Nurse Staffing and Patient Outcomes
Study Workgroup – October 29, 2013
Meeting Summary (DRAFT)
Meeting Details
Date: Tuesday, October 29, 2013
Start/End Time: 12:30 – 2:00 p.m.
Location: Retirement Systems of Minnesota Building, St. Paul
Project champion: Diane Rydrych, Minnesota Department of Health (MDH)
MDH project staff: Stefan Gildemeister and Nate Hierlmaier
Facilitator: Kris Van Amber, Management Analysis & Development (MAD), Minnesota Management and
Budget
Workgroup members in attendance: Connie Delaney, University of Minnesota School of Nursing; Marie
Dotseth, Minnesota Alliance for Patient Safety; Linda Hamilton, Minnesota Nurses Association
(MNA)/ Minneapolis Children's Hospital (phone); 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 (based on sign-in sheet): Wendy Burt, Minnesota Hospital Association (MHA);
Sarah Ford, MHA; Shawntera Hardy, HealthPartners; Mary Krinkie, MHA; Kristin Loncorich, MHA; Janice
Schade, Essentia Health; Mark Sonneborn, MHA; Marilyn Sorenson, Essentia Health; Nikki Vilendrer,
Mayo.
Workgroup members unable to attend: Shirley Brekken, Minnesota Board of Nursing and Betsy
Jeppesen, Stratis Health.
Welcome and introductions
Diane Rydrych welcomed workgroup members and observers to the meeting. She thanked workgroup
members for making themselves available. She also thanked the workgroup for the ideas and
information shared at the last meeting—MDH has used this information in preparing for today’s
meeting, and the information will be valuable going forward. MDH is here to listen to the workgroup.
Kris Van Amber explained the agenda for the day. MDH has developed a draft framework showing the
connections between nurse staffing and patient outcomes. The workgroup can use this framework as a
way to discuss data and other study considerations. The purpose of today’s meeting is to begin
discussions of data that can be used for the study. There won’t be any decisions today—today the
discussion will be divergent, allowing for a range of options.
1
Kris explained that the workgroup will likely feel pushed today and in other meetings—the hope is to
exchange a lot of information that will help MDH conduct the study.
Workgroup purpose, duration, and groundrules
Kris reminded the group of the purpose of the workgroup, which is to consult with the MDH as MDH
studies the correlation between nurse staffing and patient outcomes.
As outlined in the workgroup charter, the workgroup will consult with MDH in the areas of:




Study methodology (including whether the study is conducted across patient groups or across
institutions, whether and how to control for external factors such as acuity, etc.);
Metrics of patient outcomes to be considered in the study;
Data necessary and reasonably available for analysis; and
Level of data granularity (such as shift, unit, or daily averages) and licensure levels.
There will be approximately six workgroup meetings before March 2014, and then likely another two
workgroup meetings between March 2014 and December 2014. The legislative study is due in January
2015.
Kris reminded the group and observers about the groundrules discussed at the last meeting:
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 – avoid side conversations
 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.
Draft study framework
Stefan Gildemeister presented a draft conceptual framework MDH is developing to help show the
connections between nurse staffing and patient outcomes. MDH used the information and ideas the
workgroup shared at the last meeting, combined with information from an initial review of the literature
on this topic. This framework is a start to help the group and MDH come to an understanding of the
various factors that may affect the study, and then we can turn to data collection and methodology
2
questions. This framework is very much a draft—we are all continuing to educate ourselves on what
should be considered in the study.
The broad assumption in the framework is that administrative practices are connected to care delivery,
and care delivery is connected to patient outcomes—there are arrows demonstrating connections, not
necessarily causality. In between those broad connections are many variables and factors. We need to
have a better understanding of the factors identified, and we also need to identify data sources to
measure these factors. We also need to clearly define terms— for example, what do we mean by nurse
staffing?
The direction from the legislature is to study the correlation between nurse staffing and patient
outcomes, so the research question is essentially “What is the relationship between nurse staffing and
patient outcomes?” There are other important questions around this topic, but MDH must stick to the
core question. (MDH can note in the study that other important questions were raised by the
workgroup.)
MDH is looking to the workgroup for expertise and advice to understand the data that’s available, the
possible units of measurement, and the various factors that MDH could consider in the study. MDH also
hopes to get the group’s advice about how we may be able to address constraints in the study (like
possible lack of consistent and reliable acuity data).
Kris facilitated the group’s discussion of the framework. Workgroup members had questions about the
framework and offered thoughts about the various factors in the framework.
Discussion of the framework
Workgroup discussion included:
 The distinction between safety outcomes and clinical outcomes may not be meaningful.
 A possibility: look at outcomes in terms of desired and non-desired clinical outcomes.
 On the one hand, the framework is complex and could be simplified; on the other hand, there
may be even more information needed in the framework.
 A question to consider: Is it reasonable to limit data to only nurse sensitive quality measures?
 With EMR data, we have the capability to think innovatively about measuring nurse staffing.
 Administrative practices, care delivery, and patient outcomes are connected in a
complementary way—it’s not a single direction or flow from one to the next.
 Before we can discuss the data sources, we do need to define what we mean (patient day, for
example).
 Definitions of key terms are important, but we should not spend too much time trying to pin
down definitions of everything.
 Nurse turnover is not reflected in the framework.
 Nurse fatigue is also missing—for example, if a nurse is working double shifts, their ability to
provide care may be diminished.
 Patients & their families are not at the center of this model—the delivery system should be
based on people’s needs.
3





In the industry, the current emphasis is on the triple aims of cost, quality, and patient
experience—this thinking might be helpful in the framework.
It would be helpful to move some parts of the framework around (move the box for health care
unit activity, for example).
It’s not clear if scope of service is represented in the model. A nurse may have low confidence in
other settings and may increase scope to make sure important care is provided. The nurse’s
perspective on appropriate scope may be in conflict with industry or administration goals.
(Examples: counseling on weight management and physical activity.)
The framework doesn’t seem to account for the incentives and disincentives that affect decision
making. Some examples:
o Some organizations have a practice of charging float nurses to a nurse manager’s budget
only if they work a certain number of hours. This can prompt a manager to use a float
for a short period of time.
o Patient satisfaction surveys
o Emphasis on certain quality measures (falls, pressure sores, etc.)
o Other financial considerations affect decision-making
The framework doesn’t give priority to any particular variable—this will require more discussion.
Discussion of factors and data
Workgroup discussion included:
 One definition of “nurse staffing” could include all of the support and ancillary staff in different
departments of the hospital including outpatient departments. Another view of staffing only
considers certain certifications such as RNs in the inpatient care unit.1
 When looking at staffing in a unit, we are looking at acuity of patients. Patients are not equal, so
10 patients in one unit may require different staffing than 10 patients in another unit.
 Staffing mix and assignments evolve with the patients.
 Volume and relationship to service are very connected to staffing mix.
 The RN/LPN distinction is important.
 Education is also a factor.
 Looking at nurse staffing alone would not give a complete picture. Other relevant staffing
factors include:
1
Additional information: In the legislation that requires this study, the Minnesota Legislature defined certain terms
including the following:
 "Core staffing plan" means the projected number of full-time equivalent nonmanagerial care staff that
will be assigned in a 24-hour period to an inpatient care unit.
 "Nonmanagerial care staff" means registered nurses, licensed practical nurses, and other health care
workers, which may include but is not limited to nursing assistants, nursing aides, patient care
technicians, and patient care assistants, who perform nonmanagerial direct patient care functions for
more than 50 percent of their scheduled hours on a given patient care unit.
 "Inpatient care unit" means a designated inpatient area for assigning patients and staff for which a
distinct staffing plan exists and that operates 24 hours per day, seven days per week in a hospital setting.
Inpatient care unit does not include any hospital-based clinic, long-term care facility, or outpatient
hospital department. (2013 Minnesota Session Laws Chapter 51—H.F. No. 588 Sec. 1 (b)(c) and (d).
4
















o The whole care team
o Transfers
o Wound care consults
o Transport teams
o Therapy teams
Different hospitals have different resources available for staffing—a nurse’s duties may vary
widely.
Nurses on the floor may have a different understanding of staffing. They would be thinking less
about transport teams, etc., and more about factors like experience level of the nurses and
about what level of nursing care is possible in a situation.
Task delegation is important – the RN delegates tasks to the other personnel and is ultimately
responsible for making sure the task is done and documented.
An important question: how can we quantify the varied work of an RN on the floor?
Data is available through the University of Minnesota’s Center for Nursing Informatics for some
of the factors we’re considering. There are data sets of normalized measures of elements like
unit design and license levels. The data is available for different settings, including acute care.
Organizational culture, work environment, risk awareness, patient safety awareness, autonomy,
and teamwork are all important, but it will be challenging to measure these elements.
Hours per patient day may be a useful unit of measurement, but it will have to be defined.
Hours per patient day is a productivity measure—it does not completely measure the nurse’s
care or what is happening on the floor.
Would patient surveys provide relevant information?
There have been some decisions made about core sets of information as EMR systems were
developed—those decisions may be relevant here.
We would want to look at what algorithms were used. Maybe those could be used in the
study—perhaps in combination with other sources that would capture information on
workplace culture aspects.
The workgroup should focus on the core variables and avoid getting too far away from nurse
staffing and patient outcomes.
It is helpful to explore and examine all of these factors, even if they can’t all be fully considered
in the study.
Some hospitals rely more on rapid response teams instead of nurses stationed on the floor—this
will affect the reported number of nurses, and it affects the care delivered to patients.
Heavy use of float nurses increases the number of transitions on the floor, which can impact
communication about patients and care delivery.
Some insurance companies are following the federal government’s lead and are using metrics
including quality, safety, financial, and service outcome—monies can be awarded or withheld
based on performance.
5
Closing comments and next meeting
Kris and Stefan closed the meeting by thanking the workgroup for their discussion today. The
workgroup will be asked to provide additional feedback via email (including key assumptions regarding
variables and ideas about metrics and data sources). The workgroup will discuss elements of the
framework at future meetings.
The next meeting of the workgroup will be on Thursday, November 14, 2013 from 3:00 to 4:30 at the
Centennial Office Building (St. Paul), Lady Slipper Room.
Future meetings
The following dates and times have been set for future meetings. Locations will be announced soon:
 Monday, December 9, 2013; 2:00 – 3:30 p.m.
 Monday, January 13, 2014; 2:00 – 3:30 p.m.
 Monday, February 10, 2014; 2:00 – 3:30 p.m.
Summary prepared by: Beth Bibus, Management Analysis & Development, Minnesota Management &
Budget
6