ࡱ> t( |/ 0DArial.0̳d`tL0ԳԳ~0"DWingdingsd`tL0ԳԳ~0 DTimes New Roman0ԳԳ~0    @n?" dd@  @@`` t l  |"Yi312 4 5 089 ;< =>@A !#$BCDFGJHKMN'I%O&P(Q*S+,U-V/X:       6 7?E"L)RT.WY r 0AA0 @g46d6d~0سl ppp@  <4BdBd<4!d!dg4KdKd~0س$tp@ pp`___PPT9bZ___PPT10DTimes New Roman0:A 0DArialNew Roman0:A 0 ?  O  =`BKeeping Patients Safe: Transforming the Work Environment of Nurses<C606(,0 Committee on the Work Environment for Nurses and Patient Safety Presented by Andrew M. Kramer, MD University of Colorado Health Sciences Center November 5, 2004  PCommittee ChargeIdentify key aspects of the work environment of nurses that likely impact patient safety. Identify potential improvements in health care working conditions that would likely increase patient safety. Committee Expertise}Safety-sensitive industries Patient safety Health care delivery Nursing Medicine Interdisciplinary health care Informatics ~Z~ ~Acute care Chronic care Health professions education Organizational behavior Operations management Human factors engineeringZ Keeping Patients Safe@ Builds on two prior IOM Reports: To Err is Human and Crossing the Quality Chasm. More deeply addresses certain patient safety issues; e.g., organizational cultures of safety Addresses new issues; e.g., staffing and work hours / fatigue Unifies all three reports into a framework for health care organizations vS0Zc0ZZ"4An Evidence-Based Model for Patient Safety Defenses 5P5Errors in health care result from  active failures and  latent conditions Majority of errors (90%) arise from latent conditions (system failures) Fixing latent system conditions is more likely to achieve safety than targeting active failures (provider errors)Z Nursing Role In Patient Safety  *54 percent of all healthcare providers 2.2 million RNs 700,000 LPNs/LVNs 2.3 million unlicensed nurse assistants Surveillance and  rescue of patient status Coordination and integration of care Therapeutics, support, and education Intercepting errors Commission of errors N'ZKZZ'JiNursing WorkforcePredominantly female RNs older than US workforce and aging more rapidly (average age 45 years) Many NAs at or below the poverty level High turnover  21% of hospital RNs, 56% of nursing home RNs, 78% nursing home NAs Use of temporary workers Nursing shortage  Z ^ HCO Blueprint_ HCO Blueprint((Changes in Hospital Nursing Leadership ))( Chief nursing officer given expanded responsibilities for multiple non-nursing depts. (e.g., radiology, admitting, outpatient) in addition to nursing Many no longer have  nursing in their title; (e.g., VP of Nursing changed to VP of Operations or Patient Care. ) No longer a separate Dept. of Nursing; in some, nursing no longer visible on the organization chart Decrease in midlevel nursing managers; remaining nurse supervisors responsible for multiple nursing units and non-nursing depts.; e.g., housekeeping :PPoP) Consequences  Potential loss of a voice for nursing Weakening of clinical leadership Loss of support to staff nurses in solving work problems 0z6 ^Recommendation: HCOs should acquire nurse leaders for all management levels (e.g., organization-wide and patient care unit levels) who will: Participate in executive decisions... Represent nursing staff to management and facilitate mutual trust. Achieve effective communication between nursing and other clinical leadership. Facilitate input of direct-care nursing staff into operational decision making and the design of work. Be provided with resources to support knowledge acquisition and dissemination to support nurses clinical decision making. PPP~-'Nurse Work Environments - Evidence of: (((Increased emphasis on efficiency Weakened trust Poor change management Limited nurse involvement in work design and work flow decisions Limited use of knowledge management practices79 Recommendation: HCOs should use management processes . . . that: Balance efficiency and safety. Demonstrate and promote trust. Actively manage change. Engage workers in designing work processes and work flow. Establish the organization as a  learning organization. :BA?$ Recommendation: Professional associations, philanthropic organizations, and other health care leaders should sponsor collaboratives to support HCOs in evidence-based management practices.J$$$b HCO Blueprint;!Safe Staffing LevelsBetter nurse staffing leads to better patient outcomes Hospitals studies generally collect hospital-wide staffing data; less helpful in identifying ideal nursing unit staffing levels Nursing home studies have produced better information on ideal staffing Z=# Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes  Phase IINN$q Persistent associations between higher staffing levels and better outcomes along a continuum until a threshold beyond which no detectable benefit from additional staffing Incremental improvements in outcomes occurred at all levels below the threshold Strong relationship between CNA retention and patient safety outcomes (e.g., decreased UTI and pressure ulcers). 8rPoF&$Potential Responses to the Evidence:%%(xRegulatory approaches Internal staffing practices by HCOs Marketplace/consumer-driven approaches  Appropriate and coordinated use of all three approaches most conducive to safe staffing cZG' Recommendation: The US Dept. of Health and Human Services should update 1990 regulations that specify minimum nursing home staffing standards to: Require at least one RN within the facility at all times. Specify staffing levels that increase as the number of patients increase, based on the DHHS report to Congress, Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes  Phase II Final Report. Address staffing levels for nurse assistants, who provide the majority of patient care. R`Y\H( Recommendation: Hospitals and nursing homes should employ nurse staffing practices that : Include admissions, discharges, and  less than full-day patients in estimates of patient volume. Involve direct-care nursing staff in determining and evaluating staffing methods. Provide for staffing  elasticity or  slack to accommodate unpredicted variations in patient care workload. Approaches to providing slack should give preference to scheduling excess staff and creating cross-trained float pools within the HCO. Use of nurses from external agencies should be avoided. (Cont)L[PPP[I)'Recommended staffing practices (cont.):((=Involve direct-care nursing staff in identifying the causes of nursing staff turnover and in developing methods to improve nursing staff retention. Empower nursing unit staff to regulate unit work flow and set criteria for unit closures to new admissions and transfers as nursing workload and staffing necessitate. >Z>J* Recommendation: Hospitals and nursing homes should perform ongoing evaluation of their nurse staffing practices, and increase oversight whenever staffing falls below: In hospital ICUs one licensed nurse for every 2 patients. In nursing homes, for long-stay residents one RN for every 32 patients, one licensed nurse for every 18 patients, and one nurse assistant for every 8.5 patients.4ZZK+ Recommendation: DHHS should implement a nationwide system for collecting and managing reliable staffing data from hospitals and nursing homes. Information on individual hospital and nursing home staffing should be disclosed to the public. During the next 3 years, public and private sponsors of the new hospital report card should develop, test, and implement measures of hospital nurse staffing levels for the public. 4PPX2Better Education & Training SIncreasing complexity of patient care < half of hospital nursing administrators find new nurses prepared to deliver safe, effective care Newly licensed nurses report similar educational needs Limited mechanisms to evaluate competency Hospital orientation and CE programs scaled back Similar weaknesses in NA education and training TZTh;(Budgetary Commitments to Worker Training))(3.2-3.6 % of payroll* (multi-industry leaders) 1.9 % of payroll (average across all industries) 1.4 % of payroll (average by HCOs) n = 270 Source: ASTD, 2001 * Wages and salaries but not benefitsVZ 8Z&0Z&L, Recommendation: HCOs should support nursing staff in ongoing acquisition and maintenance of knowledge and skills: Assign nurse preceptors to nurses newly practicing in a clinical area. Annually ensure each nurse and nurse assistant has resources for educational development. Provide education and training on new technology or changes in the workplace. Provide decision support technology HsZZtM- Recommendation: HCOs should support interdisciplinary collaboration by: Adopting mechanisms such as interdisciplinary rounds, and Providing ongoing education and training in interdisciplinary collaboration for all health care providers on a regular basis. HHHd HCO BlueprintP0Dangers of Long Work Hours12 hour+ shifts with limited rests:  sustained operations Error rates in nurses increased after 12 hours of work Fatigue decreases reaction time, attention to detail, motivation, and problem-solving abilityZQ1 Recommendation: States should prohibit nursing staff from providing patient care in excess of 12 hours per day and 60 hours per 7-day period. HCOs and labor organizations should establish policies to prevent nurses from working longer than these hours. Schools of nursing, state boards of nursing, and HCOs should educate nurses about the threats to patient safety caused by fatigue. NZoZZZj<(Some Work Processes Inherently Dangerous))(3 Medication Administration 770,000 annually killed or injured from adverse drug events in hospitals in two studies, 34-38% of medication errors occurred during nurse administration of medication Remedies: decision support, unit-dose dispensing, bar-coding, smart infusion pumps, et al. Handwashing 80,000 deaths / year from hospital-acquired infections most hospital-acquired infections transmitted by hospital workers handwashing most effective at decreasing infections handwashing rates at 16-81% Remedies: decrease workload, use of alcohol-based hand rubszPPP PP   " l=2 Inefficient Work Processes Contribute to Errors 33(Documentation and paperwork 13-28% of hospital nurses time Additional time spent  hunting and gathering people, supplies, equipment Time used to perform non-nursing activities; e.g., housekeeping Zg: pRecommendation: HCOs should provide nursing leadership with resources to design the nursing work environment and care processes to reduce errors, especially those associated with: Surveillance of patient health status. Patient transfers and other patient hand-offs. Complex patient care processes.  Non value-added activities performed by nurses, e.g., locating supplies and personnel, completing redundant and unnecessary documentation. Recommendation: HCOs should address handwashing and medication administration among their first work design initiatives. P PzPPxn> Recommendation: Regulators; leaders in health care; and experts in nursing, law, informatics, and related disciplines should jointly convene to identify strategies for safely reducing the burden associated with patient and work-related documentation. "f HCO Blueprinto?Create Cultures of SafetyEssential Elements Commitment of leadership to safety Ongoing vigilance by workers Organizational learning from errors and near misses Need for Long Term Commitment by HCOs Need for action from Congress and States <ZtZPZtPr@ Recommendation: HCOs and their labor partners should create cultures of safety by: Specifying short and long-term safety objectives. Continuously reviewing success in meeting objectives and providing feedback. Conducting an annual, confidential survey of workers to assess the extent to which a culture of safety exists. Instituting a de-identified, fair, and just reporting system for errors and near misses. Engaging in ongoing employee training in error detection, analysis, and reduction. Implementing procedures for analyzing errors and providing feedback to direct-care workers. Instituting rewards and incentives for error reduction. 4TP;PT;,G :sA Recommendation: The National Council of State Boards of Nursing, in consultation with patient safety experts and health care leaders, should . . design uniform processes across states for better distinguishing human errors from willful negligence and intentional misconduct, along with guidelines for their application by state boards of nursing and other state regulatory bodies having authority over nursing. 4tB  Recommendation: Congress should pass legislation to extend peer review protections to data related to patient safety and quality improvement that are collected and analyzed by HCOs for internal use or shared with others solely for purposes of improving safety and quality. ,h HCO BlueprintzDParting Messages NDon t wait to act Costs will vary Benefits in addition to patient safety are likely Better retention of nurses Patient satisfaction Potential financial advantages 6WPWP[Research NeedsMeasures of nurses work. Descriptive studies of nursing-related errors. Safer and more efficient work processes and workspace, including information technology. A standardized approach to measuring patient acuity. Safe staffing levels within different types of nursing units. Methods to help night shift workers compensate for fatigue. Effects of successive work days and sustained work hours on patient safety. Models of collaborative care, including care by teams. P/" 12358>@CERSTUV W!Y"Z#_'`(i)k*m+p,q-u.v/{0}1@BEFGHIJLP  ` 33` Sf3f` 33g` f` www3PP` ZXdbmo` \ғ3y`Ӣ` 3f3ff` 3f3FKf` hk]wwwfܹ` ff>>\`Y{ff` R>&- {p_/̴>?" dd@,|?" dd@   " @ ` n?" dd@   @@``PR    @ ` ` p>>0 c(    6T.  `} L T Click to edit Master title style! !  0.  ` L RClick to edit Master text styles Second level Third level Fourth level Fifth level!     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Kramer, MD         . .K2 n[-University of Colorado Health Sciences Center            . .2 BNovember 5, 2004   .--"System 0-&TNPP &՜.+,D՜.+,    FOn-screen ShoweThe National Academies5\,*1 0Arial WingdingsTimes New RomanDefault DesignCKeeping Patients Safe: Transforming the Work Environment of NursesCommittee ChargeCommittee ExpertiseKeeping Patients Safe5An Evidence-Based Model for Patient Safety Defenses Nursing Role In Patient Safety Nursing WorkforceHCO BlueprintHCO Blueprint)Changes in Hospital Nursing Leadership ConsequencesNo Slide Title(Nurse Work Environments - Evidence of: No Slide TitleNo Slide TitleNo Slide TitleHCO BlueprintSafe Staffing LevelsNAppropriateness of Minimum Nurse Staffing Ratios in Nursing Homes Phase II%Potential Responses to the Evidence:No Slide TitleNo Slide Title(Recommended staffing practices (cont.):No Slide TitleNo Slide TitleBetter Education & Training )Budgetary Commitments to Worker TrainingNo Slide TitleNo Slide TitleHCO BlueprintDangers of Long Work HoursNo Slide Title)Some Work Processes Inherently Dangerous3 Inefficient Work Processes Contribute to Errors No Slide TitleNo Slide TitleHCO BlueprintCreate Cultures of SafetyNo Slide TitleNo Slide TitleNo Slide TitleHCO BlueprintParting Messages Research Needs  Fonts UsedDesign Template Slide Titles,|@%Me _PID_GUID_AdHocReviewCycleID_EmailSubject _AuthorEmail_AuthorEmailDisplayNameAN{15677B2E-09FF-4A55-9459-995219A97FB4}xݶRequest from Dr. Andrew KrameruAEKPage@nas.edu Page, Anns. _\JoAnnPet  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root EntrydO)Current UserSummaryInformation(PowerPoint Document(5\DocumentSummaryInformation8