• Case Study: Assigning the Right Nurse

    Apr 28, 2011

    Kathleen Sanford, RN, collects old nursing journals dating back to the early 1900s, and she finds one thing that never changes.

    "Staffing has been an issue for nursing forever," says Sanford, senior vice president and CNO at Catholic Health Initiatives (CHI), the second largest Catholic health system in the country. "We have been unable to get it right."

    Until now, that is. CHI, a Denver-based organization that includes 73 hospitals in 19 states, is introducing a technology-driven approach-which they are calling the Care Value System-for matching the right nurse to the right patient at the right time. Based on CHI's eight-hospital pilot that started in early 2010, Sanford thinks the healthcare industry finally has the information it needs to get staffing right.

    This case study appeared in the Leadership special report, Creating Value for Patients for Business Success

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    "This gives nursing leaders who are making staffing decisions on a day-to-day basis the data they need to help us provide good quality care in a cost-effective manner," she says. "I think this is the future."

    While the Care Value System is new in the CHI system, a hospital that has been using the software for longer found that its nurse turnover rate fell from 4.68 percent to 1.04 percent in the first 18 months. The hospital also decreased its use of contract nurses and bonus pay-and saved nearly $2.5 million during a six-month period.

    Getting Staffing Right

    Like most health systems, nursing units at CHI hospitals have traditionally assigned staff to reflect the number of inpatients on a given unit. The Care Value System allows a much more sophisticated approach to staffing decisions that considers the way patients move through the hospital. Its features include the following.

    An acuity system. While many hospitals use acuity systems, the software that CHI uses has an intensive search function, scanning both the diagnosis and notes in the patient's chart for details about the patients on a given unit. As nurses complete the patients' documentation, the system automatically calculates the staffing levels and skill mix needed to help patients progress.

    While the typical acuity system would give the same acuity score to two patients with congestive heart failure (CHF), the Care Value System analyzes more information. "One patient might have diabetes as well as CHF, and she might also have emotional problems or any number of other issues," says Sanford. "That information is then noted by our system so the nursing manager will know that this particular patient will need more time with nursing staff than another patient with the same CHF diagnosis but fewer challenges."

    Decision support for matching caregivers to patients. The software matches a patient's individual needs to the caregiver who is on duty and most qualified to prepare the patient for the next desired clinical outcome.

    For example, a patient who just had surgery may be best served by a nurse with certain experience and credentials, while a patient who is almost ready for discharge could benefit from a different set of nursing skills. 

    "All of our staff are in the system along with their years of experience, their certifications, and their specialties, so we can match the nursing staff to the needs of a patient on a particular day or during part of the patient's stay," says Sanford. "Instead of just sitting there with a list of nurses and a list of patients and trying to figure out how to match them, this system will make assignments that are not only best for the patient, but better for the nursing staff, too."


    Frequent updates. The software conducts an hour-by-hour analysis of nurse staffing levels and new patients on the unit. This allows managers to understand changes on the unit that might require adjustments to the staffing level or assignments.

    Expected length of stay. Length of stay is determined for each Medicare-severity DRG (MS-DRG). That information helps nursing leaders understand whether a patient is progressing as would be expected for a particular diagnosis. If the average patient with a certain MS-DRG should be going home within a day but that progress is not happening, then the system alerts the nurses so they can check for a reason-a missing lab report, no physical therapy, or something else-that might be rectified quickly to have a timely discharge.

    The Care Value System, which is being rolled out throughout the CHI system over the next five years, will help CHI achieve one of the tenets of its strategic vision: to be recognized as a national leader in person-centered care.

    "This fits very well with our 'person-centered' value because it helps us address the individual patient and the quality of care that patient receives," says Sanford.

    Giving Patients What They Want

    While the Care Value System is technology, its value is in the way it influences patient care.

    Within 24 hours of a patient's admission, an interdisciplinary team-a physician, a nurse, and a case manager with coding expertise-collaborate to identify a working MS-DRG.

    The software tracks the patient's progress through the hospital-for example, from ICU to medical-surgical unit to discharge-and benchmarks actual progress against expected progress and length of stay according to the standard for that MS-DRG set by the Centers for Medicare & Medicaid Services (CMS).

    "That working DRG drives the collaboration between physicians, nurses, and care managers," says Barbara Caspers, MS, RN, manager of CHI's Care Value System. "We are taking that back-office function-the coding and cost information-and giving that information to the clinicians at the front end."

    This information allows the care team-and, importantly, patients and their families-to be working together toward an expected date of discharge. Interdisciplinary rounds continue every day through the patient stay, allowing the care team to see if the patient is progressing according to schedule.

    "The biggest impact I'm hearing is that the patients clearly know when they're going home," says Caspers. "The entire team is focused on that single point of departure."

    A lesson learned during the pilot: Although the care team benchmarks length of stay to assess a patient's progress, patients and their families do not use that concept. "They just want to know 'When will I be ready to go home?'" says Caspers. "So we don't talk about length of stay to the patient. We talk about being clinically ready for discharge."

    Measuring Results

    Before the Care Value System is introduced to the remaining hospitals in the CHI system, the results in the initial eight hospitals will be analyzed.

    The outcome measures include:

    • Patient satisfaction, as measured by five questions on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey
    • Nurse and physician satisfaction
    • Premium nursing labor
    • Length of stay management
    • Cost of care

    CHI's goal for the Care Value System is to provide a higher level of care for patients at no increase in cost.

    "Using the Care Value System to transform our care delivery processes, we have achieved substantial improvements in our patients' clinical readiness for discharge, as measured by HCAHPS responses," Caspers says. "In addition, premium nursing labor cost has been consistently declining across the participating Care Value System facilities."

    As the care team monitors a patient's clinical progress against the CMS expectation for a given MS-DRG, it is also benchmarking against the financial aspects of that patient's care. "For example, we are able to manage utilization by virtue of identifying about how long a patient with a particular MS-DRG should be in a general medical-surgical unit versus an ICU," says Caspers.

    Thus, the Care Value System aligns clinicians with the finance department, which is responsible for the cost of patient care, so that clinicians and finance are collaborating on the goal of delivering cost-effective care.

    Access the full Leadership report:Creating Value for Patients for Business Success