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

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1 Rl van de verpleegkundige in het ziekenhuis Prf. Walter SERMEUS Leuvens Instituur vr Gezndheidszrgbeleid KU Leuven

2 Inhud Organisatie van ziekenhuizen Vier werelden van Mintzberg Organisatie verpleegkundig departement Divisie-rganisatie / Service-line rganisatie Het RN4CAST nderzek - Bevindingen Verpleegkundige bestaffing Impact van kwalificatiegraad Impact van werkmgeving Het RN4CAST nderzek Aanbevelingen Safe staffing ratis Full BSN staff Magneetziekenhuizen

3 Management van ziekenhuizen Ziekenhuizen zijn grte bedrijven: Niet vaak pgenmen in Trends Tp Maar vaak wel bij de grtste werkgevers in de streek Cmplexe rganisaties - nd aan ged management Running even the mst cmplicated crpratin must almst be child s play cmpared t managing any hspital (Mintzberg, 1997)

4 Definitie van een ziekenhuis Art.2 Wet p de ziekenhuizen (2/8/86) Ziekenhuis is een pdracht medisch-specialistische zrg in een samenhangend en multidisciplinair verband met de bedeling bij de patiënt p een z krt mgelijke tijd de ziekte te bestrijden f te verlichten, de gezndheidstestand te herstellen f te verbeteren f de letsels te stabiliseren

5 Organigram Belgisch ziekenhuis (ziekenhuiswetgeving: 2/8/86) Medische raad Algemeen directeur DIRECTIE Hfdgeneesheer Administratief Directeur Verpleegkundig Directeur Medisch diensthfd Bekhuding/Administratie Persneelsdienst Sciaal werk... Verpleegkundig Middenkader Artsen Hfdverpleegkundige ZIEKENHUIS Verpleegkundige lgistiek medewerker verzrgende

6 Duale ziekenhuisranisatie Histrisch gescheiden rganisatrisch / financieel Duaal functineel rganisatiemdel: Artsen: prfessinele rganisatie; bttm-up; p basis van standardisatie van bekwaamheid; vlakke rganisatie Niet-artsen: machine rganisatie: tp-dwn; p basis van prcedures; hierarchisch Van duaal naar 4 werelden: Gluberman & Mintzberg, Managing the care f health and the cure f disease, Health care Management Review, (2001)

7 4 werelden in het ziekenhuis DISCONNECTIE Gluberman & Mintzberg, Health care management Review, part I, 2001

8 4 werelden in de gezndheidszrg DISCONNECTIE Gluberman & Mintzberg, Health care management Review, part I, 2001

9 Crdinatin (1) & Cllabratin (2) Issues Gluberman & Mintzberg, Health care management Review, part II, 2001

10 Mdels f Clinical crdinatin Stacey Diagram LOW 20% LEVEL OF GREEMENT 20% HIGH HIGH --- PREDICTABILITY --- LOW 60% Gluberman & Mintzberg, Health care management Review, part II, 2001

11 Functinele rganisatie cfr. ziekenhuiswet Medische raad Algemeen directeur DIRECTIE Hfdgeneesheer Administratief Directeur Verpleegkundig Directeur Medisch diensthfd Bekhuding/Administratie Persneelsdienst Sciaal werk... Verpleegkundig Middenkader Artsen Hfdverpleegkundige ZIEKENHUIS Verpleegkundige lgistiek medewerker verzrgende

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

13 Divisie rganisatie directie Balanced screcards Brdtabellen Primaire Divisie A Bv. hartziekten Prfitcenter Primaire Divisie B Bv. geriatrie Secund. Divisie C Bv. Med. beeldvrming Stafdienst (functineel) cstcenter Secund. Divisie D Bv. hteldienst Sms meervudige leiding - Artsen - Verpleegkundigen - Adminstratie -. SLA: Service Level Agreement

14 X medical department SERVICE-LINE/PROCES ORGANISATIE X X X X X X PRA X Pa1 hspital wards hspital wards ne day hspital ne day hspital utpatient clinic utpatient clinic Service-line perating theatres perating theatres ancillary ancillary department department X-ray LAB ETC pharmacy icu X X Pa2 PRB X Pa3 X TENSOR nursing department supprting departments paramedical departments X X X

15 Evlueren van een functinele naar een prcesrganisaties Mc Crmack & Jhnsn, 2001

16 Clinical Micrsystems Definitin A Clinical Micrsystem is: a small grup f peple wh wrk tgether n a regular basis t prvide care t discrete subppulatins f patients. It has clinical and business aims, linked prcesses, and a shared infrmatin envirnment. The Micrsystem cnsists f the peple, the patients and the infrmatin system. Leadership Leadership Organizatinal supprt Perfrmance Perfrmance results Prcess imprvement Infrmatin & Infrmatin Technlgy Staff Staff fcus Educatin & Training Interdependence f care team Patients Patient Fcus Cmmunity & Market Fcus Nelsn & Batalden, 2007 (

17 Gittell J. et.al., 2000 Relatinal Crdinatin Crdinating Mechanisms Clinical Pathways Case Managers Interdisciplinary Runds Staff Fcus Relatinal Crdinatin Cmmunicatin Frequent Timely Accurate Prblem Slving Outcmes Quality Cntrl Mechanisms Selectin Perfrmance Measurement Rewards Cnflict Reslutin Relatinships Shared Gals Shared Knwledge Mutual Respect Efficiency

18 Rubin, Plvnik & Fry, 1977 GRPI-mdel f team effectiveness % team cnflicten

20 RN4CAST STUDY 7th Framewrk Prgramme fr Research and Technlgical Develpment RN4CAST: nurse frecasting in Eurpe : 3 millin funding fr q Health theme 3: Optimising the delivery f health care q 16 partners: 12 Eurpean cuntries, USA, China, Suth-Africa, Btswana q C-rdinatin: Leuven University (W. Sermeus), U. Pennsylvania (L. Aiken) Sermeus et al., 2011 BMC Nursing 20

21 RN4CAST Framewrk Framewrk: A nursing rganizatin mdel Dubis et al., 2012, BMC HSR

22 RN4CAST DESIGN Multicuntry, multilevel, crss-sectinal design t btain imprtant unmeasured factrs in frecasting mdels, cllected at the hspital, nursing unit and individual nurse and patient level: Nurse survey: wrking envirnment, quality & safety, staffing Patient survey: patient experiences with nursing staff, hspital, infrmatin Hspital survey: type f hspital, inflw & utflw Hspital Discharge data: ICD9/10, length-f-stay, adverse events, mrtality Setting At least 30 general acute hspitals in each Eurpean cuntry. At least 2 general surgical and internal medicine wards in each hspital. Sermeus et al., 2011 BMC Nursing 22

23 RN4CAST STUDY DESIGN & SAMPLE Eurpe (12 cuntries) 33,731 nurses in 486 hspitals 11,318 pafents in 210 hspitals Prtugal 2,235 nurses and 2,223 pafents in 31 hspitals U.S. (PA, CA, NJ, FL) 27,509 nurses in 617 hspitals Millins f pafents in 430 hspitals U.S ; 2015 RN4CAST Eurpe RN4CAST ICPC 2009 RN4CAST Extensin Italy, Cyprus, >40 hspitals, >5000 nurses 23 China (6 prv., 2 mun., 1 aut. reg.) 9,698 nurses in 181 hspitals 6,494 pafents in 181 hspitals Suth Africa (6 prvinces) 4,657 nurses in 62 hspitals

24 RN4CAST FINDINGS MORE THAN 50 PEER-REVIEWED PUBLICATIONS ( SELECTION OF PUBLICATIONS Aiken et al Patient safety, satisfactin, and quality f hspital care: crss sectinal surveys f nurses and patients in 12 cuntries in Eurpe and the United States. BMJ. Aiken et al Nurse staffing and educatin and hspital mrtality in nine Eurpean cuntries: a retrspective bservatinal study. The Lancet Ausserhfer et al Prevalence, patterns and predictrs f nursing care left undne in Eurpean hspitals: results frm the multicuntry crss-sectinal RN4CAST study. BMJ Qual Saf

25 VARIATION IN NURSE STAFFING (PATIENTS PER NURSE) Ireland Sweden: Prtugal: 7.7 Finland: Greece: Belgium: Germany: USA 5.3 the Netherlands: England: Spain: Nrway: China: 7.9 Switzerland: Pland: Suth-Africa: 14.3 Weighted by hspital level 25

26 Percent Bachelr prepared Nurses Aiken et al., 2013 IJNS

27 Nursing Educatin Level in EU/EEA 2015 Requirements fr entry int the prfessin 22 University Training U/HE Training 9 HE / Vcatinal Training Vcatinal Training (Own cmpilatin f data)

28 Nurses wrk envirnment Captures 5 dimensins: q Staffing adequacy q Nursing fundatins fr quality q Nurse manager ability & leadership q Nurse-physician relatins q Nurse invlvement in hspital affairs Hspitals classified int quartiles by PES scres Ttal England Sweden Pland Nrway Netherlands Ireland Greece Finland Spain Germany Switzerland Belgium pr mixed better 0% 20% 40% 60% 80% 100% 28 Aiken et al., 2013 IJNS

29 Effect f nurse staffing n patient mrtality 29 Aiken et al The Lancet

30 Aiken LH et al. Sermeus W, Nurse staffing and educatin and hspital mrtality in nine Eurpean cuntries: a retrspective bservatinal study, The Lancet 26 February % 30-day inpatient general surgery mrtality per hspital N h = 300 Hspitals, N p = patients (9 Eurpean cuntries: BE, UK, FI, IE, NL, NO, ES, SE, CH) BE hspitals are marked in red 7.00% 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% MEAN EUROPE: 1.3%, RANGE: 0.0%-7.2%, N=300 MEAN ONE COUNTRY: 1.2%, RANGE: 0.3%-3,0%, N=59

31 Significant effect Aiken et al The Lancet

32 Skills perspective: Scpe f practice Care left undne in Eurpean hspitals (N=488) STAFFING LEVELS HIGH MEDIUM LOW Mean percentages (SD) Ausserhfer et al BMJ Q&S

33 Scpe f practice: Nursing Care Left Undne because f Lack f Time 33 Ausserhfer et al BMJ Q&S

34 Jbsatisfactin f nurses in Eurpe Aiken et al BMJ

35 Intentin t leave hspital & prfessin 35 Heinen et al., IJNS, 2012

36 Hspitals with Better Wrk Envirnments: Lwer Nurse Burnut, in every cuntry 36 Best Aiken et al BMJ

37 Effect f nurse staffing n nurse utcmes Aiken et al BMJ

38 Patient satisfactin rates (1-10) Aiken et al BMJ

39 RN4CAST FINDINGS PATIENTS EXPERIENCES WITH CARE: RELATION TO NURSING Aiken et al BMJ

40 Relatinship f nurse satisfactin and patient satisfactin Aiken et al BMJ

41 Likelihd f Pr Patient Outcme - 27% The Effects f Nurse Burnut n Patient Outcmes -- 24% Recmmend Hspital Rate Hspital 9 r Percent f Nurses with High Burnut

43 Safe patient nurse ratis in Califrnia AB 394, 1999 Required frm /7(per shift, including breaks) Per Nurse Only RNs (nt including supprting staff) Nt including nurse managers rle Minimal (can be higher based n PCS systems)

44 The American Nurses Assciatin s Natinwide State Legislative Agenda NURSE STAFFING AK WA OR NV CA ID AZ UT MT WY CO NM ND SD NE KS OK TX MN IA MO AR LA NY WI MI PA IL IN OH wv VA KY NC TN SC AL GA MS FL MD VT NH MA CT NJ DE DC ME * RI HI Enacted legislatin/adpted regulatins t date: (CA, CT, IL, MA, MN, NV, NJ, NY, OH, OR, RI, TX, VT, and WA) (*DC and ME rescinded AND NC requested study nly 2009) Appraches vary; fr specific, refer t reprt.

45 Victria Nurse-t-Patient ratis Intrduced in 2000, legislated in 2015 Hspital 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 t Patient and Midwife t Patient Ratis) Bill 2015 was intrduced t Parliament n 1 September 2015 and passed n 8 Octber

46 Safe Staffing rati s in UK Directe aanleiding Francis reprt, The Mid Staffrdshire NHS Fundatin Trust Inquiry, 2013 It was the biggest scandal f NHS care in years. Several hundred, pssibly as many as 1,200, patients died at Staffrd Hspital between 2005 and 2009 after suffering neglect, indignity and shddy care. Understaffing meant the hspital's A&E unit ften psed a risk t patients' safety. A shcking catalgue f appalling care included receptinists assessing emergency cases, patients dying after falling when they were left unattended and sme f the sick being denied fd and drink. The Guardian,

47 NICE guideline fr safe nurse staffing in adult inpatient wards in acute hspitals Determining nursing staff requirements Prcedure Accuntability Respnsiveness t unplanned care Mnitring adequacy e.g. measuring utcmes Prmte staff training and educatin System f Red Flags

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49 Safe Nurse Staffing Levels (Wales) Bill Bill Intrduced December 2014 NOW: Stage 2: Cmmittee cnsideratins f Amendments

50 België: Minimale bestaffingsnrmen Dateren van eind jaren 60 Dienst FTE Bedden Bezetting Patient- Nurse rati C,D bedden 80% 10,95 E bedden 70% 8,84 M bedden 70% 6,57 G 13,3 24 bedden 90% 8,87 ICU 2 Per bed 100% 2,74 = verplicht minimum + bijkmende bestaffing via MVG, CAO s, startbanen,

51 Rapprt KCE ziekenhuisfinanciering Radmap vr een nieuwe ziekenhuisfinanciering in België, KCE rapprt 229, 2014

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53 Budget impact COST EFFECTIVENESS DISCUSSION One RN mre will generate 72% f her salary in medical savings: less deaths, less cmplicatins, shrt length f stay, less medical csts, This is nly a partial estimate f the ecnmic value f nursing, mitting the intangible benefits such as: f reduced pain and suffering by patients and family members; benefits t the hspital such as imprved reputatin, reduced malpractice claims and payuts, and reduced cmpliance-related csts; the benefits f increased staffing related t imprved wrk envirnment (e.g. reduced turnver) Dall et al Medical Care

54 Nurse staffing is a cst-effective interventin Rthberg M 2005 Medical Care

56 IOM reprt n the Future f Nursing (2010) RECOMMENDATION

57 Ecnmic Evaluatin f the 80% BSN Nurse wrkfrce recmmendatin Design: Patient-level analysis f electrnic data in 1 hspital (USA) 8526 med-surgical patients, matched with 1477 direct care nurses Results: Lwer mrtality (OR=0,89, p<0,01) Lwer rate f readmissins (OR=0,81, p=0,04) Shrter length f stay (-2%, p=0,03) Yakusheva, Lindrth & Weiss, Medical Care, Octber 2014

58 Reactin f a MD n the Aiken et al. Lancet paper Vl 384 September 6, 2014

59 What is situatin in Eurpe? DIRECTIVE 2013/55/EU, 20 Nvember 2013, n the recgnitin f prfessinal qualificatins Art.31, par.4: Theretical educatin is that part f nurse training frm which trainee nurses acquire the prfessinal knwledge, skills and cmpetences required under paragraphs 6 and 7. The training shall be given by teachers f nursing care and by ther cmpetent persns, at universities, higher educatin institutins f a level recgnised as equivalent r at vcatinal schls r thrugh vcatinal training prgrammes fr nursing.

60 Nursing Educatin Level in EU/EEA 2015 Requirements fr entry int the prfessin 22 University Training U/HE Training 9 HE / Vcatinal Training Vcatinal Training (Own cmpilatin f data)

62 Impact van werkmgeving van verpleegkundigen p kwaliteit van zrg Vijf factren Adequaatheid van de verpleegkundige bestaffing Samenwerking arts verpleegkundige Ondersteuning dr het management Betrkkenheid en inspraak in het beleid Betrkkenheid bij kwaliteit Resultaten van RN4CAST-studie in 12 Eurpese landen Bevraging van verpleegkundigen en patiënten

63 Nurses Reprting n Hspital Wrk Envirnment Ttal England Sweden Pland Nrway Netherlands Ireland Greece Finland Spain Germany Switzerland Belgium Pr Mixed Better 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

64 Enkele mdellen ter verbetering Magneetziekenhuizen ANCC Magnet Recgnitin prgramme (N=395) Transfrming care at the bedside (TCAB) IHI - Reliable Care, Vitality and Teamwrk, Patient-Centered Care, and Value-Added Care Prcesses Prductive wards (NHS) Lean management & prcesptimalisatie p verpleegafdelingen Meer tijd vr patiënten Institute fr Innvatin and Imprvement -

65 Cnclusies Ziekenhuizen zijn cmplexe rganisaties, maar met een rganisatiestructuur frm fragmentatin t cllabratin, wrdt een ziekenhuis, mre manageable than anyne thught (Gluberman&Mintzberg, 2001) Verpleegkundigen vervullen een nderschatte sleutelrl in de gezndheidszrg BMJ 2015;351:h4652

66 Dank vr uw aandacht