107 Nursing at the Crossroads Update on VA Nursing Outcomes Database VANOD

1
107 Nursing at the Crossroads-Update on VA
Nursing Outcomes Database (VANOD)

• Bonny Collins, PA-C, MPA
• VANOD Program Manager
• Mimi Haberfelde, RN, MS, AOCN
• VANOD Education Coordinator

2
Course Objectives

• State the vision, purpose and goals of the VA
  Nursing Outcomes Database (VANOD)
• Describe the Administrative and RN Satisfaction
  data available
• Explain the plan for collection of clinical
  information and status of the new skin risk
  template
• Understand limitations of the data

3
The VANOD Vision

• Stakeholders depend upon VANOD data to make
  important decisions

4
Purpose of VANOD

• Provide stakeholders with tools for
• Managing nursing resources
• Understanding clinical processes that are
  sensitive to nursing practices
• Influencing patient outcomes

5
VANOD Goals

• Provide local tools to
• Enter nationally standardized data
• E.g. Patient Assessment Template Modules, skin
  risk assessment, fall risk assessment, etc.
• Understand and validate local data
• E.g. List current nursing personnel with their
  PAID/HR, education level, codes etc
• Clinical Reminders for individual patient care
• E.g. Skin risk assessment due for this patient
• Cohort reports to manage patient populations
• E.g. List current inpatients with pressure
  ulcers

6
Goal Desired Levels of Granularity
Clinical
Safety
Fiscal Year
Quarter
Month
Pay Period
Day of Week
Shift
Location
 
 
Point of Care
 
 
 
 
 
Specialty
 
 
Facility
 
 
VISN
 
 
VHA
7
Putting The Big Picture Together
Reports about

• Nursing Processes that impact patient outcomes

• Patient Outcomes

• Patient and Staff Satisfaction

• Administrative Information

• Patient Staff Safety

• Patient Acuity Staffing Effectiveness

VANOD
Are extracted from facilities and rolled-up
nationally
Data for VANOD is a by-product of original work
processes
Patient Care Administrative processes
are documented at points of origin
8
Conceptual Model Nursing ROLES
Advanced Practice Nurses (NP, CNS)

• Direct Care
• Charge Nurse
• Staff Nurse, LPN, UAP

Will be used to compute Hours Per Patient Day
(HPPD)
PATIENT
9
On Duty Hours by Nursing Role
Drill to VISN, Facility, TL
10
How can I access the data?

• VSSC website http//vssc.med.va.gov
• OR
• VANOD website http//vaww.VANOD.va.gov

11
VSSC website http//vssc.med.va.gov
VANOD ProClarity Reports
12
VANOD Products
Briefing Books
Definitions
Cube
Dashboard
13
Workbooks can be accessed without additional
software
Click on Administrative
Hover over names for descriptions
14
Create Your Own View of Cube Measures Demographic
Financial Comparative Reports Validation Helps
15
Demographic Indicators
16
1) Percent of Nurses Eligible to Retire
5) Prepare to print icon
3) To see facilities in the VISN Click on arrow
4) To see RNs by Assignment Codes Click on arrow
2) Skill Mix
17
of RNs Eligible to Retire by Assignment Code
for a VISN
18
What of Direct Care Staff are RNs?
Demographic Briefing Book Indicators of RN
Staff Trend
19
Notice these tabs
Notice these variables in the background
Select Hospital Complexity
20
Notice Hospital Complexity Line Click arrow to
drill
21
(No Transcript)
22
Dashboard Need ProClarity installed on your
desk top
FTEE for most recent pay period
Facility A
Facility A
23
Overtime Chart by Pay Period
How Hours Used Admin/Ed, LWOP, Paid Time off,
Productive
Hours by Leave Type
24
(No Transcript)
25
Administrative Indicators Data ValidationAll
data are local only as good as the local
validity
26
How Much Can the Data be Trusted?

• Consider the source of the data
• PAID files used for payroll are EXCELLENT
• Budget Object Codes (BOC)
• RN (1061), NP (1064), LPN/LVN (1065),
• NA/UAP (1066), CNS (1067)
• HR Occupation code (Occup code)
• RN (0610), LPN/LVN (0620), NA (0621),
• Health Tech (0640)
• Cost Centers, Time and Leave Units (TL)

27
How Much Can the Data be Trusted?

• Excellent Data used in VANOD for
• Skill Mix
• Hours indicators, e.g. AL, SL, OT, etc.
• Dollar indicators, OT, etc.
• Demographics Age, Years of Service, Retirement
  Eligibility, Gender,

28
Whats Not So Trustworthy?

• Data not used in payroll or national reports
• Need local validation especially
• Assignment Codes
• Several dozens of codes, many obsolete, no codes
  for many assignments
• National clean-up underway Assignment Codes
  (PAID file)
• e.g. Staff Nurse (88), Nursing Instructor (85),
  Nursing Supervisor (86), Head Nurse (87)
• Nurse Location (Nurse Staffing file)
• Many facilities havent kept these current
• Education in the PAID file, not the nursing
  file
• Is it kept current for ongoing degrees not used
  for pay increases?

29
Where Are the Not So Trustworthy Data Used in
VANOD?

• Nursing Role
• Especially for RNs, the assignment code is used
  to determine between Direct Care, Hospital
  Support or Administration
• Nurse Location will be important to link the
  nurse to the point of care for evaluating
  workload, staffing and HPPD
• Education of staff indicators

30
How Can Data Be Validated Locally?

• Data Definitions Document
• Is available in both the VSSC and VANOD websites
• Provides definitions of each of the indicators,
  calculations for reports
• Has tables which display the BOC, Occupation
  Codes and Assignment Codes used to determine
  Nurse Role
• Local facility Nurse Staff Reports
• Class III software to run reports of current
  nursing staff which include TL, BOC, Occup Code,
  Assignment Codes, Nurse Location, Education, etc.
  
• Fiscal, HR, local reports

31
VANOD Active Nurse Staff Report

• OCC
• NAME SERIES/TITLE TL LOCATION ASSIGN
  CC BOC
• NURSE,ONE 061050 325
  88 8241 61
• NURSE,TWO 062102 073 NHCU-G
  00 8241 66
• NURSE,THREE 061055 450
  75 8107 64
• NURSE,FOUR 061055 285 OR
  88 8202 61
• NURSE,FIVE 061055 335 TCU
  88 8241 61
• NURSE SIX 061050 285 OR
  88 8202 61
• NURSE,SEVEN 061050 335 TCU
  88 8241 61
• NURSE,EIGHT 061055 325 ICU
  88 8241 61
• NURSE,NINE 062102 074 NHCU-1
  00 8241 66
• NURSE,TEN 062002 352 2A/2B
  00 8241 65
• Press Enter to continue or to exit

32
VANOD Education Validation Report

NAME SSN TL OCC BOC
EDUCATION SERIES NURSE,ONE 0004 325
0610 61 BACHELORS DEGREE IN
NURSING NURSE,TWO 0005 073 0621 66
HIGH SCHOOL ADDITIONAL TRAIN NURSE,THREE 0006
450 0610 64 BACHELORS DEGREE IN
NURSING NURSE,FOUR 0007 285 0610 61 1
SEMESTER OF GRADUATE STUDY NURSE,FIVE 0008
335 0610 61 MASTER'S DEGREE IN
NURSING NURSE,SIX 0004 285 0610 61
BACHELORS DEGREE IN NURSING NURSE,SEVEN 0005 335
0610 61 BACHELORS DEGREE IN
NURSING NURSE,EIGHT 0006 325 0610 61
BACHELORS DEGREE, OTHER NURSE,NINE 0007 074
0621 66 LESS THAN 1 YEAR OF
COLLEGE NURSE,TEN 0008 352 0620 65
NURSING DIPLOMA Press Enter to continue or to
exit
33
Data Validation Summary

• Local
• Initial Data Validation requires facility effort
• Set up a process for ongoing updates for current
  staff with changes in assignments, education
  attained, etc.
• Build liaison with HR
• National
• Nursing assignment codes need updated

34
Tackling Clinical Indicators

• Pressure Ulcers

35
Half the Picture

• Administrative data without Clinical data is
  like half a rocket
• There is a lot of power,
• but to achieve the goal the other half is
  necessary

36
Why Start with Pressure Ulcers?
Patient Morbidity Mortality 2.5 million
annually 60,000 deaths
PRESSURE ULCERS
Other Policy Drivers IHI, IG, VHA Handbook
Organizational Costs Stage 3 - 70,000 Total
11 billion
37
With the Tools Available to Us Today
Patient Care
Population Mgmt
Progress Note in CPRS
38
Template Development

• Content Based on VHA Handbook on Assessment and
  Prevention of Pressure Ulcers (3/06) and input
  from wound care nurses
• Implementation and Pilot Testing Jan - Aug 2007
• Clinical Applications Coordinator Subcommittee
• 10 pilot sites with surveys and conference call
  feedback

39
Implementation Strategy

• National Union Review
• National Release Fall 2007 as a National
  Clinical Reminder
• Facility Support Resources
• CAC installation guide with template
• Facility FAQs and Powerpoint
• Weekly conference calls for facility support with
  VANOD implementation team

40

• Its not the progress I mind, its
• the change I dont like
• Mark Twain

41
Use of the Skin Admission Assessment Template
42
Braden Scale
Hyperlink to full Braden
Select scores from dropdown boxes, then select
score range below
Select score range and check off actual score
(value will auto fill in the comment box)
43
Skin Problems
44
Skin Problems Pressure Ulcer
Selection of stage opens location prompts
populates the text box. Free text option also
available
Hyperlink to full NPUAP descriptions
45
Interventions
Select at least one Intervention per category
Add description here only required if checkbox
Is checked
Add description here only required if checkbox
Is checked
46
Add description here only required if checkbox
Is checked
Options
Option to generate alerts or consults specific to
your facility if desired (set up by your facility
CAC)
Click on URL to view VA Handbook if desired
47
Final Note After Template Completion
Creates Progress Note
48
Use of the Skin Reassessment Template
49
Braden Scale
Recalls previous data
Braden scale only selected by user if needs to be
completed based on guidelines
50
Prior Pressure Ulcer
Previous Pressure ulcer information pulled into
note via Health Summary Object
51
New Pressure Ulcer
New Pressure ulcer
Stage
Location
52
Interventions
Previous interventions are presented to user via
a Health Summary Object
Changes require all new and prior interventions
to be selected
53
Final CPRS Note - Reassessment
Health summary object information Pulled into
progress note
54
Facility Reminder Reports

• Require the Skin Assessment template to be in use
  
• Can be customized
• Examples of reports include
• List of patients without initial assessment
  within 24 hours
• List of patients with pressure ulcers, their
  Braden Scores and hosp location
• List of patients with hospital acquired pressure
  ulcers
• List of patients identified at risk by Braden
  Score (18 or less) without interventions

55
Retrospective Reports(Under Development)

• of patients with timely assessments
• of patients assessed at low risk on admission
  who developed an ulcer
• of high risk patients who did not develop a
  pressure ulcer

56
Skin Risk CR Dialog Template Summary of
Benefits

• First nationally standardized nursing
  documentation template will
• Track assessment and prevention practices
• Capture Braden risk levels
• Capture pressure ulcers by stage and location
• Capture use of pressure ulcer interventions

57
Skin Risk Template Next Steps

• Watch for National Release
• Work with Clinical Applications Coordinators,
  Nursing Education, Wound Care nurses regarding
  new template
• Recognize this is an opportunity to acquire real
  time feedback
• Know this is a prototype of tool that will be
  used again

58
RN Satisfaction Survey FY07

• RN Satisfaction is Related to Retention and
  Patient Satisfaction

59
RN Satisfaction Survey Goals

• Measure the satisfaction of VA registered nurses
  by obtaining annual feedback
• Identify opportunities for improvement in nurse
  retention and recruitment
• Support the Magnet Journey

60
Survey Administration Process

• Survey available from October 1 to October 31,
  2006
• All VHA RNs eligible, with exception of Chief
  Nurse Exec
• Web-based, VA Intranet only
• Anonymous, confidential and voluntary

61
RN Satisfaction Survey ToolPractice Environment
Scale (PES)

• 43 items total
• 6 Demographic/background questions
• 36 core PES questions
• 31 standard PES questions per Lake
• 5 additional PES-type questions related to IT
  support of nursing practice, added by VA
• 1 Overall job satisfaction question
• Taken from VA All Employee Survey

62
Demographic Questions

• Demographics (6 questions)
• Work setting (hospital, cross-settings, clinic)
• Type of nurse (CNS, NP, or other RN)
• Role (administration, direct care, hospital
  support)
• Duty basis (full-time, part-time, intermittent)
• Tenure in current position (lt1 yr, 1-5 yrs, 6-10
  yrs, 11 or more)
• Tenure in VA (lt1 yr, 1-5 yrs, 6-10 yrs, 11or more)

63
RN Satisfaction Survey Scales

• 36 questions split into 6 Summary Scales
• Nurse Participation in Hospital Affairs (9
  questions)
• Nursing Foundations for Quality of Care (10
  questions)
• Nurse Manager Ability, Leadership, and Support of
  Nurses (5 questions)
• Staffing and Resource Adequacy (4 questions)
• Collegial Nurse-Physician (RN/MD) Relations (3
  questions)
• Information technology (IT) that supports nursing
  care (5 questions)
• Response options Four-point agree/disagree
• Strongly agree (numeric value 4)
• Agree (3)
• Disagree (2)
• Strongly disagree (1)

64
Survey Results

• Data analysis and statistical significance
  Comprehensive Overview of Results Powerpoint on
  VANOD website (vaww.VANOD.med.va.gov)
• VHA, VISN, and facility results
• RN Satisfaction ProClarity Briefing Book on VSSC
  website (http//vssc.med.va.gov)

65
Survey Results Demographics(Red indicates least
satisfied)

• Skill Mix
• CNS, NP, other RN
• Work locations 12 locations grouped into
• Hospital, Clinic, Cross Settings, (e.g. infection
  control)
• Nurse Role
• Direct Care, Hospital Support, Administration

• Duty Basis
• Full time, Part time, Intermittent
• Staff tenure in VA
• lt1yr, 1-5 yrs, 6-10 yrs, gt10 yrs
• Other Ways to Compare
• Facility Complexity Levels
• VISN
• VHA

66
Results Satisfaction Summary ScoresThree
strongly predictive of overall satisfaction
Predictive
Predictive
Predictive
Quality of Care
Participation
RN Mgr
Staffing
RN/MD Relationship
IT Support
Scale 1 to 4 Higher is better
67
VHA Results Scales and Questions with Most
Opportunity for Improvement

• ( agree or strongly agree)
• Participation in Hospital Affairs
• 36 Nursing administrators consult with staff on
  daily problems and procedures
• 38 Administration that listens and responds to
  employee concerns
• Staffing and Resource Adequacy
• 43 Enough staff to get the work done
• 44 Enough registered nurses to provide quality
  patient care
• Nurse Manager Ability, Leadership, and Support of
  Nurses
• 45 Praise and recognition for a job well done
• 58 Supervisors use mistakes as learning
  opportunities, not criticism

68
Facility-Level Results Questions to Ask

• What was your percent of participation?
• Was your staff participation representative of
  your entire facility?
• How do you compare to other facilities in your
  VISN?
• How does this compare to the VHA average (better
  or worse)?

69
Survey Conclusions

• Survey process was valid
• 41 response rate overall
• Respondents were generally representative of all
  VA RNs at the national level
• Wide variation in response rates observed among
  facilities, so improvement opportunities
• Overall, RNs were
• Most satisfied with IT support of nursing care
• Least satisfied with participation, staffing and
  nurse manager

70
Next Steps FY08 RN Satisfaction

• Facility nurse executives should
• Begin planning - Next survey October 2007
• Once results are available
• Review the COLMR national results analysis and
  comparison to FY07 (will be posted on VANOD
  website)
• Look at local RN Satisfaction data in VSSC
  ProClarity Reports
• Develop Action Plans - areas of excellence
  opportunities for improvement

71
To the Future
72
National Quality Forum Nursing Sensitive
Indicators Endorsed by Joint Commission

• Failure to rescue
• Pressure Ulcer
• Falls Falls w injury
• Restraint (Vest Limb)
• Urinary cath UTI (ICU)
• Central line cath infection (ICU)
• Vent assoc pneumonia (ICU)

• Smoking cessation counseling for AMI, Pneumonia,
  Heart Failure
• Skill Mix
• Nursing Care Hours per Patient Day HPPD
• RN Satisfaction (Practice Environment
• Voluntary turnover

73
Additional Topics

• SCID pt cohort
• Dysphagia
• Nurse Staff Injury
• Oncology
• Pain
• Heart Failure Education

74
Challenges

• Linking the nurse to the point of care
• Missing Contract/Agency nurse data
• Missing Function, e.g. sitters, light duty
• National roll-up of VistA data
• Standardized data (Taxonomies)
• Triangulating on Point of Care
• Daily and shift data not available nationally
• Reliable Patient Acuity System needs to be
  developed to link to nurse staffing

75
Keep Up with What's Happening

• Attend VANOD Site Coordinator monthly conference
  calls (3rd Wednesday at 11am ET or 4th Thursday
  at 1pm ET)
• Attend monthly VANOD Nurse Executive calls (2nd
  and 4th Tuesday at 11am ET)
• Use VANOD website for Calendar, access to
  ProClarity Reports and resources, newsletters,
  etc. (vaww.VANOD.va.gov)

76
Summary

• Every facility has administrative data and RN
  Satisfaction data in VANOD database USE IT
• The first standardized clinical data (Skin Risk)
  product will be out this fall, with other
  clinical topics to follow.
• RN Satisfaction data reveal focal areas for
  improvement next survey is the month of October
  2007.

77
QUESTIONS?
VANOD Staff Bonny Collins, PA-C, MPA, Program
Manager, VANOD, 970-263-5022 Alicia Levin, RN,
MS, CLNC, Implementation Coordinator Mimi
Haberfelde, RN, MS, AOCN, CLNC, Education,
Editor Diane Bedecarre, RN-BC, MS,
Informatics VANOD Website vaww.VANOD.va.gov