Nurse Staffing and Patient Outcomes
Study Workgroup – November 14, 2013
Meeting Summary (DRAFT)
Meeting Details
Date: Thursday, November 14, 2013
Start/End Time: 3:00 – 4:30 p.m.
Location: Centennial Office 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 present: 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 present (based on sign-in sheet): Wendy Burt, Minnesota Hospital Association (MHA); Julia
Donnelly, MNA; Sarah Ford, MHA; Kim Gordon, Allina; Shawntera Hardy, HealthPartners; Eric Haugee,
AFSCME Council 5; Mary Krinkie, MHA; Kristin Loncorich, MHA; Janice Schade, Essentia Health; Mark
Sonneborn, MHA; Marilyn Sorenson, Essentia Health; Nikki Vilendrer, Mayo; Anna Youngerman,
Children’s Hospitals and Clinics.
Workgroup member unable to attend: Connie Delaney, University of Minnesota School of Nursing
Welcome and introductions
Diane Rydrych welcomed workgroup members and observers to the meeting. She thanked workgroup
members for their time and participation in these meetings, especially since the meetings have been
held on an aggressive schedule. She explained that the meeting today will be different than the first two
meetings—the hope is that there will be a deeper discussion of potential data sources for the study.
Workgroup members’ expertise and knowledge are extremely valuable.
Kris Van Amber explained that today’s meeting builds on the workgroup’s work in the last meeting and
between meetings on aspects of the conceptual framework. The workgroup’s discussions are giving
meaning and depth to the framework, and today’s meeting will help identify the main data sets that
MDH may use in the study.
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Conceptual framework responses
After the last meeting, workgroup members were asked to provide additional feedback via email.
Stefan Gildemeister thanked the workgroup for their feedback, which will be very helpful for MDH. For
use at today’s meeting, Kris Van Amber & Beth Bibus (consultants from MAD) compiled responses on
selected factors in staffing, acuity, and outcomes. The group will focus today on several specific
variables, sharing their expertise about how these variables can be measured and how MDH can use
them in the study.
Small group discussion of concepts and data sources
Kris Van Amber explained that the majority of today’s meeting will be dedicated to small group
discussions. Each small group will be asked to complete a worksheet summarizing discussions regarding
priority metrics, data sources, and considerations (such as granularity, trade-offs, and other questions).
Prior to the meeting, small groups were assigned to ensure that perspectives are more or less equally
distributed in each of the topic areas and to manage the logistics of some members planning to
participate by phone. Beyond those parameters, members were randomly assigned to the different
groups.
Kris explained that observers are welcome to listen to whatever group they’d like, but she asked that
they allow distance to let the group work and to avoid side conversations that might distract the groups.
A representative from MDH will sit with each group to ask and answer questions.
The small group discussion at today’s meeting will not be the end of the conversation—the small groups’
ideas will be shared with the whole workgroup, and workgroup members can share additional
comments.
Small group membership
Small Group 1: Administrative Practices (Staffing/Service Volume & Staffing Mix)
 Marie Dotseth
 Linda Hamilton
 Steven Mulder
 Sandy Pothoff
Small Group 2: Patient Care (Patient Medical Needs, Patient Demographics)
 Christine Milbrath
 Maribeth Olson
 Robert Pandiscio
 Vonda Vaden Bates
Small Group 3: Patient Outcomes (Nurse Sensitive Indicators)
 Shirley Brekken
 Betsy Jeppesen
 Sandra “Mac” McCarthy
 Eric Tronnes
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Group notes
The tables below contain the notes taken by members of the break-out groups at the meeting.
Small Group 1: Administrative Practices - Staffing volume/Staffing Mix
Priority Metrics
Data Source
Considerations (granularity, trade-offs, other
questions)
Number of nurses assigned to patients
Data for RNs & LPNs should be reported separately
Other direct care staff should be
considered, e.g., nursing assistants,
nursing aids
Staff who are not involved in direct care may also
significantly affect the outcomes, including social services
staff, Health Unit Coordinators, etc., but we likely are not
able to collect that data
It appears as if the source for data is in
payroll systems and in staffing systems. In
both cases the data can be connected to the
unit at which the staff was working at.
EMRs generally are not systems for staffing
data. They have, however been used to
track data nurse entries for patients. That
can be a proxy for unit activity
Granularity of data should be at the shift
level (Day/Eve/Night, or 7 to 3; 3 to 11; 11
to 7)
Factors such as staffing model (culture) and mix of
experience are important factors to consider in staffing mix,
but measuring these factors is difficult and likely not
consistent across facilities
Hospitalists do affect patient care outcomes, through
efficiency, breaking down communication barriers, abilities
to standardize, but they are likely outside the scope
While nursing staff works beyond the 8-hour shift level,
staffing is generally planned by shifts. It would be useful to
track the number of staff with double-shifts to consider
factors such as fatigue
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Small Group 2: Patient Care - Patient Medical Needs
Priority Metrics
Data Source
Considerations (granularity, trade-offs, other
questions)
Admissions
Discharges
Transfers
Claims Data
Admission – was it planned or unplanned?
Discharge status – disposition would be good to include
Would like internal transfer data, but not available. **Input
on value and options to collect may be helpful from the full
group.**
Acuity systems are not uniform or consistently used—thus
this is the best data available.
Comorbidities are a key consideration
Data Source may be different – requires
individual hospital submission.
General Issue – availability/log of claims data is not timely in
relation to future staffing data being available. Also, staffing
is not done in line with DRGs.
APR-DRG’s
Length of Stay
Rapid Responses & Cardiac Arrests
Small Group 2: Patient Care - Patient Demographics
Priority Metrics
Data Source
Considerations (granularity, trade-offs, other
questions)
Age
Claims Data
Gender
Claims Data
Would be nice at unit level but only available at hospital
level.
Would be nice at unit level but only available at hospital
level.
Payment Source
Claims Data
Would be nice at unit level but only available at hospital
level.
Socioeconomic considerations
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Small Group 3: Patient Outcomes - Nurse-sensitive indicators
Considerations (granularity, trade-offs, other
questions)
Level
Timeliness
All Hospitals?
Priority Metrics
Data Source
Surgical deaths (Death among Surgical
Inpatients with Serious Treatable
Complications)
Patient Falls
NDNQI
Quality specific & reported
SQRMS
Hospital variation – not publicly reported
Facility
Quarterly
Yes
Facility/unit – but
collection varies
Quarterly
Restraint
Not collected/hospital data
Quarterly
Catheter Associated Blood Stream
Infections
Catheter Associated UTIs
Publicly reported CDC for ICUs (PPS
hospital)
CMS/PPS hospital
Hospital
Unit?
Not collected?
ICUs only
Hospital
Engagement
Network (HEN) –
not a public
source
Yes
Quarterly
PPS only
Facility
Quarterly
PPS only
Med Admin Accuracy
Small set – associated with serious injury or
death
Facility
Units?
Quarterly
Yes? – MDH
Adverse Health
Events
Mortality
N/R
Quarterly
Not?
LOS/Readmission
Not reliable information
Correlation (--)
HEN
(not all hospitals reporting)
MHA Claims database
Quarterly
Yes
DVT
SCIP Measure
?
Shock arrest
?
N/R
Nosocomial Infection
MHA claims data
By hospital
Quarterly
Yes
Pressure Ulcer Prevalence
SQRMS
By hospital
Quarterly
Yes
Pain Management
HCAHPS/CMS
Facility (small ones?)
Quarterly
No
Ventilator Associated Pneumonia (VAP)
By hospital
Unit
By hospital
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Small group wrap-up
Members of small groups talked briefly about their discussions. Discussion included:
Small Group 1:
 We started by talking about what is meant by nurse staffing.
 We’re looking at inpatient settings.
 We agreed it would be best to separate RNs and LPNs in the analysis.
 We began to talk about things that would support the RN or LPN; those variables that may be
contributing and confounding.
 We talked about how there should be separation of day, evening, and night shifts, as well as
weekday and weekend shifts.
 We talked about how nurse staffing works today—the things that support nurse staffing and
that make it more difficult. We agreed that it doesn’t work great now. Sometimes, the algorithm
for staffing is in an experienced person’s brain—it’s not done in a standard way.
 We talked a lot about definitions and variables.
 The staffing picture is critically affected by other care staff, by staffing volume, and by staffing
mix (nursing assistants & nurse aids, as examples).
 We started to get to the questions: where is that data? does it exist at level of granularity we
can use?
 There are various places where the data is stored in hospitals. It’s likely that the data is not very
consistent across hospitals—especially with regard to data that can be linked to shifts and
patients.
 This was a tough topic. It may not be possible to reach solid conclusions at this point—some
assumptions may be too broad.
Small Group 2:
 We looked at metrics of patient medical needs and demographics—sources and considerations.
 We considered the timeframe of data—it may be hard to connect patient data with staffing data.
 Staffing is at the unit level, but claim data is at the hospital level.
 There may not be a possible good connection between staffing data and DRG information.
Small group 3:
 We got through many priority metrics and data sources—we also looked at the level of data
(facility or unit), the timeliness of the data, and if all hospitals collect the data.
Closing comments and next meeting
Stefan explained that MDH and MAD will type up notes from the small groups and share them with the
workgroup. By email and at the next meeting, all workgroup members will be able to comment on the
small groups’ work. MDH wants to make sure that the group’s time is used wisely—there may be limited
benefit in continuing to consider these factors, and MDH hopes for input on other aspects of the study.
Kris, Diane, and Stefan closed the meeting by thanking the workgroup for their discussion today.
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The next meeting of the workgroup will be on Monday, December 9 from 2:00 to 3:30 in the Skjestad
Room (Room 2000) of the Stassen Office Building (MN Department of Revenue), 600 North Robert
Street, St. Paul.
Future meetings
The following dates and times have been set for future meetings.
 Monday, January 13, 2014; 2:00 – 3:30 p.m. in the Skjestad Room (Room 2000) of the Stassen
Office Building (MN Department of Revenue), 600 North Robert Street, St. Paul,
 Monday, February 10, 2014; 2:00 – 3:30 p.m. at Hiway Federal Credit Union, 840 Westminster
Street, St. Paul.
Summary prepared by: Beth Bibus, Management Analysis & Development, Minnesota Management &
Budget
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