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					SOUTH AUSTRALIAN
PREMIER’S NURSING & MIDWIFERY
SCHOLARSHIPS 2009/2010




USA HOSPITAL STUDY TOUR
NURSING, TECHNOLOGY AND
INNOVATIONS TRANSFORMING
CARE




Jennifer Hurley
Nursing Director
Nursing Automated Systems
Royal Adelaide Hospital

Tel: 8222 5584

Jenny.hurley@health.sa.gov.au




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                                                                SOUTH AUSTRALIAN  PREMIER’S NURSING & MIDWIFERY  
                                                                                         SCHOLARSHIPS 2009/2010 




Contents
1.  Purpose of tour ............................................................................................................ 3
    1.1 Purpose and Objectives......................................................................................... 3
    1.2 Expected Benefits ................................................................................................. 4
2. Background ................................................................................................................. 6
3. Outcomes of the tour .................................................................................................... 7
    3.1 Knowledge ........................................................................................................... 7
    3.2 Observation .......................................................................................................... 9
    3.3 Skills Development.............................................................................................. 10
    3.4 Initiatives ............................................................................................................ 11
4. The relationship of the tour to outcomes ....................................................................... 12
    4.1 Overview of site visits .......................................................................................... 12
5. Identified benefits of the tour ....................................................................................... 17
    5.1 Patient/client care ............................................................................................... 17
    5.2 Management of Services ..................................................................................... 17
    5.3 New Initiatives .................................................................................................... 17
    5.4 Nursing Knowledge and Practice .......................................................................... 18
    5.5 Efficiency and Effectiveness................................................................................. 18
6. New Learnings ........................................................................................................... 19
    6.1 Nursing and Midwifery Metrics ............................................................................. 19
    6.2 Institute of Healthcare Improvement (IHI) .............................................................. 23
    6.3 Transforming care at the bedside (TCAB) ............................................................. 25
    6.6 Nursing and Technology ...................................................................................... 42
    6.7 Comprehensive Inpatient Resuscitation Program - Advanced Resuscitation Program
          (ART) ................................................................................................................. 45
    6.8 Talent Management Strategies – Recruitment and Retention .................................. 46
    6.9 LifeWings Systems.............................................................................................. 48
    6.10 Digging for Dinosaurs .......................................................................................... 48
7. Reflections ................................................................................................................ 49
8. Dissemination of Learnings ......................................................................................... 50
    8.1 Dissemination of resources .................................................................................. 50
    8.2 Presentations/Dissmenination of Information ......................................................... 50
    8.3 Implementation ................................................................................................... 50
    8.4 Abstract ............................................................................................................. 50
9. Budget ...................................................................................................................... 51
10. Itinerary ..................................................................................................................... 52
11. References ................................................................................................................ 53
12. Appendices ............................................................................................................... 54
    Appendix A : Universal Floor Model ............................................................................. 54
    Appendix B : Washington Hospital Centre Frontline Managers ....................................... 57
    Appendix C : UCSD – Digging for Dinosaurs ................................................................ 58
    Appendix D : Quadra Med ........................................................................................... 59




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                                                   SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
                                                                           SCHOLARSHIPS 2009/2010 



1.       Purpose of tour

1.1      Purpose and Objectives
The purpose of this proposed hospital study tour was to explore innovative strategies, electronic
health information, technology advancements and best practice models improving patient care and
supporting nurses and midwives. The hospital study tour of the United States of America (USA)
was undertaken in October 2009.

Hospital study tour objectives:

Knowledge
        Increase knowledge, skills and expertise in the implementation and application of nursing
         information systems including the establishment of a common language for nursing, the
         establishment of minimum data sets for nursing and midwifery, point of care technology.
        Gain first hand knowledge of the strategy used to support the introduction of new technology
         including nursing workflow and practice.
        Increase knowledge and application of initiatives that merge innovation and best practice that
         are driving improvements in patient care, increasing patient and staff satisfaction and support
         recruitment and retention in nursing and midwifery.
        Expand knowledge of the nursing metrics and outcome measures used to support
         operational and strategic goals.
        Explore ways to improve benchmarking of nursing and midwifery data across the South
         Australian public health system.

Observation/Enquiry
        Visit leading Magnet hospitals in the USA recognised for their leadership, expertise, skills,
         innovative practices related to nursing and midwifery information management, care
         management and workforce management.
        Meet with leaders in nursing informatics who have been responsible for the development of
         computer technology in the nursing profession.

Skills Development
        Enhance knowledge and skills in the use of nursing and midwifery data that will support
         improved workforce performance management tools.
        Working knowledge and skills in implementing nursing/midwifery information systems and
         related hospital systems.
        Understanding of the future directions for nursing/midwifery and health information
         management.

Initiatives
        Explore opportunities for adoption of transforming care at the bedside initiatives, point of care
         technology, communication tools and business intelligence programs.


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                                                 SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
                                                                         SCHOLARSHIPS 2009/2010 


1.2    Expected Benefits

Patient/client care
      Provide an opportunity to identify and apply innovative strategies and best practice principles
       that will improve quality patient care across the SA public health system.
      Identification of new nursing knowledge and skills will enable and support nurses and
       midwives in their transition from the current clinical information system to the new
       careconnect.sa ccsa Clinical Practice Support (ccsa CPS).
      Provide an opportunity to examine innovative models of care that have increased direct care
       time.

Leadership
      Engage and share information with nursing executives and managers in hospitals recognised
       for leadership and innovative programs supporting the implementation and the sustainment of
       major changes in nursing and midwifery workforce and health care delivery.
      Learnings from the study tour will provide a supportive leadership framework to enable
       nurses and midwives to meet the needs of a changing and diverse health care environment.

New Initiatives
      Learnings from the use of new technology including nursing and midwifery executive
       dashboards, application of innovative strategies for nursing and midwifery workforce
       management to the SA Health environment will provide an opportunity to explore the
       potential piloting of these initiatives.

Application into practice
      Information gathered from the hospital study tour will be directly applicable to the
       management and clinical practice setting and could be applied through ccsa CPS at a State,
       Regional, Hospital and Unit level and nursing and executive leaders’ forum.
      ccsa CPS components of implementation, education, training and reporting will provide
       opportunity for all nurses and midwives in the in-scope hospitals to gain from the information
       gathered from nursing and midwifery experts and best practice models.

Nursing/Midwifery knowledge and practice
      Enhance knowledge, skills and expertise in a diverse range of nursing and midwifery related
       practices.
      Establish new networks with nursing and midwifery leaders regarding current and future
       development of nursing, information systems and technology advancements.

Efficiency and Effectiveness
      Business intelligence programs and common databases for nursing/midwifery information will
       provide an opportunity for improved strategic and operational management.




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                                                SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
                                                                        SCHOLARSHIPS 2009/2010 



Evaluation Methodology
      Disseminate and share information with Chair of Nursing, Midwifery, SA Health, Nursing and
       Midwifery Executive Leaders, Directors of Nursing, Nursing Directors, Nursing Management
       Facilitators, Clinical Service Coordinators, Clinical Practice Consultants, ccsa CPS Project
       Team, ICT Services and other key stakeholders.
      Presentation at regional, hospital, service and unit forums.
      Submission of papers to national and state conferences.
      Contribute to the ccsa CPS with the sharing of information and resources gathered during the
       hospital study tour relating to nursing informatics, successful change management models,
       the incorporation of new technology in the workplace.
      Development of an information kit incorporating the best practice models and initiatives that
       will support enhanced nursing and midwifery reporting, management and evaluation.
      Incorporate the “dashboard” principles (subject to approval) to enhance nursing activity and
       workforce reporting.
      Establish network with contacts that can provide expertise and information regarding
       information management and nursing workforce management that will support the
       implementation of the ccsa CPS.




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                                                 SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
                                                                         SCHOLARSHIPS 2009/2010 



2.     Background

Health information technology has the potential to transform the delivery of care through people
and organisations making meaningful use of electronic health care data. In South Australia the
government’s health reform agenda has been the catalyst for the development of an electronic
health care record as part of the careconnect.sa.progam (ccsa). This leading project aims to
improve communications for patients, medical personnel, nursing, midwifery personnel and other
health care professionals. Achievement of this objective will streamline and interconnect
information systems within the SA public health system.

Clinical Practice Support (ccsa CPS) is a key component of the careconnect.sa.program. This
patient-centred electronic clinical decision tool that supports comprehensive patient assessment,
patient care planning, promotes quality care management, patient acuity and nursing and
midwifery workforce utilisation. Ccsa CPS will be implemented across all major metropolitan public
and large country public hospitals throughout 2010 and will have significant impact on patient care,
nursing care, workflow, work practices and nursing/midwifery workforce.

Recently, the USA has embarked on a similar journey to South Australia. The American Recovery
and Reinvestment Act of 2009 has been the vehicle for the development and adoption of an
electronic health care record. Major health organisations across the USA have partnered with
vendors to develop information technology solutions to address the need for an integrated
electronic health care record that meets the needs of consumers, health industry and government
providers/funders. These solutions are at different stages of creation, selection, deployment,
implementation and evaluation. Integral to the development of the electronic health record
solution is the creation of enterprise-wide clinical nursing and midwifery information systems. The
new information systems have enabled clinicians to streamline, document, monitor and evaluate
care resulting in significant changes in education, technology, work practices and processes.
Health organisations have invested heavily in education, nursing informatics, training and ongoing
support models that address the generational learning needs of today’s health workforce.

The South Australian Premier’s Nursing & Midwifery Scholarship 2009/2010 of USA hospital study
tour seeks to enhance knowledge and skills to support quality, safe, effective and efficient patient-
centred health care by enabling nurses and midwives to meet the challenges of the 21st century
patient.




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                                                  SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
                                                                          SCHOLARSHIPS 2009/2010 




3.       Outcomes of the tour

3.1      Knowledge
Enhanced knowledge in the use, application of nursing information systems including the
establishment of a common language for nursing, the establishment of minimum data sets
for nursing and midwifery, point of care technology.
        USA Health Care Reform initiatives and funding driving the replacement of legacy systems
         (pharmacy, laboratory respiratory), electronic health record and electronic nursing
         documentation within a relative short timeframe.
        All health organisations visited are partnered with major software vendors in pursuit of the
         goal of an integrated electronic health record with interoperable systems.
        Features of the electronic health care solutions include single sign on, scan identification,
         multidisciplinary patient care documentation, computerised physician order entry, electronic
         charting of nursing interventions (flowsheets) and medications, critical care components
         captured electronically that display data from monitors, ventilators and other medical devices
         feeding into the integrated electronic health record. Consents scanned and included in
         electronic health record.
        Application of enterprise wide agreed common language for nursing using the USA agreed
         terminologies such as Clinical Care Classification (CCC) by Virginia Saba.
        Data repositories to pulling information from the different systems such as admission-
         discharge-transfer systems, medication, radiology, pharmacy, nursing.
        Lessons learnt from the introduction of electronic health record, point of care technology,
         successful change management strategies, governance models, quality assurance (inter-
         rater reliability, audit process) and sustainment models.

Gain first hand knowledge of the strategy used to support the introduction of new
technology including nursing workflow and practice.
        Basic testing principles, strategies for testing new and updated software prior to
         implementation, thereby improving patient safety, proving better clinical outcomes, improving
         overall patient and staff satisfaction and increasing efficiency.
        Best-practice single room adaptable floor model (universal floor at Cedars-Sinai) with
         geographical U-configuration, care, technology advancements and nursing model that
         supports an optimal care environment.
        Point of care technology supports with all nurses having individual cell phones or
         walkie/talkies, computers available at the bedside or on wheels, additional workstations on
         wheels available for medical and multidisciplinary rounds, use of electronic hand held
         devices and dina cart to record vital signs, blood sugar measurements. Scanners available in
         rooms to encourage nurses to document at the bedside.
        Pre-programmed personal digital assistants (PDAs) to support analysis of time spent at the
         bedside and the affect of changes brought about by the Transforming Care at the Bedside
         initiatives underpinned by the Institute of Healthcare Improvement.




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                                                 SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
                                                                         SCHOLARSHIPS 2009/2010 


      Innovative and focussed computer literacy and competency program developed to support
       the adoption of electronic health record including clinical care planning in the health
       environment.
      Virtual learning environments (three dimensional education modules) that have enhanced the
       adoption of the health information technology changes. Generational education specific
       modules requirements such as on-line, sandpit, scenarios, game-shows.

Enhanced knowledge and application of initiatives that merge innovation and best practice
that are driving improvements in patient care, increasing patient and staff satisfaction and
support recruitment and retention in nursing and midwifery.
      Universal Unit an innovative best practice models of care enabling certain patients to remain
       in one adaptable room and bed whilst receiving different levels of care from nurses who have
       received specialised on-the-job education.
      Transforming Care at the Bedside initiatives increased nurses’ time in direct patient care by
       promoting creativity, empowering nurses, improving teamwork, improving communication,
       reducing clutter and waste, decreasing documentation, placing patient supplies inside rooms
       and placing equipment in the right place.
      Patient Acuity systems, nursing workload and productivity systems such as GRASP (patient
       scoring system) and Quadra Med nursing acuity system that inform staffing, nursing budget,
       performance, calculate nursing hours per patient day.
      California’s Safe Staffing Ratio Law for acute care, acute psychiatric, and specialty hospitals
       – RN Ratios 101 – minimum staffing numbers.
      Leadership models with comprehensive nurse leaderships programs focusing on leadership,
       human resource management, transition from clinical to manager role, critical thinking with
       ‘mock trials’, preceptor, coaching, quality, patient safety, finance and accountability skills.
      Talent Management model comprising of boot camps in orientation, dream days, nurse
       recruiters, surveys of new staff at 3, 6, 9, 12 and 18 months, preceptors for three months and
       exit process with an exit interview on the last day of duty by the Human Resource Team and
       follow-up phone call. Feedback provided directly to division/unit regarding strategies to improve
       retention.
      Recognition programs – nurses awards programs with travel, sweepstakes, benefits package
       with 13 additional days holiday and public holiday leaves, two week sick leave, forty hours of
       education leave and health benefit. Sign-on bonus for every nurse, relocation allowance.
      New roles of console technicians, clinical partners working under the direction of registered
       nurse across the USA.
      Clinical nurse leader role introduced eighteen months ago focusing on clinical care facilitation
       role managing 12-15 patients, working within a team, educating, mentoring. Minimum
       experience 2-3 years, bachelor prepared.
      ‘Wisdom at Work’ program that highlights the importance of older and experienced nurses in
       the workplace. This has been an important strategy in addressing the USA nursing shortage
       and focuses new created professional roles, roles of mentorship and preceptors, atmosphere
       of respect, on flexible working hours, increased benefits.
      LifeWings systems implemented in the operating rooms to improve patient safety, recruitment
       and retention of nurses. Lifewing focuses on improving teamwork, culture and safety
       systems by developing highly reliability organisations to create sustainable and measurable


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                                                SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
                                                                        SCHOLARSHIPS 2009/2010 


       cultural change in health care. LifeWings is based on best practices from the Aviation
       Industry.
      Electronic bed management systems facilitates centralised real-time bed management
       assisting the management of the patient from admission to discharge by interfacing with the
       environment, nursing units, transports, admitting staff and entry points such as emergency
       department.
Enhanced knowledge of the nursing metrics and outcome measures used to support
operational and strategic goals
      Data definitions, minimum data sets, tools and drivers for the development of the different
       nursing indicators across USA hospitals.
      Application of data, dashboards and scorecards in every day practice supporting supporting
       safety, quality and clinical decision making.
      Quality data outcomes using nursing terminology – meaningful use of electronic health
       systems within a framework designed for nursing that allows the retrieval of atomic-level data
       concepts into meaningful outcomes analysis.
      Clinical Care Classification (CCC) System, the first National Nursing Terminology Standard
       and represents nursing through coded structured atomic concepts at the smallest granular
       levels of actions and interventions.

Explore ways to improve benchmarking of nursing and midwifery data across the South
Australian public health system.
      USA national benchmarking activities undertaken regular based on size of hospital,
       metropolitan or rural, type of hospital eg acute, paediatric, magnet or non-magnet.
      Unit, division, hospital, organisation, state and national benchmarks established by The Joint
       Commission, Institute for Healthcare Improvement reported monthly and rolled up quarterly.
      Regular benchmarking targeting organisational goals undertaken by ward managers
       including nurse-sensitive, workforce and improvement initiatives.


3.2    Observation
Visit leading Magnet hospitals in the USA that are recognised for their leadership,
expertise, skills, innovative practices related to nursing and midwifery information
management, care management and workforce management.
      Observation of the Magnet Recognition Program® practical application driving improvements
       in patient outcomes, increasing patient and nursing satisfaction, recruitment and retention.
      Observation of the care environments, the equipment, clinical handover models based on
       best practice models.
      Observation of point of care technology to support direct care at the bedside
      Leadership role of nursing informatics in transforming care through the use of data to direct,
       support, monitor and evaluate change.
      Clinical partners working under the direction of registered nurses.
      Administrative support in the clinical environment.




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                                                  SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
                                                                          SCHOLARSHIPS 2009/2010 


Meet with leaders in nursing informatics who have been responsible for the development
of computer technology in the nursing profession, standards databases, initiated academic
computer technology programs and developed computer information systems for health
care.
      American Recovery and Reinvestment Act 2009 driving a variety of electronic health record
       development being implemented to meet individual organisation/enterprises.
      Meetings with Nursing Informatics – Caring network to discuss the role of nursing informatics
       in the USA and globally including the leadership role in the development of electronic health
       record.
      Discussion with Virginia Saba and Patti Dykes regarding the Acute Documentation Project.


3.3    Skills Development
Enhanced knowledge and skills in the use of nursing and midwifery data that will support
improved workforce performance management tools.
      Application of the magnet model driving innovation resulting in improvement in across the
       continuum of care and increasing nursing and midwifery satisfaction, recruitment and
       retention.
      Development and application of nursing and midwifery metrics to support improved outcomes
       including data definitions, reporting framework and evaluation of change.

Working knowledge and skills in implementing nursing/midwifery information systems and
related hospital systems.
      First hand knowledge and skills in the successful approaches in implemented enterprise-wide
       electronic health records.
      Knowledge of the new education models being utilised to support nursing and midwifery
       adoption of technology within the workplace.
      Point of care technology including communication systems improving the timeliness of receipt
       of critical values, compliance with use of critical value sticker, decreased the number of ‘false’
       alarms requiring action, improvement management of different alarms thus improving
       efficiency and safety, to time of medical officer notification of time.
      Acute Care Documentation Project which provides a common platform for inpatient
       documentation with the transition from paper to electronic medical records replacing paper
       flow sheets, assessments and notes thus allowing the sharing of patient data and clinical
       research. Acute Care Documentation Project framework is underpinned by Virginia Saba’s
       CCC Model.

Understanding of the future directions for nursing/midwifery and health information
management.
      Evolution of the electronic health record across USA, incorporation of electronic nursing care plan,
       progress notes, medical administration records, automatic uploading of essential patient data.
      Future directions of health policy impacts on potential funding arrangements.
      eLearning with introduction of virtual reality scenarios.
      Interoperable systems supporting information transfer, data repositories.
      Role of nursing informatics in USA informing policy, leading change across health.

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                                                 SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
                                                                         SCHOLARSHIPS 2009/2010 



3.4    Initiatives
Explore opportunities for adoption of transforming care at the bedside initiatives, point of
care technology, communication tools, and business intelligence programs.
      International recognised and national awarded best practice inpatient resuscitation program
       developed by UCSD significantly decreasing the incidence of preventable cardiopulmonary
       arrest and improving patient outcomes.
      Business intelligence programs, acuity, workload measurements and staffing systems
       influencing resource management.
      ‘Transforming Care at the Bedside’ (TCAB) Projects that have increased by 25% (35% to
       60%) the amount of time nurses and midwives spend with patients. This has resulted in
       improved patient outcomes, increased patient and nursing satisfaction, increased efficiency
       and effectiveness.
      Project RED (Re-engineering Discharge Planning) decreased preventable hospital re-
       admissions, reduced emergency department visits, increased patient safety, reduced costs
       and increased patient satisfaction.
      Communication Improvement Project using SBAR (situation, background, assessment and
       recommendation) improving the communication of critical information.
      2010 Magnet Prize for Innovation: a tool developed utilising the electronic health record that
       enhances communication, improves workflow and support decision-making at the point of
       care. The tool is formatted as a daily report which is created using the patient’s plan of care,
       computer physician order entry and clinical documentation. The daily reported is provided to
       patients and families using ‘every day’ language to communicate care, treatment and
       progress.
      Patient Flow and Electronic Bed Management System software products (Premise,
       CHIMES, Horizon Enterprise Visibility McKesson Health Solutions) optimising resources and
       improving efficiencies.




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                                                 SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
                                                                         SCHOLARSHIPS 2009/2010 



4.       The relationship of the tour to outcomes

4.1      Overview of site visits
The Advisory Board Company identified best practice sites in the USA to ensure the purpose and
objective of my South Australian Premier’s Nursing & Midwifery Scholarship were met. All
hospitals are recognised as leaders in their field being credentialed Magnet hospitals, the highest
honour for nursing excellence awarded by the American Nurses Credentialing Centre.

The Magnet Recognition Program® is based on the quality indicators and standards of nursing
practice as defined in the ANA Nursing Administration: Scope & Standards of Practice published in
2009. The new vision and conceptual model groups the fourteen characteristics into five key
components: Transformational Leadership, Structural Empowerment, Exemplary Professional
practice, New Knowledge, Innovations & Improvements and Empirical Outcomes.

Nursing executive at each site hosted my hospital study tour and coordinated meetings with key
personnel in nursing, finance, information technology, quality improvements and human resource
management over a two day period. All hospitals visited had dedicated Nursing Informatics
departments had reported directly to the Chief Nurse.

The eight leading health care organisations that I visited were:
        Cedars-Sinai Medical Centre in Los Angeles, California
        University of California San Diego, California
        University of California San Francisco, California
        Washington Hospital in Washington, Maryland
        Abington Medical Centre, Fort Washington
        Englewood Hospital, New Jersey
        Brigham Women’s Hospital, Boston
        Massachusetts General Hospital, Boston.


Cedars-Sinai Medical Centre, Los Angeles, California
Cedars-Sinai Medical Centre has been providing healthcare for more than 100 years and has
evolved into one of the most dynamic and renowned medical centres in the world. Cedars-Sinai
Medical Centre is one of the largest non-profit hospitals in western United States and features a
Level 1 Trauma Centre and Paramedic Base Station. Cedars-Sinai Medical Centre is an acute
care teaching facility, has a bed capacity of 958, with state-of the-art equipment.

The focus of my visit to Cedars-Sinai Medical Centre was to gain first-hand knowledge in the new
Universal Unit. Joanne Pileggi, Registered Nurse, Manager of the Universal Unit hosted by hospital
tour at Cedars-Sinai Medical Centre. Joanne facilitated meetings with key personnel from
information technology, workforce, safety and quality. I attended nursing executive forums such as
Critical Care Nursing Leaders groups, met with key personnel regarding initiatives, undertook a
hospital tour, gained working knowledge of the nursing clinical performance and management tools
including dashboard, attended interdisciplinary ward rounds, observed point of care technology
devices, discussed workflow/practices changes, successful recruitment and retention initiatives,

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                                                 SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
                                                                         SCHOLARSHIPS 2009/2010 


strategies for monitoring and evaluating patient and staff satisfaction including the annual opinion
survey benchmarked against organisation and ward level, observed the marketing and visibility of
the Magnet Recognition® Program in the ward environment, observed transforming care at the
bedside initiatives.

Cedars-Sinai Medical Centre in partnership with Cerner has developed C-S Link an electronic
health record with electronic care planning and progress notes. Currently, the medical centre is
under-taking an extensive education and training program to support clinicians in this new
technology.

Cedars-Sinai Medical Centre has a private staffing agreement. Registered nurse staffing is based
on ratios of a minimum standard with criteria for increasing staff based on patient acuity.



University of California, San Diego Medical Centre (UCSD), San Diego, California
The University of California, San Diego Medical Centre (UCSD) is a clinical system operated by the
University of California educational system. It is one of the most respected education and research
institutions in the world. UCSD has state-of-the art inpatient and outpatient suites, Level 1 Trauma
Centre, Level III Neonatal Intensive Care Unit and has the latest diagnostic technology and
specialised services.

UCSD operates over two campuses: UCSD Hillcrest Medical Centre (386 bed-facility) and
Thornton Hospital (119 bed facility). UCSD Hillcrest Medical Centre is the regional academic
medical centre and offers both primary and specialised services, including general and specialty
surgery, cardiology, endocrinology, diagnosis and management of genetic diseases, neurology,
orthopaedic, paediatrics, reproductive medicine, and fertility services, and pulmonary medicine.
UCSD Hillcrest Medical Centre is also the primary site for organ transplant program and houses
the National Burn Centre.

Margarita Baggett, Chief Nursing Officer sponsored my hospital study tour at UCSD and Mary
Hackim, Director of Nursing Education, Development and Research facilitated meetings with
meetings with Director of Medical Surgical Specialties/Care Coordination, Nursing Quality
Improvement and Magnet Program Coordinator, Nurse Recruitment Manager, Quality Officer,
Senior Financial Analyst, Director Nursing Informatics and Nurse Manager, Birth Centre, Family
Maternity Care Centre, Perinatal Special Care.

UCSD is partnered with ECLYPS in developing EPIC electronic health record with electronic care
planning, linkages to medical orders. EPIC has been implemented in outpatient clinics. Electronic
care planning component is under construction with “order sets” implementation in late 2010.
UCSD works within an industrial framework. Registered Nurse staffing based on GRASP an acuity
model with nurses classifying patients every day. Validation of the tool is conducted using random
audits on a daily basis.




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                                                SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
                                                                        SCHOLARSHIPS 2009/2010 


University of California, San Francisco Medical Centre (UCSF) and University of California
Children’s Hospital, San Francisco, California
UCSF Medical Centre (574 beds) and UCSF Children's Hospital (350 beds) are co-located
academic hospitals. Both hospitals are recognised for their innovation in medicine, advanced
technology and compassionate care. UCSF Medical specialises in cancer, neurological disorders,
organ (liver and kidney) transplantation and orthopaedics (internationally recognised for treating
spine, degenerative disc disease and tumours). The centre is recognised for its specialist services
for women and children. UCSF medical centre has the only nationally designated Comprehensive
Cancer Centre in North California and is amongst the top five hospitals in the nation for the
treatment of neurology and neurosurgery.

UCSF Children’s Hospital is a "hospital within a hospital" with more than 150 specialists in more
than 40 areas of medicine. The programs provided are designed specifically for young patients,
including a 50-bed neonatal intensive care nursery, recreational therapy for recovering kids and 60
outreach clinics throughout Northern California. UCSF Children’s Hospital was the first in the world
to successfully perform surgery on a baby still in the womb and is renowned for the development
for the development of life-saving treatments for premature infants whose lungs aren't fully
developed.

Craig Johnson, Clinical Informatics Specialist from the Department of Nursing, UCSF Medical
Centre hosted my visit. The focus of my visit to UC San Francisco was to gain a working
knowledge of lessons learnt from recently implementing a new electronic health care record,
electronic clinical care planning, point of care devices and lessons learnt.


Washington Hospital Centre, Washington, Maryland, Columbia
Washington Hospital Centre (WHC) is one of the largest twenty-five hospitals in the USA. WHC is
an adult acute care facility with 950 licensed beds (average daily census of 750 beds). WHC is the
flagship hospital for Med Star Health which consists on nine hospitals (six in Maryland, three in
Washington centre. At Washington Hospital Centre there are more than 46,000 deliveries per
annum and the hospital houses one of the largest neonatal intensive care units in the USA. The
majority of admissions to WHC are from the large emergency department. The hospital provides
heart, liver, organ transplantation services and conducts more than twelve heart transplants per
year.

Elizabeth Wykpisz, Senior Vice President/Chief Nursing Officer hosted my visit to Washington
Hospital Centre. Kathleen Srsis-Stoehr, Evidence-Based Practice/Quality Nursing Director,
facilitated informatics panel discussion/demonstration chaired by Elizabeth Rhodes. Products
demonstrated were Medconnect (Cerner Electronic Medical Record), Axyzzi (Patient Database/
Documentation) and Clairvia (Scheduling), PICIS (Perioperative System), IPROB (Women &
Infants Medical Record System), QS (Critical Care), Aria (Outpatient Washington Cancer Institute)
and SiTEL. TUGS Robots demonstration by Pharmacy. Talent Management Committee
representatives discussed human resources recruitment and retention initiatives including “nurse
recruiter”, Hospital tour was conducted by Kathy Srsic-Stoehr. Nursing Metrics and Outcome
Measures topics covered nursing performance improvement plan/balanced scorecards and
dashboards with clinical specialists from regulatory and co-chair falls performance improvement


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team, wound ostomy, continence and pressure ulcer performance team. Discussions with the
Director Outcomes regarding the Medicare Excellence Measures and productivity and nursing
resources discussions with Senior Director, Resource management and Director Central Staffing.


Abington Memorial Hospital, Fort Washington, Pennsylvania
Abington Memorial Hospital has a 650 bed capacity (average daily census 563), has state-of-the-
art facilities and provides paediatric, adult and maternity services. Elizabeth Archer, Senior Vice
President/Chief Nursing Officer hosted by my visit to Abington Memorial Hospital. Diane
Humbrecht, Director Nursing Informatics coordinated by visit including meetings with Nursing
Directors of emergency department, medical/surgical divisions, clinicians regarding technology,
transforming care projects. Hospital tour encompassed the maternity (labour and delivery),
neonatal intensive care, special care nursery, paediatrics, emergency department, medical and
surgical units. Abington Memorial Hospital has recently implemented and emergency department
tracking system with a bi-directional interface between PICYS and emergency department system.
Abington Memorial has partnered with Centricity to develop a labour and delivery documentation
system with automatic upload of foetal monitoring strips and partnered with ECLPSYS to develop
an electronic health care record with best practice evidence-based guideline linkages to the
National Guidelines Clearing House and Netherlands Mosby’s Nursing Consult (Elsevier).

Abington Memorial Hospital received the Magnet Prize for 2010 for taking a simple idea of
translating a daily care plan into “layman” terminology. This has provided a personalised guide for
communication between the health care team, the patient and their family. Information provided
included admission, diagnosis, code status medication, falls, respiratory, treatment plan and tests.


Englewood Hospital and Medical Centre, New Jersey
Englewood Hospital and Medical Centre is a non-profit, health care facility located in New Jersey.
The hospital is a major medical and academic institutions, providing world-class medicine in a
community setting. The hospital is licensed for 520 beds with an average occupancy of 48% (daily
census 250). Englewood Hospital and Medical Centre is the only hospital in northern New Jersey
and one of the two facilities in the State that are members of Transforming Care at the Bedside
Collaborative.

Edna Cadmus, Vice President/Chief Nurse hosted by visit. Mandy Person, Vice President Clinical
Senate, facilitated meetings with human resources, quality and safety, information technology,
productivity department and Directors of Nursing for emergency, medical, surgical and informatics.
Hospital tour was undertaken. Englewood Hospital has recently opened a new purpose-built
emergency department. Englewood Hospital has been using Optilink developed by The Advisory
Board Company for acuity, scheduling and reporting of nursing resources for the past four years.


Brigham and Women’s Hospital (BWH), Boston
Brigham and Women’s Hospital (BWH) in a 777 bed teaching affiliate of Harvard Medical School in
Boston. BWH has a 100 intensive care unit and 46 bed neonatal intensive care unit with a bed
occupancy of 98%.


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Massachusetts General Hospital (MGH), Partners Health Care, Boston
Massachusetts General Hospital (MGH) is a 900 bed medical centre located in central Boston.
The hospital is the third oldest in the USA and is consistently ranked among the top five hospitals
in USA. MGH holds concurrent Level 1 verification for adult and paediatric trauma and burn care.
MGH is renowned for worldwide innovations in cancer, digestive disorders, heart disease,
transplantation and vascular medicine.

MGH has the largest research-based program in USA and is the largest teaching hospital of the
Harvard Medical School. In 2009 47,000 patients were admission, 1.5 million outpatient visits,
83,000 emergency department visits, 37,000 operations were performed and 3,700 deliveries.

Patti Dykes, Vice-President, Partners Health Care coordinated my visits to BWH and MGH. Both
sites use Quadra MED to support acuity, staffing, reporting of nurse-sensitive indicators. Meetings
were held with the Vice President of Quality, Information Services, Financial Management and
Informatics. Panel discussions regarding informatics, dashboards, quality indicators were
coordinated with key representatives from both sites.

Virginia Saba and Patti Dykes have been successful in receiving funding from the USA
government to review documentation in the acute care environment. The Acute Care
Documentation Project (underpinned by Virginia Saba’s Clinical Care Classification Model) is led
by Virginia Saba and Patti Dykes partnered with MGH and BWH, This project will provide a
common platform for inpatient documentation with the transition from paper to electronic medical
records replacing paper flow sheets, assessments and notes thus allowing the sharing of patient
data and clinical research. Acute Care Documentation Project framework is underpinned by
Virginia Saba’s CCC Model. MGH and BWH will conduct user acceptance test pilots in November
2010.




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5.    Identified benefits of the tour

5.1   Patient/client care
         Improved patient discharge planning process supported with the implementation of
          Project RED.
         Increased direct time at the bedside for nurses and midwives with the adoption of the
          transforming care at the bedside initiatives.
         Enhanced of knowledge and lessons learnt from the implementation of integrated
          electronic health care record that will support the implementation of ccsa CPS.
         Enhanced knowledge of the impact of point of care technology devices supporting nurses
          and midwives in the delivery of timely, quality, care including lessons learnt, which
          devices increased uptake of new technology
         Successful education approaches enabling transition and supporting from paper based
          systems and records to electronic records.
         Nursing and Midwifery Leadership models focusing on incorporating evidence into
          practice, critical to delivering safe, high quality care.
         Lifewings aviation model making a difference in the peri-operative environment increasing
          patient satisfaction, improving patient safety and increasing recruitment and retention.


5.2   Management of Services
         Universal Floor developed by Cedars-Sinai Medical Centre provides an opportunity to
          adopt this best-practice model to benefit and meet the of today’s and SA future health
          system requirements.
         Electronic bed management systems optimising bed resources, improving patient flow,
          facilitating the identification and cleaning of bed stocks, improving transporting of patients.
         Nursing information governance models developed to ensure data definitions, data
          integrity, audit processes and data management.
         Nursing metric model to support development of SA Health Nursing and Midwifery
          dashboard, balanced scorecard.


5.3   New Initiatives
         Institute of Healthcare Improvement accelerating improvement of health care worldwide.
         Transforming Care at Bedside creating solutions that allows nursing more time with
          patients and empowers nurses to make positive changes through teamwork.
         Project RED decreasing preventable hospital readmissions, reducing emergency
          department visits, increasing patient safety, reducing costs and increasing patient
          satisfaction.
         Electronic health records software solution and electronic clinical nursing information
          systems replace multiple existing systems and paper-based care planning, progress
          notes.
         Nursing Workload and Productivity Models based on Patient Classification Systems
          (Patient Types) supporting resource calculation, patient type, acuity, staff mix, projecting
          resources, informing nursing budget and performance.

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         Nursing and Technology advancements supporting nursing and midwives in the care
          environment.
         UCSD Resuscitation Program - Advanced Resuscitation Training (ART) provides a
          flexible curriculum to address the unique needs of the inpatient environment and
          synchronise resuscitation training across healthcare providers. UCSD has developed six
          programs: Basic Advanced Resuscitation Training (BART), BARTLight for outpatient
          departments, PHart – for pharmacy departments and Respiratory Emergency Team
          (RET). Outcomes survival-to-discharge doubled to 41%.


5.4   Nursing Knowledge and Practice
         Clinical information systems that incorporate evidence and standardise practice at an
          organisation and enterprise-wide level.
         Nursing, Midwifery, Safety, Quality Dashboards and Scorecards developed to meet
          national, state, organisation/enterprise, hospital, unit reporting requirements.
         eLearning education and training programs implemented to support nurses and midwives
          in transitioning to an electronic health record and electronic nursing information system.
         Use of point of care technology to support nurses and midwives and impact on nursing
          workflow and work practices.
         Education programs focusing on computer literacy and competency.


5.5   Efficiency and Effectiveness
         Patient flow and electronic bed management systems optimising bed resources with
          interfaces to environment services, nursing wards, transport, emergency department, and
          multidisciplinary health care team.
         Pre-programmed PDA’s to support nursing care initiatives and nursing clinical information
          systems workload measurements.
         Established international networks with leading nursing and midwifery experts




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6.       New Learnings

6.1      Nursing and Midwifery Metrics
For SA Health to leverage the benefits to effectively drive performance improvement requires
dedicated resources to each of the following four steps. Firstly, nurse and midwifery leaders must
priortise the performance metrics deemed most critical to the nursing and midwifery. Secondly,
nursing/midwifery departments must commit to creating a robust nursing dashboard that includes
both explicit performance targets as well as action triggers. Thirdly, frontline leaders must be
equipped with supporting the resources and tools needed to effectively diagnose and address
emerging performance problems. Finally, nurse leaders must translate organisational performance
data into a format accessible and meaningful to frontline nurses/midwives.

The Advisory Board Company’s ‘Nursing Metrics Implementation Toolkit’ provides an excellent
resource to achieve the establishment of nursing and midwifery metrics for SA Health. The tool
provides a step by step approach to development of the nursing metrics map, data dictionary,
developing nursing strategy scorecard, failure modes and effect analysis (FMEA) and Root Cause
Analysis. The Advisory Board Tool Kit has been used by the USA hospitals visited to establish the
national, state, organisation, hospital and unit specific metrics, dashboards and scorecards within
the framework of people, quality, service, market, finance and throughput (For further information
go to: www.advisoryboard.company).

Specific patient population metrics for maternity (labour and delivery, neonatal), paediatrics and
nurse-sensitive specifics relevant to the different hospitals have been added to the reporting
templates and dashboards. Dashboards identify frequency and sample size, regulatory agency
benchmarks (Joint Commission, State, Maternity Practice in Infant Nutrition and Care, Centre for
Disease Control, National Database of Nursing Quality Indicators, Institute of Healthcare
Improvement) and responsible people.

Data definitions and examples of the adult acute, maternity, paediatric, transforming care at the
bedside initiatives from the different hospitals have been sourced as part of USA hospital study
tour and have been provided to the Senior Project Nurse, Nursing and Midwifery, Nursing Metrics
Project. All hospitals have agreed to share their tools to assist SA Health in the development of
nursing metrics framework and dashboard.

The nursing and midwifery metric indicators were sourced from the following leading organisations:
        The National Database of Nursing Quality Indicators (NDNQI) – database owned and
         developed by the American Nurses Association, The database collects and evaluates nurse-
         sensitive data from hospitals. For further information go to www.nursing.quality.org
        Institute of Healthcare Improvement (IHI) – not-for-profit organisation endorses six “bundles”
         of metrics for quality improvement. IHI provides a toolkit for the establishment of
         Transforming Care at the Bedside metrics and target set for direct patient care time spent >
         or = 70%. For further information go to www.ihi.org
        National Quality Forum (NQF) is a not-for-profit membership organisation created to develop
         and implement a national strategy for health care quality measurement and reporting. NQF



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           developed fifteen consensus-based standard indicators to measure nursing performance.
           For further information go to: www.qualityforum.org.
          Press Ganey – provides measuring, surveying and consulting tools on patient and employee
           satisfaction. For further information go to www.pressganey.com
          JCAHO National Patient Safety Goals – provides a set of patient safety goals established by
           JCAHO, a government agency that provides health care accreditation and related services to
           improve health care quality. For further information go to www.jointcommission.org
          The Consumer Assessment of Healthcare Providers and Systems (cahps) is a public-private
           initiative to develop standarised surveys of patients’ experiences with ambulatory and facility-
           level care. For further information go to www.cahps.ahrq.gov.

The following table provides an overview of the key common metrics reported for nursing
performance at a dashboard level for the organisations visited:
  Metric                                                                                                   Reporting
                Metric Group                           Core Measure                            Frequency
 Category                                                                                                   Rollup
 People        RN Retention      Vacancy (Operational -% FTEs)                                  Monthly     Quarterly
                                 Turnover (rolling 12 months) (Avg 1%/month). New Hire          Monthly     Quarterly
                                 Turnover rate/Voluntary Turnover Rate
                                 RN Fill Rate                                                   Monthly     Quarterly
                                 % Performance Evaluation Complete                              Monthly     Quarterly
               Workforce         Orientation                                                    Monthly     Quarterly
               Development       Education Leave/Training                                       Monthly     Quarterly
                                 Certifications                                                 Monthly     Quarterly
                                 Employee Satisfaction (%)                                      Monthly     Quarterly
                                 Physician Loyalty %                                            Monthly     Quarterly
 Quality       National          Staff Effectiveness
               Database for      Inpatient Falls per 1,000 patient days %                       Monthly     Quarterly
               Nursing Quality   Inpatient Falls per 1,000 patient days (NDNQI Average of       Monthly     Quarterly
               Indicators        Medians)
                                 Inpatient Falls with injury per 1,000 patient days %           Monthly     Quarterly
                                 Hospital Acquired Pressure Ulcer Prevalence %                  Monthly     Quarterly
                                 Hospital Acquired Pressure Ulcer Incidence Stage III & IV %    Monthly     Quarterly
                                 Back to Basics
                                 Med Errors Reaching Patients/100,000 doses                     Monthly     Quarterly
                                 Mis-labeled/Unlabeled Laboratory Specimens                     Monthly     Quarterly
                                 Cardiac/Respiratory Arrest                                     Monthly     Quarterly
                                 Rapid Response Activation
                                 National Patient Safety Goals (Audit Tools)
                                 Audits Submitted                                               Monthly     Quarterly
                                 % Blood Products with 2 RN signatures                          Monthly     Quarterly
                                 Do not use Abbreviations – Nursing                             Monthly     Quarterly
                                 Handoffs                                                       Monthly     Quarterly
                                 Falls Risk Assessment                                          Monthly     Quarterly
                                 Appropriate Falls Intervention                                 Monthly     Quarterly
                                 Suicide Risk Assessment                                        Monthly     Quarterly
               Joint             Documentation Initial Pain Assessment Admission %              Monthly     Quarterly
               Commission        Documentation Pain Reassess after intervention %               Monthly     Quarterly
               (Documentation)   Restraint Use Documentation: Initial Alternatives              Monthly     Quarterly
                                 Restraint Use Documentation: Reassessment                      Monthly     Quarterly
                                 Plan of Care                                                   Monthly     Quarterly
                                                                                                Continued over page

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 Metric                                                                                        Reporting
           Metric Group                        Core Measure                        Frequency
Category                                                                                        Rollup
                          Core Measures PNA Smoking Cessation Counselling           Monthly    Quarterly
                          Core Measures PNA Pneumococcal Vaccine                    Monthly    Quarterly
                          Core Measures PNA Flue Vaccine                            Monthly    Quarters
                                                                                               2 & 3 only
                          Core Measures HF Stroke: Smoking Cessation Counselling    Monthly    Quarterly
                          Core Measures                                             Monthly    Quarterly
                          HF Discharge Instructions
                          Stroke: Smoking cessation counselling                     Monthly    Quarterly
                          Stroke: Dysphagia Screen                                  Monthly    Quarterly
                          Stroke: Discharge Instruction                             Monthly    Quarterly
Service    Patient        Overall Rating (% of 9/10 on scale of 10)
           Experience     Willingness to Recommend                                  Monthly    Quarterly
           Press Ganey    Communication with Nurses                                 Monthly    Quarterly
                          Respect and Courtesy of Staff                             Monthly    Quarterly
                          Pain Control                                              Monthly    Quarterly
Market                    Manuscripts submitted and published                       Monthly    Quarterly
                          Abstracts submitted and presented                         Monthly    Quarterly
                          Sponsored/Hosted Educational Conferences                  Monthly    Quarterly
Finance    Budget         FTEs                                                      Monthly    Quarterly
           Compliance     Operating Budget                                          Monthly    Quarterly
                          FTE Variance >2.0 or 15%                                  Monthly    Quarterly
                          Patient Days (including babies)                           Monthly    Quarterly
                          Actual Hours Per Patient Day                              Monthly    Quarterly
                          Cost Per Patient Day                                      Monthly    Quarterly
                          Premium Labour Costs – Agency, Travellers Registry        Monthly    Quarterly




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Figure 1 : Washington Hospital Centre Balanced Scorecard




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6.2    Institute of Healthcare Improvement (IHI)
The Institute of Healthcare Improvement (IHI) is commonly known across the USA as the ‘think
tank’ of the leading government and heath care agencies. IHI aims to accelerate the improvement
of health care world wide. The following provides an overview of the IHI excellent resources
available to all.

      Transforming Care at Bedside (TCAB): what it is, how to use it, PDSA, initiative examples
      Vitality and Teamwork – how to use a talent management framework, provides access to
       formalised nursing leadership development programs, supports leaders in development of
       emotional intelligence and fosters effective succession planning
      Medical-Surgical Care – how to improve, measures, changes, improvement stores, tools,
       resources, literature and emerging contents
      Workspace – improvement tracker – how to track data over time, select measures you want
       to track or custom measure, set your aim, enter data, automatically graphs data, creates and
       customise reports. Interactive tools: likelihood of failure see how changes and consider
       impact. Trigger adverse drug events track over time. Results current and review results
       within Institute of Healthcare Improvement
      Improvement Map is user friendly online tool that assists hospitals to make sense of the
       countless requirements and focus on high-level changes to transform care. The Improvement
       Map supports the planning, setting and alignment of priorities. The IHI improvement map is
       available free of charge for anyone, anywhere and is structured around four processes: By
       domain, aim, all processes and search. Video tour of ihi.org

Institute of Healthcare Improvement website provides for SA Health a wealth of information, tools
and evidence. Institute of Healthcare Improvement has developed six bundles of metrics
(including TCAB for frontline managers) for consideration to support health care organisations to
monitor, evaluate and support change. Administrators, clinicians and managers are able to easily
accessible with download materials to support in transforming care, leadership, teamwork,
improvement activities. For further information go to www.ihi.org




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Figure 2 : Institute of Healthcare Improvement web page




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6.3    Transforming care at the bedside (TCAB)
Recent international research studies have identified that nurses and midwives are only spending 35-
40% of their time providing direct care to patients. The remainder of the time is spent undertaking
administrative duties, hunting and gathering equipment and supplies. In South Australia, the FMC
Nursing Works Project confirmed this finding.
The USA and United Kingdom have established two key national projects that have improved patient
care by increasing the direct care time nurses and midwives. These initiatives were launched to
redesign care focussing on the fundamentals of the having the right care environment, effective inter-
professional teamwork and collaboration, empowering health care professionals to make change,
and tools to support rapid-cycle changes and collect measurements to evaluate effectiveness.
The NHS Institute for Innovation and Improvement (NHS Institute) The Productive Ward: Releasing
Time to Care™ aims to empower ward teams to identify improvements by giving staff the information,
skills and time they need to regain control of their care ward and the care they give. The program was
initially piloted in 2005 and has been subsequently rolled out through the NHS hospitals. The
Productive Ward Toolkit has been developed by the NHS Institute and provides a step by step guide
with the tool and techniques for use of the Ward Nurse Manager. Outcomes from The Productive
Ward are reported against the agreed metrics framework developed by Professor Peter Griffiths and
Mr Simon Jones from the National Nursing Research Unit at King’s College, London.
In the USA, the Institute of Medicine’s report, To Err Is Human, documented wide-scale quality
problems in the nation’s health care system, including up to 98,000 hospital patient deaths each year
due to medical errors. Since the release of this landmark report many organisations have launched
initiatives to redesign care, but few have focusing on the medical and surgical wards where patients
typically spend the majority of their hospital stay.
In 2003 in the USA a national program under the direction of the Robert Wood Johnson Foundation
(RWJF), titled ‘The Transforming the Care at the Bedside’ (TCAB) initiative, was one of the key
initiatives launched in response to the ‘To Err is Human’ report, in particular the report findings of 35
to 40 percent of unexpected deaths occurred on medical and surgical units.
TCAB is sponsored by the American Organisation of Nurse Executives (AONE) and funded by the
Robert Wood Johnson Foundation. RWJF and Institute for Healthcare Improvement (IHI) agreed to
work together to create, test and implement changes that would dramatically improve care on
medical and surgical units, as well as, improve staff satisfaction.
TCAB aims to create solutions that allow nursing more time with patients and empowers nurses to
make positive change through teamwork. Evidence indicates that TCAB projects are increasing the
quality of patient care while improving the work environment, patient and staff satisfaction. The
outcome is the establishment of new models of care founded on effective inter-professional
teamwork and collaboration to meet the demanding and fast changing care setting. For nurses,
TCAB aims to create solutions that allow nursing more time with patients and empowers nurses to
make positive changes. Innovations have resulted in greater patient and staff satisfaction. Like The
Productive Ward: Releasing Time to Care™ Report an agreed metrics for reporting the outcomes of
the TCAB projects has enabled nation-wide reporting, monitoring and evaluation.
      TCAB initiatives are patient-centred, system-focused approach using the lean thinking
       principles, rapid improvement cycles, Plan, Do, Study, Act (PDSA) model to drive


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         improvements, patient safety and prevent patient harm, thorough and credible root cause
         analysis (RCA) and failure mode effects and criticality analyses (FMECA).
        Transforming Care at the Bedside initiatives increased nurses’ time in direct patient care by
         promoting creativity, empowering nurses, improving teamwork, improving communication,
         reducing clutter and waste, decreasing documentation, placing patient supplies inside rooms
         and placing equipment in the right.
        TCAB provides a guide to development of front-line managers to lead innovation and
         improvement.
        TCAB hospitals across the USA have reported that the adoption of these initiatives can double
         the time nurses and midwives are spending at the bedside.
        TCAB framework is building on four key change themes for improvement:
            o Safe and Reliable Care
            o Vitality and Teamwork
            o Patient Centred Care
            o Value-Added Care Processes
        Outcomes of TCAB initiatives have resulted in:
            o Reduced hospital-acquired pressure ulcers to zero.
            o Reduced patient injury from falls (moderate or higher) to 1 (or less) per 10,000 patient days.
            o Increased staff vitality and reduce annual voluntary turnover by 50%.
            o 95% of patients will definitely recommend the hospital.
            o Increased nurses’ time at the bedside to 60% or greater.
            o Increased patient and staff satisfaction with care delivery.
Available from the ihi.org website are the following guides to support SA Health:
        TCAB How-to Guide: Developing Front-Line Nursing Managers to Lead Innovation and Improvement
        TCAB How-to Guide: Engaging Front-Line Staff in Innovation and Quality Improvement
        TCAB How-to Guide: Increasing Nurses' Time in Direct Patient Care
        TCAB How-to Guide: Optimizing Communication and Teamwork
        TCAB How-to Guide: Reducing Patient Injuries from Falls
        TCAB How-to Guide: Spreading Innovations to Improve Care on Medical and Surgical Units
        Campaign How-to Guide: Deliver Reliable, Evidence-Based Care for CHF
        Getting Started Guide: Improving Care for Patients with Heart Failure — Focus on Ambulatory Care
For SA Health TCAB workshops would support health care professionals to lead, implement,
monitor and evaluate changes in practice, care and system. The following provides an outline of
potential workshops.
 TCAB Workshop No. 1 Outline – TCAB Why, How, What, When
    Overview of TCAB initiatives
    Leadership model for empowering nurses and midwives to achieve change within the workplace
    Use and application of the TCAB toolkit, guides, evaluation tools.
    Lean thinking and PDSA cycle to support clinicians.
    Examples of successful TCAB initiatives – use USA examples
    Clinicians brainstorm areas for improvement
    Clinicians workup projects identifying the aim, goal, name of project, PDSA, timeframe.
 TCAB Workshop No. 2 Outline – Progress, Report and Presentation Skills
    Clinicians reporting back progress to date
    Leadership model sustaining change
    Reporting writing skills
    Presentation skills
 TCAB Workshop No. 3 Outline – Sharing and Celebrating
  Presentation of TCAB initiative including outcomes
  TCAB project reporting including outcomes


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Figure3 : TCAB Framework




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The following table provides an overview of the successful TCAB initiatives:
 TCAB PROJECT : Progression of Care Communication
         Goal                                        Method                                              Outcomes
 To decrease daily   The patient care team identified that daily rounds took >60 minutes,      Time spent in
 interdisciplinary   storytelling led to increased time and pertinent information was not      interdisciplinary rounds
 rounds to 30        being communicated consistently.                                          prior to implementation of
 minutes or less.    Plan                                                                      communication tool and
                     Team studied the current process of daily interdisciplinary rounds,       ‘walking’ rounds = 60-75
 To improve          including time, information, registered nurse involvement. A tool         minutes (30 bed unit).
 communication       was developed identifying pertinent patient information.
                                                                                               Time spent in
 using a uniform     Tool Questions
                                                                                               interdisciplinary rounds
 format.             1. Why is the patient hospitalised?
                                                                                               after implementation of
                     2. If your patient is monitored, what is the reason? Do you think
                                                                                               communication tool and
                        telemetry can be discontinued? Why?
                                                                                               ‘walking’ rounds = 20-30
                     3. Where was the patient admitted from (Home, ECF)?
                                                                                               minutes
                     4. What is the functional level and mental status of your patient?
                     5. Does your patient have pressure ulcers? What stage?                    Improvement 37%
                     6. What s the plan of care and discharge goal for your patient?           decrease in amount of
                     Do                                                                        time spent in
                     Night Charge Nurse collects information from each registered nurse        interdisciplinary rounds.
                     during report; Day Charge Nurse/RNs/Interdisciplinary Team
                     conduct ‘walking’ rounds daily at 10am utilising tool and information
                     from the night shift and updates from day shift.
                     Study
                     Tool was used and then revised x3 with team input. Questions are
                     pertinent to SBAR format. Rounds were timed.
                     Act
                     Tool was incorporated into the Night Shift Registered Nurse report
                     and used by Day Shift Registered Nurse and Interdisciplinary Team
 TCAB PROJECT : Handoff Communication
        Goal                                           Method                                          Outcomes
 To implement a      The patient care team identified that pertinent patient information was   Uniform format has
 standardised        not communicated at change of shift handovers, transferring patients      ensured the
 approach to         to and from other units/facilities, during a rapid response call.         communication of the
 improve handoff     Plan                                                                      pertinent relevant
 communication       Team studied the current process of nursing handoff communi-              information and support
 among care givers   cation including written and verbal. Tools were developed:                proactive treatment of
                     Nurse to Nurse Report using the “I PASS the BATON” –                      patients.
                     pneumonic for handoffs with an opportunity to ask questions, clarify
                                                                                               Improved communication
                     and confirm
                                                                                               has supported nurses and
                     I = Introduction - introduce self/job
                                                                                               midwives critical thinking,
                     P= Patient – name, age, sex, location
                                                                                               safety and risk
                     A= Assessment – chief complaint, obis, symptoms and diagnosis
                                                                                               identification.
                     S = Situation – current status/circumstances, code status, level of
                         certainty, recent changes, response to treatment                      Note: Englewood Medical
                     S = Safety Concerns – critical lab values/reports, socio-economic         Centre introduced patient
                         factors, allergies, alerts                                            optivox – information
                     the                                                                       transferred via phone
                     B = Background – co-morbidities, previous episodes, current               using ISBAR format.
                         medications, family history
                     A = Actions – what actions were taken and required
                     T = Timing – level of urgency and explicit timing, prioritisation of
                         actions
                     O = Ownership – who is responsible (nurse/doctor/team) including
                         patient/family responsibilities
                     N = Next – what will happen next? Anticipated changes? What is
                         the plan? Contingency plans

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                                                          SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
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                       Nurse-Physician – I-SBAR used to nurse-physician and rapid
                       response communication.
                       I = Introductions – identify yourself, your role, patient’s name, age,
                            sex and location, MR#
                       S = Situation – The problem I am calling about is …………………
                            If this is a serious problem say what the code status is.
                       B = Background – briefly state why the patient is in hospital. Given
                            a synopsis of the treatment to date. Given the vital signs,
                            oximetry, and how much oxygen is being given if appropriate.
                            Relate the complaints given by the patient and the pain level if
                            appropriate. Relate the physical assessment pertinent o the
                            problem, specifically any changes. Pay special attention to
                            mental status, skin temperature and emotional state of the
                            patient.
                       A = Assessment – give your conclusions about the present
                            situation. A diagnosis is not necessary. If the situation is
                            unclear at least try to indicate what body system might be
                            involved. State how severe the problem seems to be. If
                            appropriate, state the problem could be life threatening.
                       R = Recommendations – say what you think would be helpful or
                            needs to be done, which might include: Medicines, tests, x-
                            rays, transfer to Critical Care, medical officer evaluation, or
                            consultant evaluation. Make sure to clarify how often to do the
                            vital signs and under what circumstances to call back.
                            Document the change in condition and the medical officer
                            notification.
                       Do
                       Communication tools implemented at nursing hand-off and rapid
                       response
                       Study
                       Tools were used and then revised with team input. Questions are
                       pertinent to SBAR and ISBAR format. Audits of hand-offs and
                       rapid response calls were completed
                       Act
                       Tool was incorporated to shift handovers, patient transfers,
                       handovers from nursing to medical officers and rapid response
                       team
TCAB PROJECT : Mutli-disciplinary case rounds
        Goal                                          Method                                             Outcomes
To maintain high       Plan                                                                     Multidisciplinary round has
standards of quality   Assess nursing staff’s level of confidence in caring for patients with   improved patient and staff
patient care           multiple disease processes (pathophysiologic and psychological           satisfaction, a decrease in
through structured     concepts), assessment and treatments                                     SAEs, an increased use of
interactive clinical   Work with all RNs to assess their level of knowledge, especially         rapid response team and a
conferences,           focusing on new graduate RNs                                             decrease in code blues.
involving health       Do
care team              Conduct monthly rounds (approx 45 – 60 minutes) consisting of            Well structured, interactive
members.               one complex patient.                                                     clinical conference
                       The patient is chosen based on the following:                            provides opportunities for
                        Complexity of the diagnosis                                            the health care team to
                        Staff interest in the patient population                               develop and enhance their
                        Need for consultation to determine the plan of care for the            ability to make sound
                          hospitalisation                                                       clinical decisions and
                        Psychological problems associated with the diagnosis                   judgements in caring for
                       Staff through discussion, decide which case is to be presented at        complex patients.
                       each of the monthly rounds.
                       An RN preferably one who was the primary caregiver, will present


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                    the nursing aspect of the case, and other disciplines are invited to
                    discuss the case. Primary medical consultant or other consulting
                    physicians, case management, dietary, pharmacy, allied health,
                    respiratory services and other disciplines as appropriate
                    Study
                    Analyse the outcomes and results of multidisciplinary rounds:
                     Survey patient satisfaction
                     Survey staff satisfaction
                     Quality improvement audits (use of rapid response team versus
                       code blue)
                    Act
                    Continue monthly interdisciplinary rounds
                    Involve all healthcare team members
                    Incorporate literature and research into rounds and into the
                    patients’ plan of care
                    Involve the patient/family
TCAB PROJECT : Increased Compliance of Accuracy with Daily Weights
       Goal                                        Method                                           Outcomes
To improve          Inconsistency with weights not being done or being done                Increased compliance with
compliance and      incorrectly. Inconsistency related to increase in new hires, many of   documentation of accurate
accuracy of daily   whom were not aware of the importance of monitoring daily              weights and decrease in
weights.            weights.                                                               the number of MD
                    Failed communication between staff between day and night               complaints.
                    regarding weights.                                                     Staff education, a new tool,
                    MD feedback reports regarding the lack of accuracy and                 involvement of ancillary
                    compliance with weights.                                               staff, implementing the
                    Plan                                                                   daily weight as part of the
                    Assess Registered Nurse and Clinical Partners knowledge                SBAR report led.
                    regarding the importance of obtaining accurate weights and
                    knowledge about proper utilisation of bed scales
                    Do
                    Agenda item at the Unit Practice Council Meeting
                    Staff inservices regarding importance of daily weights
                    Stryker staff in-services on how to property set out the beds, in
                    order to weigh patients accurately
                    Instructions on how to weigh patients posted on the foot of each
                    bed.
                    Request bed shop staff to check beds to ensure proper working
                    order.
                    Discuss and implement new procedure.
                    New Procedure
                    Record weights on a daily weight log sheet which was posted on
                    each side of the unit.
                    Continued documentation of weights on the physiologic monitoring
                    sheet.
                    Reporting to Registered Nurses of weights.
                    Registered Nurses to communicate the patient’s weight as part of
                    their SBAR report, to the oncoming shift.
                    Night shift charge nurse to ensure all weights recorded on the long
                    as well as the physiological monitoring sheet.
                    Address discrepancies prior to the start of the next shift.
                    Study
                    Monitor that daily weights are done accurately, reviewed and
                    reported; monitor MD Feedback Report
                    Act
                    Continue to monitor progress and provide education as necessary.



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                                                       SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
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TCAB PROJECT : RN Business Card
        Goal                                         Method                                         Outcomes
To improve            Registered nurse identified that they receive many unproductive      Use of business cards with
communication         telephone calls related to patient room numbers and the nursing      pertinent information leads
between patients,     station numbers.                                                     to better communication,
their family                                                                               decreases anxiety of family
                      Plan
members and                                                                                members, and decreases
                      Design a survey tool with three questions (one for the registered
registered nurses.                                                                         non-productive time for
                      nurse and two for the family members). Survey questions:
To decrease                                                                                registered nurses.
                      How many non-productive telephone calls have you received on a
anxiety of patients
                      seven day period regarding patient location, room number,            Cards were cost-effective
and their family
                      telephone number and nursing station?                                and easy to make,
members related to
                       Do you know how to contact your family member while he/she is      professional-looking and
communication
                          in the hospital?                                                 easy to distribute. Positive
with the registered
                       Do you know how to contact the nurse caring for your family        comments have been
nurse                     member while he/she is in the hospital?                          received from patients and
                      Pre-survey patients, family members, nursing staff regarding ease    family members.
                      of communicating
                      Design business cards with pertinent information (patient room,
                      patient phone, nursing station)
                      Post-survey patients, family members, nursing staff regarding ease
                      of communicating
                      Do
                      Registered nurses collected telephone data (pre-business cards)
                      over a seven day period
                      Pre-survey done with patients and family members
                      Data analysed
                      Business cards introduced to registered nurses
                      Business cards given to patients and family members on admission
                      Registered Nurses collected telephone data (post-business cards)
                      over a seven day period
                      Post-survey done with patients and family members
                      Study
                      Complete analysis of data, summarise what was learned.
                      Act
                      Utilise the RN Business Cards for all new patient admissions
TCAB PROJECT : Falls Prevention
       Goal                                           Method                                        Outcomes
To reduce patient     Action Plan                                                          Decreased patient falls.
falls                 Safety huddle reinforced by CN IVs/Charge nurses, each shift at      Improved communication
                      0900 and 2100 to identify high risk patients                         with proactive risk
                      Huddle after each fall to discuss incident and plan for patient      identification and
                      UPC review of all fall data and plan to prevent falls                management.
                      Reinstitute hourly toileting rounds
                      Consistent use of bed alarm:
                      Emergin system delivers “bed exist alert” to RN/Charge Nurse/CP
                      cell phone and alarms at both nursing stations.
                      Evaluation and coaching of staff who do not utilise the alarms
                      appropriately.
                      Encourage patients and caregivers to ask for assistance.
TCAB PROJECT : Toes Out Toes In
        Goal                                       Method                                          Outcomes
To improve patient    Commenced in 2006                                                    Improved patient flow,
flow from the         Business consultant reviewed processes                               decreased access block in
emergency             Lean thinking principles                                             emergency department.
department to         Standardised Work Program                                            Change from 4 hours to 55
wards                 System to Team Chimes(Patient Placement knows where beds are         mins to transfer patients

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                        available) to EVS (Cleaning services)                                   from ED to CSUV
                        Text message to unit/ward nurse-in-charge of shift that bed is
                        booked. Nurse-in-charge must call within 20 minutes to ED to
                        accept patient.
                        Wait for patient arrival
                        If the process does not work: every day reporting of benchmark
                        exceeded. Document proforma of reason why – see example
                        sheet. Nursing Director to ascertain reason why and investigate,
                        implement action plan to address issue and follow up with other
                        areas as applicable.
                        Aim transfer patients from ED to Wards/Unit within agreed
                        benchmarks
                        Emergency Department to Wards/Unit
                        PACU to Floor
TCAB PROJECT : EMERGIN
         Goal                                           Method                                            Outcomes
To improve the          Plan                                                                    Emergin is an effective
effectiveness of        Staff worked alongside EIS, Telecommunications, Clinical                communication system
communication           Engineering on a weekly basis to collect, analyse and discuss data,     that allows nursing staff to
among caregivers        and to develop alert rules.                                             receive critical patient
and to allow            Do                                                                      information in a timely
caregivers to take      In-Service to staff to introduce Emergin. Clinical Partners were        manner.
appropriate action      given cell phones in exchange for pagers                                Emergin allows the nurses
in a timely manner      Data collected weekly and meetings called to discuss the pros and       to assess, intervene, and
To improve the          cons of Emergin                                                         report vital patient
timeliness of           24 hour support received from the EIS team during the first week of     information to the
receipt of, and the     the pilot.                                                              appropriate discipline.
timeliness of           Study                                                                   Improved time of receipt of
reporting of critical   Analysis the results-evaluation of the use of the Nextel phones         critical values to time of
test results and        Assess the time difference between a critical lab value sent via text   medical officer notification
values                  message vs receiving a call from the lab                                to time of intervention.
To deliver the right    Assess that the appropriate cardiac monitor alarms are being            Emergin demonstrated
alerts to the right     delivered to the appropriate nurse in a timely manner.                  that the system text
caregiver at the        Act                                                                     messaged critical lab
right time              Weekly EMERGIN meetings to discuss data, pros and cons of               values at an average of
To respond to           system, new ways of utilising the system and to continue evaluation     eight minutes faster than
patient requests        of communication devices. Rolled out to other units.                    telephone
more efficiently and    Tools – added a section on the Critical Lab Value sticker: “Time
effectively             the text message was received”. Critical Lab Value log was
                        created. The charge registered nurse and nurse manager
                        documented every critical lab value that was received via text
                        message the time the bedside nurse received a telephone call from
                        lab regarding the critical value.

TCAB PROJECT : Talk Light, Stop Light, Noise Too Late
        Goal                                           Method                                            Outcomes
To reduce noise at      Sleep deprivation is detrimental to patients with acute illness,        20% reduction in noise
time to a               impacting on wound healing and analgesic requirements                   levels at night.
satisfactory level to   (Richardson et al, Journal of Clinical Nursing, 18, 3316-3324).         Increased patient
support patient’s       ‘Reduce Hospital At Night’ was adapted from Newcastle upon Tyne         satisfaction with improved
rest and recovery       initiative had successfully reduced noise at night.                     sleep patterns.
from acute illness.     Plan
                                                                                                Simple changes to
USA                     Ward environment was reviewed including the physical make-up of
                                                                                                routines by nurses can
Environmental           the ward. Noise intervention program developed comprising of
                                                                                                lead improvements in
Protection Agency       telephones being turned down at night or switched to vibrate, staff
                                                                                                noise levels.
recommends levels       wearing soft-soled shoes, changes were made to the night call
of 45 decibels for      systems, posters were displayed at nursing stations highlighting the

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day-time noise in      noise created by certain activities, several systems or areas were
hospital settings      reviewed, including the door entry system, the position, number
and 35 decibels for    and volume of telephones, the nurse call system.
night-time noise.      Study
                       Pre-audit of ward noise levels
                       Development, implementation and delivery of a noise reduction
                       intervention program, Post-audit of ward noise levels.
                       Act
                       Noise intervention program implemented focusing on the physical
                       make-up of the ward, telephones turned down at night or switched
                       to vibrate, staff wore soft-soled shoes, posters were displayed at
                       nurses stations highlighting the noise created by certain activities,
                       several systems or areas were reviewed including door entry
                       system, the position, the number and volume of telephones, the
                       nurse call system.
TCAB PROJECT : Tracking Board Clinical Data
         Goal                                         Method                                                 Outcomes
To identify signs      Medical Acute Complex                                                        Tool has supported
and symptoms of        Plan                                                                         proactive management of
deterioration in       Staff worked with EPIC to develop a clinical tracking board for the          medical patients.
acutely complex        medical wards which updates every hour.                                      Supported initiation of
patients with alerts   Clinical Tracking Board is linked to septa phones                            treatments. Enables
to staff of changes.   Information displayed is the patient’s name, age, MRN, location,             overall view of patient’s
                       observations, pain score, rapid response criteria - level of                 status in a complex
                       consciousness, oximetry, falls risk, restraints, isolation, skin integrity   environment with
                       (Braden score), precautions, restraints and additional information.          telephone alerts to specific
                                                                                                    staff.




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                                                      SOUTH AUSTRALIAN  PREMIER’S NURSING & MIDWIFERY  
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Figure 4 : Cedar-Sinai universal Floor – TCAB Board

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                              SOUTH AUSTRALIAN  PREMIER’S NURSING & MIDWIFERY  
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Figure 5 : Washington Hospital Centre Nursing Performance Dashboard




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                                                   SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
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Universal Floor Model
Universal Floor at Cedars-Sinai provides a comprehensive adaptable model for the SA Health
context and transferable to the new Royal Adelaide Hospital.

      Universal Floor’s model is innovative and allows certain patients to remain in one adaptable
       room and bed while receiving different levels of care from nurses that have received
       specialised on the job training.
      Geographical layout with a “U” shaped floor plan and special design single rooms
       demonstrated a working environment that promoted safe, effective and efficient patient care
       with high satisfaction by all stakeholders.
      Magnet Recognition Program® provides a framework that promotes leadership, learning,
       education, creativity, innovation, quality and safe care.
      Extensive research was undertaken prior to the establishment of the unit.
      Universal floor admits patients with a variety of critical care diagnoses and acuities (not
       paediatrics, maternity or intensive care).
      Interdisciplinary team led by nurses spent twelve months examining patient and staff work
       flows, using Transforming Care at the Bedside quality improvement tools.
      Nurses were recruited from units including emergency department, intensive care and medical-
       surgical floors.
      Nurses completed a critical care course, in-service education program on special topics and
       showed critical care nurses before becoming part of the Universal Floor team.
      Headwalls of beds accommodate infusion and monitoring devices for different levels of care,
       beds incorporate alarms and scales to minimise the risk of patient falls, and all rooms can be
       set up for telemetry surveillance.
      Placing work stations next to rooms and supply carts (patient servers see figure 7) in rooms
       reduced wasteful nurse travel time and decreased nurses frustration with hunting and gathering
      Whiteboard/Inboard (see figure 8) to support communication and education – identified nurse
       caring for patient, their contact number, identified key tests/events, section for patient/relatives
       to write questions. Pinboard – education materials, reminders re diet/fluids/mobility.
      Cell phone based messaging systems enabled critical lab values to the appropriate caregivers
       and signals when bed alarms sound provided a significant patient safety benefit.
      “Career Pool” established to reduce use of agency nurses. In-house professional pool of full-
       time permanent nurses who develop clinical competencies in more than one of the eight areas.
       “Career Pool” with a 110 headcount is defined as a nursing unit, with its own staff meetings and
       quality improvement initiatives. Nurses in the career pool receive additional 10% pay and
       additional 3% for each certification they earn. Outcome is the “Career Pool” nurses make 90%
       fewer errors than agency nurses.
      Improvement in admissions process, with the charge nurse role being eliminated (did not
       “touch” the patient) and creating of a “Resource Nurse” to provide patient care support.
      Creation of a second position, “Care Tech” by cross-training unit secretaries and Transforming
       Care at the Bedside (TCAB) - how to guide developing front-line managers to lead innovation
       and improvement
      Nurses now work as part of an “Agile Team” comprising of registered nurse, licensed practice
       nurse and a care tech (or two registered nurses and a tech) with the Resource Nurse as the
       backup support.

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                                               SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
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   Team members are free to determine their respective roles on shifts on the basis of patient
    needs and census. Each team covers a cohort of 10-12 patients.
   Agile Teams have dramatically increased staff efficiency and satisfaction with positive
    outcomes on quality, safety, recruitment and retention.
   Agile Teams model aligns staff, health information technology and design. Teams
    redesigned the electronic health record built from scratch. Nurses now carry walkie-talkies
    for instant communication and wireless portable computers that allow for bedside charting,
    automatic referrals, and clinical decision support. Pharmacists work alongside the Agile
    Teams and save them time by reviewing online patient data, dispensing medications, and
    creating the electronic medication administration record. They also placed medications in
    bedside “patient servers” specially built to hold medications and supplies that nurses
    previously had to hunt down on foot.
   Agile Teams have resulted in a change from 65% nurse turnover rate to less than 10%.
   Universal unit has work stations with desktop computers approved by occupational health
    and safety with purpose built chairs. The desktop computers display hospital initiatives such
    as pressure ulcers.
   Business case for flat screen computers on arms in rooms. As an interim arrangement
    computers on wheels are provided to support point of care delivery with a ratio of one
    computer on wheels to four patients plus one for rounds.




                  Figure 6 : Cedars-Sinai Medical Centre - PICYS Medication System




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                         SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
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               Figure 7 : Patient Server




Figure 8 : Communication/Information Board Patient Room

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                                 SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
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Figures 9 & 10 : Stryker bed with falls risk/alarms and weight features


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                                                 SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
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Project Red (Re-engineering Discharge Planning)
Boston University Medical Centre develops and tests strategies to improve hospital discharge
process with the goal of improving patient safety and reducing hospital readmissions. Recently,
the Centre has launched Project Re-Engineered Discharge (RED) Project.

Project Re-Engineered Discharge (RED) has been reported to decrease preventable hospital
readmissions (reduce by 30%), reduce emergency department visits, increase patient safety,
reduce costs per patient ($412 USD) and increase patient satisfaction (Clancy, C, 2009 p 344).
This new initiative recently launched in the USA is founded on eleven discrete, mutually reinforcing
components. Currently, virtual patient advocates are being tested in conjunction with the RED.
Building on its success, Project RED is now being implemented with hospital with diverse patient
populations.

Project RED provides a new innovation to discharge planning and SA Health would need to
consider the benefit of this tool. Funding would be required for workshops to support training,
education and AHCP materials.

Project RED Toolkit comprises of:
      After Hospital Care Plan personalised for patients
      Training Manual for health professionals
      Computerised Workstation to Print the AHCP
      RED Frequently Asked Questions
      For further information and download tool kit and training manual go to
       www.ahrq.gov.news/red



Patient Flow and Electronic Bed Management System
In today’s health system timely the effective, efficient and timely access to beds is key to the
addressing patient flow and addressing access issues. In the USA real-time bed management
systems have been implemented improving patient management from the time patient is admitted
to discharge. Electronic bed management systems interfaces with environmental services, nursing
units, transport, admitting staff and entry points to the hospital such as emergency department and
outpatients.

Electronic bed management systems provide a means for centralised bed management, with an
on-line program and a ward level white board which displays relevant information.

Bed information is easily visible with information regarding transfer in/out, discharge,
occupied/unoccupied, ward floor and bed plan.

A dedicated team of two support patient flow (medical/surgical and cardiac/intensive care triage)
using the electronic bed management system. Role is to place patients into beds using agreed
criteria. The emergency departments puts a request for a bed, patient care assistant cleans the
beds, PCA cleans phone system notifies transport. Trip ticket advises oxygen requirements,
additional precautions. Electronic bed management system tracks bed turnover, provides real time
reports, support bed management dashboard monitoring of key performances.

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                                                 SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
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Electronic Health Record and Electronic Clinical Nursing Information Systems
SA Health is currently implementing the new nursing and midwifery clinical information system,
ccsa CPS. USA hospital study tour provided an opportunity to network with different informatics,
clinicians and managers regarding the implementation of the electronic health record and
electronic clinical information system solutions.

In the USA different software solutions have been developed between the different organisations
visited and vendors. The anticipated outcome of a state-of-the-art electronic medical record
system that will replace the multiple existing clinical information systems and paper charting that is
currently used. Clinical documentation all of the patient care team will use electronic clinical
documentation tools to document their patient’s care, including medical officers and patient care
clinicians. Examples of clinical documentation tools include progress notes, flowsheets and the
electronic Medication Administration Record (eMAR). Clinical content tools will be developed to
support documentation needs.

Specific education and training programs based have been developed based on the organisation’s
culture, best practices, lessons learnt from past system implementations, adult learning principles,
and change management concepts. Training and education programs for electronic medical
record (including progress notes) have been supported with:
      Super users trained, each individual nurse provided with education and training for progress
       notes 8 hour, 4 hour and 4 hour session.
      Super users – clinical champions on every shift minimum of 2 per ward/unit.
      Super users at implementation and subsequent for 4 weeks not included in direct care
       numbers (supernumerary) to support users.

Cedars-Sinai Medical Centre has provided C-S Link (200 page manual) which discusses in depth
the education, training programs to support SA Health ccsa CPS. This material has been provided
directly to the ccsa CPS Education and Training Team.

Nursing Workload and Productivity – Optilink and QuadraMed
As part of the ccsa CPS, the Nursing and Midwifery Resource Calculation model recognises the
care process, care practice and care environment elements impacting on patient care, nursing and
midwifery productivity and workload. Massachusetts General Hospital has developed Quadra Med
using a patient classification system and the Advisory Board Company has developed OptiLink.
Both systems define and quantify nursing workload, support nurse resource, inform nursing and
midwifery indicators and nursing budget and performance.

Following discussion, analysis and review of OptiLink and Quadra Med, the later provides a
potential workable solution for consideration by SA Health for future nursing and midwifery
resource calculation. MGH has provided an extensive overview of Quadra Med Model, calculation
and resource allocation for SA Health consideration. (See Appendix D)




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                                                 SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
                                                                         SCHOLARSHIPS 2009/2010 


6.6    Nursing and Technology
Across the USA hospitals a range of technology devices have been implemented to support nurses
and midwives at the bedside.

C5 Motion Tablet
      Used to capture at the bed side vital signs, document patient assessments and
       reassessments linked to the flow sheets, record diet, fluid intake and output.
      Keyboard handwriting recognition.
      Recharged at night in the nurses’ station on the toaster rack which holds five tablets.
      Assigned to each nurses on a shift by shift base
      Weighs 3.5 pounds, has a battery life of 1.5 hours, sealed for infection control, and has
       thumb print log on, a camera, RFID.
      Education and training in the use and application of the C5 Motion Tablet were provided with
       modules on basic introduction (30 minutes) and preceptor education (30 minutes). Clinical
       champions identified to support implementation.
      OH&S compliant but issue if carrying tablets for a long period and if nurses are bending over.

MC70 hand held device by Motorola
      Single sign on, with log onto network, scan identification badge
      Used at the bedside for specimen collection, medication administration, observations, BSL
      Unverified until nurses logs on – verified by RN
      Live feed directly to database supporting documentation to flow sheet

Workstations on Wheels (WOW) – Computers on Wheels (COWS)
      Mobile tool used at a large number of hospitals visited in the USA.
      Offer flexibility to access other applications and systems.
      Most sites with WOWs had modified them to meet their needs, with drawers for medications
       and charts added.
      Applications include electronic medical record, nursing and doctor progress notes,
       documentation, laboratory results, admission, discharge, transfer information, emailing and
       medical imaging.
      Enable nurses to document at the bedside and also in other areas within the department/unit.
      For sites with motion tablets one WOW per two nursing staff members, plus one WOW for
       nurse in charge of ward/unit, two WOW for medical officers (WOW for medical officers did not
       have drawers).
      For sites with WOW only one per nurse, plus one for in-charge nurse, one for care
       coordinator and one dedicated for medical officers rounds.
      Power outlet issues

Dina cart
      Key incentive for nurses and midwives to document at the bedside.
      Enables vital signs to be taken and recorded directly into the patient’s electronic record.
      Dina carts were used by UCSF in all wards.
      Initially the Dina carts were added to the WOW but found too bulky.
      Ratio is one Dina cart one per nurse on a shift.

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             Figure 11 : Dina cart         Figure 12 : C5 Motion Tablets in Toast Rack for recharging




Figure 13 : UCSF Workstation on Wheels                 Figure 14: WHC Computer on Wheels

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                Figure 15 WHC Motorola MC70




Figure 16 : Cedars-Sinai Workstations in alcoves between rooms.

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6.7    Comprehensive Inpatient Resuscitation Program - Advanced
       Resuscitation Program (ART)

UCSD implemented in 2007 an innovative program led by Dr Dan Davis that consists of a number
of elements including an advanced resuscitation training program, new inpatient treatment
algorithm, education, a rapid response team and new technology to improve pre, intra and post
resuscitation care and processes. The intent of the program was to decrease the incidence of
preventable cardiopulmonary arrest (CPA). For SA Health this program provides a potential to
improve patient outcomes and decrease costs.

Through retrospective case review at UCSD of inpatient arrest, 90% of inpatient CPAs at UC San
Diego involved a precursory drop in heart rate in response to hypoxaemia or hypotension, with
respiratory insufficiency involved in more than two-thirds of the cases. Considering this statistic,
UCSD identified the opportunity to dramatically reduce the incidence of CPA in their hospital by
detecting subtle changes in a patient’s clinical presentation, and provide early treatment. The
innovative resuscitation program’s goal was to decrease the incidence of preventable CPA in the
inpatient environment, particularly from hypoxaemia/respiratory insufficiency.

The resuscitation program includes:
      The integration of inpatient-specific resuscitation science treatment algorithms
      A sophisticated resuscitation curriculum of advance resuscitation training (ART) and basic
       resuscitation training (BART), utilising expert instructors and high-fidelity patient simulators
      Implementation of senior nurses undertaking rounds of patients twice per shift looking for
       specific triggers of patient change/deterioration.
      All nursing staff undertake the ART (in stead of Advanced Life Support) and BART (instead of
       Basic Life Support).
      Recognition of the different work environments resulted in the development and
       establishment of the BART light program for the outpatient setting. RET Respiratory
       Emergency Team and the PHart Pharmacy advanced resuscitation team.
      Implementation of a rapid response team (RRT) that is focused on preventing inpatient
       hospital arrest, by guiding diagnostic and therapeutic response to avoid further patient
       deterioration.
      Acquisition of portable monitors with the capability to display filtered ECG, continuous end-
       tidal CO2 and CPR process data, pulse oximetry and non-invasive end-tidal CO2 bedside
       monitors, and in-home-style diagnostic monitors to prospectively identify patients who are at
       increased risk of hypoperfusion, due to obstructive sleep apnoea.
The start up costs for the comprehensive inpatient resuscitation program included the annual
salaries of instructors and administrative support ($200,000 USD), two high-fidelity patient
simulators for training purposes ($130,000 USD) and wages for staff training hours ($300,000
USD). Funding for purchase of end-tidal CO2 monitoring equipment for six step-down inpatient
beds ($23,000 USD), two hours of training specific to the advanced monitoring of airway
obstruction for approximately 65 registered nurses ($2,500 USD) and eight home-style sleep
apnoea diagnostic monitors ($40,000 USD).

At UCSD it was estimated that $3,000,000 (direct and indirect) savings based on actuarial claims
report review, with five preventable critical patient harm incidents.

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The outcomes from this innovative program have been recognised at national leaders in Advanced
Life Support and Basic Life Support. UCSD has received national recognition receiving three
awards including the American Heart Association for Best Innovative Program and more recently
international recognition for this initiative. UCSD has the reported best patient outcomes in relation
to survival to discharge in the USA.

UCSD Advanced Resuscitation Toolkit (six modules) downloadable and free of change from
www.edr.ucsd.edu Resuscitation_program



6.8    Talent Management Strategies – Recruitment and Retention
Nurse Internship/Residency Program
      Structured orientation program were developed that facilitated the transition from student to
       registered nurse.
      Program provided clinical learning experiences with a preceptor and class lecture.
      Conducted over a four month learning opportunity.


Orientation Program – New Hires
      Orientation changes with dream days, surveys at 3, 6, 9, 12 and 18 months.
      Preceptor program increased to a minimum of three months.
      Boot camps introduced, sign-off bonus, relocation allowance.
      Recruitment of retiring nurses to be preceptors and mentors.
      Changes in benefits packages with additional recreation leave, education leave and health
       benefit
      Exit Process with an exit interview on the last day of duty by human resource team
      Monitoring and evaluation of nurse-turnover rates and vacancy.


American Executive Leadership (AEL)
American Organisation of Nursing Executives (AONE) has three distinct tracks: administrative,
education and clinical
      Comprehensive nurse leadership model
      Human Resource and Management
      Transition from clinical to management
      Patient safety and quality
      Finance
Toolkits (free of charge) go to: www.aone.org


Performance Management: Developing the Professional Workforce
WHC has implemented competency based performance management model to support the
development and management of nursing/midwifery workforce focusing on the importance of
leadership in developing people (See appendix B -exampe). The following provides an overview:



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Ward Managers Model
      Leadership and accountability
      Coaching, mentoring in charge nurse role
      Meet with group separately
      Resource role rotate
      Collective bargaining


Team Leaders Model
      Code of ethics eg accountability tie in what makes us accountability to quality of care
      Journal afterwards, patient safety, quality
      How can apply learning in a group session to practice
      Interactive: Falls, pressure ulcers, pain management
      Where are opportunities improving patient outcomes, plan resources, develop scenarios, role
       play (developed from feedback)
      Concept – leaders in practice


New Leader Model
Every new leader to must read:
    X 4 books
    X 2 books Quin and Studder Headway/Results that Last
    X 1 Jean Watson theorist Human Caring
    After year one will get professional executive coaching


Scheduling and Staffing - Clinical Manager Course
Improve the management of scare human and financial resources.
Aim:
    Extrapolate and interpret the necessary data elements that become the key components in
       the development of workforce action plans targeted to achieve component staff that sustain
       staffing standards and a positive fiscal outcomes.
Objectives:
    Assess and stabilise a core staffing plan that incorporates components of an integrated
       workforce model.
    Identify the components of Best Practice in Budgeting, Scheduling, Staffing Resource Team
       and Management Information.
    Apply best practice for budget compliances by reducing overtime and enhancing
       performance improvement.
    Prepare a roster and initiative a staffing based on Patient Need with the right full-time and
       part-time skill mix.
    Audit schedules not working and develop strategic for improvement
    Determine the key factors in rostering/staffing that impact on patient outcomes and fiscal
       accountability.




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Self-assessment:
     Will be able to assess unit workforce profile data daily and biweekly, which drive evidence
       based staffing and rostering
     Will be able to identify the unit work intensity and patient needs deficient and service demand
       that will drive defective rostering and staffing
     Will be able to perform a roster audit that can lead to problem solving initiatives for the
       workforce plan.


Succession Planning Model
      Chief Nurse Officer first pilot leaders with potential, introduces participants
      Shadowed three hours clinical/administration/education
      Table top exercise – 5% budget cut what decisions are to be made
      Developing the leader program - more safety and quality focus, patient satisfaction
      Three to four block - mandatory
      Reviewing code of ethics (ethical practice)



6.9    LifeWings Systems
LifeWings systems to implement improvements in patient safety, recruitment and retention of
nurses in the operating suite was been implemented in some of the USA peri-operative services.
SA Health is currently conducting workshops on Team STEPS which is a component of the
LifeWings systems.

      Focus of LifeWings is to improve teamwork, culture and safety systems by developing highly
       reliability organisations to create sustainable and measurable cultural change in health care.
      Training is based on best practices adapted from the aviation industry which has the highest
       safety record.
      Leadership and organisational development to ensure leadership team focuses on the skills
       permanently to sustain culture change.
      Customised site-specific tools to hardwire improved performance.
      Simulation to provide training and performance improvement skills and training.
      Outcomes improved in USA to improve patient safety, nurse retention and improvement
       projects.


6.10 Digging for Dinosaurs
Digging for Dinosaurs is an initiative of UCSD. This initiative enables nurses to submit an idea
about a practice issue that the individual believes should change because there may be no
evidence to support the practice, or there may be evidence to support a practice that is not
currently in place. Ideas are submitted by individuals, teams or groups using a simple proforma
(see Appendix C). The UCSD nurse education and quality improvement teams within an
improvement practice framework then undertakes with the individual/team/group that have
submitted the initiative to examine the practice, level of evidence, opportunities to support and
improve practice. The team with successful submissions are recognised at a unit and hospital
level.


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7.     Reflections

South Australian Premier’s Nursing & Midwifery Scholarship provided a unique opportunity to travel
to the USA and meet with nursing/midwifery leaders, who are successfully leading and
implementing change that is transforming care. USA like Australia is struggling to meet the needs
of complex, changing and dynamic health care environment.

The Magnet Recognition Program® provides a tangible framework embraced by the nurses and
midwives, promoting leadership, creativity and innovation. The visibility of nurse and midwife
leaders in the clinical environment was key to the effective leadership at a ward level.
Transforming Care at the Bedside initiatives supported improvements in direct care, administrative
clerical support was visible in all wards.

Cedars-Sinai Medical Centre’s Universal Floor Model encapsulated the best elements of my
hospital study tour with its geographical layout providing an efficient work environment for all, the
professional nursing model promoted leadership, critical thinking, learning, skill knowledge.
Resources that supported nurses in the workplace such as PICYS medication system, patient
servers, Stryker beds with inbuilt falls alarms, point of care technology devices.

The pace of technology changes with electronic health records being developed at sites with
different vendors highlighted the investment of USA in health technology. The role of nurse
informatics was key to the success of the new technology with large departments (26 staff)
reporting to information technology and nursing. The different approaches to electronic nursing
clinical information systems demonstrated a significant difference between Australia and USA. All
the USA nursing clinical information systems that I viewed were based on workflow systems with
no linkages to patient assessments or automatic referrals/triggers. Quadra MED at MGH and
BWH shows how an acuity system based on patient types can be successfully used to support
staffing, budget, performance. Quadra MED at MGH has similar features to the SA Health
development of ccsa CPS Resource Calculation Model.

Nurses and midwives who hosted by visits to hospitals were opening and welcoming. All had
developed specific programs to ensure my hospital tour objectives were met and provided
resources to support SA Health, nursing and midwifery. Subsequent to my hospital study I have
continued to have conversations and share information with my USA counterparts.




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8.    Dissemination of Learnings

8.1   Dissemination of resources
         C-S Link Training and Education Manual provided to SA Health ccsa CPS Project
         Member of ccsa CPS Organisation Readiness Group – dissemination of information
          regarding implementation, support and education models, point of care technology.
         Nursing and Midwifery Metrics definitions, dashboard and scorecards examples provided
          to the Senior Project Nurse, Nursing Metrics Project, Nursing and Midwifery, SA Health
         USA Leadership Models provided are resources to nursing leaders
         Project RED toolkit provided to CNAHS discharge team
         Information regarding IHI website provided to key nursing and midwifery leaders
         TCAB initiatives discussed with Nursing Directors, Royal Adelaide Hospital


8.2   Presentations/Dissmenination of Information
         Royal Adelaide Hospital, Operating Room Services, Nursing Executive Forum
         Discussion with Ms Jenny Beutel, Chief Nurse, Nursing and Midwifery Office
         Discussion with Ms Di Rogowski, CNAHS Nursing and Midwifery Executive Lead
         Discussion with Ms Sally Soebel, DoH Workforce regarding universal floor.
         Discussion with nurse and midwifery leaders at CNAHS Regional Workforce Workshop
          regarding hospital tour findings.
         Future presentations CNAHS Regional Forum, Senior Management Forum, CNAHS,
          RAH Nursing Forum


8.3   Implementation
         Working with CNAHS RAH Staff Development Director and CNAHS Organisational
          Psychologist Consultant on developing 2010 Nursing and Midwifery Leadership
          Development Model based on USA leadership findings.
         Networking with leading nurses and midwives regarding successful critical thinking
          models.


8.4   Abstract
         Submitted to the Health Informatics Conference in August 2010




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9.              Budget

Activity                                       Accommodation         Travel Ins Gifts           Incidentials               Breakfast                     Lunch                      Dinner              Air Travel             Airport Transfer           Train Travel                     Taxi              TOTAL
                                               USD        AUD        USD          AUD          USD        AUD            USD        AUD            USD           AUD          USD            AUD      USD         AUD          USD         AUD           USD         AUD             USD          AUD        AUD
Travel Adel to LA                                                             $   401.00                                        $       9.00 $       0.75 $        0.86                                       $ 3,250.00 $      30.00 $      34.50                                                       $    3,695.36
Cedars Sinai Medical Centre                                                   $   146.00                             $    25.80 $      29.67 $      22.30 $       25.65 $      25.80 $        29.67                                                                                                      $     230.99
Cedars Sinai Medical Centre                                                                                                                                               $    49.60 $        57.04                                                                                                      $      57.04
Cedars Sinai Medical Centre                           $   586.64                                                     $     3.25 $       3.74 $       4.30 $        4.95 $      16.65 $        19.15                                                                                                      $     614.47
Travel LA to San Diego                                                                                               $     7.32 $       8.42 $      25.50 $       29.33 $      39.95 $        45.94                                                  $    29.00 $        33.35 $     199.00 $     228.85 $     345.89
UCSD, San Diego, Travel to San Francisco              $   177.66                           $     2.00 $        2.30 $      -    $        -     $     -      $       -     $    11.00 $        12.65           $      59.60 $    68.54 $      78.82                               $    50.50 $      58.08 $     389.11
UCSF, San Francisco                                                                        $     9.95 $        11.44 $    38.26 $      44.00 $       -      $       -     $    43.30 $        49.80                                                                              $    25.00 $      28.75 $     133.99
UCSF, San Francisco                                   $   598.16                                                     $     2.85 $       3.28 $      26.09 $       30.00 $      26.00 $        29.90                                                                              $    20.50 $      23.58 $     684.92
Nursing Informatics                                                                                                  $    11.03 $      12.68 $      11.73 $       13.49 $      38.05 $        43.76                                                                              $    64.95 $      74.69 $     144.62
Nursing Informatics                                                                                                             $        -                  $       -     $     6.48 $         7.45                                                                                                      $         7.45
Nursing Informatics                                                                                                  $     2.15 $       2.47 $       4.32 $        4.97 $      37.02 $        42.57                                                                                                      $      50.01
Nursing Informatics                                   $   614.56                           $    14.99 $        17.24 $    18.87 $      21.70 $      24.00 $       27.60 $      68.38 $        78.64                        $    30.00 $      34.50                                                       $     794.24
Travel Los Vegas to Washington, DC                                                                                   $    17.36 $      19.96 $      29.00 $       33.35 $      25.00 $        28.75                                                              $   136.87 $         55.00 $      63.25 $     282.18
George Washington Hospital                                                                                           $     1.92 $       2.21                              $    40.00 $        46.00                                                                              $    42.50 $      48.88 $      97.08
George Washington Hospital                                                                                           $    10.79 $      12.41 $      20.90 $       24.04 $      44.73 $        51.44                                                                              $    51.25 $      58.94 $     146.82
Washington to Philadephia                             $   759.99                                                     $    15.67 $      18.02                              $    70.39 $        80.95                                                  $    20.00 $        23.00 $      82.21 $      94.54 $     976.50
Abington Medical Centre, Philadephia                                                                                                           $    17.03 $       19.58                                                                                                                                  $      19.58
Travel Philadephia to New York                        $   172.91                                                     $    11.84 $      13.62 $      45.02 $       51.77 $      45.45 $        52.27                                                                              $     4.90 $       5.64 $     296.20
Engelwood Medical Centre, New York                                                                                   $    13.65 $      15.70 $      37.05 $       42.61 $      31.26 $        35.95                                                                                                      $      94.25
Engelwood Medical Centre, New York                                                                                   $    21.66 $      24.91 $       2.85 $        3.28 $      16.33 $        18.78                                                                                                      $      46.97
Engelwood Medical Centre, New York                                                                                   $     5.20 $       5.98 $      30.47 $       35.04 $      57.92 $        66.61                                                  $     8.80 $        10.12                           $     117.75
Engelwood Medical Centre, New York                    $ 1,789.00                           $    12.95 $        14.89 $    18.88 $      21.71 $       5.03 $        5.78 $      86.72 $        95.93                                                                                                      $    1,927.32
Travel New York to Boston                                                                                            $    13.20 $      15.18 $       8.25 $        9.49 $      20.89 $        24.02                                                                              $    20.00 $      22.00 $      70.69
Massacheustus General, Boston                                                                                                                  $    32.15 $       36.97 $      39.23 $        45.11                                                  $     4.00 $         4.40                           $      86.49
Massacheustus General, Boston                                                              $    14.95 $        17.19 $     3.00 $       3.45                              $    45.00 $        51.75                                                  $     2.00 $         2.20                           $      74.59
Travel Boston, New York to Adelaide                   $   772.81                                                     $     3.95 $       4.54                              $    18.00 $        20.70                                                                              $    30.00 $      33.00 $     831.05
                                           $      -   $ 5,471.73 $      -     $   547.00 $      54.84 $        63.07 $   246.65 $      292.65 $    346.74 $      398.75 $     903.15 $ 1,034.82 $       -     $ 3,309.60 $     128.54 $     147.82 $      63.80 $    209.94 $        645.81 $     740.18 $ 12,215.56




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10. Itinerary


    Date          Day     Country          Location                            Activity

 02/10/2009   Friday      Australia   Adelaide             Travel Adel to LA
 03/10/2009   Saturday    USA         LA                   Cedars Sinai Medical Centre
 04/10/2009   Sunday      USA         LA                   Cedars Sinai Medical Centre
 05/10/2009   Monday      USA         LA                   Cedars Sinai Medical Centre
 06/10/2009   Tuesday     USA         LA                   Travel LA to San Diego
 07/10/2009   Wednesday   USA         San Diego            UCSD, San Diego, Travel to San Francisco
 08/10/2009   Thursday    USA         San Francisco        UCSF, San Francisco
 09/10/2009   Friday      USA         San Francisco        UCSF, San Francisco
 10/10/2009   Saturday    USA         Los Vegas            Nursing Informatics
 11/10/2009   Sunday      USA         Los Vegas            Nursing Informatics
 12/10/2009   Monday      USA         Los Vegas            Nursing Informatics
 13/10/2009   Tuesday     USA         Los Vegas            Nursing Informatics
 14/10/2009   Wednesday   USA         Los Vegas            Travel Los Vegas to Washington, DC
 15/10/2009   Thursday    USA         Washington, DC       Washington Hospital Centre, DC
 16/10/2009   Friday      USA         Washington, DC       Washington Hospital Centre, DC
                                      Washington, DC to
 17/10/2009   Saturday    USA         Philadelphia         Washington to Philadelphia
 18/10/2009   Sunday      USA         Philadelphia         Abington Medical Centre, Philadelphia
                                      Philadelphia to
 19/10/2009   Monday      USA         New York             Travel Philadelphia to New York
 20/10/2009   Tuesday     USA         New York             Englewood Medical Centre, New York
 21/10/2009   Wednesday   USA         New York             Englewood Medical Centre, New York
 22/10/2009   Thursday    USA         New York             Englewood Medical Centre, New York
 23/10/2009   Friday      USA         New York             Englewood Medical Centre, New York
 24/10/2009   Saturday    USA         Boston               Travel New York to Boston
 25/10/2009   Sunday      USA         Boston               Massachusetts General, Boston
 26/10/2009   Monday      USA         Boston               Massachusetts General, Boston
 27/10/2009   Tuesday     USA         Boston to Adelaide   Travel Boston, New York to Adelaide




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11. References


Pileggi, J. (2009). Cedars Sinai’s Universal Floor, Unit Scope of Service”, Cedars-Sinai Medical
Centre, pp1-6.

Davis D (2007) ‘Comprehensive Inpatient Resuscitation Program Report, Advanced Resuscitation
Program’, University of California, San Diego, pp1-7

Clancy CM (2009) “Reengineering Hospital Discharge: A Protocol to Improve Patient Safety,
Reduce Costs, and Boost Patient Satisfaction”, American Journal of Medical Quality, 24: 344.
Available at http://ajm.sagepub.com

Millar S (2009) “Nursing Workload and Productivity Report”, Massachusetts General Hospital, pp1-
13

Miltner RS (2009) “Performance Management: Developing the Professional Workforce”,
Washington Hospital Centre, 1-12

Rutherford P, Bartley A, Miller A et al (2008) Transforming Care at the Bedside How to Guide:
Increasing Nurses’ Time in Direct Patient Care”, Cambridge, MA: Institute for Healthcare
Improvement. Available at www.IHI.org

The Advisory Board Company (2008) “The Online Metric Selection Tool”, The Advisory Board
Company, Washington, DC. Available at www.advisoryboard.com

University of California San Diego Medical Centre (2009) “Department of Nursing Education,
Development and Research Summary Report, FY08/09”, UCSD, pp1-26

SA Health Strategic Plan 2008-2011




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12. Appendices

Appendix A : Universal Floor Model
In 2006 Cedar-Sinai Medical Centre opened a 30 bed Universal Unit (CSUU) with telemetry
capabilities. This unit receives direct admits and patients from the emergency department who
need admission to a monitored or medical/surgical bed. The Unit was recently recognised as a
best practice model. Universal Floor Model allows certain patients to remain in one adaptable room
and bed whilst receiving different levels of care from nurses who have received specialised on-the-
job education at Cedars-Sinai Medical Centre.

The nursing team assumes the responsibility and accountability for the application of the nursing
process and delivery of patient care. The nursing team makes clinical judgements and carries out
related nursing intervention using the nursing process, applies clinical knowledge regarding
standard pattern of care to consolidate interventions for time and cost savings.

Unit Profile
The Universal Unit is a thirty bed unit with a projected average daily census of twenty-six. Eighty-
five percent (85%) of the patients are admitted from the emergency department and the remaining
fifteen percent (15%) from specialist/general practitioner’s offices. Daily average occupancy
eighty-six percent (86%). (26), providing twenty-four (24) hour patient care. The Unit is part of the
Cedars-Sinai Medical centre Critical Care Services and is located within the Saperstein Critical
Care Tower. The Unit has all single rooms. The ward secretary provides administrative support is
provided twenty-hours per day, each day of the week.


Scope of Service Provided:
The Universal Unit patient population is made up of adult patients that may or may not require
electronic monitoring for cardiac status. It is designed to facilitate admissions from the Emergency
Department, Ambulatory Clinics and the doctors’/specialists’ offices. Admissions to the unit are
managed by the Admissions Department and the Transfer Centre. The most common
medical/surgical diagnoses include, but are not limited to, Asthma, COPD, Pneumonia, Respiratory
Failure, Cancer, as well as, a wide variety of medical disorders such as DVT, GI Bleed, CVS,
Dehydration, Diabetes and Urosepsis, Rule-Out Myocardial Infarction, Post-Acute Myocardial
Infarction, Unstable Angina, Congestive Heart Failure, Dysrhthymias, Status Post PTCA, and
Status Post Ablation. Although adolescent through elderly patients are admitted to the unit, most
patients are adult or geriatric. Transfers of patients to appropriate beds in the main medical centre
will be accomplished to facilitate patient flow and the ‘bed ahead’ concept’.

The Universal Unit is staffed by highly qualified heath care professionals who use specialised
equipment to provide safe, competent, efficient and effective patient care through frequent medial
and nursing assessment, planning, intervention and evaluation. Patient care needs are
determined by interdisciplinary assessment and patient care planning. Patients that require a
higher level of care are transferred to intermediate care or to an intensive care unit. Patients who
do not require cardiac monitoring may be transferred to a non-monitored unit or may remain on the
Universal Unit. Standards of the American heart Association, American Cardiology Care,


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American Association of Critical Care Nurses (Progress Care Standards) and American Nurses
Association Practice Standards are used to guide patient care.

Organisation of the Unit/Department
The Nurse Manager reports to the Director of Critical Care services who reports to the Vice
President and Chief Nursing Officer. The Medical Director of Universal Unit is an active member of
the medical staff. In the absence of the medical director another full time member of the medical
staff assumes responsibility.

Staffing Plan
Staffing is based on the identified volume and acuity of patients determined by patient needs.
Core staffing is determined by analysis of annualised data from the patient classification system.
The Unit’s staff plan is Charge Nurse, Clinical Practice Consultant, Cardiac Monitor Technician and
registered nurse to patient ratio is based on Title 22, California Code of Regulations, Section
70217, patient care needs and number of patients on the unit. The Universal Unit maintains
minimally one licensed nurse to four patients. Nurses are educated to care for the medical patient
population primarily consisting of general medical, pulmonary, cardiology and the pre and post
international cardiology patients.

Assessment and reassessment timeframes and parameters:
The initial nursing assessment is completed within two hours of admission. A complete
reassessment is completed every twelve (12) hours or when the status of the patient changes.
Patients may or may not be on continuous cardiac monitoring.

Admission, Discharge and Transfer Criteria for Unit:
Admission criteria includes but is not limited to:
          IV infusions that
           o Require titration (Aminophylline, Heparin, Morphine)
           o Do not require titration (cardiac)
          Patients requiring continuous pulse oxyimetry
          Respiratory Failure
          Pneumonia
          Chronic Obstructive Pulmonary Disease or Asthma
          Patients requiring chemotherapy
          Continuous cardiac monitoring
          Patients requiring cardio version
          Rule out myocardial infarction
          Angina in the haemodynamically stable patient
          48 hour post Acute Myocardial Infarct
          Patients with arrhythmias
          Patients post-cardiac intervention procedure

Transfer criteria includes, but is not limited to:
          Availability of appropriate “specialty” beds within the main medical centre
          Patients no longer requiring cardiac monitoring or cardiac intravenous infusions

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          Patients without chest pain for twenty-four hours
          Patients in normal sinus rhythm or chronic atrial fibrillation
          Patients requiring a higher level of care as is indicated by a change in the patient’s
           physiologic condition

Patients appropriate for discharge from the unit include, but are not limited to those
patients whose:
          Initial condition requiring inpatient hospitalisaton is stable or managed
          Infection is controlled
          Acute phase of their chronic illness is reversed
          Level of comfort has improved

Interdisciplinary Patient Care Planning:
Interdisciplinary Patient Care Planning takes place daily on Universal Unit. Formal team planning
conferences occur daily Monday through Friday. Informal planning conferences occur on the
weekend and as needed. The Universal Unit interdisciplinary team is made up of staff members
representing nursing, physical therapy, case management, social services, clinical nutrition, clinical
nurse specialist and pharmacy. Other disciplines are in attendance as specific patients needs
require.


Nurse Education Program
          Diverse patient population from liver transplant, heart transplant, GI, renal, cardiac
          Telemetry Program
           o ECG Module
           o Neurology Module
           o CVS Module ACS, Vascular and Heart Module
           o Haematology/Oncology Module
           o GI Module
           o Cardiology Module including Cardiomyopathy
           o Endocrine Module
           o Rapid Response Team/Code Blue Module




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Appendix B : Washington Hospital Centre Frontline Managers

           Day 1                          Day 2                            Day 3                           Day 4
Registration/Introduction       Rostering and Staffing         Daily Staffing Strategies         Case
 Review 2 and 4 day            Overview/ Systems               Creating and Resource           Studies/Presentation
  agenda and objectives          Fair Labour Regulations        Centre/managing Staff
                                                                                                 Post Test
 Pre-test                       Principles of rostering,       Deployment
                                  rostering methodologies          Policy/Procedure              Closing
Overview for the                                                   Operational Clarity
                                  and types of rosters
Workforce Management                                                                             One on One
                                                                   Supplemental
                                Roster Development                                               consultation/problem
Budget                                                             (Agency/Casual)
Overview/Minimum
                                 Best Practice Rostering          Roster/Staffer Job
                                                                                                 solving with
                                  Assessment                                                     consultants.
Expectations/Best                                                  Description and
Practice                         Line and Staff                   Evaluation
                                  Functions in                     Daily Staffing Report
 Definitions/Formulas
                                  Staffing/Rostering               Card – Exercise
 Unit Budget Summary
  Exercise (all attendees
                                 Rostering Policy Rules           Exercise all attendees to
  bring one unit budget          Roster Guidelines and            bring a copy of job
  with corresponding              Rosterer Checklist               description for staffers,
  variable staffing plans        Employee                         rosters and staffing
  and position controls)          Requests/Conflict                coordinators used at
                                  Resolution                       each hospital, Resource
Budget/Defining Your             Unexpected Absences              Centre policies and a
(individual unit) Roster          and Implications for             sample Staffing Report,
Requirements                      Rostering                        Staffing
 Weekly Staff Pattern/Unit                                        Scorecard/Report Card
   Rostering Requirements       Deficit Demand
                                Management                     Rostering, Workload
   (Exercise)
                                 Sitters (Patient Carers)     Payroll/T&A Automation
      Exercise: all
                                                               Technology
      attendees to bring one     Overtime Management
      schedule and                    Drivers for overtime      Interfacing – What it is/What
      corresponding daily             Determining goals          it isn’t and Measuring ROI
      staffing plans for the          and creating an          Benchmarking: National
      unit, service line or           overtime plan            Survey of Hours Report
      nursing department         Fatigue Research and          Effective
      Direct FTEs                 Implications to                Dashboards/Benchmark to
      Indirect FTEs               Rostering                      Whom and Why
      Education/Orientation                                     Exercise to evaluation your
                                Measuring Roster
Position Control,               Quality/Conflict                 hospital benchmark report –
Turnover and Unit               Resolution                       Exercise
Erosions                         Roster Audit Tool                 Exercise all attendees to
 What it is and isn’t            (Exercise)                        bring a copy of the
 Full-time/Part-time Ratios         Exercise all                   benchmark report used
  (Exercise)                         attendees to bring             at each hospital for
      Exercise: all                  one fully worked and           discussion
      attendees to bring one         one newly published       Management and Variance
      unit budgets with              unit/ward roster to       Reporting (Data Vs
      corresponding                  use.                      Information)
      variable staffing plans                                   10 Most Important Numbers
      and position control                                        and Best Practices
 Best Practices                                                Manager Bi-Weekly
                                                                  Reporting
                                                                Exercise to evaluation your
                                                                  hospital report
                                                                    Exercise all attendees to
                                                                    bring a copy of bi-weekly
                                                                    management or
                                                                    productivity report for
                                                                    discussion


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                                   SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
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Appendix C : UCSD – Digging for Dinosaurs




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Appendix D : Quadra Med
Quadra Med’s Patient Classification System was first implemented at MGH in 1985. It has a factor
evaluation tool in which the critical indicators of the patient needs are used to categorise patients
into one of the six types. Patients are classified according to their needs for care rather than the
amount of time that staff is able to provide. The tool has been revalidated.

The following provides an overview of the Quadra Med working model:
      Acuity = Patient Needs for Nursing Care
      Vary from patient to patient and for same patient, from time-period to time-period.
      Measured by the Quadra Med system
        o Factor evaluation tool using 30 critical indicators
        o Aggregates patients into six homogenous categories based on nursing care needs
        o Categories have assigned values that quantify relative needs for nursing care in 24
            hours

Nursing Workload
      Nursing workload is a function of:
        o Census = number of patients requiring care
        o Acuity = extent or intensity of patients’ care needs
      Traditional measurements
        o Patient days as determined by midnight census
        o Patient location, IE ICU vs non-ICU unit
      Not captured with traditional measurements
        o Variability of numbers of patients throughout the day
        o Variability of care needs from patient to patient or, for same patient, from day to day

Workload
      Census and acuity combine to quantify workload
         o Workload = weighted census, adjusted for nursing care needs of patient
         o Similar to DRG (Diagnosis-Related Groups) case weights = cases adjusted for
            variations in medical needs of patients
      For an individual unit, workload = sum of acuity values for all patients
      For an individual patient, workload = sum of acuity values for all (length of stay adjusted)
       inpatient days.

Census and Length of Stay Adjustment
      Patients require nursing care from time of admission/transfer in to time of discharge/transfer
       out
      Midnight census x 24 does not equal total hours of patients’ stays
      Calculate length-of-stay adjusted patient days
        o Admission/transfer in and discharge/transfer out times – from admission, discharge,
            transfer system interface
        o Total hours/24 = length of stay adjusted patient days




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                                                  SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
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Advantages
      Patient – specific information
        o Daily acuity for every day of the length of stay
        o Each indicator that is marked for each day
        o Total workload for the length of stay
        o Average workload for the length of stay
      Unit – specific information
        o Midnight and classification census
        o Number of patients by type
        o Indicator utilisation
        o Staffing data
      Comprehensive management information structure
        o Standard system reports
        o Relevant data uploaded to cost accounting system, i.e. Transition systems Inc (TSI)
        o Relevant data downloaded to spreadsheets
      Creation of routine and ad hoc reports
        o Trending and forecasting
        o Variance analysis
        o Patient profiling
        o Productivity analysis
        o Unit profile comparison


Acuity/Staffing
                                                  I        II        III           IV         V          VI
 Hours of Care Per 24 Hours (Generic Times)     0-4        4-7      7=10         10-14      14-20        >20
 Hours of Care Per 24 Hours (MGH hours          3.68      5.26      7.89         12.10      16.31       24.20
 based on THPWI of 5.26)
 Acuity Value                                    0.7       1.0       1.5          2.3         3.1        4.6
                                                                           Copyright of QuandraMedTM Corporations



Validity and Reliability
      Validity – tool measures what is stays it measures
        o Validated with original research in 1970’s
        o Regularly refined, updated and revalidated
                     Most recent revalidation completed in 2006
                     MGH participated in this revalidation
      Reliability – accurate application of tool
        o Requires a clear definition and consistent interpretation of indicators
                     Initial education and reliability testing for all staff nurses
                     Continuous, ongoing monitoring of interrater reliability




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                                                SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
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Nursing Resources
      Resource allocation is based on patients’ needs for nursing care
        o Direct variable nursing staff
        o HPWI (hours per workload index) = care hours required in 24 hours for benchmark Type
           II patient
        o HPWI x total workload = total care hours in 24 hours
        o System recommends a range of hours

Additional Organisation-Determined Parameters of Staffing
      Staff mix – requirements can vary based on
        o Complexity of patient needs
        o Care delivery model
        o Availability of other professional and ancillary staff
      Distribution of care over 24 hours – requirements can vary based on patient-related activities
       and care needs over different times of the day.

Evaluating Appropriateness of HPWI
How do we assure that staffing target is adequate and reasonable?
      External review
         o Magnet review of adequacy of staffing
         o Joint Commission review of adequacy of staffing
      Institution-specific review
         o Quality outcomes
         o Patient satisfaction
         o Staff satisfaction
         o Financial/flexible budget analysis

Organisation Vs System Accountabilities
      System defines methodology for measuring workload and staffing
      Organisation defines productivity targets (HPWI, mix and shift distribution)
      Organisation applies methodology via patient assessment (classification) and staffing report
      System calculates actual workload and productivity, reporting recommended staffing and
       productivity variances based on organisation’s targets.

Implementation
      Classify every patient every day
      Input actual daily staffing every 24 hours
      Store data at the most detailed level
         o Daily acuity for every hour of the length of stay
         o Each indicator that is marked for each day
         o Detailed daily staffing data
      Interface with existing systems
         o Admission, discharge, transfer system feeds classification system for patient data
         o Classification system can feed cost account system for costing and flexible budget
             analysis

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                                                SOUTH AUSTRALIAN PREMIER’S NURSING & MIDWIFERY  
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Uses of Data
      Projecting resource needs
      Analysing performance
      Understanding patients and patients needs
      Responding to external issues and requirements
      Trending and forecasting
      Benchmarking
      Costing and cost analysis
      Research

Answering Questions
      What is the cost of nursing care for particular patients or groups of patients
      How do reductions in length-of-stay affect the average acuity, total workload and resource
       requirements of a group of patients
      If the mix of patients changes, what is the impact on nursing resource requirements
      What drives differences in nursing costs for specific patient populations across entities

Future Considerations
      Educate leaders and others outside of nursing on functionality, use and value of system
      Assure ongoing availability of resources to maintain the system
      Maintain consistent status across entities
        o Implementation of upgrades
        o Use of additional tools eg Mental Health
      Implement consistent methodology for interface with cost accounting system
      Develop uniform methodology for reporting and benchmarking.




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