National monitoring of nursing activities

(1)

National monitoring

of nursing activities

the Belgian experience Bart Geurden, RN, MSc

University of Antwerp Karel de Grote Hogeschool

Belgium

(2)

National Monitoring of nursing activities

1.

Introduction

2.

The concept “(N)MDS”

3.

Belgian-NMDS version 1

4.

Development of B-NMDS version 2

5.

Impact of NMDS; the future

Prof.Dr. Walter Sermeus

(3)

1. Introduction

•

Nurses are the main human resource in healthcare delivery

•

Up to 20 % of nurses’ time is spent to documenting the care they provide

•

Internationally: nursing is viewed as invisible (in the record of care)

(Goossen,1998; Clark, 1999; Manias & Street, 2001; Korst, 2003)

(4)

1. Introduction

• A key problem = nursing terminology:

“If we cannot name it, we cannot control it, finance it, research it,

teach it, or put it into practice”

Clark & Lang, 1992

(5)

Assessment

Nursing Diagnoses

(Problem identified)

Implemen t

Evaluat e

Objectives

Identified ^(expected

outcome)

Agree expected outcomes with client

Select Interventions

Interventions can be care pathways

Clinical Decision

Making/

Decision Support Systems

Evidenc e based practice

Models &

tools Nursing Assessment

1. Introduction

Nursing

record

(6)

Assessment

Diagnose

Problem identified

Implemen t

Evaluat e

Objectives

Identified ^(expected

outcome)

Select

Interventions

Interventions can be care pathways

Clinical Decision

Making/

Decision Support Systems

Evidenc e based practice

Models & tools Nursing Assessment

Standardised

Nursing Languages

• Diagnoses (NANDA-I)

•Interventions (NIC)

•N.S.Outcome (NOC)

1. Introduction

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1. Introduction

• 1980’s: US → Financing health care based on “Diagnosis Related Groups”

(DRGs)

• Belgian governement & hospital managers wanted to revise the financing of health

care

• DRG system is tempting….

• Nurses wanted to be more involved in the hospital management (DRG = medical

approach).

(8)

1. Introduction

Diversity of patients Dimentio2

ns ^patient^Mean ^Typical^patient ^Individual^patient

MeanCare

Typic Careal

Individual Care

VariabilityofCare

Managem ent

Clinic al

DRGs, Clinical Pathways, Analysis of variances,

profiles,

Practice guidelines, protocols

NMDS

Patient care

(9)

2. Concept (N)MDS

NMDS

(10)

2. Concept MDS

• The Nursing Minimum Data Set

(NMDS) is a classification system which allows for the standardized collection of essential nursing data.

• The collected data are meant to provide an accurate description of the nursing process used when providing nursing care.

• The NMDS allow for the analysis and comparison of nursing data across

populations, settings, geographic areas, and time.

(11)

2. Concept MDS The validity of a NMDS is predicated on identifying

1.

‘core’ elements of nursing practice, those which are used frequently by

2.

the majority of nurses

3.

across care settings, to yield a

‘powerful but limited set of nursing data’

(Goossen 2002)

(12)

2. Concept MDS

Three stages in the development of a NMDS

1. Selection of data terms

2. Turning data into information

Establishing te validity and reliability of data; devising a database for data storage and useful analysis

3. Application

Use dataset in clinical, managerial, educational or quality evaluation applications

(Sermeus, 2002)

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2. Concept MDS

• The minimum dataset concept has been utilised in different areas of healthcare

• Sometimes on a multidisciplinary basis

• Example of a comprehensive suite of MDS application: see www.interrai.org

(14)

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2. Concept MDS

NMDS in other countries:

• US (1985) (Ryan and Delaney,1995)

• Australia (Turley, 1992)

• Finland (Turtiainen, 2000) adapted the B- NMDS to Finland

• Netherlands (Goossen, 2001)

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2. Concept MDS

• International Nursing Minimum Data Set

i-NMDS

• Based on US-NMDS and Belgian-NMDS

• uses the International Classification for Nursing Practice (ICNP®)

• Australia, Thailand, Japan, Netherlands, Switzerland, Finland, Canada en Ireland

• Visit: www.nursing.umn.edu/ICNP

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2. Concept i-NMDS supports:

• Describing client health status, nursing interventions, care outcomes, and

resource consumption related to nursing services

• Improving the performance of health care systems and the nurses working within

these systems worldwide

• Enhancing the capacity of nursing and midwifery services

• Addressing the nursing shortage,

inadequate working conditions, uneven

distribution and inappropriate utilization of nursing personnel

• Testing evidence-based practice improvements

(18)

3. Belgian-NMDS

• Main purpose of the Belgian-NMDS =

1. To improve nursing performance conditions

(increase budget & better allocation of resources)

2. to increase the effectiveness of nursing care

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3. Belgian-NMDS version 1

General

• Compulsory by law since 1988

• All Belgian acute Hospitals (n=141)

• Sample: 15 days / 4 months

– (first half of March, June, Sept, Dec = 60 days/year)

• Governement chooses at random 5 days out of each month (incl. 1 weekend day) =

reference database

• >20 Million nursing records since 1988

• Largest Nursing Dataset in the world

(20)

3. Belgian-NMDS version 1

Content

• General information about hospital

• Patient demographics:

• Age; gender; date of admission and discharge from hospital; hour of admission and discharge from nursing unit

• Nurse staffing data per ward:

• number FTE; number of hours worked/nurse;

qualification; number of beds in ward

(21)

3. Belgian-NMDS version 1

23 nursing interventions:

1. Care in relation to hygiene (degree of help: 4 categories)

2. Care in relation to mobility (degree of help: 4 categories)

3. Care in relation to excretion (degree of help: 4 categories)

4. Care in relation to nutrition (degree of help: 4 categories)

5. Tube feeding

6. Oral care

7. Prevention of pressure ulcers (by alternating positions)

8. Help with clothing (daywear)

(22)

3. Belgian-NMDS version 1

9. Care of endotracheal canule or ETube 10. Nursing anamnesis

11. Selfcare training (occasionally or programme)

12. Care of emotional problems

13. Care of desoriented patient (protective measures)

14. Isolation measures to prevent contamination 15. Registration vital parameters (most frequent

parameter)

16. Registration fysical parameters (most frequent parameter)

(23)

3. Belgian-NMDS version 1

17. Supervision traction, plaster, external fixator 18. Blood samples (number/24h)

19. Medication (IM,SC,ID) (number/24h) 20. Medication IV (number/24h)

21. Supervision IV-infusion (number of lines) 22. Woundcare (surgical wound)

23a. Size of traumatic wound (4 categories)

23b. Woundcare of traumatic wounds (times/24h)

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Hygiene Mobility Excretion Nutrition Tube feeding Oral care

Pressure ulcer prevention Clothing

Tracheostomy Anamnesis Self support Emotional care Desorientation Isolation

Vital parameters Fysical parameters

Traction/plaster cast/external fixation Venous punction

Medication IM/SC/ID Intravenous medication IV Infusion

Surgical woundcare Size traumatic wound Woundcare (trauma)

fingerprintThe

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Hospital departments

Code

A = Neuro-psychiatric care

C = Surgery (diagnosis & surgery) D = Internal Medicine (diagnosis &

treatment)

E = Pediatric care G = Geriatric care I = Intensive care M = Maternity

(26)

Two dimentions of Nursing

care

CARE ^Care

oriented

SELFCARE COMPLETE CARE

Patient is independent

or nurses are instructing selfcare

CURE

Diagnoses & Therapy oriented

Patient is totally dependent Nurses are taking over

(27)

National map

CARE

CURE

SELFCARE COMPLETE CARE

(28)

National map devided in zones

Selfcare Complete care

(29)

(30)

Fingerprint Day 1 Fingerprint

Day 2 Fingerprint

Day 3 Fingerprint

Day 4

Fingerprint Day 5

Grafical projection of patient Z

(31)

4. B-NMDS version 2

• healthcare is evolving rapidly and

continuously → implications nursing care

• 23 items of NMDS version 1 (1988) → poor information in the years 2000

• Revision of NMDS 2002 - 2004

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4. B-NMDS version 2

Revision NMDS: Phase I (2002)

• Methods:

– Literature review

– Secondary data-analysis

• Choice for NIC-framework:

– Nursing intervention Classification (NIC): 433 interventions in 26 classes

– Comprehensive, research-based,

standardised, international accepted, available in French and Dutch

(33)

4. B-NMDS version 2

Revision NMDS:Phase II 2002 – 2003

• Methods:

– Panels of clinical experts (N= 75)

– Six care programmes: cardiology, geriatrics, oncology, rehabilitation, paediatrics, intensive care

– Pre-test in 15 different hospitals

• Results:

– Alpha version: 105 nursing interventions

– Definitions & scoring manual

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4. B-NMDS version 2

Revision NMDS:

Phase III Pilot testing and tool validation 2003 – 2004

• Methods:

– Data collection (dec.2003 – march 2004)

– 30 days of data collection

– 66 hospitals, 158 nursing wards, 95000 patient records

– NMDS-I, NMDS-II, DRGs, Financial data (Finhosta), Pharmaceutical data

• Results:

– Number of interventions/pat/day: Med=14 (1- 43)

– Time (N= 3504: 42 hospitals, 81) wards: Med= 4’ (IQR=3’- 7’ )

– Interrater reliability (9 cases, 66 raters): Above 70% for 80% of the interventions

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4. B-NMDS version 2

Revision NMDS: Phase IV Validity testing

• Criterion-related validity:

– comparing NMDS-II with NMDS-I

– 21146 patient records

– Correlations from 0,88 (tube feeding) to 0,16 (emotional support)

• Construct validity:

– Principal component analysis (CATPCA)

– Intra-class and interclass analysis

– Latent variables: nursing intensity, care/cure

• Face validity:

– Expert panels (2004/11) are validating final NMDS-II

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4. B-NMDS version 2

Final version:

• 78 nursing interventions

• Based on NMDS version 1 and NIC

• 2 sets of nursing data:

– Core data (comparing between care programs)

– Supplementary data (care program specific) (comparing within care programs)

• Linked with CMDS (based on ICD-10-CM);

registration started in 1990; linked since 2007

(37)

4. B-NMDS version 2

From data to applications:

• Appropriateness Evaluation protocol (AEP)

– Nursing care explains 80% of stay in hospital

– In B-NMDS: 8 nursing interventions support AEP

• Nurse Staffing

– Validating patients’ nursing care profiles in relation to nurse staffing ratios

– Selection of key-interventions for nurse staffing

• Reimbursement / funding

– Nurse staffing & nursing care profile per DRG

• Quality Management

– Nurse staffing sensitive patient outcomes (Needleman et.al. 2002)

– Relation: Nurse intervention – patient problem

(38)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

C D E G H* I Sp Total

A: Medical criteria B: Nursing criteria C: Patient status

AD: Admission OVERRIDES

B – NMDS II

EXPLAINING APPROPRIATE STAY

Source: Gillet et.al., 2004

(39)

Linking NMDS and DRGs

N patients / days-of-stay

22 31 28 37 48 61 59 92 95 142 180 211 220 242 199 236 229 239 234 251 234 N =

dag in het verblijf van de MVG registratie

20 18 16 14 12 10 8 6 4 2 0

Mean +- 2 SE RIM1_RC

4,5 4,0 3,5 3,0 2,5

2,0

1,5 1,0

Nursing profile / day-of-stay

0 1000 2000 3000 4000 5000 6000

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

*

Data: DRG 166, Coronary Artery Bypass Graft (CABG) without cardiac catherisation

Y2000 Belgian data, 5575 admissions, 74925 inpatient days, 2670 linked NMDS-days

(40)

Per Hospital; for DRG166 Comparing 2 hospitals A - B

Number

0 100 200 300 400 500 600 700

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Number

0 50 100 150 200 250 300 350 400

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Hospital A:

Median LOS=9 days

Hospital B:

Median LOS=12 days

Number of admission: 584/y Number of inpatient days: 6377 N in NMDS: 399 (6,2%)

Number of admission: 379/y Number of inpatient days: 5009 N in NMDS: 322 (6,4%)

(41)

1 1 5 3 11 11 17 25 19 26 12 20 25 21 22 29 19 N =

Day of Stay

20 16 15 13 12 11 10 9 8 7 6 5 4 3 2 1 0

95% CI RIM1_RC

6

5

4

3

2

1 0

NMDS –

nursing profile for hospital B

N in NMDS : 322

1 1 3 5 5 10 11 24 32 30 30 35 28 35 29 39 33 N =

dag in het verblijf van de MVG registratie

20 17 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0

95% CI RIM1_RC

6 5 4 3 2 1

0 -1

N in NMDS: 399 NMDS –

nursing profile for hospital A

(42)

Relationship NMDS-profile and nurse staffing ratios

1 --- 7

1/10 1/9 1/8 1/7 1/6 1/5 ¼ 1/3 ½ 1/1

Nurses/patient/day

(selfcare Highly dependent)

Analysing actual staffing ratios in hospitals

Theory

Practice

(43)

Impact of nurse staffing ratio

(44)

Impact of nurse staffing ratio

and practice environment

(45)

5. Impact and future

Impact:

• Benchmarking hospitals/care programs/

nursing wards

• Restructuring of nursing wards &

departments

• Revision nursing record (patient record)

• Improved professional communication (NIC)

• International benchmarking (NIC)

• New nursing functions: registration &

analysis

(46)

To 12/2010To 03/2010To 11/2011

Financing Nursing Care

CHU Lg / CZV Leuven - 12/2009

Steering groups & follow-up meetings

NRG-rs

Nursing Related Groups - Required Staff

ITEMS

NRGs

Nursing Related Groups

NRG-fin

Use of NRG in hospital financing

Care Units

Care Programs

…

Case-Mix …

Quality Control

EBN, DRG, AEP, Adverse Events,

…

46

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Recommendations

Evaluation

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A person’s mind, once stretched by a new idea, never regains its original

dimensions….

Oliver Wendell Holmes