VeHU Class 247

1

• VeHU Class 247
• VA Nursing Outcomes Database (VANOD) Surviving
  the Process

2
HOUSE KEEPING

• This is 1.5 Hours Lecture class
• Restrooms are located
• Cell Phones
• Please turn off or change to vibrate
• If you must answer a call, please leave the room.

3
HOUSE KEEPING

• Please,
• No questions during the presentation.
• Questions written on the 3X5 card will be
  answered at the conclusion of the presentation.
• For questions not answered,
• the question and the answer will be available on
  the web.

4
VeHU Class 247

• Segment 1 Overview, Data Projects in
  Development
• Bonny Collins, PA-C, MPA, VANOD Program Manager
• Segment 2 Patient Fall Risk Assessment Template
  
• Alicia Levin, RN, MS, VANOD Implementation
  Coordinator
• Segment 3 Facility Experiences Validation
  Application of VANOD Data
• Michelle Ernzen, RN, MSN, CCRN, Patient Safety
  Manager, Durham VAMC
• Toni Phillips, RN, MSN, C, Nursing Informatics
  Coordinator, North Florida South Georgia HCS
• Segment 4 Summary and Questions and Answers

5

• Segment 1 Overview, Data, and Projects in
  Development
• Bonny Collins, PA-C, MPA,
• VANOD Program Manager

6
Presentation Objectives

• Describe the current status of VANOD and the new
  indictors available
• Describe the significant features of the VANOD
• Describe a facility level approach to VANOD data
  validation
• Describe a facility level approach to using VANOD
  data

7
Simplified Version of the Mission of VANOD

• Provide stakeholders with tools/data to
• Manage nursing resources
• Understand clinical processes that are sensitive
  to nursing practices
• Influence patient outcomes

8
VANOD Data Goals

• Scope of Data
• Structures, Processes, Outcomes
• Full Continuum of Care
• All Nursing Personnel, Skill Mix, Role
• Administrative, Clinical, Safety, Satisfaction
  (Staff and Patient) Indicators/Reports
• Granularity of the Data
• Unit/Clinic, Specialty, VAMC, Complexity Group,
  VISN, VHA
• Shift, Day of Week, Pay Period, Month, Qtr, FY

9
Business Rules

• Manual data collection only as a last resort
• Provide front line staff the tools they need to
  document the good care they are providing
• Extract the data from nursing point of care
  documentation
• Standardize terms, data indicators to allow for
  comparison across the VA and with non-VA
  facilities
• Provide facilities the tools they need to
  understand and validate their data

10
Nursing Staff Data Currently Available(Sample of
Key Indicators)

• Distribution of Resources - of hours worked
  that were in (Role)
• Administration
• Direct Care
• Consultative (Hospital Support)
• Advance Practice
• Staff Evidence Based Demographics
• of Direct Care (DC) staff that are RNs
• of DC RNs that have at least a Bachelors degree
• Financial hours and dollars for PAID, e.g.
  Annual Leave (AL), Sick Leave (SL), Leave With
  Out Pay (LWOP), Comp Time Earned (CTO), etc.
• of Hrs worked accrued from Overtime or Comp
  Time Earned (OT/CTE)
• Nursing Staff Turnover Rates (all reasons,
  voluntary)
• Staff Injury
• RN Satisfaction
• Nursing Staff Retirement Eligibility

11
Understanding Our Work ForceVHA Staff
Demographics (FY2007)

• Direct Care Nursing Staff 62,268
• of Direct Care Staff who are RNs 60
• of Direct Care RNs with least a Bachelors
  Degree 58
• of Direct Care RNs eligible to retire 28
• Voluntary Loss Rate of RNs leaving the VA
  6.3
• RNs in the VA less than 5 years 33
• RN, LPN, Unlicensed Assistive Personnel (UAP)
  with direct patient care assignments Inpatient
  or Outpatient.

RN, LPN, Unlicensed Assistive Personnel (UAP)
with direct patient care assignments Inpatient
or Outpatient
12
How Much Can You Trust the Data?

• Trustworthy - Data used for Payroll
• Administrative indicators for skill mix, hours
  and dollars
• Reports assigned TL Unit - wont capture float
  off TL (Unit)
• Need Data Validation for less used data
• Assignment code (used to determine roles)
• Education level from PAID/HR
• Built in to new products New DSS and VANOD Skin
  Assessment/Reassessment
• Data has to be corrected locally
• Local Validation tools available (Class III
  VistA reports)
• Active NURS Staff file report
• NURS Staff Education report

13
Nurse Staff Turnover Rate

• Segment by
• All reasons for departure, e.g. retirement,
  death, etc.
• Voluntary departure JCAHO Nursing Sensitive
  Indicator, quit, regrettable loss
• Data from HR current limitations
• Only at the facility level
• Cant segment out Advance Practice Nurses (NPs
  CNSs) from other RNs (Only HR Codes)
• VANOD is working to add
• TL Unit granularity
• Tenure in VA, VAMC, Time Leave (TL) Unit
• Ability to segment NPs CNSs from other RNs
  (Budget Object Codes)
• Nursing Role, e.g. Direct Care, Admin,
  Consultative, Advance Practice

14
Nursing Assistant
LPN
15
Percent of Hours Worked That Were Overtime or
Comp Time Earned

• Which skill mix has the highest percent of worked
  hours acquired through overtime or comp time
  earned?
• RN
• NP
• CNS
• LPN, LVN
• Nursing Assistant

16
Percent of Hours Worked That Were Overtime or
Comp Time Earned
17
Nursing Assistant Overtime or Comp Time Earned,
Trend FY04 - thru April 12, 2008
18
Nurse Staff Injuries

• Types of injuries
• Types of staff
• Numbers and rates
• Staff demographics

Stop by and see the POSTER Hands-on training
Class 250
19
Current VANOD Projects in Development

• Facility Alert Profile
• Deputy Under Secretary for Operations and
  Management (DUSHOM 10N)
• Nursing Indicators - Data from Decision Support
  Service (DSS)
• Comprehensive Patient Assessment

20
Facility Alert Profile Nursing - Inpatients

• 1. Hours Per Patient Day of Care (HPPD) all
  direct care nursing staff
• 2. Hours Per Patient Day of Care (HPPD) RNs
• HPPD reported in six areas
• Critical Care, Medical, Surgical, Mixed Med/Surg,
  Mental Health, and
• Community Living Center (NHCU) units
• 3. of Direct Care Hours by RN
• Data are from DSS nurse staff mapping is
  critical
• Lowest time granularity is Month

21
Facility Alerts Profile Nursing - Outpatients

• 4. Average hours per encounter for all support
  nursing staff (RN,LPN,UAP, excludes CNS, NP) by
  clinic type
• 5. of ambulatory care support nursing staff who
  are RNs by clinic type
• Clinic type
• Mental Health
• Primary Care
• Procedures Clinics, e.g. GI Endoscopy, etc.
• SCI/Rehab Clinics
• Specialty Clinics, e.g. HTN, DM, etc.

22
Facility Alert Profile

• What is the threshold for being noted as an
  Alert?
• To be developed

23
Nationally Standardized Comprehensive Patient
Assessment Project

• Opportunity to move locally developed Class III
  software patient assessment to Class I (National
  Release and ongoing support)
• When released, the assessment will be required
  for at least acute Medical and Surgical Units

24
Development Team

• 36 members from 17 VISNs and 26 VA Medical
  Centers chartered March 9, 2008 representing
  stakeholders including
• Content and Work Flow Experts Front line staff,
  Nurse Managers, CNSs, CNLs, NPs
• Clinical Settings in ICU, Med/Surg, MH, SCID
• Informatics CACs, Clinical Informatics Subgroup,
  BCMA Coordinators, Taxonomy/Data Standardization
• Research Nurse Researchers
• Administration Nurse Executive, Magnet
  Coordinators
• OIT Programmers and OIFO Patient Safety
• VANOD Team, Field Advisory Council and Site
  Coordinators

25
Software Specifications Functionality

• Reviewed and validated a list of 64
  specifications or functionality items
• Highest Priority provide optimal work flow
  support for front line nurses (reduce
  fragmentation, disruption, redundancy)
• Save partially completed data

26
Software Specifications Functionality

• Combination of structured point and click and
  free text
• Data pulled from other sources to make available
  for review
• Production of local reports

27
Vision
Identify Key Data Terms from Patient Assessment,
Reassessment Care Plans
Embed terms in Files Clinical Observations
(CLiO), Health Factors, Vital Signs
28
Contacts

• Chief Nursing Officer Cathy Rick
• VANOD Program Manager Bonny Collins
• VANOD Implementation Coordinator Alicia Levin
• VANOD Education Coordinator Mimi Haberfelde
• VANOD Informatics Diane Bedecarre
• Analyst Becky Kellen

29

Segment 2 Patient Fall Risk Assessment Templates

• Alicia Levin RN, MS
• VANOD Implementation Coordinator

30

• Tackling Another Patient Safety Issue
• Preventing and Tracking Falls

31
Rationale

• Estimate is that by the year 2020 in the U.S.,
  there will be 17,293,000 falls resulting in
  injury. A projected cost of 85.37 billion.
  (this includes community as well as healthcare
  settings)
• Falls are the leading cause of injury-related
  death for individuals 65 and older
• Thus the need to apply current best evidence to
  reduce fall risk is clear
• Poe, S.S. et. al., An Evidence-based Approach to
  Fall Risk Assessment, Prevention and Management
  Lessons Learned, Journal of Nursing Care Quality,
  Vo. 20, , No 2, pp 107 116, 2005
• National Center for Patient Safety

32
VANOD Approach to Addressing Patient Falls

• Creation of two nationally standardized nursing
  documentation templates
• Fall Risk Assessment
• Post Fall Note

33
Fall Risk Assessment Template

• Assessment Fall risk identification (Morse Fall
  Scale)
• All patients are assumed to be at risk of falling
  in acute care settings
• Fall prevention strategies (evidence-based review
  of current measures)
• Basic interventions for universal application
  are put into place for all patients

34
Fall Risk Assessment Definitions

• Fall a unplanned decent to the floor, either
  with or without injury to the patient
• Assisted fall counts as a fall
• Injury a disruption of structure or function of
  some part of the body as a result of an unplanned
  event

35
Fall Risk Assessment Indicators to be Tracked

• Rate at which patients fall during the course of
  their hospital stay
• Rate at which patient fall and incur physical
  injury during the course of their hospital stay
• Rate of repeat patient falls (for current episode
  of care)

36
Fall Risk Assessment Indicators to be Tracked

• 4. of admitted patients who had a fall risk
  assessment using the Morse Fall Scale within the
  first 24 hours.
• 5. of patients who had a fall risk assessment
  and then fell and were injured
• 6. of moderate or high risk patients who had
  fall prevention protocols in place

37
(No Transcript)
38
(No Transcript)
39
(No Transcript)
40
(No Transcript)
41
(No Transcript)
42
(No Transcript)
43
(No Transcript)
44
(No Transcript)
45
(No Transcript)
46
(No Transcript)
47
Post Fall Note

• A standardized national template to track
  occurrence of falls along with some levels of
  injury which may occur as result of the fall.
• Short term goal is to collect information that
  will be similar to or the same as data collected
  in patient incident reports (patient event
  reports)
• Long term goal is to have the information from
  the post fall note link to an electronic incident
  report so that duplicate entry will not be
  required

48
(No Transcript)
49
(No Transcript)
50
(No Transcript)
51
(No Transcript)
52
(No Transcript)
53
(No Transcript)
54
(No Transcript)
55
(No Transcript)
56
(No Transcript)
57
(No Transcript)
58
(No Transcript)
59
(No Transcript)
60
(No Transcript)
61
(No Transcript)
62
(No Transcript)
63
Availability to the Field

• This summer both the Post Fall Note and the Fall
  Risk Assessment will be sent out as national
  templates.
• The Fall Risk Assessment will also be
  incorporated into the new nationally standardized
  patient admission assessment and shift
  reassessment templates.

64
Segment 3 Facility Experiences with Validation
and Application of Data
65

• Durhams Approach to Data Validation and Data
  Usage
• Michelle Ernzen, RN, MSN, CCRN
• Patient Safety Manager

66
Three Prong Approach

• Educate
• Monitor
• Support
• Focused primarily on the Nurse Managers

67
Educate

• Developed learning modules using 2 different
  approaches
• Briefing book
• Creating Own views
• Modules had screen shots with descriptions
• Used VANOD modules as starting point
• Offered several small hands-on classes
• Learning modules also available via email and
  hard copy
• Included introduction to VANOD

68
Monitor

• If you dont use it, you lose it
• Assignments given each month
• Annual leave/Sick leave (AL/SL) for the past 4
  quarters for TL
• Retirement eligibility
• Overtime for past 2 fiscal years for TL
• When AL/SL data was pulled, several Nurse Mangers
  found discrepancies
• VANOD notified, already known.
• Once fixed, data was re-pulled with more accurate
  results

69
Support

• Addressed varying levels of computer competency
  and data analysis
• Recommended ProClarity classes via VSSC website
• Identified a few Nurse Managers as resources

70
Data Validation

• Compare FTEE with our staffing model.
• Staffing model data is updated weekly
• Communicate with Human Resources (HR) and Fiscal
  if discrepancies are noted
• Compare VANOD OT data with Fiscal OT data
• VANOD data about 30 days behind Fiscal data,
  therefore delays in acting on data discrepancies
  can occur

71
RN Satisfaction Survey

• High response rate (82 first year)
• VISN 6 Nurse Manager Academy
• Validation with All Employee Survey
• Improvement in RN satisfaction

72
Whats Next

• Data validation for education and assignment
  codes
• Compare VANOD HPPD with how we currently extract
  HPPD
• Once new Quality Improvement Coordinator (QIC) in
  place, re-educate Nurse Managers

73
Who Else Can Use the Data?

• Patient Safety Manager
• Falls
• Pressure Ulcers
• Joint Commission Standards
• National Patient Safety Goals
• Nurse Sensitive Indicators

74

• North Florida/South Georgias Approach to Data
  Validation and Data Usage
• Toni Phillips, MSN, C
• Nursing Informatics Coordinator

75
OBJECTIVES

• Discuss the significance of validation
• Identify key stakeholders
• Share learning opportunities obtained with data
  validation
• Share NF/SG maintenance procedures
• Discuss future benefits application of
  validation

76
Share Nursing Service Strategies, Initiatives,
and Measure Outcomes
TRANSFORMATION
TRANSLATION
77
Focus on the Care of the Veteran
OFFICE OF NURSING SERVICE
78
North Florida South Georgia Validation
79
Operationally Validating Data
HR sends Nursing Informatics an Outlook message
On day ONE of entry on to duty a demographic
form is completed Nursing Informatics enters
staff into the Nurse Staff File or (210)
80
(No Transcript)
81
Class III Mumps Routine AKA Active Nurse
Staff
82
Measures Maintenance

• Nursing Informatics enters transfers and new
  employees into the nurse staff file (210) to
  maintain accuracy and historical integrity.
• Nursing Informatics enters all new staff into the
  nurse staff file (210)to validate and ensure
  integrity within the files within the nurse staff
  file (210).
• Nurse Recruitment is entering a handwritten
  assignment code on all 52 forms prior to sending
  to Human Resources.

83
Incident of nurse staff injury for lifting and
repositioning patients in our Nursing Homes
84
(No Transcript)
85
(No Transcript)
86
Benchmarking
87
Unexpected Tangible Intangible Benefits
VANOD Data is in Alignment with American Nurses
Associations Forces of Magnetism 7 Quality
Improvement 8 Consultation Resources
9 Autonomy
88
Learning Opportunities

• The primary locations within Medical
  Administration Service , the nursing package and
  Decision Support Systems didnt follow the same
  naming nomenclature.
• Historical updating of Nurse Staff File
• Corrected time cards impact the data

89
Future Changes

• Assignment codes will become a part of VHA
  Form-52-118.
• Current assignment codes will be approved to
  reflect the current roles within nursing service.
  
• Inclusion of agency data to provide increased
  precision with HPPD.
• Exploration of data within the DSS cubes on the
  VSSC.

90
Thank You ! Questions?