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Professional Caregiver Insurance Risk and NNN: Risk Theoretic Models for

Predicting Nursing Services and Costs

Thomas Cox RN, BA, BSN, MS, MSW, MSNDoctoral Candidate

Virginia Commonwealth UniversityNNN 2004

Nursing Terminology and InformaticsChicago, Illinois – March 26, 2004

Copyright 2004 Thomas Cox


What Will I ‘Try’ to Cover Today?

Professional Caregiver Insurance RiskNursing Surplus (NS)

Nursing Management Information SystemsHow NMIS Enhances or Diminishes NS

NNN, NS, & NMIS – Needs and ResourcesTracking and Forecasting Nursing Surplus

Questions - Answers



Who Am I?

Registered NurseSocial Worker

StatisticianMathematicianProgrammerResearcher

Insurance ProfessionalManagement Information Systems novice

NNN noviceDoctoral Candidate



Professional Caregiver Insurance RiskRisks to health care providers in arrangements like capitation contracts, DRGs, Medicare/Medicaid fee caps, & preferred provider relationships that inadequately fund needed/rendered care

Risks arising in budgeted nursing units subject to high variability in patient acuity, resource demands, equipment, supply shortages, mismatched patient needs/RN skills, and time constraints

Average Cost Based Reimbursement Plans (ACBRPs) force RNs into the roles of insurers – simultaneous clinical and financial decisions – who is minding the store? What are the ethical issues?

Bedside RNs forced to decide what services clients get and distribute scarce time and resources over too many patients, discharge acutely ill patients, manage gaps in care that are programmed in as recurrent & persistent features of care environments



PCIR, ACBRPs & Nursing Surplus I

During dissertation research with RNs experiencing “Risk Induced Professional Caregiver Despair” I noted a similarity between nursing units and liquidated or insolvent insurance companies

Policyholder/Insurer Surplus or solvency of insurance company: (Liquid current assets - Immediate short & long term liabilities)

But technically insolvent insurance companies do not always get liquidated… an apparent insurance regulation anomaly? No!

True insurer surplus is the synergistic effect (Synergistic Surplus) of liquid assets, physical, social, and organizational resources: professional staff, functioning equipment, rational policies and procedures, strong Intra/Inter-organizational relationships, adequate supplies, that all contribute to an insurers ability to continue operating even though they may be technically bankrupt.



PCIR, ACBRPs & Nursing Surplus IIInsurance company “traditional surplus” is:

REDUNDANCY

Nursing units need: redundant staff, redundant supplies, redundant equipment, redundant beds, redundant linens, redundant sterile equipment, redundant surgical supplies, redundant housekeeping staff, redundant auxiliary personnel, redundant medical and professional staff, redundant time to care for patients

Last few years - all out assault on redundancy in nursing units - redundancy is the key to preparedness for the unexpected – the norm in nursing and key to the ability to manage the unexpected



PCIR, ACBRPs & Nursing Surplus IIIRNs dealt with inadequate supplies, unavailable resources when needed, staff changes q 4 hours, inappropriate patient assignments, unfamiliar staff, and persistent dangerous work/care conditions

Nursing surplus reduces when units are chaotic, resources inadequate, temporary, agency, or float personnel are unfamiliar with patient care needs, equipment, policies, and resources, nurses cannot rely on the quality/availability of supplies or co-workers

Nursing surplus rises if RNs’ needs are the optimization focus of the organization, primary to supporting services, patients assigned to RNs able to care for them, services & resources seamless, policies & procedures rational & realistic, managers and executives manage variability – not ‘hope’ and ‘depend’ on best possible outcomes

Insurers cannot operate without Synergistic Surplus and nursing units cannot deliver quality care with inadequate nursing surplus



PCIR, ACBRPs & Nursing Surplus IVAssessment of nursing surplus: What has been done, needs to be done, what resources are available/missing, and what is going awry

NNN crucial in documenting what did/should have happen(ed), what the result was – how nursing surplus was used

NNN crucial in forecasting what should/will happen next

NNN & Nursing surplus tie what was & what needs to be with the ability of RNs, units, departments to meet demands RIGHT NOW!

Accountability/visibility: What RNs do – what RNs could do, expose care impediments from persistent, hidden, correctable dysfunctions

Nursing surplus deficits must be documented and corrected in minutes not months or years. RNs, managers and executives need to identify bottlenecks and resolve them RIGHT NOW!Copyright 2004 Thomas Cox


What Should the NMIS Focus On?MISs serve others – do they measure nursing surplus well?

Monitor and control nursing surplus - analyse & forecast past, present & future nursing surplus needs

NMIS influences character, usability, quality, quantity, & availability of critical nursing surplus management data

Some people want nursing/nursing surplus invisible just as some insurers want their surplus status invisible

MISs designed for other fields do not meet nursing’s needs – monitoring, maintaining, and building nursing surplus

Nursing surplus is always the battleground issue – only question – who is best equipped to win corporate battles?



Why Should We be Concerned

Some NMISs designed & implemented poorly - more rather than less tedium and redundancy, difficult for RNs, and analyses do not meet RNs needs

Equipment outdated, interfaces slow RNs, computer use slower than paper methods – may replicate paperwork and lower RN productivity

Benefits of digitization are lost if MIS specifications, hardware & software are not designed to enhance nursing surplus rather than simply ‘digitize’ some nursing functions and responsibilities



Why Am I Interested in NMISs INMIS is an integral environmental feature – “how well does it work for nursing” not whether we have one

I worked with some really poor MISs in and out of nursing

I enjoy programming and interface design

My work on impact of risk transfers requires this data

I am an open source software fan

NMIS costs are high, systems fragmented, lack uniformity across facilities, training is often inadequate & NMISs rarely address ‘real time’ needs of RNs, Mgrs & Execs



Why Am I Interested in NMISs IIBedside RNs’ needs unmet – decreases nursing surplus

Available equipment is often spartan, influences utility and design for nurses, managers, clients, and IS personnel

Many issues everyone wants to avoid seem to creep in

NMISs useful to RNs requires re-thinking the management of the high variability in demands for nursing services and resources - synergistic surplus for insurers

RNs cope with new NMIS in each new setting with little experience in school, too little uniformity from site to site, even in same facility – while caring for clients…

Let’s try to remember it is all about caring for clients…Copyright 2004 Thomas Cox


Problems I Had With NMISsAdds to redundant paperwork – RNs may work harder not faster and smarter with digitization

RN-Machine interfaces slow down not speed up RNs – little anticipation of unique RN’s needs/behaviors

Digitization is not inherently good – some digital forms may be more tedious than paper, failing to deliver increased productivity & improved analyses

Examples:Client education documentation at CSHMultiple data entry screens without shortcutsRNs must ask for not automatically get critical

client/operating/resource information Copyright 2004 Thomas Cox


Design Concerns

RN design input may fall flat if they do not know what computers, systems designers, and programmers can do

IS people may not understand RNs work rhythms & needs

Why digitize old inefficient tasks - redesign work and NMISs to meet real needs of RNs/Mgrs/Execs

Ask for the right data & analyses or live w/others’ systems – RNs remain invisible & do not have data for ‘change’

NMIS that fails to reduce RNs’ paperwork work by 90+% should get an F – NMIS should double RN productivity

Productivity increases better staffing & higher salaries



Competing Standards and Systems

Many competitors in the NMIS field

NMISs costly to adopt, implement, adapt, & maintain

NMIS fragmentation - each fragment increases costs

Result - hodge-podge of old & new systems, hardware & software: incompatible, redundant data entry, inefficient & little utility for RNs, Mgrs & Execs

NMISs difficult to learn & mastery is little advantage to RNs changing jobs or in different settings within one facility – could be using a different NMIS when ‘floated’Copyright 2004 Thomas Cox


What is Possible? IDigital capture/transcription – asynchronous reports

Common architecture and appearance and have many proprietary support services

Complete access to data where & when needed – within HIPAA policies, regulations, protections

‘Wearable’ equipment - eliminate WS bottlenecks

More bar codes for common nursing services, Rx, identity checks, anticipate individual RN’s actions and documentation needs & wearable computers

Reduce Rx/Tx errors with programmed safeguards and faster alerts to problemsCopyright 2004 Thomas Cox


What is Possible? IIWearable computers for clients - continual non-invasive monitoring of clients’ conditions/needs

Seamless connection to clients – alerted to changes in real time - not only when in clients’ rooms

Rethink RNs processes - increase quality by building on what works & using new technology

Automatic programming - distinguish important from trivial – avoid data overload - improve care

NMIS document & FIX nursing surplus deficits: patient-RN mismatches, resource shortages, malfunctioning equipment, Rx needs -- RN refer once – NMIS not RN remind others until resolved…Copyright 2004 Thomas Cox


Proprietary v Open Source SoftwareWhat is Free Open Source Software (FOSS):

Free access to underlying source code Program source code free or minimal costExamples: GNU/Linux vs MS Windows

FOSS NMIS would encourage and support:Anyone can get programs and source code

SONs, RNs, Programmers, Mgrs & Execs Free to adapting code to local needsEncourage & Support open, uniform standards:

Units, Facilities, States, Countries…Reduce acquisition and maintenance costsIncrease RN use, innovation & sharingLearn once use everywhere



Types of Equipment to Consider

Work stations at the nursing station???Work stations in each clients room???Work Stations outside the clients room???Work station carts wheeled by RNs???Shared vs dedicated work stations???...

Wearable computers & WIFI are the real answerBar code scanning equipmentVoice recognition interfacesAutomate assessment documentation



How NMIS Bolsters Nursing SurplusMD to RN/Admin/Lab/Rx/Aux simultaneously

Decrease RN follow-ups – reminders automated

Automated analysis of pt/unit conditions (trending and forecasting), Rx problems and needs for service

Store and provide anecdotal data unique to clients but easily retrieved: social status, housing, welfare, medicaid, medicare, individual notes to aid care

Automate reports – know what is wrong & fix it:RNs/mgrs/execs get in seconds not monthsManage staffing more efficiently and quicklyAvoid each RN dealing w/ system issuesRNs know where resources are: Pumps, supplies, MDs,

Aides, Orderlies, chairs, beds…Copyright 2004 Thomas Cox


Potential Solutions IUse extant/new OSS projects to make a complete health care/nursing NMIS that is inexpensive, anticipates needs for data analysis, uniquely focuses on nurses, managers, and executives needs

Timely, reliable, and accurate information to better assess and manage nursing surplus

Anticipate RNs needs at every level of skill – intuitive design and automated analyses

Involvement of people with different paradigmatic values to augment nursing and IS personnel.



Potential Solutions IISoftware free or at minimal cost & licensed to permit and encourage innovation, modification, sharing & redistribution – GNU/Linux standard - GPL

Solicit funding from health care organizations, foundations, government grants, collaborating hospitals, & software and management companies

Provide training on and off the internet on a free or fee for service basis

Rethink embedding nursing in technology rather than imposing technology on nursingCopyright 2004 Thomas Cox

http:// professional caregiver insurance risk and nnn: risk theoretic models for predicting nursing...

Documents

acbrps nursing surplus

redundant equipment

nursing services

redundant staff

redundant supplies

thomas cox slide

nursing terminology

redundant beds