Nurse Staffing and Patient Outcomes
Study Workgroup – October 7, 2013
Meeting Summary (DRAFT)
Meeting Details
Date: Monday, October 7, 2013
Start/End Time: 3:30 – 5:00 p.m.
Location: Retirement Systems of Minnesota Building, St. Paul
Project champion: Diane Rydrych, Minnesota Department of Health (MDH)
Facilitator: Kris Van Amber, Management Analysis & Development (MAD), Minnesota Management and
Budget
Workgroup members in attendance: Shirley Brekken, Minnesota Board of Nursing; Marie Dotseth,
Minnesota Alliance for Patient Safety; Linda Hamilton, Minnesota Nurses Association (MNA)/
Minneapolis Children's Hospital; Betsy Jeppesen, Stratis Health; Sandra “Mac” McCarthy, Essentia
Health; Christine Milbrath, Metropolitan State University; Steven Mulder, Hutchinson Health;
Maribeth Olson, Mercy Hospital - Allina Health; Robert Pandiscio, Minnesota Nurses Association;
Sandy Potthoff, University of Minnesota School of Public Health; Eric Tronnes, Abbott
Northwestern/MNA; Vonda Vaden Bates, patient representative (by phone).
Others in attendance: Wendy Burt, Minnesota Hospital Association (MHA); Julia Donnelly, MNA; Sarah
Ford, MHA; Stefan Gildemeister, MDH; Kerri Gordon, Allina; Nate Hierlmaier, MDH; Rachel Jokela, MDH;
Andrea Ledger, MNA; Kristin Loncorich, MHA; Buck McAlpin, North Memorial Marilyn Sorenson,
Essentia Health; Mary Krinkie, MHA; Mark Sonneborn, MHA; Nikki Vilender, Mayo.
Welcome and introductions
Diane Rydrych welcomed workgroup members and observers to the meeting. She explained that MDH’s
Health Policy Division has been charged with conducting the Nurse Staffing and Patient Outcomes study.
This topic has been discussed at the legislature and other forums; the legislation requiring this study is
the most recent development in this ongoing discussion. The division takes its responsibility very
seriously; the division will use a balanced approach based on the best evidence and methodology
possible. Diane thanked workgroup members for agreeing to assist in this work over the coming months.
The legislature would not have asked for a study if the answer to the question was easy, and the
workgroup’s expertise will be very valuable.
Kris Van Amber explained that Management Analysis and Development (MAD) is providing facilitation
and project management for the workgroup. MAD is an independent consulting group in state
government.
1
Kris asked workgroup members to introduce themselves, their organization, and what their expectations
are for the workgroup. Workgroup members offered the following expectations and goals for the
workgroup:












To advance a common goal of patient safety and quality
To bring a systems perspective
To do constructive work and bring perspective
To examine the correlation (not causation) between nurse staffing and patient outcomes
To have new and innovative ways to improve patient safety
To identify the best data and methods for the study
To reach a common understanding of what the evidence does and does not tell us
To support quality research
To understand how the evidence affects practice
To use the information to get better staffing at hospitals
To use the information to get the best patient outcomes
To work collaboratively and come together
Kris asked observers to identify themselves and their organizations. Organizations included the
Minnesota Nurses Association, the Minnesota Hospital Association, the Minnesota Department of
Health, and several health care organizations.
Groundrules
Kris Van Amber described some possible groundrules for the group. Individuals come to the workgroup
with different perspectives; the groundrules can help the group work together.
Mindset




Minds for ideas
Voices to share your ideas
Ears to listen
All in an atmosphere of respect
Conduct and process







All “at table” are equal
One person speaking at a time
Raise hands to talk
Meetings are open to public to observe
Documentation: meeting notes
Distribute documents to work group 5 days prior to meeting
Meetings begin and end on time
Workgroup members can discuss additional ground rules if needed.
2
Workgroup charter
Stefan Gildemeister from MDH explained the workgroup charter (a copy of the charter is available
online here).
The legislature posed a very specific question about the correlation between nurse staffing levels and
patient outcomes, and MDH will approach the study with transparency and objectivity, using the best
empirical evidence and methods available. MDH will also have the self-discipline not to try to answer
questions that haven’t been asked. There may be tradeoffs during the research, and it may not be
possible to answer all the questions we have.
MDH is consulting with this workgroup to gather input and help guide the study. In particular, the
workgroup will provide input on:




Study methodology
Metrics of patient outcomes to be considered in the study
Data necessary and reasonably available for analysis
Level of data granularity (such as shift, unit, or daily averages) and licensure levels
This is a big topic, but there are certain questions that are clearly outside of the scope, including
questions about whether staffing levels are appropriate or whether the legislature should take particular
action. Fortunately, this means MDH and the workgroup can focus on narrow (but complex) questions.
The workgroup’s knowledge and expertise will enrich MDH’s research, and MDH will help the workgroup
by providing information it needs. MDH will consider all of the input of the group. MDH is ultimately
responsible for the approach and method used in the study, and for writing the report and presenting
findings.
Workgroup Resource Identification
Kris Van Amber facilitated a discussion among workgroup members to identify what information the
workgroup needs and who may be able to provide it. Workgroup members also discussed what data
sources and variables may be necessary to conduct the study.
The group identified several areas where further exploration or information will be necessary:








A literature review would be helpful; decisions would be necessary about the scope and time
period for that review
Activities on the floor are more than just the staffing ratio
Averages or overall ratios can mask wide variation
Clarify scope and assumptions
Define granularity of data: hourly, shift
Define patient outcomes: data being tracked may not align with outcomes
Define terms: patient outcomes, nurse staffing levels
Examine approaches and methods used in other studies
3















Frame what data is being collected
Identify hospitals and institutions
Identify the variables in patient/nurse relationship from a system level
Include information on relevant settings: emergency room, recovery room
Limitations of data (ex: acuity is beyond what’s in the EMR)
Need better activity- and acuity-adjusted data
Other attributes may affect outcomes and staffing: culture, design of physical space, geography
Quantitative data is the focus; qualitative data will also be meaningful
Realize that policies in hospitals drive behavior (ex: moving a float nurse just before 4 hours so
the time isn’t charged to the budget)
Support structures affect staffing levels and outcomes
The critical thinking skills of nurses are real factors
The staffing plan required by statute talks about inpatient care and about RNs, LPNs, and other
nonmanagerial staff. How broadly should the study cast the net?
There are different types of units: which type should the study focus on?
Ways to account for differences in organizations in records and weighting systems
Workload, patient distribution, patient flow & turnover—these are all relevant
The group identified several existing data points/data sources that may be relevant:

















30 day mortality
Case mix index
Current patient load
EMR systems
EPIC, McKesson, ADT
Extended hospital stays
Failure to rescue
Heart failure
Infections (already tracked and monitored)
Medication errors
Near misses
Other nursing sensitive indicators
Placement of the patient
Readmission rates
Staffing plans required under the statute are a potential source of data (MHA has a workgroup
on staffing plans)
Time stamp data exists, census, ADT data—the problem is variability across shifts
Think about data in different groupings:
o Patient as individual
o Patient in the nursing relationship
o Patients collectively
4
o
o
Nurses collectively
Supports in the unit
The group also considered what resources may be available:



Other research—the literature review will help
University of Minnesota
The legislation requiring the study can be a guide
Project Timeline
Stefan Gildemeister discussed the project timeline with the workgroup. A copy of the timeline is
available online here. In setting the timeline for the workgroup, MDH has considered several factors:




The due date of the report
Hospitals will need time to collect or gather data
Three months’ worth of data is the minimum for analysis
The staffing information being collected by MHA (available in July 2014) may be a source of
information.
With those factors in mind, MDH must make some key decisions about the study in early 2014. MDH
values the workgroup’s input, so it’s important not to rush. There will likely be five other workgroup
meetings from 2013 to early 2014, with two follow-up meetings in the second half of 2014.
The workgroup and MDH may find that the study we’d like to do is different than the study we can do:
the study is bounded by the legislative language, the timeline, and the data systems in place now.
Next meeting
The next meeting of the workgroup will be on Tuesday, October 29, 2013 from 12:30 to 2:00 at the
Retirement Systems of Minnesota Building. Prior to the meeting, workgroup members may be asked to
do some homework. Workgroup members were asked to keep thinking about data and resources. At
the next meeting, the group will discuss a logic model that MDH is developing.
MDH is developing plans for upcoming meetings; information will be shared as soon as possible.
Summary prepared by: Beth Bibus, Management Analysis & Development, Minnesota Management &
Budget
5