Provide one example, with supporting evidence, where a nurse leader, with clinical nurse input, used trended data to acquire necessary resources to support the care delivery system(s).
Our care delivery system is a blended model of primary and total patient care. Background In 2009, FF Thompson embarked on a journey to review and revise the way we managed our most expensive commodity (our associates). We engaged a consultant to review our method of measuring productivity. The new productivity system was based on the premise that achieving efficiency was essential to reducing cost while maintaining quality of care which is at the heart of health care. Our previous methodology revolved around measuring ourselves against "national benchmarks" and an annual salary budget. The new methodology is much more fluid and hence responsive to the changing health care environment, service development and local landscape. Our new model is based on our own performance, that is, we benchmark against ourselves at a unit level. This allows the nurses and Directors to review on a bi-weekly basis the successes and opportunities for improvement. New processes can be evaluated for effectiveness and impact on unit efficiency. Using this data along with data on nurse sensitive quality indicators nurses can build compelling arguments for additional resources. In the new methodology, there is an opportunity at any point in the year to review and revise the unit model to adapt to changes in the internal or external environment. The example below highlights how the nurses on 2 West (2W) along with their new Director Elizabeth Alexander, MS, RN, CN-E worked to gather the necessary trended data to support our care delivery system on their unit. Elizabeth assumed responsibility for 2W in the January of 2014. The unit was experiencing significant volume growth. The staffing plan had previously been based on an average daily census of 12 beds. Our staffing is based on a productivity model that was introduced in 2009. This model is intended to allow flexibility based on performance against the productivity target. In the case of the medical surgical units our standard was originally set based on equivalent inpatient days and hours of care. This standard takes into account not only patients admitted as a full inpatient status but also the extended recovery and observation patients. The standard, and thus staffing, is variable based on the hours of care per patient day.
In 2013 the actual productivity 2W was down 11% when compared to the baseline standard. This could indicate one of two things:
Although the goal of productivity management is to manage the worked hours and maintain fiscal responsibility, the challenge in a clinical arena is to identify when productivity has surpassed efficiency and is affecting the ability of staff to provide optimal patient care.
By the beginning of 2014 the hours per equivalent patient day decreased again, and through the first quarter of 2014, 2W's productivity was down 15.7% when compared to the standard. The trend was worrying to Elizabeth and her team as they had also noticed an adverse trend in nursing sensitive indicators; specifically falls were increasing. Through the first two quarters in 2013 there were 7 falls on 2W and in the first quarter of 2014, 2W had 8 falls. The increasing falls and the decreasing productivity metric were recognized by Elizabeth and the team as a contributing factor to the overall stress levels on the unit. Elizabeth reviewed the staffing complement across all her units and identified that there was an opportunity for the other units to shift some Full Time Equivalents (FTE) to 2W to create a more balanced staffing compliment across the whole of the medical surgical department, identifying and embracing our care delivery system as a blended model of primary and total patient care. In April 2014 1.8 FTE's were moved from 3 East and 3 West to increase the staffing complement. In addition, Elizabeth continued to collect additional data to present to the Joint Executive Team to request additional resources for 2W (see exhibit TL7.1- 2W positions April 2014). To support the team, Elizabeth requested additional nursing, patient care tech and administrative support for 2W. The positions were approved at the Executive level and posted internally and externally. Over the next several months these positions were filled.
Exhibit TL7.1 - Presentation to Executive Team with Trended Data
Exhibit TL7.1 2W Positions April 2014.pdf
Overall the ability of the clinical RN's to provide sound primary care has been enhanced since adding additional positions. Previously, the staff on 2W was unable to holistically provide the overall care needed to their assigned patients as they did not have enough RN's available and were often overwhelmed with tasks. Since the introduction of more staff, nursing care is once again based on the needs of individual patients, their families and significant others. Falls is one area where improvement has been seen. In the first quarter 2014 2 West had 8 falls, the second quarter falls decreased to 6, and in July, 2014, 2 West had zero falls for the month. Additionally, customer satisfaction has risen to levels not seen in over a year. When looking at the overall rating of the hospital for HCAHPS in all of 2013 60% of customers rated the hospital a 9 or 10 based on a 10 point scale. This put 2 West in the 2nd percentile. The first half of 2014 2 West dropped to 53.2% and the 1st percentile. Since the introduction of more staff July and August 2 West was at 71.1% and the 27th percentile.