- Email: [email protected]
Mentoring data accountability in managers to improve staffing
Deborah Crist-Grundman, RN, BSN Successful manager behaviors and approaches of the past are no longer effective because they are not in sync with the organizations needs to prosper not only today but also well into the future. Why are past approaches vulnerable? First, too much emphasis was placed on decentralizing processes and decision making. We’re different often became a banner response for variation, and we lost a sense of common values and shared principles surrounding patients and nursing. At times, individual managers opted out of nursing-wide activities on the premise that their service was different and those things didn’t apply. This resistance created discord among managers. When operational questions arose, managers naturally responded with opinion-based information and seldom were asked to provide data to support their positions. Managers tended to be very process oriented rather than focused on outcomes. 46 Nurse Leader
July/August 2003
In many instances we have done a disservice to middle managers. Only in the past 5 years have we recognized the need to push accountability for business outcomes down within management ranks. Managers have not always been integrally involved in the development of organizational objectives, plans, and budgets, yet the manager is the essential front line in positioning the organization to achieve desired outcomes. One challenge for the chief nurse executive (CNE) is the need to make an investment in the management team that promotes data-oriented decision making and accountability for outcomes. As Jan Carlzon, former chief executive officer of SAS and author of Moments of Truth, once said, “An individual without information cannot take responsibility; an individual who is given information cannot help but take responsibility.”1
WHY SYSTEMS AND DATA-ORIENTED DECISIONS ARE NECESSARY
such professional services as planning, evaluating, and teaching. The nurse-generated patient acuity data are used in care management decisions, such as assignments, care prioritization and delegation, and patient placement and triage, to name a few. The staffing system creates hospitalspecific staffing standards at each acuity level that take into account the care requirements of patients and families, the physical plant structure, availability of support systems, and skill mix requirements. The activity studies that generated the staffing standards also provide information about how staff spend their time and how patients and their families consume staff time. The productivity management system provides nurse managers with a unit-specific, patient-sensitive staffing plan. This system also provides managers who are accountable for appropriate use of resources with the ability to objectively determine units with the greatest need or risk when those resources are limited. Once staffing decisions have been made, the productivity management system provides information, on a daily and shift basis, on the effectiveness of staffing decisions by defining the variance between what was required and what was provided. And finally, the audit system provides ongoing information surrounding the validity and reliability of the patient acuity information that is driving decisions. All of these systems and the data they generate are nursing based, positively positioning nursing for compliance with state and JCAHO staffing effectiveness standards.
Why are systems that generate objective, quantifiable data necessary? The answer is simple. The organization must perform critical decision making based on objective data. It is clear to CNEs that someone will measure us (nursing), and it is better that we choose the tools by which we will be measured than letting others choose. This statement does not presume a negative intent on the part of others, but are we not best able to determine what accurately and completely captures the essence of nursing? Benchmarks are useful but tend to be single-dimensional models based on total worked hours, adjusted patient days, or unit type, such as step-down, medical or surgical, MENTORING DATA ACCOUNTABILITY telemetry, etc. The vulnerability of these benchmarks is Weisinger2 said, “A work organization is a holistic entity, that they tend to negate individualized patient-care an integrated system that depends upon the interrelationrequirements. ship of the individuals who We must have systems are part of it. How each that put the patient at the person performs affects the The activity studies that generated hub of care, the center that company as a whole. That’s the staffing standards also provide influences decision making. why it’s so important to the For many years Scott & success of the company not information about how staff spend White Memorial Hospital only that all employees pertheir time and how patients and their had a homegrown patient form to the best of their acuity system that was task abilities but that they also families consume staff time. oriented and driven by time help others do the same.” and frequency of tasks. The CNEs should not be naive acuity system was different for every unit, did not weigh in thinking that just because their managers have data they the value of professional nursing services or the nursing know what to do with it. After ensuring that managers process, and did not address the collaborative nature of have tools in place to generate necessary data, the next care on a continuum. To this end, Scott & White implestep is to assess manager skill sets surrounding data assimmented a series of systems on the basis of recommendailation and application. The following steps were impletions from a nationally recognized firm. Information genermented to address this need. ated by these management systems includes patient acuity, Scott & White’s CNE and a consultant developed a manstaffing standards by acuity, required direct care hours, ager self-assessment tool. It was organized by the 4 core systems that defined principles at play within each system, actual worked hours, productivity variance, and validity the processes used to generate data, and potential applicameasures of patient acuity. tions of data. The CNE, consultant, and director of producThe patient classification system now crosses clinical tivity and quality reviewed the self-assessments; then the services, units, diagnoses, and DRGs. The classification consultant and director conducted one-on-one sessions criteria are multidimensional and weighted, emphasizing July/August 2003
Nurse Leader 47
Table 1. Total Hip Standards of Care Nursing diagnosis: Pain related to surgical procedure as evidenced by verbal/nonverbal behavior Patient outcome: Patient will receive adequate pain relief with use of prescribed analgesics as evidenced by verbal/nonverbal behavior Nursing interventions: RN: Assess pain, provide comfort measures, apply ice to incision prn, administer analgesics as ordered, keep affected leg in abduction with pillow in place as ordered, assess effectiveness of pain relief measures LVN: Assess pain, provide comfort measures, apply ice to incision prn, administer analgesics as ordered, keep affected leg in abduction with pillow in place as ordered UAP: Provide comfort measures, apply ice to incision prn, keep affected leg in abduction with pillow in place as ordered
with each manager to respond to specific learning needs. Using data specific to the individual manager and his or her unit or units, data analysis was performed, and action plans were developed. The director and consultant also met with unit-level leaders (managers and lead staff nurses) to review system principles, data generated, and application of data at the point of care. This meeting is an essential step in ensuring the ongoing accuracy of nursing data generated at the point of care. The staff were engaged and interested in understanding how to do things right. They asked important questions and voiced concerns, making the interchange very healthy. The CNE incorporated standing agenda items surrounding productivity management and audit report data within established manager meetings (individual and group). Action plans were reviewed and modified when goals were achieved or the plans failed to resolve issues. This protocol provided natural forums for mentoring to occur by the CNE, director, and manager peers. The CNE and managers incorporated data values from productivity management and audit reports as performance targets within the manager performance appraisal.
ADDRESSING PERFORMANCE WEAKNESSES One of the most important yet difficult courses of action a CNE must take is defining and implementing consequences when managers and units do not meet targets. An illustration of this was when at Scott & White several managers’ units had not achieved the targeted acuity validity on monthly audits within reasonable time frames. Audit reports consistently demonstrated that the acuity levels of patients on several units were overstated by unacceptable margins. The unit-generated acuities were feeding into the productivity management system to create the staffing plan 48 Nurse Leader
Table 2. Acuity-based Budgeting and Skill Mix Development Unit name: 5W Budgeted patient days: 4563 Average acuity: 2.49 Acuity Level
% Distribution
1 2 3 4 5 6 7
5 55 27 12 1 0 0
Unit constant Total variable hours Skill mix %
RN Hours
LVN Hours
UAP Hours
329 5772 5014 3510 472 0 0
281 3212 1676 750 0 0 0
329 3840 1676 750 84 0 0
664 15761 52
398 6317 21
1595 8274 27
for required direct care hours. Overstated acuities led to overstated required hours. The CNE met with each affected manager and said that, until audit measurements demonstrated that they had achieved targeted accuracy, the staffing plan for required hours would be adjusted down on the basis of the degree of inaccuracy measured and reported monthly on the unit’s audit reports. The CNE also required the managers to develop time-limited, measurable action plans to resolve the discrepancies. Although this effort clearly took the CNE’s time and energy, it was necessary to demonstrate that the performance targets had meaning and that each manager would be held accountable for achieving them. Think of the message that would have been sent to the managers who were achieving performance targets if the CNE had not taken this step. The director provided opportunities to all managers who thought they needed additional support in interpreting and applying the data generated by their nursing management systems. Next, the CNE used established performance targets in the annual performance appraisal process. These actions reinforced the stated expectation that managers are accountable for achieving set goals and that managers are responsible for the integrity and application of the data being generated by their systems. At Scott & White, nursing now is not only using its own data for internal decision making and outcome evaluation, but also driving data and information about the business of patient care up within the organization.
NURSE DATA USED IN STRATEGIC PLANNING Responding to the nursing crisis, the Scott & White CNE defined an initiative to re-evaluate the patient care delivery July/August 2003
model along with roles and responsibilities of nursing care of professional and licensed care givers. By evaluating acuteam members. Questions at issue included how to retain ity-based skill mix, our fiscal year 2002 full-time equivalent the registered nurses we currently have, have them do the employees increased by 23 and costs were reduced by $1.2 things that they must do, figure out who can do the rest, million, as shown in Table 2. and engage support from other departments. Directors, managers, and staff nurses evaluated activity study data in MANAGEMENT ACCOUNTABILITY AND DATA combination with Texas regulatory role and scope docuINTEGRATION ments to identify ways to maximize scope of practice in Ownership of data has changed. Figures once were each team member role. They ultimately decided on a somebody else’s, like finance or management engineering. modified team nursing care model and began refining their We in nursing had little influence over tool design, and we standards of care by role. Table 1 gives an example of stanwaited for our information to be handed to us. Today, the dard care for hip patients, broken down by role. health care environment demands that nursing contribute Optimizing bed availability and capacity management is to the data forming the business of patient care. We must another challenge. How do ensure that we establish we ensure that patients are systems and tools that crein the right place, provide ate valid, reliable data and Acuity-based budgeting positions an an appropriate level of that we monitor and elevate organization to discretely define the care, and have beds availthe level of data sophisticaable for patient admissions? tion of our managers. We required resource dollars and skill mix Patient acuity data are one integrate data and its necessary to care for the population of must variable in aligning individapplication into our daily ual patient care requireoperational practices, patients served on each specific unit. ments with appropriate becoming proactive rather placement on a shift-bythan reactive. Nursing shift basis. needs to anticipate and provide answers to organizational Patient acuity data also can be valuable in facility planquestions before they are asked. It is time that nursing ning when defining how many of each type of bed are leaders came prepared to the proverbial table with quantruly necessary. Do we need more critical care beds tifiable information focused on ensuring quality outcomes and affordable care. because intensive care patients are consistently being held in the emergency department? Do we need more med/surg beds because patients who could be cared for References 1. Woods J. The quotable executive. New York: McGraw-Hill; 2000. p. appropriately there are occupying ICU beds? Are postacute 131. care beds available? Using occupancy and availability data 2. Weisinger H. Emotional intelligence at work. San Francisco: alone does not always tell the true story. Adding patient Jossey-Bass Inc; 1998. p. 183. acuity to the decision mix helps identify the real capacity 3. Crist-Grundman D. Demand-side management: link patient, staff data to promote quality, reduce cost. Patient Care Staffing Report needs of the patient population being served. 2002 Dec:3-4. Budget forecasting and skill mix development are other 4. Texas Department of Health Texas Register Title 25, Chapter 133, uses of acuity and staffing data. Acuity-based budgeting Article 133.41 Subchapter C, November 2001. positions an organization to discretely define the required 5. Joint Commission on Accreditation of Healthcare Organizations. resource dollars and skill mix necessary to care for the 2002 Hospital standards manual. Oakbrook Terrace (IL): The Commission; 2002. p. 234. population of patients served on each specific unit. It moves away from the concept of a financial plan on the Deborah Crist-Grundman, RN, BSN, is a senior consultant for basis of the “average patient” to the actual range of care Van Slyck & Associates in Phoenix, Ariz. She can be reached at intensity (acuity) of patients served. Consistent with princi(909) 351-2099. ples from the classification system in which acuity represents the risk, complexity, and skill (registered nurse, 1067-991X/2003/$30.00 + 0 licensed, or unlicensed) required to provide care to doi:10.1067/nrsl.2003.39 patients, units with a greater percentage of patients at higher acuity levels require a staff with a high proportion
July/August 2003
In many instances we have done a disservice to middle managers. Only in the past 5 years have we recognized the need to push accountability for business outcomes down within management ranks. Managers have not always been integrally involved in the development of organizational objectives, plans, and budgets, yet the manager is the essential front line in positioning the organization to achieve desired outcomes. One challenge for the chief nurse executive (CNE) is the need to make an investment in the management team that promotes data-oriented decision making and accountability for outcomes. As Jan Carlzon, former chief executive officer of SAS and author of Moments of Truth, once said, “An individual without information cannot take responsibility; an individual who is given information cannot help but take responsibility.”1
WHY SYSTEMS AND DATA-ORIENTED DECISIONS ARE NECESSARY
such professional services as planning, evaluating, and teaching. The nurse-generated patient acuity data are used in care management decisions, such as assignments, care prioritization and delegation, and patient placement and triage, to name a few. The staffing system creates hospitalspecific staffing standards at each acuity level that take into account the care requirements of patients and families, the physical plant structure, availability of support systems, and skill mix requirements. The activity studies that generated the staffing standards also provide information about how staff spend their time and how patients and their families consume staff time. The productivity management system provides nurse managers with a unit-specific, patient-sensitive staffing plan. This system also provides managers who are accountable for appropriate use of resources with the ability to objectively determine units with the greatest need or risk when those resources are limited. Once staffing decisions have been made, the productivity management system provides information, on a daily and shift basis, on the effectiveness of staffing decisions by defining the variance between what was required and what was provided. And finally, the audit system provides ongoing information surrounding the validity and reliability of the patient acuity information that is driving decisions. All of these systems and the data they generate are nursing based, positively positioning nursing for compliance with state and JCAHO staffing effectiveness standards.
Why are systems that generate objective, quantifiable data necessary? The answer is simple. The organization must perform critical decision making based on objective data. It is clear to CNEs that someone will measure us (nursing), and it is better that we choose the tools by which we will be measured than letting others choose. This statement does not presume a negative intent on the part of others, but are we not best able to determine what accurately and completely captures the essence of nursing? Benchmarks are useful but tend to be single-dimensional models based on total worked hours, adjusted patient days, or unit type, such as step-down, medical or surgical, MENTORING DATA ACCOUNTABILITY telemetry, etc. The vulnerability of these benchmarks is Weisinger2 said, “A work organization is a holistic entity, that they tend to negate individualized patient-care an integrated system that depends upon the interrelationrequirements. ship of the individuals who We must have systems are part of it. How each that put the patient at the person performs affects the The activity studies that generated hub of care, the center that company as a whole. That’s the staffing standards also provide influences decision making. why it’s so important to the For many years Scott & success of the company not information about how staff spend White Memorial Hospital only that all employees pertheir time and how patients and their had a homegrown patient form to the best of their acuity system that was task abilities but that they also families consume staff time. oriented and driven by time help others do the same.” and frequency of tasks. The CNEs should not be naive acuity system was different for every unit, did not weigh in thinking that just because their managers have data they the value of professional nursing services or the nursing know what to do with it. After ensuring that managers process, and did not address the collaborative nature of have tools in place to generate necessary data, the next care on a continuum. To this end, Scott & White implestep is to assess manager skill sets surrounding data assimmented a series of systems on the basis of recommendailation and application. The following steps were impletions from a nationally recognized firm. Information genermented to address this need. ated by these management systems includes patient acuity, Scott & White’s CNE and a consultant developed a manstaffing standards by acuity, required direct care hours, ager self-assessment tool. It was organized by the 4 core systems that defined principles at play within each system, actual worked hours, productivity variance, and validity the processes used to generate data, and potential applicameasures of patient acuity. tions of data. The CNE, consultant, and director of producThe patient classification system now crosses clinical tivity and quality reviewed the self-assessments; then the services, units, diagnoses, and DRGs. The classification consultant and director conducted one-on-one sessions criteria are multidimensional and weighted, emphasizing July/August 2003
Nurse Leader 47
Table 1. Total Hip Standards of Care Nursing diagnosis: Pain related to surgical procedure as evidenced by verbal/nonverbal behavior Patient outcome: Patient will receive adequate pain relief with use of prescribed analgesics as evidenced by verbal/nonverbal behavior Nursing interventions: RN: Assess pain, provide comfort measures, apply ice to incision prn, administer analgesics as ordered, keep affected leg in abduction with pillow in place as ordered, assess effectiveness of pain relief measures LVN: Assess pain, provide comfort measures, apply ice to incision prn, administer analgesics as ordered, keep affected leg in abduction with pillow in place as ordered UAP: Provide comfort measures, apply ice to incision prn, keep affected leg in abduction with pillow in place as ordered
with each manager to respond to specific learning needs. Using data specific to the individual manager and his or her unit or units, data analysis was performed, and action plans were developed. The director and consultant also met with unit-level leaders (managers and lead staff nurses) to review system principles, data generated, and application of data at the point of care. This meeting is an essential step in ensuring the ongoing accuracy of nursing data generated at the point of care. The staff were engaged and interested in understanding how to do things right. They asked important questions and voiced concerns, making the interchange very healthy. The CNE incorporated standing agenda items surrounding productivity management and audit report data within established manager meetings (individual and group). Action plans were reviewed and modified when goals were achieved or the plans failed to resolve issues. This protocol provided natural forums for mentoring to occur by the CNE, director, and manager peers. The CNE and managers incorporated data values from productivity management and audit reports as performance targets within the manager performance appraisal.
ADDRESSING PERFORMANCE WEAKNESSES One of the most important yet difficult courses of action a CNE must take is defining and implementing consequences when managers and units do not meet targets. An illustration of this was when at Scott & White several managers’ units had not achieved the targeted acuity validity on monthly audits within reasonable time frames. Audit reports consistently demonstrated that the acuity levels of patients on several units were overstated by unacceptable margins. The unit-generated acuities were feeding into the productivity management system to create the staffing plan 48 Nurse Leader
Table 2. Acuity-based Budgeting and Skill Mix Development Unit name: 5W Budgeted patient days: 4563 Average acuity: 2.49 Acuity Level
% Distribution
1 2 3 4 5 6 7
5 55 27 12 1 0 0
Unit constant Total variable hours Skill mix %
RN Hours
LVN Hours
UAP Hours
329 5772 5014 3510 472 0 0
281 3212 1676 750 0 0 0
329 3840 1676 750 84 0 0
664 15761 52
398 6317 21
1595 8274 27
for required direct care hours. Overstated acuities led to overstated required hours. The CNE met with each affected manager and said that, until audit measurements demonstrated that they had achieved targeted accuracy, the staffing plan for required hours would be adjusted down on the basis of the degree of inaccuracy measured and reported monthly on the unit’s audit reports. The CNE also required the managers to develop time-limited, measurable action plans to resolve the discrepancies. Although this effort clearly took the CNE’s time and energy, it was necessary to demonstrate that the performance targets had meaning and that each manager would be held accountable for achieving them. Think of the message that would have been sent to the managers who were achieving performance targets if the CNE had not taken this step. The director provided opportunities to all managers who thought they needed additional support in interpreting and applying the data generated by their nursing management systems. Next, the CNE used established performance targets in the annual performance appraisal process. These actions reinforced the stated expectation that managers are accountable for achieving set goals and that managers are responsible for the integrity and application of the data being generated by their systems. At Scott & White, nursing now is not only using its own data for internal decision making and outcome evaluation, but also driving data and information about the business of patient care up within the organization.
NURSE DATA USED IN STRATEGIC PLANNING Responding to the nursing crisis, the Scott & White CNE defined an initiative to re-evaluate the patient care delivery July/August 2003
model along with roles and responsibilities of nursing care of professional and licensed care givers. By evaluating acuteam members. Questions at issue included how to retain ity-based skill mix, our fiscal year 2002 full-time equivalent the registered nurses we currently have, have them do the employees increased by 23 and costs were reduced by $1.2 things that they must do, figure out who can do the rest, million, as shown in Table 2. and engage support from other departments. Directors, managers, and staff nurses evaluated activity study data in MANAGEMENT ACCOUNTABILITY AND DATA combination with Texas regulatory role and scope docuINTEGRATION ments to identify ways to maximize scope of practice in Ownership of data has changed. Figures once were each team member role. They ultimately decided on a somebody else’s, like finance or management engineering. modified team nursing care model and began refining their We in nursing had little influence over tool design, and we standards of care by role. Table 1 gives an example of stanwaited for our information to be handed to us. Today, the dard care for hip patients, broken down by role. health care environment demands that nursing contribute Optimizing bed availability and capacity management is to the data forming the business of patient care. We must another challenge. How do ensure that we establish we ensure that patients are systems and tools that crein the right place, provide ate valid, reliable data and Acuity-based budgeting positions an an appropriate level of that we monitor and elevate organization to discretely define the care, and have beds availthe level of data sophisticaable for patient admissions? tion of our managers. We required resource dollars and skill mix Patient acuity data are one integrate data and its necessary to care for the population of must variable in aligning individapplication into our daily ual patient care requireoperational practices, patients served on each specific unit. ments with appropriate becoming proactive rather placement on a shift-bythan reactive. Nursing shift basis. needs to anticipate and provide answers to organizational Patient acuity data also can be valuable in facility planquestions before they are asked. It is time that nursing ning when defining how many of each type of bed are leaders came prepared to the proverbial table with quantruly necessary. Do we need more critical care beds tifiable information focused on ensuring quality outcomes and affordable care. because intensive care patients are consistently being held in the emergency department? Do we need more med/surg beds because patients who could be cared for References 1. Woods J. The quotable executive. New York: McGraw-Hill; 2000. p. appropriately there are occupying ICU beds? Are postacute 131. care beds available? Using occupancy and availability data 2. Weisinger H. Emotional intelligence at work. San Francisco: alone does not always tell the true story. Adding patient Jossey-Bass Inc; 1998. p. 183. acuity to the decision mix helps identify the real capacity 3. Crist-Grundman D. Demand-side management: link patient, staff data to promote quality, reduce cost. Patient Care Staffing Report needs of the patient population being served. 2002 Dec:3-4. Budget forecasting and skill mix development are other 4. Texas Department of Health Texas Register Title 25, Chapter 133, uses of acuity and staffing data. Acuity-based budgeting Article 133.41 Subchapter C, November 2001. positions an organization to discretely define the required 5. Joint Commission on Accreditation of Healthcare Organizations. resource dollars and skill mix necessary to care for the 2002 Hospital standards manual. Oakbrook Terrace (IL): The Commission; 2002. p. 234. population of patients served on each specific unit. It moves away from the concept of a financial plan on the Deborah Crist-Grundman, RN, BSN, is a senior consultant for basis of the “average patient” to the actual range of care Van Slyck & Associates in Phoenix, Ariz. She can be reached at intensity (acuity) of patients served. Consistent with princi(909) 351-2099. ples from the classification system in which acuity represents the risk, complexity, and skill (registered nurse, 1067-991X/2003/$30.00 + 0 licensed, or unlicensed) required to provide care to doi:10.1067/nrsl.2003.39 patients, units with a greater percentage of patients at higher acuity levels require a staff with a high proportion