What are our options?

Legislative Options – Staffing Ratios

• 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?

Regulatory Options – Patient Classification Systems

• 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

Regulatory Options – Pay-for-Performance

• 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?

Regulatory and Legislation Options – Other Measures

• 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

What can we learn from California?

• 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.

Historical Background

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

Psychiatric 1:6

Medical-Surgical 1:5

Telemetry, Emergency, Pediatrics 1:4

Step down 1:3

Critical Care/ICU, Neonatal ICU, PACU

1:2

Current Ratios

• 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 facilitiesto those paying higher salaries

• No evaluation measures to assess effectiveness

Outcomes and Consequences

Cost effectiveness of Nurse-to-Patient Staffing Ratios (continued)

• 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

What is the best decision for the future?

• Ratios can be dangerous• Evolve science around care requirements

• Workload intensity• Patient acuity• Patient classification

Pamela F. Cipriano, PhD, RN, FAAN, CNAA-BCChief Clinical Officer and Chief Nursing Officer

University of Virginia Health System

P.O. Box 800788

Charlottesville, VA  22908

(434) 924-9112

pfc4n@virginia.edu

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/ONAonNurseStaffing.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.

References

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