Rol van de verpleegkundige in het ziekenhuis. Prof. Walter SERMEUS Leuvens Instituur voor Gezondheidszorgbeleid KU Leuven

Rol van de verpleegkundige in het ziekenhuis

Prof. Walter SERMEUS Leuvens Instituur voor Gezondheidszorgbeleid KU Leuven 07.11.2015

Inhoud •  Organisatie van ziekenhuizen Vier werelden van Mintzberg o  Organisatie verpleegkundig departement o  Divisie-organisatie / Service-line organisatie •  Het RN4CAST onderzoek - Bevindingen o  Verpleegkundige bestaffing o  Impact van kwalificatiegraad o  Impact van werkomgeving •  Het RN4CAST onderzoek – Aanbevelingen o  Safe staffing ratios o  Full BSN staff o  Magneetziekenhuizen o 

Management van ziekenhuizen •  Ziekenhuizen zijn grote bedrijven: o  o 

Niet vaak opgenomen in Trends Top 20000 Maar vaak wel bij de grootste werkgevers in de streek

•  Complexe organisaties - nood aan goed management •  “Running even the most complicated corporation must almost be child’s play compared to managing any hospital” (Mintzberg, 1997)

Definitie van een ziekenhuis •  Art.2 Wet op de ziekenhuizen (2/8/86) o  o 

Ziekenhuis is een opdracht “ medisch-specialistische zorg in een samenhangend en multidisciplinair verband met de bedoeling bij de patiënt op een zo kort mogelijke tijd de ziekte te bestrijden of te verlichten, de gezondheidstoestand te herstellen of te verbeteren of de letsels te stabiliseren”

Organigram Belgisch ziekenhuis (ziekenhuiswetgeving: 2/8/86) Algemeen directeur

Medische raad

DIRECTIE

Hoofdgeneesheer

Administratief Directeur

Verpleegkundig Directeur

Medisch diensthoofd

Boekhouding/Administratie Personeelsdienst Sociaal werk ...........

Verpleegkundig Middenkader

Hoofdverpleegkundige

Artsen

Verpleegkundige logistiek medewerker verzorgende

ZIEKENHUIS

Duale ziekenhuisoranisatie •  Historisch gescheiden – organisatorisch / financieel •  Duaal functioneel organisatiemodel: Artsen: professionele organisatie; bottom-up; op basis van standardisatie van bekwaamheid; vlakke organisatie o  Niet-artsen: machine organisatie: top-down; op basis van procedures; hierarchisch •  Van duaal naar 4 werelden: Glouberman & Mintzberg, Managing the care of health and the cure of disease, Health care Management Review, (2001) o 

4 werelden in het ziekenhuis DISCONNECTIE

Glouberman & Mintzberg, Health care management Review, part I, 2001

4 werelden in de gezondheidszorg DISCONNECTIE

Glouberman & Mintzberg, Health care management Review, part I, 2001

Coordination (1) & Collaboration (2) Issues

Glouberman & Mintzberg, Health care management Review, part II, 2001

Models of Clinical coordination – Stacey Diagram LOW

20%

LEVEL OF AGREEMENT

20%

60% HIGH HIGH --- PREDICTABILITY --- LOW Glouberman & Mintzberg, Health care management Review, part II, 2001

Functionele organisatie cfr. ziekenhuiswet Algemeen directeur

Medische raad

DIRECTIE

Hoofdgeneesheer

Administratief Directeur

Verpleegkundig Directeur

Medisch diensthoofd

Boekhouding/Administratie Personeelsdienst Sociaal werk ...........

Verpleegkundig Middenkader

Hoofdverpleegkundige

Artsen

Verpleegkundige logistiek medewerker verzorgende

ZIEKENHUIS

Organisatie van het verpleegkundig departement K.B. van 7 augustus 1987 - wet 29 december 1990

Divisie organisatie directie Stafdienst (functioneel)

Balanced scorecards Boordtabellen Profitcenter Primaire Divisie A Bv. hartziekten

Primaire Divisie B Bv. geriatrie

costcenter Secund. Divisie C Bv. Med. beeldvorming

Secund. Divisie D Bv. hoteldienst

Soms meervoudige leiding

-  -  -  - 

Artsen Verpleegkundigen Adminstratie ….

SLA: Service Level Agreement

X medical department

SERVICE-LINE/PROCES ORGANISATIE X hospital wards hospital wards

X

Pa1

X

Pa2

X

Pa3

X

X

one day one day hospital hospital

outpatient clinic outpatient clinic

operating operating theatres theatres

X

X

ancillary ancillary department department X-ray LAB ETC

pharmacy icu

Service-line

PRA X

X

PRB X

TENSOR nursing department

supporting departments

paramedical departments

X

X

X

Evolueren van een functionele naar een procesorganisaties

Mc Cormack & Johnson , 2001

Clinical Microsystems •  Definition – A Clinical Microsystem is: o  o  o  o  o  o 

a small group of people who work together on a regular basis

and a shared information environment.

•  Staff focus •  Education & Training •  Interdependence of care team

•  Leadership •  Organizational support

to provide care to discrete subpopulations of patients. It has clinical and business aims, linked processes,

Staff

Leadership

Information & Information Technology

Performance •  Performance results •  Process improvement

•  The Microsystem consists of the people, the patients and the information system. Nelson & Batalden, 2007 (www.clinicalmicrosystem.com)

Patients •  Patient Focus •  Community & Market Focus

Relational Coordination Coordinating Mechanisms Clinical Pathways Case Managers Interdisciplinary Rounds Staff Focus

Control Mechanisms Selection Performance Measurement Rewards Conflict Resolution

Gittell J. et.al., 2000

Relational Coordination

Outcomes

Quality Communication Frequent Timely Accurate Problem Solving Efficiency Relationships Shared Goals Shared Knowledge Mutual Respect

GRPI-model of team effectiveness % team conflicten

Rubin, Plovnik & Fry, 1977


RN4CAST STUDY 7th Framework Programme for Research and Technological Development §  ‘RN4CAST: nurse forecasting in Europe’: €3 million funding for 2009-2011 q  Health theme 3: Optimising the delivery of health care q  16 partners: 12 European countries, USA, China, South-Africa, Botswana q  Co-ordination: Leuven University (W. Sermeus), U. Pennsylvania (L. Aiken)

Sermeus et al., 2011 BMC Nursing

20

RN4CAST Framework

Framework: A nursing organization model

Dubois et al., 2012, BMC HSR

RN4CAST DESIGN §  Multicountry, multilevel, cross-sectional design to obtain important unmeasured factors in forecasting models, collected at the hospital, nursing unit and individual nurse and patient level: § 

Nurse survey: working environment, quality & safety, staffing Patient survey: patient experiences with nursing staff, hospital, information

§ 

Hospital survey: type of hospital, inflow & outflow

§ 

Hospital Discharge data: ICD9/10, length-of-stay, adverse events, mortality

§ 

§  Setting § 

At least 30 general acute hospitals in each European country.

§ 

At least 2 general surgical and internal medicine wards in each hospital.

Sermeus et al., 2011 BMC Nursing

22

RN4CAST STUDY DESIGN & SAMPLE Europe (12 countries) 33,731 nurses in 486 hospitals 11,318 paFents in 210 hospitals

Portugal 2,235 nurses and 2,223 paFents in 31 hospitals

U.S. (PA, CA, NJ, FL) 27,509 nurses in 617 hospitals Millions of paFents in 430 hospitals

Italy, Cyprus, … >40 hospitals, >5000 nurses China (6 prov., 2 mun., 1 aut. reg.) 9,698 nurses in 181 hospitals 6,494 paFents in 181 hospitals

South Africa (6 provinces) 4,657 nurses in 62 hospitals

U.S. 2009 ; 2015 RN4CAST Europe 2009-2010 RN4CAST ICPC 2009 RN4CAST Extension 2014-15

23

RN4CAST FINDINGS MORE THAN 50 PEER-REVIEWED PUBLICATIONS (www.rn4cast.eu) SELECTION OF PUBLICATIONS §  Aiken et al. 2012 Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ. §  Aiken et al.. 2014. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. The Lancet §  Ausserhofer et al. 2014. Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study. BMJ Qual Saf

VARIATION IN NURSE STAFFING (PATIENTS PER NURSE)

Belgium: 10.7 6.2-16.2

Finland: 8.3 5.3-15.6

Ireland 7.0 5.4-8.9 Sweden: 7.6 5.4-10.6

Greece: 9.8 6.3-15.5

Germany: 13.0 7.5-19.2

Portugal: 7.7

USA 5.3 Norway: 5.4 3.4-8.2 Weighted by hospital level

Spain: 12.4 9.4-17.9

England: 8.6 5.6-11.5

the Netherlands: 7.0 5.1-8.1 China: 7.9

Poland: 10.4 7.2-14.9

Switzerland: 7.9 4.6-12.6 25

South-Africa: 14.3

Percent Bachelor prepared Nurses 100 90 80 70 60 50 40 30 20 10 0

100

51

60

52

59 32

56

22

20

10 0

26

Aiken et al., 2013 IJNS

100

Nursing Education Level in EU/EEA 2015 Requirements for entry into the profession 22

University Training U/HE Training HE / Vocational Training

9

(Own compilation of data)

Vocational Training

Nurses’ work environment Captures 5 dimensions: q  Staffing adequacy q  Nursing foundations for quality q  Nurse manager ability & leadership q  Nurse-physician relations q  Nurse involvement in hospital affairs Hospitals classified into quartiles by PES scores

Total England Sweden Poland Norway Netherlands Ireland Greece Finland Spain Germany Switzerland Belgium

poor mixed better

0% 20% 40% 60% 80%100% 28

Aiken et al., 2013 IJNS

Effect of nurse staffing on patient mortality

29

Aiken et al. 2014 The Lancet

30-day inpatient general surgery mortality per hospital Nh = 300 Hospitals, Np=422730 patients (9 European countries: BE, UK, FI, IE, NL, NO, ES, SE, CH) BE hospitals are marked in red 8.00% 7.00% 6.00% 5.00% 4.00% 3.00% 2.00%

0.00%

1 7 13 19 25 31 37 43 49 55 61 67 73 79 85 91 97 103 109 115 121 127 133 139 145 151 157 163 169 175 181 187 193 199 205 211 217 223 229 235 241 247 253 259 265 271 277 283 289 295

1.00%

MEAN EUROPE: 1.3%, RANGE: 0.0%-7.2%, N=300 MEAN ONE COUNTRY: 1.2%, RANGE: 0.3%-3,0%, N=59 Aiken LH et al…. Sermeus W, Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study, The Lancet 26 February 2014

Significant effect

Aiken et al. 2014 The Lancet

Skills perspective: Scope of practice Care left undone in European hospitals (N=488) STAFFING LEVELS

Mean percentages (SD) Ausserhofer et al. 2014 BMJ Q&S

HIGH

MEDIUM

LOW

Scope of practice: Nursing Care Left Undone because of Lack of Time

33

Ausserhofer et al. 2014 BMJ Q&S

Jobsatisfaction of nurses in Europe

Aiken et al. 2012 BMJ

Intention to leave hospital & profession

35

Heinen et al., IJNS, 2012

Hospitals with Better Work Environments: Lower Nurse Burnout, in every country

36


Best

Effect of nurse staffing on nurse outcomes


Patient satisfaction rates (1-10)


RN4CAST FINDINGS PATIENTS’ EXPERIENCES WITH CARE: RELATION TO NURSING

Aiken et al. 2012. BMJ

Relationship of nurse satisfaction and patient satisfaction


Likelihood of Poor Patient Outcome

The Effects of Nurse Burnout on Patient Outcomes

-- 24% Recommend Hospital

- 27%

Rate Hospital 9 or 10

5

25

45

Percent of Nurses with High Burnout


Safe patient nurse ratios in California AB 394, 1999 – Required from 2004

•  24/7(per shift, including •  •  •  • 

http://www.nursingworld.org/

breaks) Per Nurse Only RNs (not including supporting staff) Not including nurse managers’ role Minimal (can be higher based on PCS systems)

The American Nurses Association’s Nationwide State Legislative Agenda

NURSE STAFFING WA MT

ND MN

OR

ID WY NV

CA

VT

SD

AZ

CO

NM

AK

IL

KS OK TX

MO

IN KY

PA OH

MS

AL

RI

NJ MD

wv VA

DE DC

NC

TN

AR

MA

CT

MI

IA

NE UT

NY

WI

NH

ME *

GA

SC

LA FL

HI

Enacted legislation/adopted regulations to date: (CA, CT, IL, MA, MN, NV, NJ, NY, OH, OR, RI, TX, VT, and WA) (*DC and ME rescinded AND NC requested study only 2009) Approaches vary; for specific, refer to report.

http://www.nursingworld.org/

Victoria Nurse-to-Patient ratios Introduced in 2000, legislated in 2015 Hospital Type

AM shift

PM shift

Night shift

1

1:4 + in charge

1:4 + in charge

1:8

2

1:4 + in charge

1:5 + in charge

1:8

3

1:5 + in charge

1:6 + in charge

1:10

4

1:6 + in charge

1:7 + in charge

1:10

Aged HC Res Ward

1:7 + in charge

1:8 + in charge

1:15

The Safe Patient Care (Nurse to Patient and Midwife to Patient Ratios) Bill 2015 was introduced to Parliament on 1 September 2015 and passed on 8 October 2015.

http://www.health.vic.gov.au/nursing/ratios-legislation

Safe Staffing ratio’s in UK Directe aanleiding •  Francis report, The Mid Staffordshire NHS Foundation Trust Inquiry, 2013 o 

o 

It was the biggest scandal of NHS care in years. Several hundred, possibly as many as 1,200, patients died at Stafford Hospital between 2005 and 2009 after suffering neglect, indignity and shoddy care. Understaffing meant the hospital's A&E unit often posed a risk to patients' safety. A shocking catalogue of appalling care included receptionists assessing emergency cases, patients dying after falling when they were left unattended and some of the sick being denied food and drink. The Guardian, 2011

http://www.midstaffsinquiry.com

NICE guideline for safe nurse staffing in adult inpatient wards in acute hospitals

•  Determining nursing staff requirements Procedure o  Accountability o  Responsiveness to unplanned care o  Monitoring adequacy e.g. measuring outcomes •  Promote staff training and education •  System of Red Flags o 

https://www.nice.org.uk/guidance/sg1/chapter/1-Recommendations

https://www.nice.org.uk/guidance/sg1/chapter/1-Recommendations

Safe Nurse Staffing Levels (Wales) Bill Bill Introduced December 2014

NOW: Stage 2: Committee considerations of Amendments

België: Minimale bestaffingsnormen Dateren van eind jaren ‘60

Dienst

FTE

Bedden

Bezetting

PatientNurse ratio

C,D

12

30 bedden

80%

10,95

E

13

30 bedden

70%

8,84

M

14

24 bedden

70%

6,57

G

13,3

24 bedden

90%

8,87

ICU

2

Per bed

100%

2,74

= verplicht minimum + bijkomende bestaffing via MVG, CAO’s, startbanen, …

Rapport KCE ziekenhuisfinanciering

Roadmap voor een nieuwe ziekenhuisfinanciering in België, KCE rapport 229, 2014

Budget impact COST EFFECTIVENESS DISCUSSION •  One RN more will generate 72% of her salary in medical savings: less deaths, less complications, short length of stay, less medical costs,… •  This is only a partial estimate of the economic value of nursing, omitting the intangible benefits such as: o  o 

o 

of reduced pain and suffering by patients and family members; benefits to the hospital such as improved reputation, reduced malpractice claims and payouts, and reduced compliance-related costs; the benefits of increased staffing related to improved work environment (e.g. reduced turnover)

Dall et al. 2009 Medical Care

Nurse staffing is a cost-effective intervention

Rothberg M 2005 Medical Care


IOM report on the Future of Nursing (2010) RECOMMENDATION

Economic Evaluation of the 80% BSN Nurse – workforce recommendation •  Design: Patient-level analysis of electronic data in 1 hospital (USA) o  8526 med-surgical patients, matched with 1477 direct care nurses •  Results: o  Lower mortality (OR=0,89, p<0,01) o  Lower rate of readmissions (OR=0,81, p=0,04) o  Shorter length of stay (-2%, p=0,03) o 

Yakusheva, Lindrooth & Weiss, Medical Care, October 2014

Reaction of a MD on the Aiken et al. Lancet paper 2014

www.thelancet.com Vol 384 September 6, 2014

What is situation in Europe? •  DIRECTIVE 2013/55/EU, 20 November 2013, on the recognition of professional qualifications •  Art.31, par.4: o  Theoretical education is that part of nurse training from which trainee nurses acquire the professional knowledge, skills and competences required under paragraphs 6 and 7. The training shall be given by teachers of nursing care and by other competent persons, at universities, higher education institutions of a level recognised as equivalent or at vocational schools or through vocational training programmes for nursing.

Nursing Education Level in EU/EEA 2015 Requirements for entry into the profession 22

University Training U/HE Training HE / Vocational Training

9

(Own compilation of data)

Vocational Training


Impact van werkomgeving van verpleegkundigen op kwaliteit van zorg •  Vijf factoren o  o  o  o  o 

Adequaatheid van de verpleegkundige bestaffing Samenwerking arts – verpleegkundige Ondersteuning door het management Betrokkenheid en inspraak in het beleid Betrokkenheid bij kwaliteit

•  Resultaten van RN4CAST-studie in 12 Europese landen •  Bevraging van 33000 verpleegkundigen en 11000 patiënten

Nurses Reporting on Hospital Work Environment Total England Sweden Poland Norway Netherlands

Poor

Ireland

Mixed

Greece

Better

Finland Spain Germany Switzerland Belgium 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Enkele modellen ter verbetering •  Magneetziekenhuizen ANCC Magnet Recognition programme (N=395) www.nursecredentialing.org/ •  Transforming care at the bedside (TCAB) o  IHI - Reliable Care, Vitality and Teamwork, Patient-Centered Care, and Value-Added Care Processes www.ihi.org •  Productive wards (NHS) o  Lean management & procesoptimalisatie op verpleegafdelingen o  Meer tijd voor patiënten o  Institute for Innovation and Improvement - www.institute.nhs.uk o 

Conclusies •  Ziekenhuizen zijn complexe organisaties,.... •  .... maar met een organisatiestructuur “from fragmentation to collaboration”, wordt een ziekenhuis, “more manageable than anyone thought” (Glouberman&Mintzberg, 2001)

•  Verpleegkundigen vervullen een “onderschatte” sleutelrol in de gezondheidszorg

BMJ 2015;351:h4652

Dank voor uw aandacht

Rol van de verpleegkundige in het ziekenhuis. Prof. Walter SERMEUS Leuvens Instituur voor Gezondheidszorgbeleid KU Leuven

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