...

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28 American Nurse Today Volume 11, Number 3 www.AmericanNurseToday.com N urse staffing is a complex issue. Matching the right nurse to the right patient at the right time requires an understanding of the individual patient’s need for care, nurse charac- teristics, workflows, and the context of care, in- cluding organizational culture and access to re- sources. Many experts believe patient acuity is an im- portant component of nurse staffing because acuity-informed staffing approaches have been shown to improve patient outcomes and en- hance nurse satisfaction. Patient acuity systems have been around for many years, but earlier systems required extra work by nurses and pro- duced subjective results. Nurse leaders hesitated to adjust staffing when every patient was de- scribed as having “high needs.” Current technol- ogy used to generate acuity scores in today’s sys- tems enables objective, valid, and reliable meas- ures that can inform staffing decisions. Massachusetts recently passed legislation re- quiring, among other things, acuity-adjusted staffing in intensive care units (ICUs). Therefore, nurses in Massachusetts are now discussing strategies for using acuity to optimize patient care. A panel of nurse leaders explored this issue at a roundtable, “Using Acuity: Optimizing Patient Care and Nursing Workload,” held in December 2015. The panel presented research and real-life examples to illustrate how astute determination of patient acuity can optimize patient outcomes and help balance nurse workloads. (See Who, what, when, where, and why.) The panel discussion was hosted by CeCe Lynch, MS, RN, NEA-BC, FACHE, vice president of patient care services and chief nurse executive at Lowell General Hospital (LGH) in Lowell, Mas- sachusetts. The moderator was Lillee Smith Geli- nas, MSN, RN, FAAN, Editor-in-Chief of American Nurse Today and system chief nursing officer for CHRISTUS Health. Using acuity to optimize patient care and nursing workload The goal of the roundtable, Lillee Gelinas, MSN, RN, FAAN, began, was to present information and tools for nursing leaders to implement in their organizations. “We want to stimulate a na- tional conversation on this important topic,” she said. “How do we use acuity to optimize outcomes through nurse staffing?” Gelinas discussed the impact of the Affordable Care Act and the challenge to adopt the Triple Aim: better access, better quality care at lower cost. She also pointed out that healthcare organi- zations are looking through the lens of state legis- lation focused on safe nurse-patient ratios. (See Nurse staffing legislation.) Whatever the motivation, Gelinas said, “At the end of the day, we’re trying to achieve better care at lower cost so we can have a viable healthcare system.” Nurse staffing legislation Gelinas noted that this era is a challenging one for nursing, with competing pressures for S PECIAL R EPORT : ACUITY-ADJUSTED STAFFING Acuity-adjusted staffing: A proven strategy to optimize patient care By Meaghan O’Keeffe, BSN, RN n The orange states have passed some type of legislation related to nurse staffing. At a recent roundtable, nurse leaders discussed ways to use acuity to optimize patient care and nurse workloads.

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Page 1: Acuity-adjusted staffing...28 American Nurse Today Volume 11, Number 3 N urse staffing is a complex issue. Matching the right nurse to the right patient at the right time requires

28 American Nurse Today Volume 11, Number 3 www.AmericanNurseToday.com

Nurse staffing is a complex issue. Matchingthe right nurse to the right patient at theright time requires an understanding of the

individual patient’s need for care, nurse charac-teristics, workflows, and the context of care, in-cluding organizational culture and access to re-sources. Many experts believe patient acuity is an im-

portant component of nurse staffing becauseacuity-informed staffing approaches have beenshown to improve patient outcomes and en-hance nurse satisfaction. Patient acuity systemshave been around for many years, but earliersystems required extra work by nurses and pro-duced subjective results. Nurse leaders hesitatedto adjust staffing when every patient was de-scribed as having “high needs.” Current technol-ogy used to generate acuity scores in today’s sys-tems enables objective, valid, and reliable meas-ures that can inform staffing decisions.Massachusetts recently passed legislation re-

quiring, among other things, acuity-adjustedstaffing in intensive care units (ICUs). Therefore,nurses in Massachusetts are now discussingstrategies for using acuity to optimize patientcare.A panel of nurse leaders explored this issue at

a roundtable, “Using Acuity: Optimizing PatientCare and Nursing Workload,” held in December2015. The panel presented research and real-lifeexamples to illustrate how astute determinationof patient acuity can optimize patient outcomesand help balance nurse workloads. (See Who,what, when, where, and why.) The panel discussion was hosted by CeCe

Lynch, MS, RN, NEA-BC, FACHE, vice presidentof patient care services and chief nurse executiveat Lowell General Hospital (LGH) in Lowell, Mas-sachusetts. The moderator was Lillee Smith Geli-nas, MSN, RN, FAAN, Editor-in-Chief of AmericanNurse Today and system chief nursing officer forCHRISTUS Health.

Using acuity to optimizepatient care and nursingworkload The goal of the roundtable, LilleeGelinas, MSN, RN, FAAN, began,was to present information and toolsfor nursing leaders to implement in

their organizations. “We want to stimulate a na-tional conversation on this important topic,” shesaid. “How do we use acuity to optimize outcomesthrough nurse staffing?” Gelinas discussed the impact of the Affordable

Care Act and the challenge to adopt the TripleAim: better access, better quality care at lowercost. She also pointed out that healthcare organi-zations are looking through the lens of state legis-lation focused on safe nurse-patient ratios. (SeeNurse staffing legislation.) Whatever the motivation,Gelinas said, “At the end of the day, we’re tryingto achieve better care at lower cost so we can havea viable healthcare system.”

Nurse staffing legislation

Gelinas noted that this era is a challengingone for nursing, with competing pressures for

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By Meaghan O’Keeffe, BSN, RN

n The orange states have passed some type of legislation related to nurse staffing.

At a recent roundtable, nurse leaders discussed ways to use acuity to optimize patient care and nurse workloads.

Page 2: Acuity-adjusted staffing...28 American Nurse Today Volume 11, Number 3 N urse staffing is a complex issue. Matching the right nurse to the right patient at the right time requires

www.AmericanNurseToday.com March 2016 American Nurse Today 29

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JUSTED STAFFING

both nursing and healthcare dollars. Becausenursing salaries are the largest operational ex-pense in acute care, many organizations consid-er cutting nursing positions when they have toreduce costs. At the same time, though, it’s an exciting time

for nursing. One example is the electronic healthrecord (EHR), which makes rich clinical dataavailable; computer analysis of this data offersbetter decisional support for nurses. Panel leaders were asked to share their expert-

ise on patient acuity-adjusted staffing, exploringthe question: How do we ensure patients get thecare they need while creating a safe, effectivework environment for nurses?Before introducing the first speaker, Gelinas

discussed the problem of variations in definingand implementing acuity-adjusted staffing in themore than 5,600 hospitals across the country. Forthe purpose of this panel discussion, she definedacuity as the individual patient’s need for care.

Shared governance: The key toimplementing changeAndrea Erickson, MSN, RN, CNML,director of inpatient critical care serv-ices at LGH, spoke of the large taskher organization faced as it worked tocomply with the Massachusetts

staffing bill passed in November 2014. Using theshared governance model to guide its journey, LGHbegan to develop and implement an acuity tool tomeet the state’s January 2017 deadline.The shared governance model, Erickson ex-

plained, proved vital to LGH as it worked toward

implementing those changes. (See Shared gover-nance model.) “Shared governance gives nursespower in their practice,” she said. “It gives them avoice, which promotes innovation and allowsthem control over their practice. It lets nurses ex-tend their influence beyond their unit walls andpermits staff in the leadership team to share in thedecision making process.”

Shared governance model

The shared governance model at LGH keepsthe patient and family as the central focus, withunit-based councils and evidence-based practiceson the second tier, followed by other councils andcommittees that funnel up through the coordinat-ing council. The acuity-tool advisory committeebegan the process for developing an acuity toolby identifying key stakeholders, including man-

ModeratorLillee Smith Gelinas, MSN, RN, FAAN Editor-in-Chief, American Nurse TodaySystem Vice President and Chief Nursing OfficerClinical Excellence ServicesCHRISTUS HealthIrving, Texas

PanelistsAndrea Erickson, MSN, RN, CNMLFormer Director of Inpatient Critical Care ServicesLowell General HospitalLowell, Massachusetts

Amy L. Garcia, MSN, RNDirector and Chief Nursing OfficerWorkforce and Capacity ManagementCerner CorporationKansas City, Missouri

Miriam Halimi, DNP, MBA, RN-BCVice President and Chief Nursing Informatics OfficerTrinity HealthLivonia, Michigan

Eileen T. Lake, PhD, RN, FAANJessie M. Scott Term Chair in Nursing and Health PolicyAssociate Professor of SociologyAssociate Director, Center for Health Outcomes and Policy Research

University of Pennsylvania School of NursingPhiladelphia

William Dan Roberts, PhD, ACNP Data and Analytics ScientistAssistant Clinical Professor, School of Medicine, Biomedical Informatics

Assistant Clinical Professor, School of NursingStony Brook MedicineLong Island, New York

Who, what, when, where, and why An educational program sponsored by Cerner, “Using Acuity: Optimizing Patient Care and Nursing Workload” was held December4, 2015, at Lowell General Hospital, a large, non-profit, 424-bed community hospital in Lowell, Massachusetts. The aim of theprogram was to stimulate a national conversation on using acuity to optimize patient outcomes and nurse staffing.

The model illustrates the structure of shared governance at LGH. Note that the patient and family appear at the center of the model.

Nursing qualitycouncil

Nursing retentionand recognition

council

Patient and family

Professionaldevelopment council

Nursing leadershipcouncil

Nursing EBP andresearch council

Nursing informaticscouncil

Nursing practicecouncil including

UBCs

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agement, educators, informatics experts, and staffRNs across both campuses. (See Key stakeholders.)The aim, Erickson said, was to include individualswith varied levels of experience who worked var-ied shifts.

Key stakeholders

Erickson explained, “We used the Johari windowconcept to identify stakeholders based on two pa-rameters — interest and power. We focused onthose who fell into the high-interest, high-powersection of the grid.” The committee then conducted a survey to de-

termine which indicators determined high acuityand which warranted 1:1 or 1:2 nursing care. Af-ter the survey was completed, the committee de-veloped a task force of nursing administrators,informatics experts, educators, and 6 to 10 staffRNs who met and communicated regularly. Erick-son remarked, “We relied heavily on email andone-to-one meetings in both ICUs to identify bestpractices related to patient acuity, whether theywere practices occurring in Massachusetts or oth-er states with mandated safe staffing ratios.” Theorganization maintained quality reporting, in-cluding central line–associated bloodstream in-fection rates, catheter–associated urinary tract in-fection rates, and pressure ulcer and patient fallsincidence.Erickson stressed the importance of seeking to

understand how these changes affect work areas,resources, and staff educational needs. “Changetakes hard work and requires engraining the cul-ture,” she pointed out. “This kind of project has tobe nurtured and grown from beginning to end.”She emphasized the necessity of preserving nurs-ing’s voice in the process. “At the end of the day,we want an acuity-tool system that fulfills require-ments of the law, but we don’t want to lose nurs-ing judgment along way,” she said. “We muststrike a balance between science and judgment,marked by open dialogue, trust, and teamwork.”

Acuity-adjusted staffing linkedto better outcomes Eileen T. Lake, PhD, RN, FAAN, JessieM. Scott Term Chair in Nursing andHealth Policy at the University ofPennsylvania School of Nursing, pre-sented research on acuity-adjusted

nurse staffing as it relates to preterm infant out-comes. Among the 912 neonatal ICUs (NICUs) in theUnited States, sizable variations in mortality existthat can’t be attributed to infant factors, Lake said.The goal of measuring acuity-adjusted staffing

was threefold, Lake explained, “First, to look at howinfant acuity relates to the assignment a nurse re-ceives. Second, to see how accounting for acuity andstaffing relates to infant outcomes. And third, tolook at how nurse workload relates to infant acuity.” Research shows staffing is significantly associat-

ed with infection among very low-birth-weight in-fants; 15% of these infants develop an infection,which in turn doubles their risk of mortality. Litera-ture findings also reveal staffing influences the rateof breast milk at discharge. Across hospitals, aracial disparity in breast milk at discharge exists,linked to poorer staffing in hospitals with predomi-nantly African-American patients. Of particularnote, hospitals with a largely minority populationhad higher rates of infection and discharge withoutbreast milk. They also had a higher degree of nurseunderstaffing and poorer practice environments. Lake said that across the acuity spectrum, all of

the infants had similar parent needs, includingteaching, emotional support, and developmentalsupport. “We observed that when nurses care formultiple low-acuity infants, if you add events andparent needs together, their workloads are actuallyhigher than those of nurses who care for one ortwo high-acuity infants,” she noted. “This shows usthat acuity has a significant relationship withstaffing and outcomes but doesn’t account com-pletely for workload.” Lake went on to discuss the need for adequate

decisional support in the NICU setting, includingacuity assessment systems that apply to that set-ting, as well as the need to ensure that these sys-tems are evidence based.

Acuity calculation driven bynursing documentation Miriam Halimi, DNP, MBA, RN-BC,vice president and chief nursing infor-matics officer at Trinity Health inLivonia, Michigan, discussed the im-portance of using an electronic health

system that’s integrated with nursing documenta-tion. According to Halimi, this helps ensure thatacuity-level calculation doesn’t come at the cost ofdirect nursing time. “We hypothesized that an acu-

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ity system that’s electronic and integrated withnursing documentation will create better and time-lier information, leading to better decisions that optimize both the process and practice of nursingcare,” she said. “We’re looking to leverage an acu-ity solution that will allow for flexibility and pro-vide the information needed in real time to supportnursing down to the unit level.” Trinity Health, new to using an integrated acuity

solution, successfully implemented a solution with-in a 6-month period at one of its hospitals in fall2015; a second hospital is scheduled to go live withits solution this spring. While nursing leadershipdebated whether all nurses should have access tothe tools, ultimately they decided that was the bestway to go. Halimi said this approach providesgreater transparency.The Trinity Health planning team focused on

keeping staff nurses engaged throughout theprocess by:• using scheduling and acuity solutions togetherto provide powerful tools that empower nurses

• giving staff nurses access to acuity tools, as wellas education on how to use them

• leveraging the role of a patient-outcomes expert toensure partnership in the use of acuity tools daily.Halimi showed a screenshot of a medical-surgi-

cal critical-care evaluation depicting how an acuityscore is generated based on the nursing interven-tions classification and nursing outcomes classifica-tion (NOC). “For instance, in the respiratory do-main, a patient on room air would be considereduncompromised and receive a score of 5. But a pa-tient on a ventilator would be considered severelycompromised, with a score of 1,” she explained.“The lower the score, the more severely deviatedthe patient is and the more nursing care he or sheneeds. Therefore, the level of acuity is higher.” Thesystem calculates acuity scores every 4 hours, withscores generated 2 hours before shift change, to en-sure the most updated scores. This helps identifyappropriate staffing for the next shift. (See Nursingdocumentation and acuity levels.) How does an integrated acuity system work? By

entering and saving clinical documentation inthe EHR, which is sent automatically to the acuitysolution. The acuity solution maps the observa-tions and values using the NOC and indicatorvalues. Mapping of the clinical documentation isassigned to a domain (each domain has multipledata elements), which identifies the patient’s acu-ity assessment within that domain. As Trinity leaders evaluate implementation of

the acuity tool, Halimi said, they’re looking at

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Nursing documentation and acuity levels

Reprinted with permission from Cerner Clairvia®

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measuring such outcomes as staffing expenses,staff and patient satisfaction, and productivity.“Acuity matters with or without the [nurse-staffing] law,” Halimi concluded, pointing outthat acuity-adjusted nurse staffing holds impor-tance whether or not it’s mandated by legislation.“An integrated acuity solution creates accuracyand precision in staffing, ultimately moving to-ward positive patient outcomes.”

Balanced staffing: Wherefinance and operationsconverge William Dan Roberts, PhD, ACNP,data and analytics scientist at StonyBrook Medicine in Long Island, NewYork, moved the discussion in another

direction. He addressed how patient acuity affectsnurse staffing from both a financial and an opera-tional perspective. He stressed the dynamic natureof patient acuity, stating, “It changes by the minute,by the hour, by the shift, so you want to make sureyou’re able to be flexible with your staffing.” Staffing is more than just allocating full-time

equivalents (FTEs) during a budgeting process,Roberts said. Considering the FTE allocation thathas been allotted is important. This includesachieving a balanced schedule based on how nurs-

es and unlicensed assistant personnel are sched-uled. From this, the allocated skill mix for the dayis available for assigning to patient needs. Roberts posed a pertinent question: How can a

patient’s needs be best matched with the nurse’sskills to allow for the best nursing care, while stillmeeting the expected care processes and out-comes necessary for efficient and cost-effectivehealthcare delivery? To view his formula forachieving this, see Staffing: Financial to operational.The forms above show the usual financial allo-

cation of staff during the budgeting process. Theyincorporate Roberts’ staffing formula, which in-cludes assignment, RN competency, and patientacuity. The staffing formula relies on operationaland financial flexibility.Roberts showed a screenshot of a nurse-staffing

document depicting a breakdown of the nursingworkload on a general medicine unit during theday shift, illustrating the effect of patient acuity onnursing care hours. “Predictably, we can ask, whatis the nursing work going to be for that patient?Does the nurse have a balanced workload? Howdo we achieve that? We would reallocate resourcesso that nurse is able to carry the load,” he said.Roberts went on to explore differences in de-

mand between the medical ICU (MICU) and themedical intermediate care (MICR) unit, with a

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Staffing: Financial to operational

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slide illustrating a higher workload demand in theMICR unit. Data aggregated from acuity calculat-ing tools created visibility that allowed more staffcoverage for the MICR unit by adding anothernurse to each shift. It also enabled leaders to advo-cate for additional unlicensed assistant personnelas well as support staff, such as physical therapyand respiratory therapy, for the MICR unit.Roberts closed with an encouraging message:

Nursing and finance departments can work togeth-er to use the data effectively. He stressed the needfor objective measures and standard terminologyto ensure congruency among or gani zations.

Patient acuity: Realizing theclinical potentialAmy L. Garcia, MSN, RN, directorand chief nursing officer for workforceand capacity management withCerner Corporation, spoke about theexciting potential for patient acuity

data to promote efficient, cost-effective care withbetter patient outcomes. She discussed the use ofacuity to inform the assignment of nurses to pa-tients, as well as levels of care. She highlighted thiswith an example of a patient who was beingtreated for a myocardial infarction. Garcia ex-plained that a patient who follows the typical re-

covery trajectory might be ready for transfer fromthe ICU to a step-down unit after about 50 hours,then discharged home after about 30 hours of careon a telemetry or step-down unit. Taking patient variance into account, Garcia

pointed out, a patient who recovers more quicklythan expected may be a low-acuity outlier on anICU. Likewise, a patient who recovers more slowlythan expected may be transferred to a lower levelof care, resulting in the nurse having a largerworkload than he or she can manage in a settingmeant for lower-acuity patients. Garcia discussed the positive effect of aligning

acuity with adjusted nursing hours per patient day,which promotes budget neutrality and optimizesnurse-to-patient assignments. Garcia noted thatnurse-to-patient assignments are often made by di-viding the available nursing hours by the numberof patients and assigning the nurse to a number ofbeds or a geographic area. However, this practiceignores fundamental questions: How many hoursof care does an individual patient need to progresstoward optimal outcomes? Can that care be deliv-ered on this unit? And which nurse is best suited toprovide that care? Garcia showed an illustration ofa system that provides visibility to the nursingworkload, adjusted for acuity, census, and activityon the unit (See Balancing workloads).

Balancing workloads

Reprinted with permission from Cerner Clairvia®

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One East Coast hospital she works with imple-mented acuity considerations to help balance nurses’caseloads. “The rate of staff who called out of theirshifts on med surg units dropped 42%,” Garcia said.“Nurses were able to see that their caseloads werebalanced and that when they came to work, theyhad a good opportunity to actually make a differ-ence. That’s what we ask for in nursing—to be ableto impact patient care in a positive way. Balancedworkloads are important.” She concluded that whenthe right nurse is aligned with the right patient at

the right time, both nurses and patients benefit. “Inan ideal world, organizations can view nursing asan investment rather than a cost center,” she said.Garcia noted that the work of nursing is com-

plex, beyond just a simple list of nursing tasks orvital signs. She shared how Cerner approachesacuity—based on the nursing work needed tochange patient outcomes. Patients have a widerange of needs, including activities of daily living,physical, psychosocial, learning, perceived health(such as pain scales), and family support. Each as-pect of care is important. For example, a patientwho has suffered a stroke may have few medica-tions and little technology; instead, the nurse mayneed to focus on swallowing, teaching self-care, orusing strategies to cope with depression. Familymembers have much to learn to ensure a success-ful discharge—and that takes nursing time. Thework of nursing is holistic, and acuity systemsshould represent the needs of the whole patient.

Nurses weigh in In a question-and-answer period after the paneldiscussion, three major themes emerged.

Psychosocial needs and the nurse’s workload Several panelists agreed on the need to improve doc-umentation of, and consideration for, the psychoso-cial well-being of the patient and family. Patientand family support needs vary and hinge on manyfactors. We must continue to look at what organiza-tions are doing, concretely and quantifiably, to takepatient and family needs into consideration whenit comes to staffing. As Garcia pointed out, “Withacuity, it’s very easy to focus narrowly on a list oftasks or interventions. That’s one of the reasonsCerner uses a nursing taxonomy to help us definemore broadly the holistic needs of the patient andfamily within the context of their personal lives.”

The churn: Workload associated withpatient admissions, transfers, anddischarges Nurses spend considerable time performing anddocumenting admission and discharge assess-ments. The work can vary in intensity, dependingon individual patient characteristics. For instance,admission of a patient who is unable to communi-cate or has complex care needs (such as a bonemarrow-transplant patient) can be quite intense. The time required to transfer patients also varies

from one unit to another, relative to workflowsand the facility’s physical setting. Discharge timevaries, too. With a newborn infant, for example,discharge is faster if the parents have receivedsome education before discharge day, rather thanreceiving all of it at the time of discharge.

Measuring nursing work intensity Roberts stated that when considering acuity andstaffing, we need to incorporate tools that accountfor two characteristics—the patient’s physiologicparameters, which are used to create the plan ofcare); and nursing work intensity, which describesthe measure of work required to care for the pa-tient. We should continue to emphasize how tomeasure nursing work, as well as the parametersassociated with the patient’s physiologic state.

Acuity-adjusted staffing: A promisingfuture Although response to legislative staffing guidelineshas provided a more urgent incentive for develop-ing acuity-adjusted staffing tools, each panelist ex-pressed optimism about acuity-adjusted staffingand the promise it holds for improving both pa-tient outcomes and nursing workload. Nonetheless,Gelinas reiterated that an acuity score is merely anumber until it’s harmonized with each patient’sunique needs. “After working with acuity systemsfor a while now, I believe acuity is just a numberuntil you align it with a process or an outcome.Acuity alone is not a magic bullet,” she noted,adding that acuity must be considered within thecontext of the care required for a specific patient.

For a robust discussion of variables that affectstaffing, including acuity, read the 2015 white paper“Optimal Nurse Staffing to Improve Quality of Careand Patient Outcomes” at http://goo.gl/xTMuzB.Commissioned by the American Nurses Associationand developed by Avalere Health, LLC, in collabora-tion with nurses and policy experts, this documentcan be used as a resource to advocate for and imple-ment sound, evidence-based staffing plans.

Meaghan O’Keeffe is a freelance writer and clinical editor based in Framingham,Massachusetts.

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An acuity score is just a numberuntil it’s harmonized with each

patient’s unique needs.