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VA Nursing Outcomes Database and the Clinical Nurse Leader


VA Nursing Outcomes Database and the Clinical Nurse Leader Bonny Collins, PA-C, MPA, Director, VA Nursing Outcomes Database Jan 30, 2009 Agenda VANOD Big picture ... – PowerPoint PPT presentation

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Title: VA Nursing Outcomes Database and the Clinical Nurse Leader

VA Nursing Outcomes Database and the Clinical
Nurse Leader
  • Bonny Collins, PA-C, MPA,
  • Director, VA Nursing Outcomes Database
  • Jan 30, 2009

  • VANOD Big picture Purpose, Goals Conceptual
  • Current Content Whats in it?
  • Caveats, Challenges and Future Plans
  • Feedback What do you need?

Purpose and Goal of VANOD
  • Provide stakeholders with tools for
  • Managing nursing resources
  • Understanding clinical processes that are
    sensitive to nursing practices
  • Influencing patient outcomes
  • Goal No manual data collection or reporting

Conceptual Model for Nursing ROLES
Depends on Assignment Codes
Advance Practice Nurses (NP, CNS)
  • Direct Care
  • Charge Nurse, CNL
  • Staff Nurse, LPN, UAP

Will be used to compute Hours Per Patient Day
Caveats to the Data
  • Nurse Role Direct Care staff are identified by
    Human Resource/PAID Budget Object Codes and
    Assignment Codes
  • Data probably over estimate the number of direct
    care staff prior to FY09 Qtr 3
  • Facility Action Assignment Code List has been
    updated all RN Codes by Dec 2008
  • CNL assignment code is Q4

Types of Data Currently Available (at various
levels of granularity and historical trend data
from two to four years)
  • Administrative
  • All nursing staff - all facilities (PAID/HR data)
  • Demographics about Staff and Facilities
  • Age retirement eligibility
  • Role direct care, hospital support,
  • Education
  • Skill Mix NP, CNS, RN, LPN/LVN, UAP
  • Facility Complexity Levels
  • Financial
  • Hours and Dollars, worked, and other categories
  • Nursing Staff Injuries incidence reported
    (ASISTS data)
  • Nursing Staff Turnover Rates Voluntary All
    Reasons (HR data)

Data Currently Available (at various levels of
granularity and historical trend data from two to
four years)
  • Satisfaction (annual survey data)
  • RNs - Practice Environment Survey (PES)
  • All nursing staff - All Employee Survey (AES)
  • Coming Soon - Patient satisfaction (SHEP)
  • Clinical
  • Skin Risk, Pressure Ulcers
  • Data captured from Nationally Standardized
    Templates released Oct 07
  • Nursing Processes and Patient Outcome Indicators
    available now for Skin Risk

Do these questions interest you?
  • What is the rate of
  • Nurse staff injuries reported by type and skill
  • RNs, LPNs, UAPs voluntarily quitting VA last
    year? Your facility?
  • Which RNs are most likely to quit and leave VA?
  • What of
  • Patients were at risk for skin breakdown on
  • Patients had documentation of a daily skin
  • Patients had a Hospital Acquired Stage 2 or
    greater Pressure Ulcers (HAPU) by admission
    treating specialty?
  • Patients had A Pressure Ulcer Stage 2 or greater?

Data Currently Available (DSS data at various
levels of granularity and historical trend data)
  • Deputy Under Secretary for Operations and
    Management (10N) Facility Profile - Joint
    effort with DSO/DSS
  • Inpatient
  • Nursing Direct Care Hours Per Patient Day of Care
  • of HPPD hours from RNs
  • Reported by
  • Community Living Center (CLC)
  • Critical Care
  • Medical
  • Surgical
  • Mixed Medical/Surgical

Caveats to the Data
  • Contract/Agency Not correctly captured and
    included in staffing data. DSS has an
    infrastructure to collect the data, but it hasnt
    been used in a standardize way across the system
  • Facility Action DSS has issued (Dec)
    standardized instruction for capturing and
    mapping contract and agency staff. Work with
    your facility DSS Staff to implement these changes

Caveats to the Data
  • Hours Hrs worked are attributed to the assigned
    TL unit or mapped DSS unit if floated off those
    units hours are attributed to the mapped/assigned
  • Facility Impact will require additional data
    capture and entry
  • VACO Action OIT Project is in development to
    add nursing location worked to the time and
    attendance process so time off the unit and the
    location actually worked will be captured and
    rolled up nationally.
  • Estimate 18 months for release.

Unbelievable units excluded
At Risk
  • Which RNs are most likely to Quit VA?
  • Would having a CNL in the work unit help avoid

RNs that Quit VA in FY08 76 left in their
first 5 years
40 left in less than 1 yr
6 left between 4 to 5 yrs
16 left between 1 to 2 yrs
7 left between 2 to 3 yrs
7 left between 3 to 4 yrs
96 of RNs who Quit VA in less than a year were
Nurse I or II
69 left lt1 yr were Nurse I
27 left lt1 yr were Nurse II
Caveats to the Data
  • Nursing Unit Location PROBLEM can not yet
    consistently link the nursing staff to the point
    of care (Patient Care Unit) on which they worked.
  • Reports by
  • Local unit, e.g. 3North Med/Surg (From DSS
  • HPPD
  • VANOD RN Survey
  • Time Leave Unit (TL) not necessarily a
    geographic unit
  • PAID Demographic/Financial information
  • MAS WARD, Bedsection, Treating Specialty
  • VANOD Skin Risk Indicators
  • Action Working to have a standardized Nursing
    Unit for reporting. Probably 18 months away

Skin Risk Assessments
  • Data captured electronically from the VANOD Skin
    Risk Assessment Templates
  • 15 indicators available that describe nursing
    processes, patient risk groups and patient
    outcomes, e.g.
  • Can see in table, graphs, trend by month, etc.
  • Can drill to VISN, Facility, MAS Ward, treating
  • Can see list of patients in the numerator and the
    denominator for each indicator

Some Skin Risk Indicators
  • pts with initial assessment within 24 hrs
  • pts with daily skin inspections
  • pts at risk on admission (nursing burden)
  • pts at risk with plan for intervention
  • pts with any Pressure Ulcer stage 2 or greater
    (nursing burden)
  • pts with Hospital Acquired Pressure Ulcers
    (HAPU) stage 2 or greater

VHA Initial Skin Risk Assessment (Initial
Assessment and Braden score) within 24 hrs of
admission - BY MONTH
Click on a bar to see the VISN distribution
Click to see table of of pts assessed and
VHA Hospital Acquired Pressure Ulcers Stage II
and above, Oct 08 BY VISN
Click on a bar to see the monthly trend for the
Hospital Acquired Pressure Ulcers Stage II and
Use drop down menu to select facility
of Patients Screened within 24 hours of
Admission Using the Braden Scale (All Discharges)
- Higher is Better
Can drill down to facility and to admitting
treating specialty
of Patients with Hospital Acquired Pressure
Ulcer (HAPU) Stage II or higher - BY
Bed-section and Treating Specalty
Can drill to specific patient information (If
you have SSN Access)
Fall Risk Indicators External Peer Review
Program (EPRP) Pilot Data
  1. of pts with a fall risk assessment using the
    Morse Scale w/I 24 hrs of admission (Ns6)
  2. of pts identified as high risk (Ns7)
  3. of high risk pts with plan for intervention
    within 24 hrs of admission (Ns8)
  4. of pts with documentation of a fall during
    hospitalization (Ns9)
  5. of pts who had more than one fall (Ns10)

EPRP Data Patients Screened for Fall Risk
w/i24 hours of Admission Using the Morse Scale
(Nsg 6)
EPRP Data Patients at high risk for falls on
admission (Nsg 7) (Morse Scale gt45)
Products in Development
Key Data Elements from Patient Assessment,
Reassessment Care Plans
Embed in Files Clinical Observations (CLiO),
Health Factors, Vital Signs
Clinical Indicators the Queue
  • Nationally Standardized Comprehensive Patient
  • Fall Risk Assessment and Falls
  • Restraint use and Avoidance Strategies
  • Dysphagia Screening
  • Pain
  • Heart Failure Education
  • sample already collected via EPRP chart review
  • Tobacco Use Counseling
  • sample already collected via EPRP chart review

Falls templates already available
What Do You Need?
  • Administrative Information
  • Clinical Information
  • Satisfaction

More Tools - Patient Flow Sheet
  • What is it?
  • Generic flow sheet tool that can be configured
  • Standardized terms Clinical Observations
    Database (CliO)
  • In ICU links to peripheral monitoring equipment
    to bring data into flow sheet and CPRS
  • Currently in pilot testing
  • Creates the opportunity to
  • Locally develop a variety of flow sheets, e.g.
    wound care, dialysis, restraint/seclusion
    monitoring, etc. using nationally standardized
    terms and national repository of data.
  • Ability to track and trend data locally and

VANOD Next Generation
  • Continue to pursue unit level data and link staff
    to patients
  • Find new data sources i.e. eProficiency or LMS
    for nurse specialty certification data
  • Lead the initiative to create standard clinical
    terms to be used in all products
  • E.g. CliO, Patient Assessment, CIS/ARK Databases
    (CareVue, PICIs)
  • Create new reports that consolidate several data
    sources into one web-based tool Performance
    Point Dashboards
  • Collaborate with DSS, IPEC, OIT, our Nursing
    stakeholders to develop products that improve the
    work environment of both front line and
    administrative nurses

Contact VANOD
  • VANOD Data (On the VSSC Website)
  • VANOD Website http//
  • Bonny Collins,
  • Program Manager
  • VANOD Program Team
  • Diane Bedecarre
  • Dee Bishop
  • Mimi Haberfelde
  • Alicia Levin
  • Shawn Loftus
  • Email V21SFC VANOD Program Team

Be Critical Consumers of Data
  • What do these data represent?
  • Example FY08 VHA had 38,513 Direct Care RNs
  • Full Time Employee Equivalent (FTEE) or Employee
  • If Employee Count does that include full-time,
    part-time, and/or intermittent?
  • Full year or end of year snapshot?
  • Nursing Cost Center or in ANY Cost Center?

How to Find DSS Reports
  • VSSC Webpage http//
  • DSS link
  • Index of Reports, scroll to N (for nursing)
  • Nursing Hours / Costs / Workload by Clinic and
    Outpatient Encounter
  • Nursing Hours / Costs / Workload by Ward and DSS
    Bed Days of Care

Comparison of HPPD RNs
Unit Type VHA1 (Oct 07 - July 08) LMI (2007) NDNQI (2007)
Mental Health Acute HPPD 7.6 7.9 4.3
Mental Health Acute RN 51 50 59
CLC (LTC) HPPD 5.1 7.1 N/A
CLC (LTC) RN 31 36 N/A
1VHA Data from DSS see other slides for caveats