Nursing and Patient Care Services FY 2009 Report UWHC Authority Board

1. Nursing and Patient Care ServicesFY 2009 ReportUWHC Authority Board Maureen P. McCausland, DNSc, RN, FAANNovember 4, 2009

2. Agenda • Nursing and Patient Care Services Accomplishments • Respiratory Care • Clinical Nutrition • Initial Nursing Goals – March, 2004 • Strategic Goals 2006-2008 • Professional Practice Model • Recruitment and Retention • Nursing Sensitive Outcome Measures • Financial Measures • Conclusions • Future Challenges

3. Respiratory Care Services • The Respiratory Care Practice Council has continued to focus on practice enhancements. • The department provided 260,000 treatments and diagnostic tests. • The shortened ventilator days LOS related to increased use of protocols has been maintained. • The FY 2009 turnover rate was 2.0%. • The FY 2009 year-end vacancy rate was 0%. • No travelers were used in FY 2009.

4. Respiratory Care • Involved in all health-link application go-lives • Members of the department continue to be leaders in professional organizations • Matt O’Brien received the Presidential Scholarship for Master’s in Biotechnology • Anne Flaten elected President-elect of the WSRC • Pulmonary Function Lab added exhaled Nitric Oxide testing capability (used as a clinical guide for asthma management) • Expanded the use of mini-bal procedure (improves accuracy of diagnosing ventilator associated pneumonia and reduces the use of unnecessary antibiotics) • Implemented the Rapid Response Team

5. Infection Control • A significant leadership transition occurred with the retirement of Dennis Maki, MD • Nasia Safdar, MD, has ably assumed leadership • The department has led the organizational response to H1N1

6. Clinical Nutrition Services • Successfully matched applicants for our internship program. For 6 openings, we went down to number 13 for our first choices. • Facilitated role of clinical nutrition in inpatient model of care redesign. • Expanded role of clinical nutritionist in adult nutrition support team and developed staff capable of supporting a pediatric nutrition support team. • Continued to successfully train future professionals in the UWHC Dietetic Internship Program. • Collaborated with Princeton Club West & East to provide nutrition education and individual counseling to membership. • Consulted on healthy cafeteria initiatives. Effectively worked with Food Service management staff to modify recipes, menus, portions, and service. Analyzed nutrient content of recipes and foods offered. Worked with Public Affairs to market and disseminate information. Provided café patron education during heart and nutrition month.

7. Strategic Goals 2006-2008 UWHC Nursing Strategic Goals • Deliver excellent patient care across the continuum which is evidence based and fiscally responsible. • Create a professional practice environment which supports clinical nurses characterized by collaborative governance, participative decision-making and a commitment to professional development. • Provide superior customer service to patients and their families. • Identify and act upon opportunities to advance collaboration with the University of Wisconsin School of Nursing. • Enhance operational efficiency by minimizing barriers to patient access and streamlining patient throughput. • Apply the power and potential of technology and informatics to support delivery of superior care and enhance the effectiveness of professional nursing. • Recruit, retain and develop nursing leaders in clinical practice and clinical management. • Create and nurture a spirit of inquiry in all nurses from the systematic evaluation of one’s own practice, to the translation of research findings into practice and contribution to established programs of research at the University of Wisconsin-Madison School of Nursing.

8. UWHC Professional Practice Model

9. Practice Model Update: Nursing Care Delivery System • The primary nursing model at UWHC continues to be mature, but still has the potential to be more substantive. • Primary nursing is an essential component of the interdisciplinary model of care.

10. Professional Practice Model: Interdisciplinary Collaboration • Clinical nurses continue to report high satisfaction with “physicians appreciate what I do” in the NDNQI survey. • We continue to address concerns related to improving communication and relationships between nurses and physicians as necessary.

11. Professional Practice Model: Evidence Based Practice • The Nursing Practice Council completed three EBP guidelines for: • Catheter associated UTI • Care of patients in isolation • Care of patients in restraints and use of patient safety attendants

12. Professional Practice Model: Clinical Advancement & Recognition • The recognition activities for National Nurses’ Week were successful. • Leah Curtin, RN, FAAN was the keynote speaker. • Genevieve Nicol-Sey, BSN, CCRN, CNRN, RN received the Primary Nursing Award. • The clinical advancement program design was completed.

13. Professional Practice Model: Clinical Advancement & Recognition • Peggy Wiederholt, RN, Head and Neck Oncology nurse coordinator received the inaugural American Society for Therapeutic and Radiation Oncology (ASTRO) Nurse Excellence Award. • UWHC nurses outscored peers at 27 academic medical centers in their knowledge and treatment of pressure ulcers, sleep, incontinence and use of restraints in the Geriatric Institutional Assessment Profile funded by the Hartford Institute at NYU Division of Nursing • Dianne Danis, MS, RN, NEA-BC, FAAN, Director of Nursing Practice Innovation, was inducted into the American Academy of Nursing. Dr. Paul Harari, Jack Fowler Professor and Chairman of the Department of Human Oncology at the UWHC and UW Carbone Comprehensive Cancer Center and Peggy Wiederholt, RN Dianne Danis, MS, RN, NEA-BC, FAAN, Director of Nursing Practice Innovation

14. Professional Practice Model: Clinical Supports • The HealthLink design and implementation benefited tremendously from the leadership of the clinical nurse specialists, nursing education specialists and the nursing informatic specialists. Two major applications were installed: • Clinical Documentation • CPOE • The AFCH Pain Clinical Nurse Specialist has continued to develop clinical nurses as pain resource nurses and has standardized care of children having painful procedures.

15. Professional Practice Model: Organizational and Managerial Structure • The collaborative governance structure received outstanding reviews from the Magnet appraisers. • The Advanced Practice Nursing Council was launched.

16. Collaborative Governance Structure

17. Non Clinical Supports • Support from non clinical areas continue to be a strength for our organization, particularly environmental services and facilities planning.

18. Recruitment and Retention of Professional Nurses • Steady progress has been made in both the recruitment and retention of professional nurses. • The RN vacancy rate continues to decrease and this has a positive impact on UWHC operations and on nursing sensitive outcome variables. • The total RN vacancy rate as of June 2009 was -3.4%. • The use of traveler and agency nurses was 19.0 FTE YTD across the entire organization.

19. Recruitment and Retention of Professional Nurses

20. Recruitment & Retention of Professional Nurses • Turnover of professional nurses was at its lowest point since tracking began in FY 02 or 6.2% (104 individuals) in FY09. • Turnover of nurse residents in the first year of practice was 6.5% (N=11) which was a decrease from FY08 (11.5%, N=19).

21. Recruitment & Retention of Professional Nurses

22. Recruitment and Retention of Professional Nurses • UWHC continues to be dependent on new to practice nurses but successfully recruited more experienced RNs in FY09. • FY 2008 hires-289 FY 2009 hires-259 101 experienced RNs (35%) 70 experienced RNs (27%) 166 new to practice nurses (57%) 163 new to practice nurses (63%) 22 per diems (8%) 26 per diems (10%)

23. Registered Nurse Workforce Planning • Nurses continue to practice part-time at UWHC but 59.87% now work .9 or greater FTE. • The mean age of registered nurses is 39.1 at UWHC with a range from 21.4 years to 68.4 years. • The bell shaped distribution of the age of RNs in direct care continues to be an advantage for UWHC. • We have a substantial mid-career brain trust. • The aging of the RN workforce and the numbers of RNs projected to reach retirement are significant issues for the organization especially in the ambulatory, surgical services and psychiatric nursing areas. • Ambulatory positions are predicted to fill easily with transfers from inpatient areas. New graduates will be the primary source of staff for inpatient and surgical services areas. • 7 of 62 eligible RNs retired in FY09. The average age at retirement remains 60 years of age.

24. Percent of Nurses in Age Bracket Includes Residents/ADNTP

25. Mean Age of Nurses by Division With and Without Residents/ADNTP Data as of 6/30/09

26. Minimum/Maximum Ages of RN StaffFY 2005 – FY 2009

27. Number of RN’s Who RetiredFY 2005 – FY 2009

28. Forecast of RN Retirement

29. Professional Job Satisfaction and Engagement • The national sample contains • 696 hospitals • 234,588 RNs • 14,738 nursing care units. • Nurses’ professional job satisfaction trends continue to demonstrate progress on variables that are meaningful to them. • We now have 6 years of NDNQI comparative data. The response rate for 2008 was 77% (N=1259). • 26 UWHC units achieved a 100% response rate.

30. Professional Job Satisfaction and Engagement • Participation decreased 6 points from last fiscal year. • Scores have remained high since 2003: Individual Satisfaction Scores • Satisfied with the status of nursing – 17% increase • Career Development – 16% increase • Participation in decision making – 8% increase Work Group Satisfaction Scores • Autonomy – 10% increase • Professional status - 11% increase • Task - 11% increase

31. Professional Job Satisfaction and Engagement • Individual nurses continue to report moderate to high satisfaction with no variables in the low category. • High satisfaction • teamwork between co-workers • physicians appreciate what I do for patients • satisfied with my job • nurse manager is a good leader

32. Professional Job Satisfaction and Engagement • Moderate satisfaction • Time for patient care • Participate in decision making • Autonomy in daily practice • Satisfied with status of nursing • Salary is satisfactory • Satisfied with CNO • Career development opportunities • Low satisfaction • No variables

33. Professional Job Satisfaction and Engagement • Intent to leave1 has increased from 2007 • 89.8% of nurses reported that they plan to stay at UWHC (1.6 pt (1.7%) decrease) • 82.6% plan to remain on their same unit • 7.2% plan to transfer to another unit at UWHC • 10.2% reported intent to leave UWHC • 3.6% plan to seek a direct patient care role outside UWHC • 2.7% plan to leave direct care • 1.3% plan to seek a new career • 2.6% plan to retire • 18% improvement from 2003 to 2008 regarding nurses’ intent to leave UWHC • particularly true for those that would seek a direct patient care role outside of UWHC • 1 Percentages do not equal 100% due to rounding

34. Professional Job Satisfaction and Engagement

35. Educational Preparation and Professional Certification • UWHC nurses are well educated • 74% hold a BSN or higher degree • 65% hold a BSN • 11% hold a Masters degree and 9% hold a Masters degree in nursing • 0.2% hold an earned doctorate • The number of UWHC nurses achieving professional certification has increased again in FY09 from only 7% (N=81) in 2004 to 21% (N=376) in 2009.

36. Career Development • Experienced nurses have voiced their concerns about lack of learning opportunities and this was a concern of the Magnet appraisers as well. • Career development for all professional nurses continues to be a priority at UWHC. • Two visiting scholars have accepted an invitation to do an external review of our educational program. • The new cultural diversity theoretical framework is being implemented.

37. Leading and Managing in a Professional Practice Discipline • The grand rounds series, Leading and Managing in a Professional Practice Discipline, was continued in FY 2009. • The FY 2009 series was built on four major conceptual areas: • Evidence based leadership and management • Emerging knowledge in clinical practice • Language of reflective practice and clinical skill acquisition • Quality and safety • Nationally recognized leaders who joined us in the Leading and Managing in Clinical Practice Discipline were: • Susan Adams, DScN, University of Iowa, Director of the National Nursing Practice Network • Leah Curtain, RN, FAAN • Katharyn May, DNSc, RN, FAAN

38. Nursing Sensitive Outcome Measures • The American Nurses Association named UWHC the #1 Academic Medical Center for Nursing Quality. • There is a very concerning trend in satisfaction with nursing care with all practice areas ending FY 2009 below the 90th percentile. • A variety of analyses and interventions are underway. • Themes related to the impact of HealthLink and the financial environment in FY 2009 have emerged. • The following slides show the current status of nosocomial pressure ulcers, falls and patient satisfaction with nursing.

39. Nursing Sensitive Outcome Measures: Falls

40. Nursing Sensitive Outcome Measures: Falls

41. Nursing Sensitive Outcome Measures: Nosocomial Pressure Ulcers

42. Patient Satisfaction with Nursing

43. Patient Satisfaction with Nursing

44. Patient Satisfaction with Nursing

45. Patient Satisfaction with Nursing

46. Staffing Effectiveness • We continue to evaluate our staffing effectiveness and submit our data to national benchmarking programs. • We have continued a number of strategies to meet these requirements: • UWHC-wide staffing plans are developed at the cost center level • Staffing variables are reviewed in all RCAs

47. Staffing Effectiveness Strategies continued: • Each inpatient unit reviews monthly data on three clinical indicators (falls, pressure ulcers and patient satisfaction with pain) and two human resource indicators (direct care vacancy rate and direct nursing hours per patient day). • Staffing level related performance metrics include the RN vacancy rate, NHPPD, RN skill mix and nursing sensitive outcome variables.

48. Total Holdovers

49. Operational Efficiency and Patient Access

50. Conclusions • We have had an outstanding year • Magnet Recognition • ANA Quality Award • The UWHC nursing and patient care services team continues to make substantial, quantifiable progress. • Significant increase in capacity, particularly ability to accept transfers • Improved financial performance • Improved patient satisfaction • Improved RN satisfaction • RN turnover is continuing to decrease and this is being driven by improvements in the practice environment and the economy. • UWHC has a very large number of RNs with less than three years of experience. Continuing development of them as well as experienced nurses.