Developing a Clinically Integrated Health System: A System Chief Nurse Executive Perspective -...

Developing a Clinically Integrated Health System

A System Chief Nurse Executive Perspective

March 7 and 8, 2016

10 Hospitals

>10,000 Employees

1,061 Staffed Beds

147,910 ER Visits

$168 million Charity

7,422 Home Health

Admissions

45,884 Hospital

Admissions

1,200 Physicians

4

Vision 2020

Patient Centered, High Value

System of Care

6

7

SLHS Professional Nursing and Clinical Structure

Structural Framework *Saint Luke’s Hospital Designation

2

Level of Care Nurse Executives

Critical Care Medicine Surgery

Maternity/NICU

Emergency

System Directors Allied Health Professions

Pharmacy Laboratory Radiology

Director of Professional Practice

• Magnet Coordinator

• Pathways to Excellence Consultation

• Shared Governance

• Clinical Advancement Program

System Chief Nurse Executive

System Coordinating Council

System Level of Care Practice

Councils

Surgical

Medicine

Critical Care

Ambulatory

Behavioral

Post-Acute

Emergency

Neonatal

Peri-Natal

Cardiac Rehab

Specialty Councils

Falls

Value Analysis Team

SVAN

Wound Care

Saint Luke’s Care Connection with

System Level of Care Practice Councils

System Clinical Advancement

Council

System Nursing Research Council

System Chief Nursing Officer

Council

Clinical Leadership Council Connection

with CNO/CNEs

System Clinical Quality Connection

with CNO/CNEs

System Advanced Practice Provider

Council

Clinical nurse representation at

these Councils.

SLHS Professional Practice Model

13

Entity Shared Governance Executives

• System level outcomes with two measureable system outcomes

• BSN Requirement by 2020 for existing RN’s

• All new promotions must have BSN

• Certification required

Level 4

• Outcomes involving more than one unit through informal and formal leadership.

• BSN Requirement by 2020 for existing RN’s

• All new promotions must have BSN

Level 3

• Unit based outcomes through informal and formal leadership

Level 2

• Novice Registered Nurse

Level 1

System Clinical Advancement Program (CAP)

CAP Key Changes

Clinical Advancement and maintenance now have the same requirements

Level IV promotions all reviewed and approved at System CAP Council

4% increase between each level of promotion and $0.50/hour differential for certification

Strategic Plan Linkage

Individual Goals/Clinical Advancement Program

Department Goals

Entity Strategic Plan

Saint Luke’s Health System Nursing Strategic Plan

Saint Luke’s Health System Strategic plan

Integrated Electronic Medical Record

Chief Nursing Informatics Officer

EMR

System Education Department

- 18 -

System Director of Education Services

Jamie Luark

Program Coordinator

Jessica Walker

Med Surg

Kristin Carlson

Makenzie Stuck

OR

Cheryl Fisher

SLH

Amy Adkison

Meagan Randle Robinson

SLN & Smithville

1.0 FTE Entity

Director of Research

Jacque Carpenter

SLHS CNE

Kathy Howell

SLHS Patient Care Services Clinical Education Specialists

ER

1.0 FTE

Intermediate

Alisa Barker

Colleen Lad

Critical Care

Kristin Sollars

Marci Ebberts

Women’s / Children’s

Julie Mitchell

Kim Dishman

Program Coordinator

Nancy McEntee

Administrative

Assistant

Anna Hawthorne

Level of

Care

SLEH

Michelle Rennolds

1.0 FTE

SLS & Anderson County

Kathleen Bennett

SLCH

Brenda Potter

HMC & WMH

Jewell Harris

Jenni Kennebeck

CES at SLCH, HMC, WMH and ACH are responsible for all staff education CES at SLN, SLEH, SLS and SLH are responsible for nursing education

Neuroscience Productline –Grant Funded

Donna Hunt

Education Solutions Specialist

Christina Carlos-Moke

Productive Hours

Specialty Unit Registered Nurse Ratios Nursing Assistant Ratios

Medical Surgical Day Shift: 5:1 Night Shift: 6:1

Day Shift: 8:1 Night Shift: 10:1

Intermediate Day Shift: 4:1 Night Shift: 5:1

Day Shift: 8:1 Night Shift: 10:1

High Acuity Intermediate (Located in SLH)

Day and Night Shifts: 3:1 Day Shift: 8:1 Night Shift: 10:1

Intensive Care Unit & NICU Day and Night Shifts: 2:1 Day and Night Shifts: 1 per Unit

Mother and Baby (Varies slightly by facility based on AWHONN Standards)

Day Shift: 1:1 (Land D); 3:1 (Couplet) Night Shift: 1:1 (Land D); 4:1 (Couplet)

Day and Night Shifts: 1 OB Tech

Standardized: Productive and Other Productive Hours

Established both productive and other productive hours standards across all facilities by levels of care

Other Productive Hours

Medical Surgical

Intermediate Intensive Care Unit

Mother and Baby

Labor and Delivery

NICU

Education (per FTE)

24 hours 24 hours 24 hours 24 hours 24 hours 24 hours

Meetings (RN) 8 hours 8 hours 8 hours 8 hours 8 hours 8 hours

Orientation 220 hours 292 hours 436 hours 220 hours 724 hours 580 hours

Workflow Redesign – Central Staffing Office

Decentralized

Model

Variability of staffing

functions and structure

Inability to share staff

resources

Competition for available

float and/or agency staff

Sub-optimal

understanding of nursing

demand & capacity

Central Staffing

Office Model

Standardization of staffing

function and structures

Ability to share staff across

System entities

Resources dedicated to

staffing projections and

analytics

System-view of demand

and capacity

Key Staffing Functions

Self-Scheduling

Schedule Leveling

Assign PRNs, Float staff

and Agency

Predictive Analytics

Daily Staffing

JIT Needs Management

Assign Agency

Assign Float Staff

Track & Back-Fill Call-Ins

Future Needs Projections

Open Shift – Post/Approve

Long Term Needs – FMLA

Agency Competencies/Files

Centralized Float Pool Tiered Pay Structure

Tier 1* Tier 2* Tier 3*

Registered Nurse

Staff will only be required to work at

one entity

Pay differential is $2.00 above base

salary

It is estimated 60% of staff will be

allocated to this Tier

Staff will be assigned to work at two

entities

Pay differential is $4.00 above base

salary

It is estimated 25% of staff will be

allocated to this Tier

Staff will be assigned to work all four

entities

Pay differential is $6.00 above base

salary

It is estimated 15% of staff will be

allocated to this Tier

Nursing Assistant and Information Associate

Staff will only be required to work at

one entity

No pay differential

It is estimated 70% of NA staff will be

allocated to this Tier

Staff will be assigned to work at two

entities

Pay differential is $1.25 above base

salary

It is estimated 20% of NA staff will be

allocated to this Tier

Staff will be assigned to work at all four

entities

Pay differential is $2.00 above base

salary

It is estimated 10% of NA staff will be

allocated to this Tier

Additional Pay Differentials

All other pay differential will continue per system policies:

- Evening shift differential

- Night shift differential

- Weekend pay differential

- Holiday pay differential *Only applies to full-time and part-time staff. PRN staff will remain at current rates

All float staff will start in Tier 1 on 11and 4

System Float Pool Management Structure

Director of Central

Staffing & Float Pool

Entity Nursing House

Supervisors *

Central Staffing

Office

Manager

Float Pool Clinical

Nurse Managers

System Float Pool

* House Supervisors will still report to their specific entity

Sr. VP and CNE

Central Staffing

Office Coordinators

Clinical Analysts

Manual to Automated Analytics

Manual to Automated Analytics

System Policies and Procedures

Care Progression – Overview of Model

26

Care Integration

Case Management

Hybrid approach consisting of utilization review and

discharge planning

Social Work

Identify barriers to transition and facilitate

placement into appropriate care setting

Care Coordination

• Unit based Care Coordinators

• Overcoming obstacles to delivery of care and ensuring care progression

Utilization Review

• Centralized Utilization Review RNs

• Utilization review, referral authorization, and denials management.

Social Work

• Identify barriers to transition and facilitate placement into appropriate care setting

Care Progression

New Model Former Model

System Care Progression

Chief Nursing Officer, Ambulatory Nursing and Advanced Practice Providers

Ensure all APP’s are practicing to the full extent

of their licensure

Executive Sponsor of the System APP Council and

Ambulatory Nursing Council

Ensure consistent standards of care throughout all

ambulatory clinics.

Quality Outcomes

0.00

0.20

0.40

0.60

0.80

1.00

1.20

20

14

-01

20

14

-02

20

14

-03

20

14

-04

20

14

-05

20

14

-06

20

14

-07

20

14

-08

20

14

-09

20

14

-10

20

14

-11

20

14

-12

20

15

-01

20

15

-02

20

15

-03

20

15

-04

20

15

-05

20

15

-06

20

15

-07

20

15

-08

20

15

-09

SLHS Sepsis Mortality O/E Ratio (SLE, SLH, SLN, SLS)

Financial & Productivity Results

2013 2014

Patient Care Services 15.17 14.87

Laboratory 0.09 0.09

Pharmacy 0.04 0.04

Radiology 1.24 1.29

Respiratory Therapy 0.63 0.70

0.56 0.66

Emergency Services 2.76 2.77

Savings by Year $ 21,096,980 $ 17,996,028

• APP Fellowship

• New Graduate Residency and Preceptor Enhancements

• Central Logistics Center

• Ambulatory Float Pool

• System wide Nursing Peer Review

• Quality – Zero Patient Harm

Clinical Integration 2016 Strategic Priorities

• Katherine Howell, MBA, BSN, RN, NEA-BC

Sr. Vice President, Chief Nurse Executive

khowell@saint-lukes.org

Phone: 816-932-1585

901 E 104th Street, Mailstop 900 N

Kansas City, MO 64131

saintlukeshealthsystem.org

Contact Information