Exam 2 Flashcards
1
Q
Hospital Consumer Assessment of Healthcare Providers + Systems: HCAHPS
Basics (4)
A
- nationally standardized publicly reported survey about patient perspectives of hospital stay
- measures patient satisfaction
- hospital needs 300 surveys a year
- 29 items (18 r/t to critical aspects of care)
2
Q
HCAHPS
- Eligibility Criteria (6)
- Exclusions (4)
A
- randomized
- 18 yr. or older at admission (no pediatric)
- at least 1 over night stay and admitted as inpatient (med surg or maternal child)
- Survey given within 48 hrs to 6 weeks after discharge
- NON psychiatric diagnosis
- Alive at discharge
Exclusions
- not discharged home (prisoners, hospice, nursing home)
- observation/outpatients or psych
- foreign address
- no publicity patients (patients who request for their room # to not be shared ex. Famous or IPV cases)
3
Q
HCAHPS: Uses (3)
A
- 25% of value based purchasing (2% penalty if hospital chooses not to report)
- Used to get a star rating on Hospital Compare website where you type hospital name and get quality info
- LeapFrog scoring, r/t hospital SAFETY (letter grade to analyze hospital efficacy
4
Q
HCAHPS: Domains (10)
A
- Communication with Nurses (Reason for whiteboards in rooms)
- Communication with Doctors
- Responsiveness of Hospital Staff (Answering call lights)
- Communication about Medication (Med ed. at discharge)
- Discharge Information
- Care Transition
- Cleanliness of Hospital Environment
- Quietness of Hospital Environment (Stoplights on units)
- Overall Rating of Hospital
- Recommendation of Hospital
5
Q
HCAHPS: 3 goals
A
- Produce Comparable objective data across hospitals
- Create incentive for hospitals to improve quality of care b-c they are publicly reported, comparisons can be made
- Increases public accountability b-c increases transparency
6
Q
Nursing Sensitive Quality Indicators: (NDNQI)
Purpose (3)
How does it differ from HCAHPS?
A
Purpose
- compare data of healthcare orgs to support QI (only national nursing quality data comparison across facilities)
- part of ANA’s safety and quality initiative
- Developed to understand link between nursing staffing and patient outcomes
Difference from HCAHPS: represents Nursing Sensitive indicators i.e nurse driven quality (things nurse can control)
7
Q
NDNQI Clinical Indicators: Structure (4)
A
- Nurse turnover
- ED throughput
- Patient volume and flow
- Staffing and skill mix
8
Q
NDNQI Clinical Indicators: Process (5)
A
- Care coordination
- Patient falls
- Pressure ulcers (prevent via turning)
- Restraints
- Device utilization
9
Q
NDNQI Clinical Indicators: Outcomes (7)
A
- CAUTI (prevent via timely foley removal)
- CLABSI
- Hospital readmissions b-c nurse does education
- C-diff
- MRSA
- Pediatric peripheral IV infiltrations
- VAPS
10
Q
Standardization
Definition
Types
- Clinical protocol - 2
- Critical/Clinical Pathway - 2
A
- Process improvement approach where you develop and adhere best practices via repeating key processes the same way every single time
Types
Clinical protocol (Ex. MRT, stroke team, standing order; blood glucose control; protocol for codes, sepsis protocol (draw lactic acid)
- Decision path that has been approved by the physician based on a specific episode
- Don’t need to call for permission for these incidences
Critical pathways
- written plan that describes optimal sequencing of events for common diagnoses
- Explains what needs to be done on each DAY to get pt through the SYSTEM over the length of their stay
11
Q
Health Information for Economic + Clinical Health Act (HITECH)
Purpose (2)
Unintended consequences (4)
A
- Promote the use /adoption of EHRS in the U.S via giving incentives to hospital (If hospital chose not to participate, received 1-3% decrease in incentives)
- Supports the meaningful use of technology in healthcare
Unintended consequences
- Security threats r/t malware
- Increased burden and complexity of documentation
- usability issue
- safety concerns
12
Q
Meaningful Use: Examples
Purpose of both
CPOE (2)
Bar Code Scanning (2)
A
Purpose of both: reduce errors (Prior to bar code scanning, 1 med error per patient per day)
Computerized Provider Orders Entry (CPOE)
- rule that providers have to put orders in the computer rather than just verbalizing it to you
- Goal = physician put in 80% of discharge prescriptions, 60% of med order, 30% of lab orders, and 30% of radiology orders in computers to meet meaningful use standards
Bar Code Scanning
- Still need to do 5 rights of med administration and look at labels
- MUST SCAN MEDS b-c shows up if meds not scanned and can lead to decreased reimbursement
13
Q
Medicare Promoting Interoperability
What is it?
Program Objectives (4)
A
- replaces meaningful use but hospital still submit data to receive incentives
Objectives
- Focus on electronic prescriptions
- Health information exchange
- Provider to patient information exchange
- Public health + clinical data exchange
14
Q
Meaningful Use: Priorities (5)
A
- improve quality, safety, efficiency, and reduce health disparities
- engage pt + families in their own health
- Improve care coordination
- Improve public + population health via looking at trends
- Ensure privacy + security protection for personal health record (i.e passwords on computer)
15
Q
Meaningful use: Basics (3)
A
- Defines minimum U.S govt standards for electronic health records
- Outlines clinical data that can exchanged b/w providers, insurance, and patient
- Provide exchange of healthcare info to improve quality of care
16
Q
Risk management
What is it?
Responsibilities (3)
A
- Process of developing and implementing strategies to minimize risk and mitigate the impact of adverse events on the hospitals
Responsibilities
- Preventing patient injury in hospital
- Minimizing financial loss after a problem (i.e. prevent hospital being sued or reducing amount sued for)
- Preserving the organization’s reputation
17
Q
Risk Manager: Role (9)
A
- Mandatory reporting
- Identifying risk + any vulnerabilities r/t patient safety, equipment malfunction via risk assessment and reports
- Do claims management (investigation and coordinate legal depositions)
- Regulatory compliance (DNV, TJC, CMS)
- Investigate errors via Root cause analysis (looks at processes)
- Track and trend events or incidents
- Responsible to ensure hospitals compliant w/ policy and security
- Concerned w/ safety of patient and hospital
- Collab w/ state and local officials
18
Q
Mandatory Event Reporting (15)
A
- Any abuse or neglect regardless of unit
- Nosocomial infections (SSI, CAUTI, CLABSI)
- Unexpected occurrences or accidents that lead to death (Any death within 24 hrs of admission)
- EMTALA Violations (25-50K fine for violations)
- Deaths related to restraints and seclusion
- Wrong site surgery (Reason for marking site; time out; checklists)
- Retained surgical objects
- Infant deaths, births, and reportable fetal deaths
- Infants discharge to the wrong person
- Patient suicides or attempted suicides
- Stage 3 or 4 hospital acquired pressure ulcers
- Patient deaths from falls
- Sexual assaults of patients
- Drug overdoses r/t Opioid crisis
- Sentinel events
19
Q
Healthcare law: EMTALA (Emergency Medical Treatment and Labor Act)
Basics (4)
A
- prevents patient dumping
- Must do medical screening exam in ED before transferring patient or asking about insurance
- Must have legitimate reason for transfer; cannot be r/t insurance and cannot be unstable patient including pregnant woman
- Hospital have to document every pt that was transferred out of ED, where they were transferred, and need to say WHY VIA EMTALA log
21
Q
Falls
Definition
Tips (3)
Factors (5)
A
Definition: unplanned descent to the floor WITH or WITHOUT injury (even if someone catches you)
Tips
- Always need to assess pt fall hx (falls at home = will fall at hospital)
- Multidisciplinary issue! Everyone in the hospital can help prevent a fall!!
- CMS does not pay for fall-related injuries issue (1/3 preventable)
Factors
- Age is a key factor of fall due to physical changes + cognitive changes (20-30% of older people who fall suffer moderate to severe injuries (Fractures))
- medication (meds for cholesterol = rhabdomyolysis risk)
- disease process
- ambulatory issues
- noncompliance
21
Q
Unusual Occurrence Report/Incident Report:
Tips (6)
A
- Needs to be confidential, not discoverable!!!
- Should not be mentioned in the pt’s medical records b-c it could then be discovered
- Be objective (do not make assumptions)
- Do not photocopy or take pictures of the incident report
- Never ordered by physician
- always assess patient and let HCP know about incident prior to filing report
22
Q
Sentinel Event: Types (11)
A
- Discharge pt from ED and then they commit suicide within 72 hrs
- Unintentional death of full-term infant
- Discharge of infant to the wrong family
- Any event that requires transfer to higher level of care
- Abduction of patient
- Hemolytic transfusion reaction
- Elopement: pt leaves that has been admitted (if results in adverse outcome) —Different from AMA; Elopement is they go missing and you do not know they are gone
- Wrong site surgery
- Raped, assaulted, or killed
- Fire, flame, smoke in equipment during direct patient care
- Maternal deaths unrelated to admission reason
23
Q
Unusual Occurrence Report/Incident Report:
When to file? (5)
A
- Patient injury
- Unanticipated patient death
- Malfunction or failure of equipment
- Adverse events related to patient care
- Safety issues related to the physical environment
24
Q
Sentinel Event: Basics (3)
A
- patient safety event that reaches a patient and results in death, permanent harm, or severe temporary harm.
- Unrelated to patient’s condition
- Require additional surgery, or treatment or transfer to higher level of care
25
Never Event: definition
Ex. Stage 3 or 4 pressure ulcer, DVT, fall, HAI, air embolism, blood incompatibility, poor glycemic control
Serious and costly preventable complication or error that occurs during an in-patient stay that could be reasonably prevented through adherence to evidence-based guidelines.
26
How to avoid risk management issues (9)
- Remain current in skills
- Know job description
- Be confident w/ the skills you perform
- Follow all safety protocols when administering meds
- Ensure you follow orders and get clarity if you need it
- Be trained on any equipment you use
- Document all patient activities and communication
- Be familiar w/ policies + procedures of hospital
- ALWAYS USE PROPER PT IDENTIFICATION
27
Health Insurance Portability and Accountability Act (HIPAA)
Basics (2)
What to know (5)
Basics
- privacy rule and confidentiality law for PHI
- Gives patient rights to control the release of information
What to know
- Only professionals that are directly involved in care can look at medical records
- Cannot disclose to unauthorized family member
- Policies on viewing your own medical records (may not be able to review until finalized)
- No part of record can be copied except b/w health care institutions
- Communication with patient needs to take place in a private place i.e., patient room; password protection on computer; no social media
28
Healthcare law: Patient Self-determination Act
Basics (2)
Concerns (2)
- Requires written notification on admission of rights regarding end of life care
- all patients must be asked about advance directives and educated about them if does not have it
Concerns
- If have living will or power of attorney, need to bring with them to hospital.
- CPR must be initiated UNLESS there is a written order for DNR even if living will says otherwise
29
Differences between the following:
Nurse Practice Act (7)
- law/ statute in each state that regulates practice of nursing
- Defines scope of practice (Procedures, actions, duties, processes that RN can do)
- Delineates categories of nurses and the scope of practice for each: RN, LPN, APRN
- sets the educational and examination requirements necessary for licensure
- Defines the standard of competent performance
- Defines what behaviors represent misconduct or unprofessional behavior for disciplinary action
- If state is in compact agreement, they are regulated by the nurse practice act they are working in not the state their license is in
30
Nursing Consideration: Leaving AMA
Nurse role (4)
- cannot detain a pt who is MENTALLY COMPETENT (cannot block patient from leaving)
- notify supervisor and HCP
- need to tell pt what the risks are + document that you did
- Get patient to sign AMA document if possible otherwise two RNs sign it
31
Informed Consent
Components HCP must discuss (4)
Nurse role (3)
Components HCP must discuss
- Reason for procedure
- Risks and benefits of procedure or treatments
- Risks/Consequences for not doing treatment
- Other options available
Nurse role
- Witness signature
- ensure informed consent is obtained by HCP
- If you find out that pt does not understand, stop everything and tell HCP to come back and re-explain (part of patient advocacy)
32
Restraints
Components of order (4)
Tips (4)
Components
- Reason (type of behaviors warranting restraints?)
- Type
- Location of restraint: where the restraints are going
- How long they can be used
Tips
- Always use least restrictive and they are never the first option
- Reevaluated q24h and document, need a new order q24 hrs
- ensure current and adequate documentation (Need to include that you toileted pt and got them up etc. No redness, good pulses; fed)
- wrongful restraint = False imprisonment
33
Liability
Personal (3)
Vicarious (2)
Corporate (1)
Personal
- you are accountable for your practice and compliance
- Each person responsible for their own actions or omission of actions
- “I am responsible for what I do and for what I do not do”
Vicarious
- Because I work for someone, they are accountable for my actions
- employer can be held accountable for negligence of employee
Corporate
- institution (corporation) is responsible and accountable to ensure an environment where quality health care will be delivered to all consumers
34
Nurse Practice Act: Behaviors that represent misconduct (11)
* Practicing without a valid license
* Conduct representing boundary issues (Questionable behavior between nurse and patient OR sexual misconduct)
* Practicing while impaired with alcohol or drugs
* Violating HIPAA/patient confidentiality
* Failure to supervise someone that you've delegated to
* Inaccurate or false documentation
* Failure to use appropriate Nursing judgment
* Medicare Fraud (billing Medicare for services not rendered)
* Not reporting violations r/t poor nursing conduct by another nurse
* Gross negligence or failure to follow standards of practice or care
* Non-professional conduct (ex. felony convictions, practicing outside the scope of license or misuse of drugs)
35
Differences between the following:
Board of Nursing (2)
Nursing License (2)
Board of Nursing
- the law enforcement (Board of nursing enforces the nursing practice act)
- required by Nurse Practice Acts
Nursing license
- privilege and not a right
- Purpose: protect the public and protect title of RN
36
Negligence: Most common charges that become Malpractice (6)
- Failure to follow standard of care
- Failure to use equipment in a responsible manner (must know what you're using)
- Failure to communicate (w/ provider or patient)
- Failure to document in the medical record
- Failure to assess and monitor pt correctly (shift assessments)
- Failure to act as a patient advocate
37
Negligence: Definition (2)
- Failure to use such care
as a reasonably prudent and
careful person would use under
similar circumstances (below standard of care)
- Equated with carelessness (deviation from standard of care)
38
Malpractice: Basics (3)
- Improper or unethical conduct or unreasonable lack of skill
by a holder of a professional
or official position
- Type of negligence by someone with a license
- Must prove 6 elements: Duty, breach, foreseeability, causation, injuries, damages (note: license does not have to be proved)
39
Elements of Malpractice
* Duty Owed the Patient - 2
* Breach of the Duty of Care Owed the Patient- 1
* Foreseeability - 1
* Causation - 2
* Injury - 2
* Damages - 1
Duty Owed the Patient
- Must be employed wherever this incident happened
- If you accept the assignment, you are accepting duty
Breach of the Duty of Care Owed the Patient
- if your actions fall below standards of care
Foreseeability
- Certain events can reasonably be expected to cause specific results
Causation
- hardest to prove esp. if many comorbidities
- Direct relationship between nurse’s failure to meet standard of care and patient’s injury
Injury
- Must sustain some physical harm
- Cannot be psychological harm or transient harm
Damages
- Financial damages have come from the events that happened
40
Avoiding Liability: Nurse Manager's role (5)
- Ensure all personnel have a current license
- Report unethical, illegal,and incompetent practices (i.e. assessment w/o stethoscope)
- Address disciplinary issues with employees
- Ensure that the standard of care, policies, and procedures are followed by employees (via random documentation reviews and annual performance appraisals)
- Educate the staff on policy changes or standard of practice changes
41
Malpractices: Causes for Nurse Managers (5)
- Assignment, Delegation and Supervision (delegating to incompetent people OR not effectively communicating)
- Duty to Orient, Educate and Evaluate staff ( must investigate any allegation made by patient about someone who is incompetent)
- Failure to Warn (not warning potential employers or board of nursing about staff misconduct)
- Staffing Issues (inadequate staff:patient ratio (need to notify CNO); inadequate training of agency staff; floating RNs w/o training
- Protective and Reporting laws (Elder and child abuse; STDs, Other certain infections; Incompetent practitioners)
42
Avoiding Liability: Staff Nurse's role (6)
- Always have open, honest respectful communication practices with patient and their family
- Maintain competence and best practices in your area of practice
- Only practice within your scope of practice and under your job description (esp. if in school for higher degree)
- Know what your strengths and weaknesses are.
- Be familiar with nurse practice act of state you work in
- only tell facts in deposition
43
Healthcare Laws
Title VI - 1
Age Discrimination in Employment act - 2
Equal Pay Act of 1963 - 1
Family and Medical Leave Act - 2
Title VI (discrimination law)
- Law that says it’s illegal to refuse to hire, discharge, or discriminate against someone because of their sex, race, gender, or origin
Age Discrimination in Employment Act of 1967
- Prevents discrimination for those > 40 years old
- no mandatory retirement
Equal Pay Act of 1963
- Illegal to pay lower wages to one gender over another when job requires equal circumstances (skills, effort, exertion, accountability, training, and education)
Family and Medical Leave Act
- Ability to take 12-week unpaid medical leave if you're sick or need to take care of a family member (includes births) w/o losing job
- Applicable for men and women
Provides job security if you must take unpaid leave (12 weeks)
44
Healthcare Law: Occupational Safety and Health Act (OSHA)
What is it?
Includes (4)
- Ensures healthcare workers are working in safe environment
Includes
* isolation procedures and universal precautions
* proper handling and grounding of equipment
* violence in workplace
* Certain place to store things to keep safe (cannot set O2 tanks on floor)
45
Healthcare Law: American with Disabilities Act (4)
- Prohibits employers from discriminating against hiring someone who has a disability unless that person is not qualified or otherwise unable to do the job
- Disability: physical or mental impairment that limits 1 or more functions of the person; must be record of disability
- You don’t HAVE to hire them but you cannot NOT hire them if they are qualified
- Employer must make reasonable accommodations for the disability
46
Healthcare Law: Good Samaritan Law
Basics (2)
Requirements if you stop (3)
- Protects HCP from malpractice when giving emergency assistance outside normal job
- nurse not required to stop
Requirements if you stop
- Must meet standard of care
- Stay with victim until handed off to another provider (b-c you have established nurse-patient relationship)
- Must not provide care with expectations of getting paid for care
47
Ethical Principles: Definition and Leadership Perspective
Autonomy
Beneficence
Nonmaleficence
Autonomy
- addresses personal freedom and right to self determination. “I have the right to make the decisions I want to make”
- Leadership perspective: employee has responsibility to meet job expectations or accept the consequences of actions
Beneficence
- obligation to do GOOD by acting in ways that promote welfare in best interest of others
- Leadership perspective: nurse management encourage staff to grow and assume additional responsibility for growth
Nonmalefiecence
- Do no HARM, act in a way to not harm
- Leadership perspective: in performance appraisal giving both positive and negative feedback to not harm employee; just giving bad feedback can be harmful
48
Differentiate the following:
Ethical Dilemmas - 1
Moral Courage - 2
Moral Dilemma - 1
Ethical dilemma
- Decisions must be made on what's right or wrong in a situation where individual must make a choice between equally unfavorable alternatives
Moral Courage
- Being able to stand up for what is right and acting based on ethical principles regardless of consequences
- Protects ethical values such as honesty, integrity, respect, fairness, empathy, compassion
Moral Dilemma
- Occurs when someone knows the ethically correct action to take, but they feel powerless to act
Internal values conflict with what is happening
49
Ethical Principles: Definition and Leadership Perspective
Veracity
Fidelity
Justice
Veracity
- Telling the truth or demanding that the truth be told completely
- Leadership perspective: Nurse manager should inform an employee about the challenges + benefits of the position
Fidelity
- Keeping promises or commitment
- Leadership perspective: Honoring commitment to days off
Justice
- Treating all people equally and fairly
- Leadership perspective: nurse manager uses it to decide whose turn it is to float to another unit OR who gets time off
50
ANA Code of Ethics: Nurse will... (9)
- practice with compassion and respect
- primary commitment is to the patient
- advocate for the health, safety and rights of the patient
- has authority, accountability, and responsibility for nursing practice
- owes same duty to self as to others
- contributes to the healthcare environment
- promotes advancement of the nursing profession
- promotes community and world health (health diplomacy, protect human rights and reduce health disparities)
- promotes profession of nursing
51
Hospital Ethics Committee: Models (3)
- Autonomy Model (Facilitates decision-making)
- Patient-Benefit Model (Use judgement to consider what patient wants)
- Social Justice Model (Looks at broader social models and accountable to overall institution)
52
Hospital Ethics Committee: Role (4)
- Provide structure and guidelines for potential problems
- serves as a RESOURCE and open forum to discuss and make decisions
- provide guidance and recommendations (not decisions)
- Serves as patient advocate (Patient must be consulted before ethical committee involved)
53
Change
What is it? (4)
- alteration to make something different
- complex process which occurs over time
- can flow back and forth through stages
- influenced by many variables
54
Types of Change
Planned (2)
Unplanned (3)
Planned
- change that is well-thought out, organized, and deliberate
- advance planning w/ goal to improve something
Unplanned
- change that is unorganized and unanticipated
- adaptive response to something
- does not include staff input (leader says what to do)
55
Three changes organizations constantly undergo
- Organizational restructuring (flattening leadership)
- Quality improvement
- Employee retention
56
Forces Driving Changes in Healthcare (8)
- Rising healthcare costs
- Declining reimbursement (insurance does not want to pay for things)
- New quality imperatives
- Workforce shortages (Ex. Agency nurses)
- New and emerging technologies (robotic surgery)
- Growing elderly population b-c people are living longer
- Alternate methods of care (Telemedicine)
- Increase in use of health care extenders i.e. APRNs
57
Lewin's Change Theory: Three stages
Unfreezing: thawing out of the system via assessing readiness and motivation for change (has disequilibrium and no status quo)
Moving: visual change takes places and is implemented
Refreezing: change is integrated, stabilized and becomes new status quo
58
Lewin's Change Theory: Unfreezing Stage
Manager's role (5)
- Gather data
- Accurately diagnose what the problem is
- Decide if change is really needed
- Make employees aware that there needs to be a change
- Help employees accept, buy in, and be on board with the change
59
Lewin's Change Theory: Moving Stage
Manager's role (8)
- Develop strategies and plan for change
- Set goals + objectives w/ target date
- Identify areas of support + resistance
- INCLUDE everyone impacted by the change in process
- Implement change
- Offer support + encouragement about the change
- Evaluate change
- Revise plan as necessary
60
Lewin's Change Theory: Refreezing Stage
Manager's role (3)
- Inspect and reinforce positive behavior to hardwire change
- respond to employee concerns
- ensure everyone is doing what they should be
61
Force Field Analysis
* What is it?
* Driving Forces
(Ex. scheduling, informal leaders that encourage everyone to do walking rounds)
* Restraining Forces
(Ex: employees that don’t want to participate and protest changes; employee fear)
- CURRENT STATE BEFORE the change occurs (present or desired state)
Driving forces: positive forces that push change forward or advance system toward change
Restraining forces: obstacles that impede change
62
How do Lewin's Theory of Change match up with nursing process and problem solving?
Unfreezing
- Nursing Process: assessing and diagnosis
- Problem Solving: Identification of problem, define problem
Moving
- Nursing Process: planning and implementing
- Problem Solving: Problem Analysis, seeking alternate solutions, implementation
Refreezing
- Nursing Process: Evaluating
- Problem Solving: Evaluation
63
Lewin's rules for Implementing Change (7)
- need good reason for making change (do not change for sake of change)
- Always needs to be planned and implemented gradually (Should never be abrupt or unexpected)
- All people affected by change should be involved in planning process to help them buy into change via giving them ownership
- Varied reactions and Resistance to change are normal
- Communication is important (rumors need to be dispelled)
- Managers must plan to inspect change to ensure it is sustained
- Celebrate small wins
64
Reactions to Change (7)
- Active resistance (May be aggressive)
- Passive resistance (i.e. Silent noncompliance)
- Indifference (i.e. Redirect conversations, Ignore changes)
- Fear of loss (of job)
- Fear of unknown
- Fear of failure
- Disruption of interpersonal relationships (Ex: change that makes it so you can’t see your friend during shift change anymore = disruption of interpersonal relationships)
65
Budget: Basics (4)
- financial plan that includes estimated expenses + revenues
- Designated for period of time (typically 12-month period)
- Dynamic process that guides the allocation/distribution of resources and expenditures to ensure business can function daily and achieve goals
- Aligns with identified strategic plan, mission, and vision
66
Budgeting Process: 4 steps
- Planning
- Coordinating & Communicating
- Monitoring Progress
- Evaluating Performance
67
Budgeting Process:
- Planning (4)
- Coordinating and Communicating (2)
Planning (Ex. Plan to give 3% raise so plan for increase in expenses)
- Most important function of budgeting process
- Determine the goals of organization
- Identify resources
- makes Budget assumptions (reasonable expectations on revenue (income) and expenses)
Coordinating and communicating (Ex. If you are going to open a new service, you will talk about that here)
- Bring various people together to discuss resources and involved factors
- Discuss allocation and distribution of resources based on strategic plan
68
Budgeting Process:
- Monitoring Progress (2)
- Evaluating Performance (3)
Monitoring progress
- Compare actual performance against budget
- Do variance analysis (deviations from budgeted dollars are examined by comparing actual performance results to expected or budgeted performance) if there is variance
Evaluating performance
- Determine effectiveness of manager (i.e. managing of overtime, labor, and supplies)
- Staff role in preventing variance: ensure you clock in and out on time AND be mindful of supplies taken into patient's room
- Staffing office role in preventing unfavorable variance: controlling budgeted staff
69
Variance
What is it?
Favorable vs unfavorable
The difference between the planned budget and the actual results
Favorable: results better than expected = SPENDING LESS (Ex. Less sick patients, understaffing)
Unfavorable: results are worse than you thought = SPENDING MORE (Ex. Sicker patients, Overstaffing , staff turnover)
70
Factors that cause Variance (5)
- Vacation/sick days
- Patient acuity (favorable if less sick, unfavorable if more sick)
- Staff calling in sick (unfavorable labor variance but favorable budget variance because you save money)
- Staffing level and overtime
- Hours not moved correctly when nurse is floated to a different unit
71
Differentiate the Following:
Productive time
Nonproductive time
Productive time (Ex. Secretary (responds to call lights), UAP, RN)
- any time directly in patient care. Includes hourly and overtime
Non-productive time (Ex. Orientation, education, doing chart audits, vacations, holidays, sick time)
- working on/off the unit not in direct patient care
72
Budgets: Operational Budget (4)
- financial plan for organization that lists the plans, revenues, and expenses in a designated period
- looks at day-to-day expenses
- Every hospital has operational budget
- includes labor and supply expenses
73
Budgets: Labor Budget (4)
- includes salaries, Overtime, benefits, education, staff development and training
- subset of operational budget
- LARGEST EXPENSE OF OPERATIONAL BUDGET
- Nursing typically makes up 65% of labor budget
74
Budget: Capital Budget (5)
- Money allocated for major equipment and construction projects
- expenses between >$500-$2000
- item has to have a life expectancy of >1yr
- Considered long term investments
- Payment for capital expenses spread over couple of years
75
Budget: Cash budget (3)
- Money that flows in and out of organization
- Includes billing + collections, cash on hard
- Helps CFO know if they are spending budget productively.
76
Budgeting Methods
Incremental (2)
Zero-based budgeting (3)
Incremental budgeting
- Used most often b-c simple
- Look at historical data and make adjustments based on growth or declines
Zero-based budgeting
- Start from scratch (0) every year
- Requires justification and detail for every expense (labor intensive)
- Hospitals don’t do this type of budgeting
77
Unit of Service
What is it?
What are the unit of services for:
- Nursing Units
- Cath lab
- OR/PT/OT
- Home health
Unit-of-service: basic measure of product or service being produced
- Nursing Units: patient days (total # of days patients admitted over time period)
- Cath lab: procedures
- OR/PT/OT: time (15-minute increments)
- Home health: patient visits
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Costs considered to determine cost of healthcare (4)
- Definition of each
- Example of each
Direct Costs
- costs directly associated w/ a unit of service
- Ex: nursing care, admission kits
In-direct costs
- things r/t to operating expenses but not directly r/t to things servicing patient
- Ex: housekeeping services, utilities, maintenance fees
Fixed costs
- do not change regardless of unit of service i.e., business of unit
- Ex. manager or administrative salary
Variable costs
- cost that varies based on changes in the unit of service
- varies w/ volume of patients
- Ex: IV supplies will vary w/ the amt of pts that you have
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Budgeting: Nurse Manager's Role (6)
- Responsible for unit-level budget (labor and supply)
- managing patient flow such as ADT
- Eliminate never events (something that happens in HCO that should never happen if best practice is followed)
- Reduce 30-day readmission and length of stay
- Improve pt satisfaction on the unit
- Reduce staff turnover (costs $60,000 to train a new nurse)
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Patient Protection and Affordable Care Act (ACA): 3 goals
- Improve quality of healthcare
- Slow the unsustainable growth in healthcare costs
- Move the focus to prevention vs acute illness
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ACA: Key Components (10)
- individuals b/w 100-400% FPL receive subsidies
- Companies w/ > 200 employees must provide insurance
- Healthcare exchange allows people to afford insurance at lower rate
- Healthcare must cover certain services: mental health, Ambulatory, L& D, preventative care, emergency
- Must cover preexisting conditions
- Allows you to stay on parental insurance until 26 yrs old
- 80% of premium must go toward healthcare
- Establish Hospital Acquired Infection Program (Medicare will no longer pay for HAIs)
- Establish Hospital Readmission Reduction Program (Medicare reduced payment for preventable readmissions)
- Establish Value Based Purchasing
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Healthcare Reimbursement/Financing: Fee for Service (3)
- hospitals bill and receive payment for EVERY SINGLE service provided
- No incentive to manage the costs because all services paid for by hospital
- Frequency of services provided did not = quality care
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Healthcare Reimbursement/Financing: Inpatient Prospective Payment System (IPPS) - 4
- hospital payment system in which 3rd party payer or CMS decides what will be paid
- Utilizes the DRG (Diagnosis-related group) for basis of payment (every diagnosis falls under a DRG)
- If pt discharged earlier, then hospital gets to keep the money if they get out later the hospital eats the money
- Encourages efficiency but no real incentive for quality and safety
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Healthcare Reimbursement/Financing: Value Based Purchasing
Basics (3)
- Hospital paid based on quality, safety, and efficiency measures (paid for performance)
- ONLY program WHERE HOSPITAL CAN EARN A BONUS IF DO WELL OR BE PENALIZED IF THEY DO POORLY (Hospitals are rewarded if quality care; hospitals are punished for poor outcomes)
- Budget neutral for healthcare consumers (b-c some hospitals do bad and others do good at end of year performance eval
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Healthcare Reimbursement/Financing: Value Based Purchasing
What does it promote? (5)
- quality care (adopt EBP)
- safe experience (reduce healthcare errors)
- cost effectiveness (redesign programs for efficiency)
- Positive experience of Medicare beneficiary
- Transparency b-c quality metrics are out there for everyone to see
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Healthcare Reimbursement/Financing: Value Based Purchasing
What nurse can do on front line (7)
- Infection prevention (wash hands to prevent c-diff and MRSA)
- Isolation precautions
- C-Diff. = prevention and timely testing (may be protocol to test in ED if pt has diarrhea)
- Nurse-driven protocols for urinary catheters (may can be removed in 24 hr)
- Evaluate patient needs for central lines
- Clear, concise documentation
- Discharge planning (Chronic condition education, Patient and family engagement, Medication reconciliation)
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Healthcare Reimbursement/Financing: Value Based Purchasing
4 domains (each 25% of score)
- Safety
- Patient and Community engagement (HCAHPS)
- Efficiency and Cost Reduction (spending per hospital Patient with Medicare Beneficiary)
- Clinical Outcomes
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Value-Based Purchasing: Domains
Safety (6)
- Patient Safety and Adverse Events
- C-Diff: Clostridium Difficile Infection
- CAUTI: Catheter-Associated Urinary Tract Infection (Reason to remove foley early)
- CLABSI: Central Line Associated Blood Steam Infections
- MRSA: Methicillin-resistant Staphylococcus aureus bacteremia
- SSI: Post Surgical Site Infections for Colon Surgery or Abdominal Hysterectomy
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Value-Based Purchasing: Domains
Clinical Outcomes (6)
- AMI: Acute Myocardial Infarction 30-day mortality rate
- HF: Heart Failure 30-day mortality rate
- PN: Pneumonia 30-day mortality rate
- COPD: Chronic Obstructive Pulmonary Disease 30-day mortality rate
- CABG: 30-day mortality rate
- Complications Hip & Knee: Total hip and knee arthroplasty complications
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Staffing
Basics (4)
- process of identifying + allocating right # of nurses on a unit based on patient needs (acuity)
- Daily operational function each shift
- No perfect staffing method (JCO/ CMS don’t tell you how to staff, just say you have to provide adequate care)
- staffing is complex and challenging and longest management function)
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Staffing: Outcomes of Adequate Staffing (9)
- Reduced medical and medication errors
- Reduced potential for errors
- Decreased patient complications b-c patient gets more attention, assessed more frequently so complications noticed earlier
- Decreased mortality (1.98% decrease)
- Improved patient satisfaction b-c nurses checking on them more often and more attentive
- Reduced nursing fatigue and burnout
- Increased job retention and satisfaction
- Decreased lengths of stay b-c you know more about the patient
- Reduced readmissions
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Goal of Staffing (4)
- Provide right number of nurses
- with the right qualifications/skillset
- to deliver safe, high-quality, and cost-effective care to a group of patients and their family
- evidenced by positive health outcomes
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Conceptual Framework for Nursing Staffing and Patient Outcomes
Chart flow (4)
- Patient factors and nurse characteristics impact nurse staffing
- nurse staffing impacts nurse outcomes
- nurse staffing, nurse outcomes, patient factors, hospital factors, organization factors, medical care impact patient outcomes
- patient outcomes impact length of stay
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Conceptual Framework for Nursing Staffing and Patient Outcomes
Factors
- Patient (5)
- Nurse Characteristics (5)
Patient Factors
- age
- primary diagnosis
- acuity and severity
- comorbidity
- treatment stage
Nurse Characteristics
- education
- experience
- age
- contract nurses
- Internationally educated nurses are very different than the nurses trained in U.S (More orientation needed b-c function more like nursing assistants)
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Conceptual Framework for Nursing Staffing and Patient Outcomes
Factors
- Nurse Staffing (3)
- Hospital (4)
- Organization (3)
Nurse Staffing
- HPPD (delivered care hours and total paid hours)
- Skill mix
- Nurse Staffing Ratio
Hospital factors
- size (Small hospital may do something very different and people wear different hats)
- volume
- technology
- teaching (Teaching hospital you may have interns and residents)
Organization factors
- Clinical units
- Duration of shift (8 vs 10 vs 12)
- Shift rotation
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Conceptual Framework for Nursing Staffing and Patient Outcomes
Factors
- Nurse Outcomes (3)
- Patient Outcomes (4)
Nursing Outcomes
- Satisfaction
- Retention
- Burnout
Patient outcomes
- Mortality
- Adverse drug events
- Patient satisfaction
- Nurse quality outcomes
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Define the following:
- Skill mix
- Staffing pattern
- Forecasted workload
- Average Daily Census (3)
Skill mix
- combo of categories of workers employed to take care of the patients (Ex. RN, LPN, UAP)
Staffing Pattern
- lists the total number of direct-care staff by level of skill scheduled for each day and each shift (i.e. 1:5 nurse; 1-12 UAP ratio)
Forecasted workload
- determines staffing pattern based on combo of average daily census (ADC) and recommended standards (Hours per patient day (HPPDY))
Average Daily Census
- sum of daily census for 1 yr/365 days
- perfect staffing = adequate for ADC
- may be under or over staffed if ADC differs from actual patient load
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HPPD: Hours per patient day
What is it?
What is the problem?
- hours of nursing care provided per patient by various levels of nursing personnel
- used to determine forecasted workload with average daily census
Problems
- financial metric that does not take into account patient acuity
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Define the Following:
- FTE (2)
- ADT (3)
- Average Length of stay (2)
- RIF (2)
Full Time Equivalent
- one FTE = 40 hrs in one wk; 2080 in yr (36 hr per week = 0.9 FTE)
- does not equal people (only used for developing staffing pattern)
Admissions, discharges, transfer (ADT)
- turnover of patients
- not factored into staffing b-c hard to predict
- adds to complexity of nurse work each day
Average Length of Stay
- average # of days each patient is in hospital
- has reduced overtime b-c used in DRG and decreased reimbursement for longer stays
Reduction in Force (usually not nurses)
- Permanent separation of employment due to
lack of funds, work, or redesign OR elimination of the positions with no likelihood that employee will be recalled
- not the same thing as a “work call-off”
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Scheduling
Definition
Types (4)
process of determining the set number and type of staff for a future time period (4 weeks) by assigning individual personnel to work specific hours, days and shifts in a specific unit for a designated time period
Types
- centralized
- decentralized
- self-scheduling (nurse creates schedule based on certain requirements)
- fixed/cyclic scheduling (set hrs and days worked each week)- not common in nursing
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Define the following:
Patient Acuity (3)
Nursing intensity
Patient acuity
- severity of illness or complexity of care needs
- higher acuity = more assistance
- Forecasted workload (HPPD and ADC) do not account for acuity
Patient intensity
- amount of care required by patient
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Factors that affect patient acuity (9)
- Age of patient (older = higher acuity)
- Functional ability
- Communication skills (If they do not speak English, acuity will increase b-c need translator)
- severity and urgency of the condition
- Procedures scheduled
- Complexity of care needs of patient. (Ex: extensive ulcers will require extensive wound care)
- Geography of the environment (ex: better for nursing station to be in the middle for access)
- Availability of technology
- Experience of staff providing care
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Models of Nurse Staffing
- Budget based on HPPD (2)
- Nurse-patient ratio (3)
- Patient acuity (3)
Budget based on HPPD
- Most predictable model of nurse staffing
- financial metric used by hospitals
Nurse-patient ratio
- Pure method
- Not cost effective b-c one patient over budget = need a whole nurse for that one person
- Not used by hospitals
Patient acuity
- Most likely need people on call
- Must be calculated everyday
- ambiguous so not used
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Productivity Index
Basics
Factors (4)
Basics: how well workforce uses available staff; you want correct # of staff to take care of patients so productivity = 100% ( > 100% = understaffed; <100% = overstaffed)
Factors
- Variance (do variance analysis)
- Overtime
- agency nurses
- nurses in nonproductive time (training, orientation,education)
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Factors Impacting Staffing Requirements
- Nursing Leadership Considerations (9)
- Projected unit workload and units of service for next year (is anything on unit going to change)---Ex: if you have a new cardiac surgeon and now the unit will have more cardiac pts, predict a change
- Historical staffing requirements
- Effectiveness of current staffing plan (may need a change)
- Trends of acuity on the unit
- Anticipation of skill mix. ex: using LPN, UAP
- Experience + education of staff (new physicians; educational hours)
- New technology (new programs or service needs)
- Patient outcomes (ex. if you have a lot of bad pt outcomes w/ current staffing, there may need to be a change)
- Productivity index
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Factors Impacting Staffing Requirements
- Staff Preparation (3)
- Must have competencies to work in the unit you are supposed to be working in
- Must have knowledge and skills for the unit
- Are they experienced? (novice to expert) ---Never schedule all new nurses to work at once
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Factors Impacting Staffing Requirements
- Organizational Needs (4)
- Financial (salaries are the largest expense for any HCO)
- Productivity (Has DIRECT impact on bottom line/budget)
- Licensing + Accreditation ( does not mandate any type of staffing, but they observe unit’s atmosphere to see if nurses are freaking out or calm and collected; interview patients, and check licenses)
- Customer Satisfaction (ex. HCAHPS publicly reported)---NEVER okay for nurse to discuss short staffing with a patient b-c jeopardizes pt’s trust; Critical to be competitive in the market
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Scheduling: Decentralized
Basics
Pros (2)
Cons (2)
Decentralized: Nurse manager responsible and accountable for schedule on individual unit including covering scheduled + unscheduled absences
Pros
- Staff can request time off directly to manager
- Staff has more flexibility and autonomy b-c can change shifts w/ coworkers
Cons
- May lead to manager giving certain people special treatment (unfairness)
- May not be as cost effective because there is not a single person seeing all the units of the hospital
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Scheduling: Centralized
Basics
Pros (5)
Cons (2)
Centralized: When staffing decisions are made by staffing office rather than the manager
Pros
- wide view of whole organization rather than just one unit
- encourages optimal utilization of staffing resources
- Easier to consistently implement staff policy (float pool, agency, Per diem (1 day) nurses are pulled in and often paid more b-c must be flexible and work wherever they’re sent)
- More cost effective than decentralized staffing
- Frees up manager to have more time to do other management functions since not dealing with staffing all day
Cons
- Office doesn’t always know the particulars regarding patient acuity on individual units
- manager not in tune w/ productivity on unit b-c not worried about staffing
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Patient Assignments
- Acuity (3)
- Block (3)
Acuity
- Take into consideration the complexity of care and the resources needed for the patient
- skip rooms
- Ideal way to do it (but not always possible if no tool to rate acuity)
Block
- Easiest way to make assignments
- Rooms are dives up amongst number of nurses
- You take patients in a row
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Considerations in Making Patient Assignments
- Continuity of care (2)
- Patient Safety (3)
- Patient Satisfaction
- Staff Satisfaction
Continuity of care: consistency of care provided
- Promotes quality of care
- Facilitates positive outcomes (patient satisfaction and increased rapport w/ patients)
Patient Safety
- Assign nurses based on knowledge, skills, competencies
- Factor in acuity + severity of pt conditions
- Look at primary diagnosis, comorbidity + where patient is in their treatment.
Patient Satisfaction
- If pt does not want the nurse, may be reassigned
Staff Satisfaction
- If you have difficult pt, may need to rotate staff to prevent staff burnout
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Staffing Effectiveness: Indicators (2)
Clinical/Service Indicators (quality indicators)
- # of patient and family complaints
- # of adverse drug events
- # of injuries to patients
- post-op infections
- Upper GI bleeding incidences
- Cardiac arrest
- Length of stay
Human Resource Indicators (people things)
- Overtime
- Staffing vacancy rate -> Understaffing compared to budgeting staffing plan
- Staffing turnover rate
- Nursing care hours per patient days
- Staff injuries (Ex: needle stick)
- sick call
- Use of on call or per diem
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Case Management: Role (5)
* Coordinating care by interprofessional team from admissions to discharge for group of patients
* not in staffing, do not provide direct patient care of patient!!! (Can be nurse, social worker, or another discipline)
* May be unit based, service line (follow patient through specific areas), or for group of patients
* Help w/ utilization management by identifying barriers to discharge (very aware of DRG and length of stay)
* Coordinate care after discharge (DME, home health, wound care, med at home, follow up MD visit)-community resources
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Patient Navigator: role (3)
- Help patient navigate through maze of all visits, labs, and radiology needs instead of patient having to make individual appointments on their own
- Emerged after healthcare reform onset (expensive inpatient moved to less expensive outpatient)
- Must be careful and not try to make choices for patient
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Nursing Care Delivery Models
What is it?
What does it describe? (3)
- Method used to provide care to the patient ( # and types of caregivers matched to patient needs)
Describes
- how healthcare workers will perform tasks
- Who is responsible for doing what
- who has authority to make decisions
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Total Patient Care
What is it? (2)
Where is it used?
Pros (3)
Cons (2)
- Oldest model of organizing patient care
- Nurses are doing everything: planning, organizing, performing all care including hygiene, med, treatment, education --“ I am doing everything as the RN”
Used in ICU
Pros:
- Care is not fragmented
- Nurses have a high degree of autonomy
- Lines of responsibility and accountability are clear b-c RN reports to charge nurse and that is it
Cons:
- May not be enough nurses available for this model
- Costly because RNs are doing things UAP can do for cheaper (B-c no nursing assistances)
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Functional Nursing
What is it? (3)
Pros (3)
- Staff assigned to complete certain tasks for a group of patients rather than care for specific patients
- Very task oriented (tasks determined by scope of practice)
- Charge nurse = coordinates assignments and has to be knowledge about everyone’s skill set
Pros
- tasks completed quickly and efficiently
- Little confusion about who's responsible for what because assignments are clear
- Do not need as many nurses to supervise
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Team Nursing
What is it?
Requirements of team leader (4)
- RN functions as team leader and each team given group of patients to care for
Requirements of team leader
- coordinates care for group of patients
- responsible for knowing condition and needs of all pts on her team
- Requires cooperation within team w/ delegation and supervision
- Requires clear communication and leadership skills (Be careful who you pick as a team lead)
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Primary Nursing
What is it? (2)
Requirement of Primary Nurse (4)
Where is it used?
- You have a patient and you provide total care for it 24h/day
- Associate nurse fills in for primary and follows primary nurse plan of care when primary nurse is not on shift
Requirements
- needs to be able to communicate effectively because she delegates + manages care 24 hr. a day
- Must coordinate care even when not on shift (is called)
- Must have high degree of clinical judgment, decision making
- Works better with 5 8h shifts rather than 3 12h shifts
Used in home health or hospice
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Functional Nursing
Cons (5)
Cons
- fragmented care
- huge potential to overlook priority needs of its since everyone is task oriented
- Very confusing model to patient b-c patient does not really know who their nurse is
- Care is not individualized or personalized so patient can perceive this module as lack of customer service
- caregivers can become frustrated b-c repetitive work all day
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Team Nursing
Pros (2)
Cons (2)
Pro
- provide high quality, safe, effective care
- Each team member can bring their own expertise and decision making
Cons
- Expensive
- Continuity of care can be lost b-c assignments can change every day
