1. Nurse Sensitive Quality Indicators (NSQI) Definitions and Reports October 2, 2008 12:00 – 1:00 p.m.

2. Presenters Jim Cannon, Executive Director, Health Information Program, Washington State Hospital Association Carol Wagner, Vice President, Patient Safety, Washington State Hospital Association Anne Wagg, National Database of Nursing Quality Indicators (NDNQI) Program Coordinator, Central Washington Hospital, Wenatchee, Washington Photo Not Available

3. Web Cast Overview Why are we making this effort? Jim Cannon What are you going to be asked to do? Carol Wagner What is the tool? What are the definitions? Stories from the field Anne Wagg What will you get out of the system? Jim Cannon

4. Nurse Staffing Agreement NWONE, WSHA, and the three nursing unions agreed to work together to address nurse staffing and quality of care issues, including data collection. One outcome was a Memorandum of Agreement. NWONE and WSHA boards endorsed the legislation and Memorandum of Agreement.

5. Memorandum of Agreement Data Collection Surveyed on nurse sensitive quality indicators. Based on the results, five indicators were selected for collection. Steering committee agreed to give due consideration for the need not to create unreasonable data collection burdens.

6. Overview of the NSQI Project Monthly, five NSQIs will be collected at the unit level. Hospitals report data to WSHA via web-based tool – Quality Benchmarking System (QBS). Reports will be generated for hospitals and nurse staffing committees.

7. Nurse Sensitive Quality Indicators Consistent definitions between: National Quality Forum (NQF) National Database on Nursing Quality Indicators (NDNQI) Coalition for Nursing Outcome Indicators (CalNOC) The Washington NSQI Project

8. Data and Quality Care Unit level data will inform administrators, managers, and clinicians Use by hospitals’ nurse staffing committees Illustrates effect of staffing decisions on patient care Support quality performance improvement

9. NSQI: The Indicators Patient falls Falls with injury Pressure ulcer rate/prevalence Nursing care hours per patient day – direct variable hours Skill mix

10. Collection Tool: QBS Data collection is through WSHA’s Quality Benchmarking System (QBS). Six hospitals are piloting the system: Grays Harbor Community Hospital, Central Washington Hospital, Harrison Medical Center, Kadlec Medical Center, United General Hospital, and Swedish Health Services. Secure, easy to use, web-based application. Help is available for data display, analysis, and timely dissemination.

11. Quality Benchmarking System QBS allows users to input data and track, compare and analyze their hospital’s data immediately. Data displayed using trend, bar, and control charts. Data exportable for reports and presentations.

12. Score Card

13. Unit Level Drilldown

14. Drilldown Trend

15. Indicator Trend Matrix

16. Definitions

17. Indicator Data - Units The indicator data are collected for each of the following units: 1.Medical 2.Surgical 3.Medical / Surgical 4.ICU 5.Step-down units

18. Patient Falls Description: All documented falls with or without injury, experienced by patients on an eligible unit in a calendar month.

19. Patient Falls Data Elements: 1.Month / Year 2.Type of unit 3.Number of Patient Falls 4.Patient Days

20. Patient Falls Numerator: Number of patient falls, with or without injury to the patient, by type of unit during the calendar month x 1,000.

21. Patient Falls - Numerator Included Populations: Inpatients, short stay patients, observation patients, and same day surgery patients who receive care on eligible inpatient units for all or part of a day. Excluded Populations: Patients in units other than medical, surgical, medical/surgical, ICU and step-down.

22. Patient Falls Denominator Statement: Patient days by type of unit during the calendar month.

23. Patient Falls - Denominator Included Populations: Inpatients, short stay patients, observation patients and same day surgery patients who receive care on eligible inpatient units for all or part of a day. Excluded Populations: Patients in units other than medical, surgical, medical/surgical, ICU and step-down.

24. Falls with Injury Description: All documented patient falls with an injury level of minor or greater.

25. Falls with Injury Data Elements: 1.Month / Year 2.Type of unit 3.Number of injury falls 4.Patient days

26. Falls with Injury Numerator Statement: Number of patient falls with an injury level of minor or greater by type of unit during the calendar month X 1000.

27. Falls with Injury - Numerator Included Populations: Patient falls occurring while on an eligible reporting unit An injury level of minor or greater defined as: 1.None – patient had no injuries resulting from the fall. 2.Minor – results in application of a dressing, ice, cleaning of a wound, limb elevation, or topical medication. 3.Moderate – results in suturing, application of steri-strips/skin glue, or splinting. 4.Major – results in surgery, casting, traction, or required consultation for neurological or internal injury. 5.Death – results in death as a result of the fall.

28. Falls with Injury - Numerator Excluded Populations: Visitors Students Staff Members Falls by patients from eligible reporting unit, however patient was not on unit at time of fall (e.g., patients falls in radiology department) Falls with an injury level of “none” Falls by persons who are not patients, e.g., hospital staff, visitors. Falls on other unit types (e.g., pediatric, obstetrical, rehab, etc)

29. Falls with Injury Denominator Statement: Patient days by type of unit during the calendar month.

30. Falls with Injury - Denominator Included Populations: Inpatients, short stay patients, observation patients and same day surgery patients who receive care on eligible inpatient units for all or part of a day. Excluded Populations: Patients in units other than medical, surgical, medical/surgical, ICU and step-down.

31. Pressure Ulcer Rate/Prevalence Description: The total number of patients that have nosocomial (hospital-acquired) stage II or greater pressure ulcers on the day of the prevalence study.

32. Pressure Ulcer Rate Data Elements: 1.Day of First Staff Discovery/Documentation of Pressure Ulcer 2.Day of Hospitalization for Patient on Prevalence Study Day 3.Observed Pressure Ulcer 4.Observed Pressure Ulcer – Hospital Acquired 5.Observed Pressure Ulcer – Stage 6.Admission Date 7.Birthdate 8.Month 9.Year 10.Type of Unit

33. Pressure Ulcer Rate Numerator Statement: Patients surveyed on an eligible reporting unit that have at least one stage II or greater [National Ulcer Advisory Panel (NPUAP)] nosocomial pressure ulcer on the day of the prevalence study.

34. Pressure Ulcer Rate - Numerator Included Populations: Hospital Acquired Pressure Ulcers – Pressure Ulcers of Stage II or greater AND the Day of First Staff Discovery/Documentation of Pressure Ulcer is greater than or equal to 0003.

35. Pressure Ulcer Rate - Numerator Excluded Populations: Patients with skin breakdown due to arterial occlusion, venous insufficiency, diabetes related neuropathy, or incontinence dermatitis. Patients with NO ulcers greater than stage I on the day of the prevalence study. Patients with an ulcer (any stage) present on the patient’s first day in the hospital. Patients with ulcers greater than Stage I on the day of the prevalence study where ALL the ulcers were documented to be present on day 2 of the patient’s hospitalization.

36. Pressure Ulcer Rate Denominator Statement: All patients on the selected unit at the time of the study who are surveyed for the study by type of unit.

37. Pressure Ulcer Rate - Denominator Included Populations: Patients 18 years or older who are admitted to medical, surgical, medical-surgical combined, critical care and step-down units that are surveyed for the study. Excluded Populations: Patients less than 18 years of age.

38. Pressure Ulcer Stage Stage I – non blanching erythema of intact skin. Stage II – partial thickness involving epidermis and/or dermis; superficial and presents clinically as an abrasion, blister, or shallow crater.

39. Pressure Ulcer Stage Stage III – Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia; presents clinically as a deep crater with or without undermining of adjacent tissue. Stage IV – Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting tissues. Eschar – Unable to stage

40. Nursing Care Hours per Patient Day Description of Indicators: 1.The number of productive hours worked by RN nursing staff per patient day. 2.The number of productive hours worked by nursing staff (RN, LPN and UAP) per patient day.

41. Nursing Care Hours Data Elements: 1.Month / Year 2.Type of unit 3.Hours by RN, LPN, and UAP [Contract: Agency] 4.Hours by RN, LPN, and UAP [Employee] 5.Patient days

42. Nursing Care Hours Numerator Statement: Total number of productive hours worked by RN staff with direct patient care responsibilities by type of unit during the calendar month. Total number of productive hours worked by RN, LVN, UAP with direct care responsibilities by type of unit during the calendar month.

43. Nursing Care Hours Included Populations: Productive hours worked by RN staff with direct patient care responsibilities for greater than 50% of their shift. Includes: 1.Staff who are counted in the staffing matrix, and 2.Who are replaced if they call in sick, and 3.Work hours are charged to the unit’s cost center 4.Contract staff

44. Nursing Care Hours Excluded Populations: Persons whose primary responsibility is administrative in nature. Specialty teams, patient educators or case managers who are not assigned to a specific unit.

45. Skill Mix Indicators Percentage of hours worked… Registered Nurse Licensed Vocational/Practical Nurse Unlicensed Assistive Personnel Contract Staff

46. Skill Mix Data Elements: 1.Month / Year 2.Type of unit 3.RN hours [Contract: Agency] 4.RN hours [Employee] 5.LPN hours [Contract: Agency] 6.LPN hours [Employee] 7.UAP hours [Contract: Agency] 8.UAP hours [Employee]

47. Skill Mix - Numerator Included: Productive hours worked by [RN, LPN, UAP] staff with direct patient care responsibilities for greater than 50% of their shift. Includes: Staff who are counted in the staffing matrix, and Who are replaced if they call in sick, and Work hours are charged to the unit’s cost center Contract staff

48. Skill Mix - Numerator Included Populations: Productive hours worked by contract staff [RN, LPN, UAP] with direct patient care responsibilities for greater than 50 percent of their shift. Includes: Staff not employed by your facility. Staff hired on a contractual basis to fill staffing needs for a designated shift or on another short-term basis. Registry staff from outside the facility (e.g., not floating staff from within the facility). Traveling nurse staff contracted to the facility for a designated period of time.

49. Skill Mix - Numerator Excluded Populations: Persons whose primary responsibility is administrative in nature. Specialty teams, patient educators or case managers who are not assigned to a specific unit. Unit secretary, monitor techs.

50. Skill Mix - Denominator Included Populations: Units: 1.Medical 2.Surgical 3.Medical/Surgical 4.ICU 5.Step-down Excluded Populations: Other unit types: (e.g., pediatric, obstetric)

51. Stories from the Field What are your suggestions for collecting the data? Have you been able to use the information to improve care or staffing? Central Washington Hospital

52. NSQI: The Project WSHA’s Health Information Program (HIP) coordinating the NSQI Project and the interface with QBS. HIP will analyze the data based on WSHA and steering committee guidance. HIP will provide technical assistance and guidance for project reporting.

53. Future WSHA Web Casts Tomorrow, October 3, from 12:00-1:00 p.m. Topic: Technical Components Connection information is the same as for today.

54. Contact Information Contact for help or more information: With the NSQI Project: Jane Feldman: janef@wsha.orgjanef@wsha.org About House Bill 3123 or the Memorandum of Agreement: Kristin Petersen: kristinp@wsha.org

55. Any Questions?