1.6 Provide evidence of data-driven decision-making regarding budget formation, implementation, monitoring, and evaluation.

Transcription

1 1.6 Provide evidence of data-driven decision-making regarding budget formation, implementation, monitoring, and evaluation. The framework for the budgeting process is the relationship between the services or products provided and the resources needed to provide them. Identification, measurement and projection of volume with associated revenue and resources with associated expense quantifies the plan for the organization, department and unit. Formation The formal budgeting process begins with the identification of the budget assumptions and operational goals for the coming fiscal year. Historical and current data are key to the projection of volume statistics. The organization uses operational and fiscal data sources (e.g., admissions and discharges, length of stay, discharge diagnoses, etc.) to identify trends and patterns in volume of services (attachment 1.6.a). Together with information about internal and external factors affecting the organization, these data are used to forecast overall volume. At the inpatient unit level, these volume projections are converted to a projected average daily census based on the comparison of the projected days by clinical service to the current unit distribution of patient days (derived from census reports). In converting this to nursing workload, the Nursing Directors and Associate Chief Nurses review data on current performance and trends in patient acuity from the QuadraMed AcuityPlus Productivity, Benchmarking and Outcomes System (the AcuityPlus System). A sample acuity trend graph used during the FY 2008 budget planning process is included as attachment 1.6.b. These data, together with information related to any anticipated changes that would affect budget predictions, such as new or developing programs, are used to project patient acuity and calculated nursing workload. Data from the AcuityPlus System are also used on an ongoing basis to measure productivity, relating direct care staff utilization to workload and resulting in a ratio of hours per workload index (HPWI). The productivity data are also used in the budget planning process to project staffing requirements (attachment 1.6.c). In other clinical departments, such as the Operating Room, Labor and Delivery, IV Therapy and the Endoscopy Unit, workload measurement programs have been developed internally. They measure procedural workload, metrics derived from volume adjusted for time and intensity of resource need. Regularly generated reports provide data related to both activity and productivity. The data are available for specific time periods and cumulatively for trending and forecasting 70

2 (attachment 1.6.d). In all areas, data are also available for variables such as staff mix and benefit time utilization. In addition to using internally generated data, there are situations in which data analysis provided by external consulting groups can be incorporated into the formation of the budget. For example, the Obstetric service retained an external consultant to look at patient flow and utilization of space and resources in the Obstetric areas to identify opportunities for increasing efficiency. Analysis of the data in the Labor/Delivery /Recovery (LDR) suite indicated potential benefits from the introduction of an obstetric scrub technician role. The unit piloted this role and determined that it had a positive impact on the management of unit activity. In the FY 2008 budget planning process, the RN mix was adjusted to reflect the new model that included scrub technicians (attachment 1.6.e). Implementation The finalized operational budget becomes the blueprint for implementation of the plans for the new fiscal year. For the most recent number of years, increases in nursing workload have led to increases in authorized full time equivalents (FTEs) and changes in direct care staffing mix or in level and type of support staff. One of the first issues in implementation, therefore, is recruiting and hiring into newly approved positions while continuing to fill positions vacated through normal turnover. To assist managers in position management, the department produces a monthly report comparing budgeted FTEs to FTEs on staff in the major personnel categories (Staff Nurse, non-rn direct care, clerical and environmental). The report details by unit the budgeted FTEs in each category, FTEs currently on staff (filled positions), vacancies, staff hired but not yet started and staff with identified future termination dates. A sample portion of the report for staff nurses is included as attachment 1.6.f. Generation of this report at the beginning of each month gives the Nursing Directors an opportunity to review their positions, determine priorities for recruitment and provide the Human Resource staff with information about their staffing needs. Implementation of the staffing plan includes both periodic scheduling and daily staffing. Staffing schedules are developed and produced in four-week cycles, tailored to the needs of the individual unit s patients and staff. Unit staff participate in the scheduling process according to established guidelines and under the direction of the Nursing Director. The core schedule is based on overall budget projections adjusted for predictable variations in workload, for example, weekday to weekend differences or seasonal fluctuations, as identified through analysis of trended unit- 71

3 specific data. Day-to-day and shift-to-shift staffing decisions are made by the Nursing Director, Resource Nurse or Staff Nurse delegate. Workload data from the classification system are available in real time (attachment 1.6.g) and are considered together with other information, such as projected patient turnover, staff skill and experience levels. Budget implementation also requires adjustments to the original plan as new or changing issues are identified. For example, on the vascular unit the night staff identified changing care needs related to increased patient acuity, numbers of admissions and later transfers from the postanesthesia recovery area. The Nursing Director reviewed the volume and patterns of admissions, transfers and sheath removals and concluded that additional staff nurse coverage was required on the night shift. In the nonsalary sector, Staff Nurses in the PICU identified an issue with the probes on oxygen saturation monitoring. The Departments of Nursing and Biomedical Engineering worked together with the vendor to identify issues for all areas using the product, and tested a variety of sensors and monitors. A trial was conducted on one step-down and three critical care units. Survey data from 161 nursing staff respondents were compiled and used as the basis for final product selection. Monitoring and Evaluation The department and the organization produce a variety of reports that monitor actual experience against budget. In addition to real-time data on capacity and workload, leadership and staff have access to data reports on operational, clinical, staff and fiscal parameters that are generated on appropriate schedules (daily, weekly, monthly, quarterly or annually) (attachment 1.6.h). As specific reports become available, they are placed on a common on-line network file location and the designated leadership are notified via with a hyperlink to the report (attachment 1.6.i). Because of the number of reports and the volume of data available, the department developed a nursing dashboard to provide Nursing Directors with unit-specific data as a tool for monitoring and evaluating unit performance. The dashboard was developed by the Patient Care Services Financial Management Systems staff who met with a group of interested Nursing Directors to identify the metrics that would be of most significance to the managers in evaluating their units. The dashboard includes metrics in each of the major data categories (operational, clinical, staff and fiscal). The metrics are updated as new data are generated. For example, workload data are updated weekly, fiscal data monthly, turnover data quarterly and staff satisfaction data annually. As they are 72

4 updated, the managers receive an with a hyperlink to the dashboard. The dashboard is also available on a shared drive for easy access at any time. A sample section of the dashboard is included as attachment 1.6.j. The data reported on the dashboard provide a snapshot of the status of the unit using data from various reports. The format includes benchmarks, target ranges and flags for metrics that are outside of the target ranges. In addition, there are links to the source reports so that managers are able to drill down as necessary for further information. The unit-based dashboard assists the Nursing Director in making informed decisions regarding ongoing unit management, utilization of existing resources and advocacy for additional resources when needed (attachment 1.6.k). Information from the dashboard, together with data from the underlying reports and from ad hoc analyses, become the basis for the formation of the budget in the next budget cycle. 73

5 Attachment 1.6.a FY08 INPATIENT & OBSERVATION BUDGET GH ADMISSIONS January January FY07 FORECAST Base FY08 Budget FY05 FY FY07 YTD YTD % VP Submits FY07 FC VP Submits FY08 Budget Actual Actual Budget Variance Variance FY07 FC v. FY07 Budget FY08 Bud v. FY07 Forecast Medicine 19,307 20,004 19, % 19,710 (280) -1.4% 20, % Surgery/Plastics/Burn 8,194 8,674 8, % 8, % 8, % Orthopaedics/Hand 3,738 3,823 4,000 (75) -5.7% 3,704 (296) -7.4% 3, % Neurosurgery 2,292 2,137 2,294 (2) -0.3% 2,266 (28) -1.2% 2, % Pediatrics 2,905 2,862 3,084 (44) -4.4% 2,955 (129) -4.2% 3, % Urology 1,277 1,234 1, % 1, % 1, % Neuromedicine 1,872 2,091 1, % 1, % 1,978 (16) -0.8% Gynecology 1,271 1,208 1, % 1, % 1, % Psychiatry % % % Oral/Max % % 161 (3) -1.8% Obstetrics 3,723 3,456 3, % 3,596 (54) -1.5% 3, % Total Admits 45,359 46,276 46, % 46,214 (565) -1.2% 47, % Hospice % % % Grand Total Admits 45,386 46,3 46, % 46,307 (502) -1.1% 47, % 74

6 Attachment 1.6.b Unit Workload/Productivity Trend - Ellison 14 Patient Classification Statistics - March 20 - February 2007 CENSUS WORKLOAD Avg. LOS Census Avg. Workload Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- 07 Feb Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- 07 Feb- 07 Actual Budget Linear (Actual) Actual Budget Linear (Actual) ACUITY HPWI Avg. Acuity Avg. LOS Census Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- 07 Feb Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan-07 Feb- 07 Actual Budget Linear (Actual) Actual Budget Linear (Actual) 75

7 Attachment 1.6.c Massachusetts General Hospital 49 MG4137 Patient Care Services MG4518 FY'2007 Personnel Budget FTE's by Job Code PeopleSoft Dept. ID: MG4137 & MG4518 Total Nurse Manager: Ellen Fitzgerald Job Code Description Regular Overtime Authorized 0080 Operations Associate Ellison Patient Care Associate Staff Nurse Clinical Nurse Specialist Description FY' FY'07 Diff Adv. Nurse Practitioner Nurse Manager Midnight ADC Operations Coordinator Unit Service Associate Classification ADC Nurse, Staff-Entry Nurse, Staff-Clinician Acuity Nurse Staff-Advanced Clinician Nurse, Staff, Weekends-Clinician Workload Index Nurse, Staff, W/E-Clinical Scholar Total FTE's Hours / Workload Index FTE's by Job Code Shifts / 24 Hours PeopleSoft Dept. ID: MG4137 Total Job Code Description Regular Overtime Authorized Indirect Time 5.0% 5.0% 0.0% 0080 Operations Associate Benefit Time RN 10.3% 10.9% 0.6% 0259 Patient Care Associate Benefit Time Non-RN 13.0% 10.0% -3.0% 0430 Staff Nurse Non Productive Factor Clinical Nurse Specialist Adv. Nurse Practitioner Direct Care FTEs - WI Nurse Manager Operations Coordinator Staff Nurse Unit Service Associate Non RN Direct Nurse, Staff-Entry Total Direct Care FTE Nurse, Staff-Clinician Nurse Staff-Advanced Clinician Nurse Manager Nurse, Staff, Weekends-Clinician Other RN Nurse, Staff, W/E-Clinical Scholar Op. Assoc Total FTE's Unit Assist/ USA Other Support FTE's by Job Code Other Non-RN PeopleSoft Dept. ID: MG4518 Total Other FTE's Job Code Description Regular Overtime Authorized 0430 Staff Nurse Total FTE's Patient Care Associate Nurse, Staff-Clinician HPPD - Direct Care Worked Nurse, Staff, Weekends-Clinician HPPD - Direct Care Paid Total FTE's % RN Direct Care 85.2% 85.7% 0.5% % RN Total Budget 69.6% 70.3% 0.7% Notes: Other RN =1.2 CNS; 2.0 Advanced Nurse Practitioner Other Non-RN: 0.5 OC 76

8 Attachment 1.6.d 77

9 Attachment 1.6.e Massachusetts General Hospital Patient Care Services FY'07 Personnel Budget Nursing Director: Susan Caffrey FTE's by Job Code PeopleSoft Dept ID: MG4165 Blake 14 - LDR Total Job Code Description Regular Overtime Authorized Description FY'07 FY'08 Difference Staff Nurse (1.5) 0430 Staff Nurse Non RN Direct Clinical Nurse Specialist Nursing Director Total Direct Care FTE Operations Coordinator Unit Service Associate Nursing Director Birth Certificate Registrar Other RN Patient Care Info. Assoc Op. Associate Surgical Tech Unit Asst./ USA Team Leader, II Other Support Nurse, Staff-Clinician Other Non RN Nurse Staff-Advanced Clinician Other FTE's Nurse Staff-Clinical Scholar Nurse, Staff, Weekends-Clinician Total FTE's Nurse, Staff, W/E-Adv Clin Nurse, Staff, W/E-Clin Scholar Total FTE's % RN Direct Care 100.0% 94.9% -5.1% % RN Total Budget 72.0% 68.6% -3.3% Notes: Other RN = 0.5 CNS Other Support = 1.0 Team Leader. 1.0 Birth Certificate Registrar Other Non RN =1.0 Operations Coordinator 78

10 Attachment 1.6.f Budget FY 07 Authorized Positions Direct Care RN Filled Positions as of 3/2/2007 Job codes 132, 430, 442, 708, 1149 and 1201 thru 1219 MGH - PATIENT CARE SERVICES FILLED POSITION REPORT Cost Center Budget On Staff Hired Total Filled % Filled Vacant % Vacant Agency Super Group 846: Emergency Dept. Nursing Service Emergency Room MG % % 2.7 ED Observation - Nsg. MG % % Subtotal ED Nursing Service % % 2.7 Super Group 847: Perioperative Nursing Service OR Nursing Administration MG % % Main Operating Room MG % % 2.0 PACU Same Day Surgery Unit MG3615 MG7116 MG % 97.8% (1.4) % 2.2% 1.9 Pre-Admission Clinic MG % % Endoscopy MG % (5.9) -16.3% Endoscopy at CRP MG % % Instrument Room MG % % Subtotal Perioperative Nursing % % 3.9 Super Group 848: Cardiology/Cardiac Surgery Nursing Service Cardiac SICU MG % % 2.8 Ellison 8 MG % % 0.9 Ellison 9 CCU MG % (0.5) -1.2% 1.8 Ellison 10 MG % % 0.9 Ellison 11 CAU MG % % Subtotal Cardiology/Cardiac Surgery Nsg % % 6.4 Super Group 849:Surgical Nursing Service SICU MG % (4.3) -5.7% 0.9 Burn / Bigelow 13 MG4513 MG % % 0.9 Transplant / Blake 6 MG4163 MG % % 3.6 White 7 MG % % Ellison 7 MG % % 2.7 Ellison 19 MG % % Phillips House 22 MG % % Bigelow 14 MG % % Subtotal Surgical Nursing % %

11 Attachment 1.6.g Daily Assignment Report Unit: 04 CARD SICU (MGH) Date: 5/10/2007 Location Patient Name Type WI Notes B0854 A SURGERY, ONE B0856 A SURGERY, TWO B0866 A SURGERY, THREE B0868 A SURGERY, FOUR B0874 A SURGERY, FIVE B0876 A SURGERY, SIX B0878 A SURGERY, SEVEN B0882 A SURGERY, EIGHT B0886 A SURGERY, NINE B0888 A SURGERY, TEN B0892 B SURGERY, ELEVEN Total Workload: 34.6 Report Run Date: 5/10/ :37:29 AM 80

12 Attachment 1.6.h REGULAR REPORTS AVAILABLE TO LEADERSHIP AND STAFF 81

13 Attachment 1.6.i -----Original Message----- From: Stechmann, Scott Sent: Monday, April 23, :53 PM To: Keeley, Adele L., R.N.; Tubridy, Aileen, R.N.; Stefancyk, Amanda Lynn,R.N.; Peters-Lewis, Angelleen, R.N.; Kennedy, Ann,M.,Mgh Nursing, R.N.; Digiovine, Anthony D., R.N.; Mahoney, Barbara L., R.N.,MGH Nursing; Glass, Bonnell W., R.N.; Miller, Brenda, R.N.; Manley, Bessie A, R.N.; Feilteau, Charlene A., R.N.; Annese, Christine Donahue, R.N.; Caster, Coleen R.,R.N.,C., MN,FNP; Snydeman, Colleen K., R.N.; Tenney, Dawn L., R.N.; Burke, Debra, Mgh R.N.; Jenkins, Donna L., R.N.; Flaherty, Eileen D., R.N.; Fitzgerald, Ellen M., R.N.; Reardon, George; Peirce, Georgia W.; Somerville, Jacqueline A., R.N.; Madigan, Janet M.,R.N.; Mulligan, Janet L., R.N.; Quigley, Janet Dauphinee, R.N.; Ives Erickson, Jeanette, R.N.; Fitzmaurice, Joan, R.N.; Lafrancesca, Joanne, R.N.; Murphy, John C. Jr.,MGH Nursing, R.N.; Silva, Judith H., R.N.; Newell, Judith,A., R.N.; Myers, Kathleen, R.N.; Perleberg, Keith, R.N.; Pugsley, Lori, R.N.; Settle, Margaret D., R.N.; Shaw, Margaret L., R.N.; Ditomassi, Marianne, R.N.; Freehan, Marion L., R.N.; Prater, Marita, R.N.; Hughes, Maryfran, R.N.; Schnider, Maureen E.,R.N.; Lipkis-Orlando, Robin, R.N.; O'Malley, Rosemary, R.N.; Millar, Sally G., R.N. MGH; Stechmann, Scott; Bouvier, Sharon M.,R.N.; Gordon, Susan J.,R.N., Mgh Ellison 16; Tully, Susan M., R.N.; Morash, Susan, R.N.; Capodilupo, Theresa A, R.N.; Gallivan, Theresa M., R.N.; Moulaison, Walter J, R.N.; Caffrey, Susan,R.N.; Ciesielski, Scott, R.N.; Ellbeg, Mary Elizabeth; Sylvia, Mary H.,R.N.; Winne, Maria D., R.N.; Macchiano, Sara A.,R.N. Cc: McCarthy, Nancy J., R.N. Subject: Workload/Productivity Report The shared folder has been updated with the Workload/Productivity Report for the week ending Apr. 21, file:\\sfa7\pcsmgr$\workload_productivity_reports\winpfs_weekly_reports\fy'07\wrkld_prod_ xls I have also included the updated information and % classified on the dashboard. file:\\sfa7\pcsmgr$\dashboard\dashboard.xls. Scott Stechmann Massachusetts General Hospital Patient Care Services Management Systems Tel: (617) Fax: (617)

14 Attachment 1.6.j UNIT DASHBOARD - Sample Unit UNIT HEALTH COMPONENT METRIC Benchmark Flag Level < Flag Level > ALERT TRIGGER FORMULAS Trigger < Trigger > Actual Score Last Updated Links to Main Report Census OK ALERT! /22-4/28/07 Workload Productivity Acuity OK OK /22-4/28/07 Workload Productivity Operations Workload OK ALERT! /22-4/28/07 Workload Productivity % of Patients Classed 100% 100% 100% ALERT! OK 99% 4/22-4/28/07 % Classified % Occupancy (Noon) 0.0% 84.1% 93.0% OK ALERT! 93.3% March '07 Unit LOS ALERT! OK 3.34 March '07 Unit Activity/LOS Report Vacancy/LOS Graph Activity Ratio OK ALERT! 0.61 March '07 Unit Activity/LOS Report Patient Falls OK OK 2.51 March-07 Falls/HPWI graph Infection Rate (MRSA) OK OK 0.00 Q1 FY'07 Infection Rate (VRE) OK OK 0.00 Q1 FY'07 Clinical Infection Rate (Cdiff) OK ALERT! 1.42 Q1 FY'07 Quality Infection Rate (LRB) OK OK 0.00 Q1 FY'07 Hand Hygiene (Before) 80.0% 40.0% 90.0% OK OK 81.0% Q2 FY'07 Hand Hygiene (After) 80.0% 60.0% 90.0% OK OK 83.0% Q2 FY'07 Sample Portion of Unit-Based Dashboard 83

15 Attachment 1.6.k Portion of Notes Page from Unit-Based Dashboard METRIC OPERATIONAL DEFINITION SOURCE FREQUENCY RELIABILITY BENCH MARK FLAG OPERATIONS CENSUS LOS-adjusted WinPFS Weekly Monitored N/A - +/- 5% of budget contextual metric ACUITY WI / LOS-adjusted census WinPFS Weekly Monitored N/A - +/- 5% of budget contextual metric WORKLOAD Census x Acuity PCS MS calc from WinPFS data Weekly Consistent with monitoring N/A - contextual metric +/- 5% of budget % PATIENTS CLASSED % of patients classed / total patients WinPFS Weekly Monitored 100% <100% to be classed % OCCUPANCY Numerator = Noon census PATCOM WinPFS Denominator = Total operational beds Admitting report (Bedsliop) UNIT LOS (LOS adj days) / (D/C + trans out) PATCOM feed to WinPFS ACTIVITY RATIO (Adm + trans in + trans out + D/C) / MN census CLINICAL PATCOM feed to WinPFS PATIENT FALLS # falls / 1000 patient days Quality and Safety Monthly Primary source N/A - +/- 5% of budget contextual metric w/ changes Primary source Monthly Monthly Calculated from primary sources Calculated from primary sources 2.0% < previous FY minimum 2.0% > previous FY maximum +/- 5% of previous FY average +/- 5% of previous FY average Monthly Primary source 3.0 Upper = 3.0 Lower = 0.0 INFECTION RATE - MRSA # MRSA (hospital acquired) / 1000 patient days Infection Control Unit Quarterly Primary source 0.0% + / - 2 SD from mean of prev 8 quarters 84